TAVR Beyond Fetal Viability: An Alternative to Preterm Delivery in Symptomatic Severe Aortic Stenosis.

A patient with structural valve degeneration of an aortic bioprosthesis with stenosis stage 3 underwent valve-in-valve transcatheter aortic valve replacement (TAVR) at 29 weeks with improvement. This is the first reported TAVR in the third trimester. TAVR may be an alternative to preterm delivery in cases of symptomatic aortic stenosis.

Neonatal outcomes and rationale for timing of birth in perinatal diabetes: a retrospective cohort study.

BACKGROUND: The American College of Obstetricians and Gynecologists recommends delivery in the 39th week of pregnancy for patients with pregestational and medication-controlled gestational diabetes with consideration for earlier delivery among those with poor glucose control. OBJECTIVE: We sought to evaluate the impact of birth before 39 weeks' gestation exclusively for diabetes-related indications on neonatal outcomes and clinician rationale for these recommendations. STUDY DESIGN: This was a retrospective cohort study of all singleton, nonanomalous pregnancies complicated by diabetes. Patients were identified through an obstetrical database containing information of 90,185 births from 2011 to 2021. Patients who delivered in a given week of gestation exclusively for diabetes-related indications were compared with ongoing pregnancies. Recommended births for other obstetrical indications were excluded from the diabetes-related indications cohorts. The primary outcome was neonatal intensive care unit admission. Secondary outcomes included neonatal intensive care unit length of stay, stillbirth, neonatal death, hypoglycemia, respiratory distress syndrome, and shoulder dystocia. For all births before 39 weeks' gestation, the electronic medical records were reviewed to confirm the rationale for the intervention for a diabetes-indicated condition. RESULTS: From the 90,185 recorded births that occurred in 2011 to 2021, 4750 patients with diabetes were identified. Of those, 30.5% (n=1449) had a recommended birth for a diabetes-related indications with 2.2% of those (n=32) occurring at 36 weeks' gestation, 7.9% (n=114) at 37 weeks' gestation, 9.7% (n=141) at 38 weeks' gestation, and 63.0% (n=913) at 39 weeks' gestation. Births that occurred at 36 and 37 weeks' gestation exclusively for diabetes-related indications had higher rates of neonatal intensive care unit admission than the respective ongoing pregnancies (62.5% vs 8.7%; P<.001 and 25.4% vs 7.2%; P<.001). There was no difference in neonatal intensive care unit admission for births at 38 or 39 weeks' gestation when compared with ongoing pregnancy. For neonates born at 36 and 37 weeks' gestation in comparison with ongoing pregnancies, the median neonatal intensive care unit length of stay was 11.0 vs 2.8 days, (P<.001) and 4.4 vs 2.6 days (P=.026), respectively. There were significantly increased rates of neonatal hypoglycemia and respiratory distress syndrome among births that occurred at 36, 37, and 38 weeks' gestation when compared with ongoing pregnancies. There were no differences in the rate of stillbirth in this cohort. Primary factors cited for early birth were poor glycemic control (71.4%), recommendation by a maternal-fetal medicine specialist (38.7%), and suspected fetal macrosomia (27.9%). Overall, 46.7%, 32.8%, and 20.6% of patients had 1, 2, or ≥3 indications, respectively, listed as rationale for early birth. Overall, few objective measures were used to recommend birth before 39 weeks' gestation owing to diabetes. CONCLUSION: In pregnancies complicated by diabetes, early birth exclusively for diabetes-related indications was associated with increased neonatal intensive care unit admission and length of stay and with neonatal morbidity. Little objective data are documented by clinicians to support their recommendations for early birth associated with diabetes. Additional clinical guidelines are needed to define suboptimal glucose control necessitating birth before 39 weeks' gestation.

Postpartum remote home blood pressure monitoring: the new frontier.

There has been an alarming and substantial increase in hypertensive disorders of pregnancy, which are a significant driver of maternal morbidity and mortality. The postpartum period is an especially high-risk time, with >50% of pregnancy-related deaths and significant morbidity occurring during this period. The American College of Obstetricians and Gynecologists suggests inpatient or equivalent monitoring of blood pressures in patients with hypertensive disorders of pregnancy for the immediate 72 hours postpartum and again within 7 to 10 days postpartum. Hypertensive disorders of pregnancy significantly contribute to healthcare costs through increasing admission lengths, rates of readmissions, the number of medications given, and laboratory studies ordered, and through the immeasurable impact on the patient and society. Telemedicine is an essential option for patients with barriers to accessing care, particularly those in remote areas with difficulty accessing subspecialty care, transportation, childcare, or job security. The implementation of these programs also has potential to mitigate racial inequities given that patients of color are disproportionately affected by the morbidity and mortality of hypertensive disorders of pregnancy. Remote blood pressure monitoring programs are generally acceptable, with high levels of satisfaction in the obstetrical population without posing an undue burden of care. Studies have reported different, but encouraging, measures of feasibility, including rates of recruitment, consent, engagement, adherence, and retention in their programs. Considering these factors, the widespread adoption of postpartum blood pressure monitoring programs holds promise to improve the identification and care of this at-risk population. These immediate clinical effects are significant and can reduce short-term hypertension-related morbidity and even mortality, with the potential for long-term benefit with culturally competent, well-reimbursed, and widespread use of these programs. This clinical opinion aims to show that remote monitoring of postpartum hypertensive disorders of pregnancy is a reliable and effective alternative to current follow-up care models that achieves improved blood pressure control and diminishes racial disparities in care while simultaneously being acceptable to providers and patients and cost-saving to hospital systems.

Defining the risk profile of women with stage 1 hypertension: a time to event analysis.

BACKGROUND: Chronic hypertension complicates up to 5% of pregnancies and is increasing in prevalence. Women with hypertension have increased risks of serious maternal morbidity and mortality in pregnancy, including the development of preeclampsia. In 2017, new guidelines reclassified blood pressure into the following 4 categories: normal (<120/<80 mm Hg), elevated (120-129/<80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), and stage 2 hypertension (>140/>90 mm Hg). This new classification doubles the number of reproductive-aged women with hypertension. Furthermore, studies have demonstrated that women entering pregnancy with stage 1 hypertension have an increased risk of developing hypertensive disorders of pregnancy compared with their normotensive counterparts, but the time course to the development of hypertensive disorders of pregnancy in these women remains uncertain. OBJECTIVE: We sought to evaluate the risk of developing a hypertensive disorder of pregnancy and the time to the development of these disorders in women with stage 1 hypertension vs both normotensive women and those with stage 2 hypertension. STUDY DESIGN: This was a retrospective cohort study of all patients from a single tertiary care center with singleton gestations from 2014 to 2016. Patients at prenatal visits before 20 weeks of gestation were classified into 3 blood pressure groups: normotensive (<130/80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), or stage 2 hypertension (≥140/90 or a history of chronic hypertension). The primary outcome, time to the development of a hypertensive disorder of pregnancy, was compared among groups using Kaplan-Meier curves and the log-rank test. Cox proportional-hazards models were used to adjust for age, race and ethnicity, pregestational diabetes mellitus, and body mass index. In addition, multiple secondary obstetrical, maternal, and neonatal outcomes were assessed. RESULTS: Of the 3000 women in our cohort, 2370 (79.0%) were categorized in the normotensive group, 315 (10.5%) were categorized in the stage 1 hypertension group, and 315 (10.5%) were categorized in the stage 2 hypertension group. The gestational age at diagnosis was significantly earlier in gestation among blood pressure groups (normotensive [38.7 (37.0-39.7)] vs stage 1 hypertension [38.0 (36.4-39.4)] vs stage 2 hypertension [36.4 (33.7-37.8)]; P<.001). When the analysis was restricted to only those patients diagnosed with preeclampsia with severe features, the same findings were observed. Women with stage 1 hypertension exhibited a 2-fold increased risk of developing hypertensive disorders of pregnancy compared with normotensive women. Compared with women with stage 2 hypertension, women with stage 1 hypertension exhibited a milder phenotype of hypertensive disorders of pregnancy and exhibited significantly less risk of maternal and neonatal morbidities. CONCLUSION: Women with stage 1 hypertension are at increased risk of developing hypertensive disorders of pregnancy at earlier gestational ages compared with normotensive women; however, their development of a hypertensive disorder of pregnancy is skewed toward milder diseases compared with women with stage 2 hypertension. These new insights into the graded risk profile of obstetrical hypertensive diseases associated with new blood pressure categories can better inform our antepartum counseling and monitoring and surveillance plans near term and in the postpartum period.

Management of Fontan circulation in pregnancy: a multidisciplinary approach to care.

The Fontan operation was first performed in 1968 and is a palliative procedure for children born with single ventricle forms of congenital heart disease. Today, 70,000 patients worldwide have Fontan circulation today, half of them women, and with an expected 30-year survival of >80%, this population is expected to double in the next 20 years. The Fontan operation surgically redirects systemic venous blood return directly to the pulmonary circulation, bypassing the single ventricle. This abnormal anatomy results in significant challenges for the cardiovascular system and is marked by a sustained, abnormally elevated systemic venous pressure combined with decreased cardiac output. As more women with Fontan circulation reach childbearing age, understanding the unique risks of pregnancy to the mother and fetus and how to best provide clinical care for these women during pregnancy is imperative. However, there are limited clinical data to guide counseling and management in this population. This expert review offers an analysis of the literature about Fontan circulation during pregnancy and describes our center's current multidisciplinary approach to care for these women in the preconception, antepartum, intrapartum, and postpartum periods.

A new definition of gestational hypertension? New-onset blood pressures of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation.

BACKGROUND: Diagnostic criteria for hypertensive disorders in pregnancy have historically been based on the American Heart Association and American College of Cardiology's definition of hypertension, previously defined as a blood pressure of ≥140/90 mm Hg. With the recent redefinition of hypertension, blood pressures of 130 to 139/80 to 89 mm Hg are now considered abnormal. OBJECTIVE: In this study, we aimed to test whether the new-onset blood pressure elevations of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation in previously normotensive women are associated with increased risk for adverse pregnancy outcomes, specifically the development of hypertensive disorders in pregnancy. STUDY DESIGN: We performed a retrospective cohort study at a single tertiary care center of all women who delivered singleton gestations after 20 weeks of gestation from January 01, 2014, to June 08, 2016. Normotensive patients were defined as having maximum blood pressure of <130/80 mm Hg before 20 weeks of gestation and no previous diagnosis of chronic hypertension. Patients who remained normotensive for the remainder of pregnancy were then compared with patients who developed new-onset blood pressure elevations of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation before delivery admission. The primary outcome was the development of a hypertensive disorder in pregnancy at hospital admission or during delivery. Clinical outcomes were assessed using χ2 test and multivariable logistic regression. RESULTS: Of the 2090 normotensive women from our cohort who were analyzed, 1318 (63.0%) remained normotensive for their entire antenatal course before delivery admission and 772 (37.0%) had new-onset blood pressure elevations between 130 and 139/80 and 89 mm Hg. Women with new-onset blood pressure elevations between 130 and 139/80 and 89 mm Hg after 20 weeks of gestation have a significantly increased risk for developing a hypertensive disorder in pregnancy at admission or during delivery (adjusted relative risk, 2.41; 95% confidence interval, 2.02-2.85) including an almost 3-fold increased risk for preeclampsia with severe features, even after adjusting for confounders. There were no differences in other secondary obstetrical outcomes. CONCLUSION: Normotensive women with new-onset blood pressures elevations between 130 and 139/80 and 89 mm Hg after 20 weeks of gestation are more likely to experience hypertensive disorders in pregnancy and preeclampsia with severe features at or during their delivery hospitalization. These more modest blood pressure elevations may be an early indicator of disease and call into question our current blood pressure threshold for diagnosis of hypertensive disorders in pregnancy.

Intravenous compared with oral iron for the treatment of iron-deficiency anemia in pregnancy: a systematic review and meta-analysis.

OBJECTIVE: To assess the effect of intravenous versus oral iron on hematologic indices and clinical outcomes for iron-deficiency anemia (IDA) in pregnancy. STUDY DESIGN: Searches in Ovid Medline, Embase, SCOPUS, Cochrane Database, and ClinicalTrials.gov identified randomized-controlled trials comparing intravenous to oral iron for treating IDA in pregnancy. Primary outcomes were maternal hematologic indices at delivery. Secondary outcomes were blood transfusion, cesarean delivery, neonatal outcomes, and medication reactions. RESULTS: Of 15,637 studies, 20 randomized trials met inclusion criteria and were analyzed. Mean hemoglobin at delivery (9 studies: WMD 0.66 g/dL (95% confidence Interval 0.31 -1.02 g/dL)) was significantly higher after intravenous iron therapy. Intravenous iron was associated with higher birthweight (8 studies: WMD 58.25 g (95% CI: 5.57-110.94 g)) but no significant differences in blood transfusion, cesarean delivery, or neonatal hemoglobin. There were fewer medication reactions with intravenous iron (21 studies: RR 0.34% (95% CI: 0.20-0.57)). CONCLUSION: Intravenous iron therapy is associated with higher maternal hemoglobin at delivery with no difference in blood transfusion and fewer mild medication reactions.

Growth restriction: identifying fetuses at risk.

PURPOSE: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10-20th%, and compare outcomes using umbilical artery Doppler (UAD). MATERIALS AND METHODS: Retrospective, cohort evaluating ultrasound (US) EFW 10-20th%, between 2002 and 2012. Cases were identified with EFW % 10-20. Controls, EFW >20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes. RESULTS: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10-20th% (GA 33.6 ± 3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2-68.7], p < .01), small for gestational age (SGA) (OR 9.2 [6.9-12.3], p < .01), neonatal intensive care unit (NICU) admissions (OR 2.4 [1.6-3.6], p < .01), and composite perinatal morbidity (OR 7.8 [6.0-10.1], p < .01) on adjusted analyses. Abnormal UAD in cases had greater rates of 5 min Apgar <7, NICU admission and composite morbidity (p < .05). CONCLUSIONS: Pregnancies with EFW 10-20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.

Quality Improvement and Patient Safety on Labor and Delivery.

There has been an emphasis on redesigning our health care system to eliminate medical errors and create a culture of safety. The American College of Obstetrics and Gynecologists defines a culture of safety as an environment in which all care providers are empowered to identify errors, near misses, risky behaviors and broader systems issues while engaging in active collaboration to improve and resolve processes and system failures. This article reviews key components that promote a culture of safety and help to implement safer, more effective, evidence-based quality care on labor and delivery units.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels.

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.

Acidemia in neonates with a 5-minute Apgar score of 7 or greater - What are the outcomes?

BACKGROUND: The Apgar score is universally used for fetal assessment at the time of birth, whereas, the collection of fetal cord blood gases is performed commonly in high-risk situations or in the setting of Apgar scores of <7, which is a less standardized approach. It has been well-established that neonatal acidemia at the time of delivery can result in significant neonatal morbidity and death. Because of this association, knowledge of the fetal acid-base status and detection of acidemia at the time of delivery can serve as a sensitive and useful component in the assessment of a neonate's risk. Umbilical cord blood gas analysis is an accurate and validated tool for the assessment of neonatal acidemia at the time of delivery. Because the collection of fetal cord blood gases is not a standardized practice, it is possible that, with such a varied approach, some cases of neonatal acidemia are not detected, particularly in the setting of reassuring Apgar scores. OBJECTIVE: In a setting of universally obtained cord blood gases, we sought to identify the rates of acidemia and associated factors in neonates with 5-minute Apgar scores of ≥7. STUDY DESIGN: This retrospective cohort study identified all term, singleton, nonanomolous neonates with 5-minute Apgar scores of ≥7. The incidence of umbilical artery pH ≤7.0 or ≤7.1 and base excess ≤-12 mmol/L or ≤-10 mmol/L were examined overall and in association with obstetric complications and adverse neonatal outcomes. Chi-squared tests were used to compare proportions, and multivariable logistic regression was used to control for potential confounders. RESULTS: In this cohort, the incidence of an umbilical artery pH of ≤7.0 was 0.5%, of a pH ≤7.1 was 3.4%, of a base excess ≤-12 mmol/L was 1.4%, and of ≤-10 mmol/L was 4.0%. Rates of neonatal acidemia were greater in the setting of meconium (4.3% vs 3.2%; P<.001), placental abruption (13.2% vs 3.4%; P<.001), and cesarean deliveries (5.8% vs 2.8%; P<.001), despite normal 5-minute Apgar scores. Additionally, umbilical artery pH ≤7.0 was associated with an increased risk of respiratory distress syndrome (adjusted odds ratio, 6.5; 95% confidence interval, 2.9-14.3) and neonatal intensive care unit admission (adjusted odds ratio, 10.8; 95% confidence interval, 6.8-17.4). Base excess of ≤-12 mmol/L was also associated with an increased risk of neonatal sepsis (adjusted odds ratio, 4.7; 95% confidence interval, 1.9-12.1). Finally, when examined together, neonates with both a pH of ≤7.0 and base excess of ≤-12 mmol/L continued to demonstrate an increased risk of neonatal intensive care unit admission and respiratory distress syndrome, with adjusted odds ratios of 9.6 and 6.0, respectively. This risk persisted in neonates with a pH of ≤7.1 and base excess of ≤-10 mmol/L as well, with adjusted odds ratios of 4.5 and 1.1, respectively. CONCLUSION: Because neonates with reassuring Apgar scores have a residual risk of neonatal acidemia that is associated with higher rates of adverse outcomes, the potential utility of obtaining universal cord blood gases should be further investigated.

Vaginal birth after cesarean: an effective method to reduce cesarean.

Cesarean deliveries represent almost one third of US births. Given that repeat cesarean is the most common single indication for cesarean, trial of labor after cesarean (TOLAC) with subsequent vaginal birth after cesarean (VBAC) is an important mechanism to reduce the overall cesarean rate. The 2010 National Institutes of Health Conference found that one of the biggest barriers to VBAC is the lack of patient access to TOLAC. Many women who currently deliver by repeat cesarean would be candidates for a TOLAC. This manuscript will summarize the evidence on VBAC to help clinicians identify candidates, provide evidence-based counseling, and guide management of TOLAC.