Cardiovascular Risk Assessment as a Quality Measure in the Pregnancy and Postpartum Period.

Background: Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. Contributing factors such as lack of recognition and delayed diagnosis of CVD are primarily due to the overlap of signs and symptoms of a normal pregnancy with those of CVD. Objectives: This study aimed to demonstrate the feasibility of introducing CVD risk assessment into clinical practice using the California Maternal Quality Care Collaborative algorithm to detect CVD during pregnancy and postpartum periods. Methods: We implemented the CVD risk assessment algorithm into electronic health records at 3 large hospital networks serving over 14,000 patients at 23 sites. We determined the percentage of pregnant and/or postpartum patients who were screened for CVD risk and the follow-up rate for patients in whom the tool recommended a follow-up assessment. Rates were stratified according to clinical site characteristics. We obtained clinician feedback regarding the feasibility and acceptability of the tool. Results: The rate of patients screened for CVD risk in the 3 hospital networks was 57.1%, 71.5%, and 98.7%. For those with a positive screen, follow-up rates were 65.8%, 72.5%, and 55.9% in the 3 networks. The rates of screening and follow-up varied based on the clinic size and specialty. Clinician-identified barriers were busy clinics, competing priorities, and the type of clinical practice. Conclusions: This innovative population-based approach for universal CVD risk assessment during pregnancy is feasible and may be a helpful strategy to decrease CVD-related maternal morbidity and mortality.

Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn. METHODS: Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS). RESULTS: Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS. CONCLUSIONS: Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.

Pregnancy outcomes and anxiety in nulliparous women.

OBJECTIVE: To examine pregnancy outcomes in women with treated and untreated anxiety in a well-characterized cohort. STUDY DESIGN: Secondary analysis of the NuMoM2b study, a prospective multi-center cohort of nulliparous women. Anxiety was assessed at 6 weeks 0 days - 13 weeks 6 days using the State Trait Anxiety Inventory (STAI-T). Women were divided into three groups: anxiety and medical treatment, anxiety and no medical treatment, and no anxiety (controls). The primary outcome was a composite of preterm birth, small for gestational age infant, placental abruption (clinically diagnosed), and hypertensive disorders of pregnancy. Multivariable logistic regression was used to adjust for potential confounding variables. RESULTS: Among 8293 eligible women, 24% (n = 1983) had anxiety; 311 were treated medically. The composite outcome (preterm birth, small for gestational age infant, placental abruption, hypertensive disorders of pregnancy) occurred more often in women with untreated anxiety than controls (28.6% vs 25.9%, p=.02), with no difference between treated anxiety and controls (27.7% vs 25.9%, p=.49). After adjustment for confounders, including controlling for depression, there were no differences in the primary outcome among groups. Untreated anxiety remained associated with increased odds of neonatal intensive care unit admission. CONCLUSION: Anxiety occurred in almost a quarter of nulliparas. There was no association between treated or untreated anxiety and our primary outcome of adverse pregnancy outcomes after adjustment for confounders. However, neonates born to women with untreated anxiety were at increased risk for NICU admission.

Blood pressure trajectory and category and risk of hypertensive disorders of pregnancy in nulliparous women.

BACKGROUND: Recently updated American College of Cardiology/ American Heart Association (ACC/AHA) guidelines redefine blood pressure categories as stage 1 hypertension (systolic, 130-139 mm Hg or diastolic, 80-89 mm Hg), elevated (systolic, 120-129 mm Hg and diastolic, <80 mm Hg), and normal (<120/<80 mm Hg), but their relevance to an obstetric population is uncertain. OBJECTIVE: We sought to evaluate the risk of gestational hypertension or preeclampsia based on early pregnancy blood pressure category and trajectory. STUDY DESIGN: We utilized data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort, a prospective observational study of nulliparous women with singleton pregnancies conducted at 8 clinical sites between 2010 and 2014. Women included in this analysis had no known history of prepregnancy hypertension (blood pressure, ≥140/90 mm Hg) or diabetes. We compared the frequency of hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, among women based on ACC/AHA blood pressure category at a first-trimester study visit and blood pressure trajectory between study visits in the first and second trimesters. Blood pressure trajectories were categorized based on blood pressure difference between visits 1 and 2 as stable (<5 mm Hg difference), upward (≥5 mm Hg), or downward (≤-5 mm Hg). Associations of blood pressure category and trajectory with preeclampsia and gestational hypertension were assessed via univariate analysis and multinomial logistic regression analysis with covariates identified a priori. RESULTS: A total of 8899 women were included in the analysis. Study visit 1 occurred at a mean gestational age of 11.6 ± 1.5 weeks and study visit 2 at a mean gestational age of 19.0 ± 1.6 weeks. First-trimester blood pressure category was significantly associated with both preeclampsia and gestational hypertension, with increasing blood pressure category associated with a higher risk of all hypertensive disorders of pregnancy. Elevated blood pressure was associated with an adjusted relative risk of 1.54 (95% confidence interval, 1.18-2.02) and stage 1 hypertension was associated with adjusted relative risk of 2.16 (95% confidence interval, 1.31-3.57) of any hypertensive disorder of pregnancy. Stage 1 hypertension was associated with the highest risk of preeclampsia with severe features, with an adjusted relative risk of 2.48 (95% confidence interval, 1.38-8.74). Both systolic and diastolic blood pressure trajectories were also significantly associated with the risk of hypertensive disorders of pregnancy independent of blood pressure category (P < .001). Women with a blood pressure categorized as normal and with an upward systolic trajectory had a 41% increased risk of any hypertensive disorder of pregnancy (adjusted relative risk, 1.41; 95% confidence interval, 1.20-1.65) compared to women with a downward systolic trajectory. CONCLUSION: In nulliparous women, blood pressure category and trajectory in early pregnancy are independently associated with risk of preeclampsia and gestational hypertension. Our study demonstrates that blood pressure categories with lower thresholds than those traditionally used to identify individuals as hypertensive may identify more women at risk for preeclampsia and gestational hypertension.

New Opportunities for Breastfeeding Promotion and Support in WIC: Review of WIC Food Packages, Improving Balance and Choice.

Although breastfeeding (BF) is the recommended way to feed infants, this may be difficult for the low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The 2017 recommended revisions to the WIC food packages provide substantial support to both exclusively and partially BF dyads, remove barriers to partial BF choices within the first 30 days postpartum, and increase flexibility in determining the amount of formula offered to partially breastfed infants. When combined with adequate support and tailored counseling, these changes are intended to make it easier for women served by WIC to choose to breastfeed.

Necrotizing pancreatitis associated with severe preeclampsia.

BACKGROUND: Necrotizing pancreatitis is rare in pregnancy and usually is associated with symptomatic cholelithiasis. We present a case of fatal necrotizing pancreatitis in a patient with severe preeclampsia. CASE: A 25-year old primigravid woman at 35 weeks of gestation presented with decreased fetal movement, pruritus, and malaise. Intrauterine fetal demise was diagnosed in the context of severe thrombocytopenia, hypertension, proteinuria, hemolysis, elevated transaminases, and renal failure. Postpartum, the patient developed metabolic acidosis, hyperglycemia, and hypoxemia followed by cardiopulmonary arrest and death. Autopsy revealed extensive acute pancreatic necrosis, pleural effusions, ascites, and fatty liver without evidence of microthrombi. The cause of death was acute necrotizing pancreatitis resulting from severe preeclampsia. CONCLUSION: Severe preeclampsia may cause widespread end-organ damage and may affect the gastrointestinal system, resulting in fatal necrotizing pancreatitis.

Limitations of the fetal anatomic survey via ultrasound in the obese obstetrical population.

OBJECTIVE: To evaluate limitations of the fetal anatomic survey in obese women. METHODS: Retrospective cohort study of obese gravidas with singleton gestations who had at least one, sonographic fetal evaluation at ≥ 14 weeks between January 2009 and March 2011. The impact of pre-pregnancy body mass index (BMI), placental location, prior cesarean scar and sonographer experience on ability to achieve an adequate ultrasound was evaluated using multilevel modeling. Ability to visualize specific fetal parts by BMI class and gestational age was also evaluated. RESULTS: There were 245 obese women (42% with class III obesity). Senior faculty (>20 years experience) were more likely to achieve adequate visualization (adjusted odds ratio [aOR] 3.27; 95% confidence interval [CI] 1.15-9.25) compared with junior faculty. Among women with BMI > 40.0, odds of inadequate views of the face and spine were 10.0 (95% CI 1.31-76.0) and 5.17 (95% CI 0.65-40.8), when compared with women with a BMI = 30-34.9. Odds for inadequate views of sex (OR 3.83; 95% CI 0.86-17.1) and extremities (OR 4.37; 95% CI 0.99-19.4) were similarly increased with a BMI ≥ 40. The optimal gestational age for a complete anatomic survey was 22-24 weeks (93% completion rate), with an OR of 41.3 (95% CI 7.89-215.8), compared with a survey at 14-16 weeks. CONCLUSIONS: Attending sonographer experience is associated with improved visualization of fetal anatomy among obese gravidas. Face, spine, sex and extremity views are particularly difficult in the highest BMI category.

Magnetic resonance imaging demonstrates long-term changes in brain structure in children born preterm and exposed to chorioamnionitis.

OBJECTIVE: We sought to determine if children born preterm and exposed to chorioamnionitis have differences in brain structure measured at 6-10 years of age using magnetic resonance imaging (MRI). STUDY DESIGN: Structural MRI was performed with 11 preterm children (8.5 ± 1.7 years) with chorioamnionitis and 16 preterm children (8.7 ± 1.4 years) without chorioamnionitis. Cortical surface reconstruction and volumetric segmentation were performed with FreeSurfer image analysis software. Subcortical structures were analyzed using multivariate analysis. RESULTS: Widespread regional differences in cortical thickness were observed. With chorioamnionitis, the frontal and temporal lobes were primarily affected by decreased cortical thickness, and the limbic, parietal, and occipital lobes were primarily affected by increased cortical thickness when compared to the comparison group. Subcortical differences were observed in the hippocampus and lateral ventricle. CONCLUSION: Using MRI, chorioamnionitis is associated with longterm widespread regional effects on brain development in children born prematurely. Our study is limited by its small sample size.

Murine typhus in a pregnant woman.

BACKGROUND: Murine typhus is a flea-borne disease caused by Rickettsia typhi. Although uncommon in most of the United States, it is endemic in Southern California. Most cases are unrecognized given its nonspecific viral symptoms and rare complications. CASE: A pregnant patient presented with complaints of fever and chills. Physical examination was benign. Laboratory abnormalities included elevated transaminases, proteinuria, and thrombocytopenia. The patient gave a history of exposure to cats and opossums in an area endemic for murine typhus. After empiric treatment with azithromycin, her clinical symptoms and laboratory abnormalities promptly improved. Serologies confirmed acute infection with R. typhi. CONCLUSION: Although the signs and symptoms of murine typhus can mimic other pregnancy-related complications, a high index of suspicion in endemic areas can lead to the correct diagnosis and prompt treatment.

Synchronous autotransfusion during cesarean hysterectomy.

Placenta accreta is associated with major morbidities including massive hemorrhage. We report a cesarean hysterectomy for placenta accreta with synchronous autotransfusion using a standard cardiopulmonary bypass machine. This technique requires complete intraoperative heparinization yet has the advantage of autotransfusion of autologous clotting factors and platelets in addition to red blood cells.

The use of ultrasound to detect small-for-gestational-age infants in patients with elevated human chorionic gonadotropin on maternal serum screening.

We evaluated serial sonography for the antenatal detection of small-for-gestational-age (SGA) infants in pregnancies with elevated human chorionic gonadotropin (hCG) levels on midtrimester triple-marker screen. A retrospective cohort study was performed at Saddleback Memorial Medical Center where serial ultrasounds from 26 weeks to delivery are generally recommended for patients with hCG levels >2.0 Multiple of the Median (MoM). From 1999 to 2007, 659 subjects were identified for analysis. The incidence of intrauterine growth restriction (IUGR) and SGA were 5.2% and 7.3%, respectively. Antenatal ultrasound identified 31.3% of SGA infants. Compared with estimated fetal weight (EFW) <10th percentile alone, abdominal circumference (AC) <10th percentile improved the detection of SGA from 31.3% (95% confidence interval [CI], 18.7 to 46.3) to 35.4% (95% CI, 22.2 to 50.5). Using either EFW or AC further increased the sensitivity to 45.8% (95% CI, 31.4 to 60.8). The sensitivity for the detection of SGA was 100% when an EFW cutoff of 75% was used. Ultrasound can be used to detect SGA infants in patients with elevated hCG levels on midtrimester serum screening. A sonographic estimated fetal weight > or = 75th percentile appears to be a safe cutoff to rule out all fetuses at risk for SGA.

Successful pregnancy after aortic stent-graft in a patient with middle aortic syndrome.

A 32-year-old multigravida woman had 3 pregnancies complicated by hypertensive disease, requiring iatrogenic preterm delivery. Middle aortic syndrome was diagnosed when uncontrolled hypertension persisted postpartum, and was treated with aortic stent-graft placement. A pregnancy subsequent to the endovascular repair was uneventful, culminating in repeated cesarean section at term.

Goodpasture's disease in pregnancy: case report and review of the literature.

Goodpasture's disease is a rare phenomenon in pregnancy. It is characterized by antiglomerular basement membrane antibodies resulting in glomerulonephritis and pulmonary hemorrhage. We present a case of a patient with a preconceptional diagnosis of Goodpasture's disease and chronic hypertension. Multidisciplinary antepartum care included close monitoring and treatment of blood pressure, renal function, and fetal status. Our patient ultimately was delivered at 33 weeks for superimposed preeclampsia but recovered without incident. Her infant also did well after 36 days in the neonatal intensive care unit, requiring only supportive care. This case demonstrates that successful pregnancy outcomes can be achieved in patients with Goodpasture's disease with a careful multidisciplinary approach involving maternal fetal medicine and nephrology.