Equitable Representation of Race, Ethnicity, and Ancestry Among Genomic Studies of Preterm Birth: A Systematic Review.

We conducted a systematic review of representation of race, ethnicity, and ancestry among genomic studies of preterm birth. Our data sources included CINHAL, EMBASE, MEDLINE (PubMed), and Scopus. Studies were included if they were human, genomic studies of preterm birth that analyzed greater than 1,000 genes and included race, ethnicity, and/or ancestry information. Two authors independently reviewed all abstracts and full-text manuscripts. Twelve studies were included. Ancestry was reported for 139,189 (93.6%) participants. Race was reported for 4,841 (3.3%) participants and ethnicity was reported for 7,154 (5.0%) participants. Of the 148,644 births represented in this systematic review, over 90% were reported to be of European ancestry, and race and ethnicity were not further described. When examining the smaller subset of individuals described by race alone, 2,444 individuals were identified as Black or African American and 1,853 were identified as White. Race, ethnicity, and ancestry were not reported in a uniform manner, which makes ascertainment of the genetic contribution to population differences in preterm birth inequities impossible. When reported as race, ethnicity and ancestry, Black or African American populations were under-represented among the studies in this review. Research of the genomics of preterm birth not only requires increased representation of populations that are disproportionately affected, but it also requires standardized reporting of race, ethnicity, and ancestry.

Incidence of small-for-gestational-age infant birthweight following early intertwin fetal growth discordance in dichorionic and monochorionic twin pregnancies.

BACKGROUND: Serial growth scans are routinely recommended for twin pregnancies to identify fetal growth restriction (defined as an estimated fetal weight of <10th percentile), which can result in increased perinatal morbidity and mortality. However, the clinical significance of early intertwin growth discordance in the absence of fetal growth restriction remains unclear. OBJECTIVE: This study aimed to compare the rates of small-for-gestational-age infants among twin pregnancies with intertwin growth discordance in the absence of fetal growth restriction with that among twin pregnancies with concordant, normal growth identified by ultrasound between 24 0/7 and 31 6/7 weeks' gestation. STUDY DESIGN: This was a retrospective cohort study of twin deliveries at a single hospital from 2010 to 2019. Pregnancies without fetal growth restriction were categorized as discordant or concordant using the earliest prenatal growth ultrasound between 24 0/7 and 31 6/7 weeks' gestation. Discordance was defined as an estimated fetal weight difference of ≥18% between twins. Pregnancies with major fetal anomalies, no growth ultrasound between 24 0/7 and 31 6/7 weeks' gestation, or twin-twin transfusion syndrome were excluded. The cohort was stratified by chorionicity. Our primary outcome was small-for-gestational-age defined as <10th percentile per the Fenton growth curve at delivery. Secondary outcomes included gestational age at delivery, mode of delivery, neonatal intensive care unit admission, length of stay, and neonatal complications and placental pathology. RESULTS: Of the 707 twin pregnancies that met the inclusion criteria, 558 (79%) were dichorionic and 149 (21%) were monochorionic. Most pregnancies were concordant on ultrasound between 24 0/7 and 31 6/7 weeks' gestation (dichorionic, 93%; monochorionic, 87%). Regardless of chorionicity, twin pregnancies with discordance at ultrasound, were more likely to have a small-for-gestational-age infant than concordant twin pregnancies (dichorionic: 51% vs 29%; P=.002; monochorionic: 65% vs 24%; P<.001). Furthermore, women with twin pregnancies with discordance were delivered at an earlier gestational age (dichorionic: 36 weeks [interquartile range, 33-36] vs 34 weeks [interquartile range, 34-38]; P<.001; monochorionic: 34 weeks [interquartile range, 32-34] vs 36 weeks [interquartile range, 34-37]; P=.003). Pregnancies with growth discordance were more likely to be delivered by cesarean delivery (dichorionic: 90% vs 72%; P=.01; monochorionic: 65% vs 60%; P=.70), although this was only statistically significant for dichorionic twin pregnancies. Neonates of pregnancies with growth discordance had a higher incidence of respiratory distress syndrome (dichorionic: 54% vs 37%; P=.04; monochorionic: 70% vs 45%; P=.04) and neonatal intensive care unit admission (dichorionic: 71% vs 50%; P=.01; monochorionic: 90% vs 65%; P=.03). Furthermore, dichorionic infants had longer neonatal intensive care unit stays (30 [interquartile range, 18-61] vs 18 [interquartile range, 10-35] days; P=.02). CONCLUSION: Regardless of chorionicity, twin pregnancies with discordance without fetal growth restriction identified on growth ultrasound between 24 0/7 and 31 6/7 weeks' gestation were nearly twice as likely to develop small-for-gestational-age neonates, deliver earlier in gestation, and experience greater neonatal morbidity than twin pregnancies without discordance. Patients with pregnancies complicated by isolated intertwin discordance between 24 0/7 and 31 6/7 weeks' gestation will need counseling regarding adverse perinatal outcomes.

A multidisciplinary telemedicine model for management of coronavirus disease 2019 (COVID-19) in obstetrical patients.

Background: The COVID-19 pandemic caused by the SARS-CoV-2 has increased the demand for inpatient healthcare resources; however, approximately 80% of patients with COVID-19 have a mild clinical presentation and can be managed at home. Objective: This study aimed to describe the feasibility and clinical and process outcomes associated with a multidisciplinary telemedicine surveillance model to triage and manage obstetrical patients with known exposures and symptoms of COVID-19. Study Design: We implemented a multidisciplinary telemedicine surveillance model with obstetrical physicians and nurses to standardize ambulatory care for obstetrical patients with confirmed or suspected COVID-19 based on the symptoms or exposures at an urban academic tertiary care center with multiple hospital-affiliated and community-based practices. All pregnant or postpartum patients with COVID-19 symptoms, exposures, or hospitalization were eligible for inclusion in the program. Patients were assessed by means of regular nursing phone calls and were managed according to illness severity. Patient characteristics and clinical and process outcomes were abstracted from the electronic medical record. Results: A total of 135 patients were enrolled in the multidisciplinary telemedicine model from March 17 to April 19, 2020, of whom 130 were pregnant and 5 were recently postpartum. In this study, 116 of 135 patients (86%) were managed solely in the outpatient setting and did not require an in-person evaluation; 9 patients were ultimately admitted after ambulatory or urgent evaluations, and 10 patients were observed after hospital discharge. Although only 50% of the patients were tested secondary to limitations in ambulatory testing, 1 in 3 of those patients received positive results for SARS-CoV-2 (N=22, 16% of entire cohort). Patients were enrolled in the telemedicine model for a median of 7 days (interquartile range, 4-8) and averaged 1 phone call daily, resulting in 891 nursing calls and 20 physician calls over 1 month. Conclusion: A multidisciplinary telemedicine surveillance model for outpatient management of obstetrical patients with COVID-19 symptoms and exposures is feasible and resulted in rates of ambulatory management similar to those seen in nonpregnant patients. A centralized model for telemedicine surveillance of obstetrical patients with COVID-19 symptoms may preserve inpatient resources and prevent avoidable staff and patient exposures, particularly in centers with multiple ambulatory practice settings.

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

OBJECTIVE: To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. METHODS: This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. RESULTS: There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). CONCLUSIONS: In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Employing a Multi-level Approach to Recruit a Representative Sample of Women with Recent Gestational Diabetes Mellitus into a Randomized Lifestyle Intervention Trial.

OBJECTIVE: The postpartum period is a window of opportunity for diabetes prevention in women with recent gestational diabetes (GDM), but recruitment for clinical trials during this period of life is a major challenge. METHODS: We adapted a social-ecologic model to develop a multi-level recruitment strategy at the macro (high or institutional level), meso (mid or provider level), and micro (individual) levels. Our goal was to recruit 100 women with recent GDM into the Balance after Baby randomized controlled trial over a 17-month period. Participants were asked to attend three in-person study visits at 6 weeks, 6, and 12 months postpartum. They were randomized into a control arm or a web-based intervention arm at the end of the baseline visit at six weeks postpartum. At the end of the recruitment period, we compared population characteristics of our enrolled subjects to the entire population of women with GDM delivering at Brigham and Women's Hospital (BWH). RESULTS: We successfully recruited 107 of 156 (69 %) women assessed for eligibility, with the majority (92) recruited during pregnancy at a mean 30 (SD ± 5) weeks of gestation, and 15 recruited postpartum, at a mean 2 (SD ± 3) weeks postpartum. 78 subjects attended the initial baseline visit, and 75 subjects were randomized into the trial at a mean 7 (SD ± 2) weeks postpartum. The recruited subjects were similar in age and race/ethnicity to the total population of 538 GDM deliveries at BWH over the 17-month recruitment period. CONCLUSIONS: Our multilevel approach allowed us to successfully meet our recruitment goal and recruit a representative sample of women with recent GDM. We believe that our most successful strategies included using a dedicated in-person recruiter, integrating recruitment into clinical flow, allowing for flexibility in recruitment, minimizing barriers to participation, and using an opt-out strategy with providers. Although the majority of women were recruited while pregnant, women recruited in the early postpartum period were more likely to present for the first study visit. Given the increased challenges of recruiting postpartum women with GDM into research studies, we believe our findings will be useful to other investigators seeking to study this population.

Neglected diseases and ethnic minorities in the Western Pacific Region exploring the links.

Ethnic minority groups (EMGs) are often subject to exclusion, marginalization and poverty. These characteristics render them particularly vulnerable to neglected diseases, a diverse group of diseases that comprise bacteria, ecto-parasites, fungi, helminths and viruses. Despite the health policy relevance, only little is known of the epidemiological profile of neglected diseases among EMGs. We reviewed country data from Australia, Cambodia, Lao People's Democratic Republic, Malaysia, the Philippines and Vietnam and found several overlaps between regions with high proportions of EMG population and high prevalence rates of neglected diseases (infections with soil-transmitted helminths, filarial worms, schistosomes, food-borne trematodes and cestodes). While the links are not always clearly evident and it is impossible to establish correlations among highly aggregated data without control variables-such as environmental factors-there appear indeed to be important linkages between EMGs, socio-economic status and prevalence of neglected diseases. Some determinants under consideration are lack of access to health care and general health status, poverty and social marginalization, as well as education and literacy. Further research is needed to deepen the understanding of these linkages and to determine their public health and socio-economic significance. In particular, there is a need for more data from all countries in the Western Pacific Region that is disaggregated below the provincial level. Selected case studies that incorporate other control variables-such as risk factors from the physical environment-might be useful to inform policy makers about the feasibility of prevention and control interventions that are targeted at high-risk EMGs.