The Association Between Maternal Mortality, Adverse Childhood Experiences, and Social Determinant of Health: Where is the Evidence?

INTRODUCTION: Social determinants of health and adverse childhood experiences have been implicated as driving causes of maternal mortality but the empirical evidence to substantiate those relationships is lacking. We aimed to understand the prevalence and intersection of social determinants of health and adverse childhood experiences among maternal deaths in Colorado based on a review of records obtained for our state's maternal mortality review committee. METHODS: A 5-member interdisciplinary team adapted the Protocol for Responding to and Assessing Patients' Assets, Risk, and Experiences and the Adverse Childhood Experiences tools to create a data collection tool. The team reviewed records collected for the purpose of maternal mortality review for pregnancy-associated deaths that occurred in Colorado between 2014 and 2016 (N = 94). RESULTS: The review identified an overwhelming lack of information regarding social determinants of health or adverse childhood experiences in the records used to review maternal deaths. The most common finding of the social determinants of health was a lack of conclusive evidence in the record (35.1-94.7%). Similarly, the reviewers were unable to make a determination from the available records for 92.1% of adverse childhood experience indicators. DISCUSSION: The lack of social and contextual information in the records points to challenges of relying on medical records for identification of non-medical causes of maternal mortality. Maternal mortality review committees would be well served to invest in alternative data sources, such as community dashboards and informant interviews, to inform a more comprehensive understanding of causes of maternal mortality.

Disseminated intravascular coagulation complicating mild or asymptomatic maternal COVID-19.

BACKGROUND: Hypercoagulability frequently complicates moderate or severe COVID-19 and can result in venous thromboembolism, arterial thrombosis, or microvascular thrombosis. Disseminated intravascular coagulation, however, is uncommon. OBJECTIVE: We sought to describe the clinical presentation and outcome in a series of pregnant patients with mild or asymptomatic COVID-19 who had disseminated intravascular coagulation. STUDY DESIGN: This was a retrospective case series. Cases were solicited via e-mails targeted to obstetrical providers in the Mednax National Medical Group and a restricted maternal-fetal medicine Facebook page. Inclusion criteria were: hospital admission during pregnancy, positive test for SARS-CoV-2 within 2 weeks of admission, and maternal disseminated intravascular coagulation defined as ≥2 of the following: platelet count ≤100,000 per mm3, fibrinogen ≤200 mg/dL, and prothrombin time ≥3 seconds above the upper normal limit. Exclusion criteria were severe COVID-19 requiring ventilation within an hour of diagnosis of coagulopathy or use of anticoagulants at the time of diagnosis. Maternal and newborn records were abstracted and summarized with descriptive statistics. RESULTS: Inclusion criteria were met in 19 cases from October 2020 through December 2021. Of these, 18 had not received any COVID-19 vaccine, and 1 had unknown vaccination status. Median gestational age on hospital admission was 30 weeks (interquartile range, 29-34 weeks). The main presenting symptom or sign was decreased fetal movement (56%) or nonreassuring fetal heart rate pattern (16%). COVID-19 was asymptomatic in 79% of cases. Two of the 3 defining coagulation abnormalities were found in 89% of cases and all 3 in the remaining 11%. Aspartate aminotransferase was elevated in all cases and ≥2 times the upper normal limit in 69%. Only 2 cases (11%) had signs of preeclampsia other than thrombocytopenia or transaminase elevation. Delivery was performed on the day of admission in 74% and on the next day in the remaining 26%, most often by cesarean delivery (68%) under general anesthesia (62%) because of nonreassuring fetal heart rate pattern (63%). Postpartum hemorrhage occurred in 47% of cases. Blood product transfusions were given in 95% of cases, including cryoprecipitate (89% of cases), fresh/frozen plasma (79%), platelets (68%), and red cells (63%). Placental histopathology was abnormal in 82%, with common findings being histiocytic intervillositis, perivillous fibrin deposition, and infarcts or necrosis. Among the 18 singleton pregnancies and 1 twin pregnancy, there were 13 live newborns (65%) and 7 stillbirths (35%). Among liveborn neonates, 5-minute Apgar score was ≤5 in 54%, and among cases with umbilical cord blood gases, pH ≤7.1 was found in 78% and base deficit ≥10 mEq/L in 75%. Positive COVID-19 tests were found in 62% of liveborn infants. CONCLUSION: Clinicians should be alert to the possibility of disseminated intravascular coagulation when a COVID-19 patient complains of decreased fetal movement in the early third trimester. If time allows, we recommend evaluation of coagulation studies and ordering of blood products for massive transfusion protocols before cesarean delivery if fetal tracing is nonreassuring.

Bleeding cervical varices in pregnancy: A case report and review of the literature.

BACKGROUND: Venous varicosities are a relatively common finding during pregnancy. Rarely, varices can arise in the cervix and cause life-threatening maternal hemorrhage. This article offers an example of a patient who was diagnosed with bleeding cervical varices during pregnancy and summarizes the diagnosis and treatment strategies for the 20 other reported cases in the literature. METHODS: A PubMed literature search using the following terms was performed to gather data for the literature review: "bleeding" or "hemorrhage" and "cervical varices" or "cervical varix" or "cervical varicosities" and "pregnancy" or "obstetric" or "maternal." Individual references cited in each article were also evaluated for inclusion in this review. RESULTS: A 50-year-old gravida 7 para 1 presented at 12 4/7 weeks with vaginal bleeding. Endo-vaginal ultrasound showed enhanced color Doppler signal in the endocervical canal. During a speculum exam, she was found to have active bleeding from ruptured cervical varicosities and required blood and fresh frozen plasma transfusion. Hemostasis was achieved with interrupted suture ligation. A McDonald cerclage was subsequently placed. She continued pregnant until delivery via cesarean section at 37 2/7 weeks. To date, there have only been 20 other reported cases of bleeding cervical varices during pregnancy. CONCLUSIONS: This case report and review of the literature highlight the importance of including bleeding cervical varices in the differential diagnosis of maternal hemorrhage and offer a treatment strategy if cervical varicosities are discovered during pregnancy.

Can Fetal Limb Soft Tissue Measurements in the Third Trimester Predict Neonatal Adiposity?

OBJECTIVES: Neonatal adiposity is associated with chronic metabolic sequelae such as diabetes and obesity. Identifying fetuses at risk for excess neonatal body fat may lead to research aimed at limiting nutritional excess in the prenatal period. We sought to determine whether fetal arm and leg soft tissue measurements at 28 weeks' gestation were predictive of neonatal percent body fat METHODS : In this prospective observational cohort study of singleton term pregnancies, we performed sonography at 28 and 36 weeks' gestation, including soft tissue measurements of the fetal arm and thigh (fractional limb volume and cross-sectional area). We estimated the neonatal body composition (percent body fat) using anthropometric measurements and air displacement plethysmography. We estimated Spearman correlations between sonographic findings and percent body fat and performed modeling to predict neonatal percent body fat using maternal characteristics and sonographic findings. RESULTS: Our analysis of 44 women yielded a mean maternal age of 30 years, body mass index of 26 kg/m(2), and birth weight of 3382 g. Mean neonatal percent body fat was 8.1% by skin folds at birth and 12.2% by air displacement plethysmography 2 weeks after birth. Fractional thigh volume measurements at 28 weeks yielded the most accurate model for predicting neonatal percent body fat (R(2) = 0.697; P = .001), outperforming models that used abdominal circumference (R(2)= 0.516) and estimated fetal weight (R(2)= 0.489). CONCLUSIONS: Soft tissue measurements of the fetal thigh at 28 weeks correlated better with neonatal percent body fat than currently used sonographic measurements. After validation in a larger cohort, our models may be useful for prenatal intervention strategies aimed at the prevention of excess fetal fat accretion and, potentially, optimization of long-term metabolic health.

Predictors of glyburide failure in the treatment of gestational diabetes.

OBJECTIVE: Our objective was to identify among women with gestational diabetes mellitus (GDM) the patient characteristics that predict treatment failure with glyburide. METHODS: Historical cohort of 95 GDM women offered glyburide after dietary failure with defined entry criteria. RESULTS: From November 2000 to May 2005, 118 women had 124 pregnancies and were offered glyburide therapy by the 2 codirectors of our Diabetes Clinic. All but 2 women elected glyburide, and 27 pregnancies were excluded due to criteria defined a priori to the study. A cohort of 95 women with 95 pregnancies were included for analysis. Nineteen percent failed glyburide. Significant predictors of failure were maternal age (34 years compared with 29 years, P = .001), earlier diagnosis of GDM (23 weeks compared with 28 weeks, P = .002), higher gravidity (P = .01) and parity (P = .03), and a higher mean fasting blood glucose (112 compared with 100 mg/dL; P = .045) compared with those successfully treated. After adjustment in the multivariable logistic regression analysis, GDM women diagnosed at a gestational age less than 25 weeks were 8.3 times more likely to fail glyburide compared with those diagnosed after 25 weeks. Maternal and fetal outcomes were favorable with a cesarean delivery rate of 25% and macrosomia rate of 7%. CONCLUSION: Glyburide was more likely to fail in women diagnosed earlier in pregnancy, of older age and multiparity, and with higher fasting glucoses, suggesting that earlier glucose intolerance and a reduced capacity to respond to an insulin secretagogue may distinguish this group. The time for glyburide as an alternative treatment has come; however, it should be prescribed after careful consideration of these patient characteristics to minimize the likelihood of failure. LEVEL OF EVIDENCE: II-2.

Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice.

OBJECTIVE: To evaluate the prospective risk of fetal death in singleton, twin, and triplet pregnancies and to compare this risk with fetal and neonatal death rates. METHODS: We analyzed 11,061,599 singleton, 297,622 twin, and 15,375 triplet gestations drawn from the 1995-1998 National Center for Health Statistics linked birth and death files. Prospective risk of fetal death was expressed as a proportion of all fetuses still at risk at a given gestational age and compared with fetal death rate. Fetal death risk and neonatal death rates were represented graphically for singletons, twins, and triplets. RESULTS: The prospective risk of fetal death at 24 weeks was 0.28 per 1000, 0.92 per 1000, and 1.30 per 1000 for singletons, twins, and triplets, respectively. At 40 weeks, the corresponding risk was 0.57 per 1000 and 3.09 per 1000 for singletons and twins, respectively and, at 38 or more weeks, 13.18 per 1000 for triplets. Plots of gestation-specific prospective risk of fetal death and neonatal mortality converged for singletons and twins at term but crossed for triplets at approximately 36 weeks' gestation. CONCLUSION: Prospective risk of fetal death is greater for triplets and twins than for singletons and greater for triplets than for twins during the third trimester. The pattern corroborates with uteroplacental insufficiency as a suspected underlying mechanism. When prospective risk of fetal death exceeds neonatal mortality risk, delivery might be indicated. When this model is used, this data set suggests that it might be reasonable to consider delivery of twins by 39 weeks and triplets by 36 weeks to improve perinatal outcome.