Sonographic Predictors of Antepartum Bleeding in Placenta Previa.

OBJECTIVE: To evaluate the association between sonographic features of placenta previa and vaginal bleeding (VB). STUDY DESIGN: Retrospective cohort study of women with placenta previa identified on ultrasound between 160/7 and 276/7 weeks gestation. Placental distance past the cervical os (DPO), placental thickness, edge angle, and cervical length (CL) were measured. The primary outcome was any VB and the secondary outcome was VB requiring delivery. Median values of the sonographic features were compared for each of the outcomes using the Mann-Whitney U test. Receiver operating characteristic curves were used to compare the predictive value of sonographic variables markers and to determine optimal cut points for each measurement. Logistic regression was used to estimate the association between each measure and the outcomes while controlling for confounders. RESULTS: Of 149 women with placenta previa, 37% had VB and 15% had VB requiring delivery. Women with VB requiring delivery had significantly more episodes of VB than those who did not require delivery for VB (1.5, interquartile range [IQR] [1-3] vs 1.0 [1-5]; p = 0.001). In univariate analysis, women with VB had decreased CL (3.9 vs. 4.2 cm; p < 0.01) compared with those without. Women with VB requiring delivery had increased DPO (2.6 cm IQR [1.7-3.3] vs. 1.5 cm [1.1-2.4], p = 0.01) compared with those without. After adjusting for confounders, only CL < 4 cm remained independently associated with increased risk of VB (adjusted odds ratio: 2.27, 95% confidence interval [1.12-4.58], p = 0.01). None of the measures were predictive of either outcome (area under the curve < 0.65). CONCLUSION: Decreased CL may be associated with risk of VB in placenta previa. KEY POINTS: · Placenta previa is associated with VB.. · Sonographic markers of placenta previa are associated with VB.. · CL is associated with VB in placenta previa, whereas placental DPO is associated with higher rates of bleeding leading to delivery..

A Prediction Model for Severe Maternal Morbidity and Mortality After Delivery Hospitalization.

OBJECTIVE: To develop a risk stratification model for severe maternal morbidity (SMM) or mortality after the delivery hospitalization based on information available at the time of hospital discharge. METHODS: This population-based cohort study included all pregnancies among Ohio residents with Medicaid insurance from 2012 to 2017. Pregnant individuals were identified using linked live birth and fetal death records and Medicaid claims data. Inclusion was restricted to those with continuous postpartum Medicaid enrollment and delivery at 20 or more weeks of gestation. The primary outcome of the study was SMM or mortality after the delivery hospitalization and was assessed up to 42 days postpartum and up to 1 year postpartum separately. Variables considered for the model included patient-, obstetric health care professional-, and system-level data available in vital records or Medicaid claims data. Parsimonious models were created with logistic regression and were internally validated. Receiver operating characteristic curves were used to evaluate model performance, and model calibration was assessed. RESULTS: There were 343,842 pregnant individuals who met inclusion criteria with continuous Medicaid enrollment through 42 days postpartum and 287,513 with continuous enrollment through 1 year. After delivery hospitalization discharge, the incidence of SMM or mortality was 140.5 per 10,000 pregnancies through 42 days of delivery and 330.7 per 10,000 pregnancies through 1 year postpartum. The final model predicting SMM or mortality through 42 days postpartum included maternal prepregnancy body mass index, age, gestational age at delivery, mode of delivery, chorioamnionitis, and maternal diagnosis of cardiac disease, preeclampsia or gestational hypertension, or a mental health condition. Similar variables were included in the model predicting SMM or mortality through 365 days with chronic hypertension, pregestational diabetes, and illicit substance use added and chorioamnionitis removed. Both models demonstrated moderate prediction (area under the curve [AUC] 0.77, 95% CI 0.76-0.78 for 42-day model; AUC 0.72, 95% CI 0.71-0.73 for the 1-year model) and good calibration. CONCLUSION: A prediction model for SMM or mortality up to 1 year postpartum was created and internally validated with information available to health care professionals at the time of hospital discharge. The utility of this model for patient counseling and strategies to optimize postpartum care for high-risk individuals will require further evaluation.

Using simulation to train clinical providers in the effective use of telehealth.

With the onset of the COVID-19 pandemic, telehealth became a widely used method to provide patient care. Providers had to quickly learn how to adapt traditional clinical care to the virtual environment. The existing literature focuses on the technological aspects of telehealth with only a few publications addressing optimization of communication, with even fewer looking at the use of simulation to fill the knowledge gap in this area. Simulation training is one such avenue that can be used to practice virtual encounters. This review outlines how to effectively use simulation as an educational method to teach clinical skills needed for effective telehealth communication. The experiential nature of simulation provides learners with an opportunity to adapt their clinical skills to a telehealth encounter, and an opportunity to practice challenges unique to a telehealth environment, such as patient privacy, patient safety, technology disruption, and performance of an examination virtually. The goal of this review is to discuss how simulation may be used to train providers for best practices in telehealth.

Characterization of Patients with Frequent Utilization of the Obstetric Triage Unit: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to identify characteristics of patients with frequent obstetric triage visits ("superusers") compared to those with fewer visits and to evaluate the association of frequent obstetric triage visits with preterm birth and cesarean delivery. STUDY DESIGN: This retrospective cohort included patients presenting to the obstetric triage unit at a tertiary care center from March through April 2014. Superusers were defined as individuals having four or more triage visits. Participant characteristics, including demographic, clinical, visit acuity, and health care characteristics of superusers and nonsuperusers, were summarized and compared. In the subset of patients where data were available regarding prenatal care, prenatal visit patterns were analyzed and compared between the two groups. The outcomes of preterm birth and cesarean were compared between groups using modified Poisson regression to control for confounding. RESULTS: Of the 656 patients evaluated in the obstetric triage unit during the study period, 648 patients met the inclusion criteria. Factors associated with frequent triage use included race/ethnicity, multiparity, insurance status, high-risk pregnancy, and a prior preterm birth. Superusers were more likely to present at an earlier gestational age and had a higher proportion of visits for hypertensive disease. Patient acuity scores were not different between the groups. In the subset of patients receiving prenatal care at the institution, prenatal visit patterns were similar. The risk of preterm birth (adjusted risk ratio [aRR]: 1.06; 95% confidence interval [CI]: 0.66-1.70) did not differ between groups; however, the risk of a cesarean delivery was increased in superusers (aRR: 1.39; 95% CI: 1.01-1.92) when compared to nonsuperusers. CONCLUSION: Superusers, compared to nonsuperusers, have distinct clinical and demographic characteristics and are more likely to be seen in the triage unit at earlier gestational ages. Superusers tended to have a higher proportion of visits for hypertensive disease and had an increased risk of cesarean delivery. KEY POINTS: · Patients with frequent triage visits did not have an increased risk of preterm birth.. · Patients with frequent triage visits were more likely to undergo cesarean delivery.. · Acuity scales were similar for patients with frequent visits compared to those with few visits..

Association of Prepregnancy Body Mass Index With Risk of Severe Maternal Morbidity and Mortality Among Medicaid Beneficiaries.

Importance: The association between body mass index (BMI, which is calculated as weight in kilograms divided by height in meters squared) and severe maternal morbidity (SMM) and/or mortality is uncertain, judging from the current evidence. Objective: To examine the association between prepregnancy BMI and SMM and/or mortality through 1 year post partum and to identify both the direct and indirect implications of maternal obesity for SMM and/or mortality by examining hypertensive disorders and pregestational diabetes as potential mediators. Design, Setting, and Participants: This population-based cohort study was conducted from March to October 2021 using the vital records and linked Medicaid claims data in the state of Ohio from January 1, 2012, through December 31, 2017. The cohort comprised pregnant Medicaid beneficiaries who delivered at 20 weeks' gestation or later and had prepregnancy BMI information. Exposures: The primary exposure was maternal prepregnancy BMI, which was categorized as follows: underweight (<18.5), healthy weight (18.5-24.9), overweight (25.0-29.9), class 1 obesity (30.0-34.9), class 2 obesity (35.0-39.9), and class 3 obesity (≥40.0). Main Outcomes and Measures: The primary outcome was a composite of SMM (defined using Centers for Disease Control and Prevention criteria) and/or maternal mortality between 20 weeks' gestation and 1 year post partum. Additional periods were assessed, including 20 weeks' gestation through delivery hospitalization and 20 weeks' gestation through 42 days post partum. Generalized estimating equation models were used to estimate adjusted relative risks (aRRs) for the primary outcome according to BMI category. Maternal hypertensive diseases and pregestational diabetes were assessed as potential meditators. Results: In a cohort of 347 497 pregnancies among 276 691 Medicaid beneficiaries (median [IQR] maternal age at delivery, 25 [21-29] years; 210 470 non-Hispanic White individuals [60.6%]), the prevalence of maternal obesity was 30.5% (n = 106 031). Composite SMM and/or mortality outcome occurred in 5.3% of pregnancies (n = 18 398). Overweight (aRR, 1.07; 95% CI, 1.03-1.11) and obesity (class 1: aRR, 1.19 [95% CI, 1.14-1.24]; class 2: aRR, 1.37 [95% CI, 1.30-1.44]; class 3: aRR, 1.71 [95% CI, 1.63-1.80]) were associated with an elevated risk of SMM and/or mortality during pregnancy to 1 year post partum compared with healthy BMI. Similar findings were observed when the follow-up period was shortened to 42 days post partum or the delivery hospitalization. Hypertension mediated 65.1% (95% CI, 64.6%-65.6%) of the association between obesity and the primary outcome. Conclusions and Relevance: Results of this study showed that maternal prepregnancy obesity was associated with an elevated risk of SMM and/or mortality. Hypertensive disorders appeared to mediate this association, suggesting that improved prevention and management of hypertensive disorders in pregnancy may reduce morbidity and mortality in individuals with obesity.

Mother-Infant Dyad program in primary care: evidence-based postpartum care following gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT. OBJECTIVE: To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening. STUDY DESIGN: All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants' outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4-12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses. RESULTS: A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (n = 62) had a mean age of 30.75 years, were 43% Non-Hispanic White and 30% Non-Hispanic Black. Women who participated in the program were more likely to receive T2DM screenings than women who did not participate (87 vs. 79%, p<.001) and complete postpartum visits (95 vs. 58%, respectively; p<.001). Additionally, a higher rate of new prediabetes diagnoses was observed (12 vs. 6%, p < .001). CONCLUSION: The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Obstetric History and Risk of Short Cervix in Women with a Prior Preterm Birth.

OBJECTIVE: We aimed to assess the relationship between obstetric history and incidence of short cervical length (CL) at <24 weeks gestational age (GA) in women with a prior spontaneous preterm birth (PTB). STUDY DESIGN: Women with a singleton gestation and a history of spontaneous PTB on progesterone who received prenatal care at a single center from 2011 to 2016 were included. Those who did not undergo screening or had a history-indicated cerclage were excluded. The associations between short CL (<25 mm) before 24 weeks and obstetrical factors including: number of prior PTBs, history of term birth, and GA of earliest spontaneous PTB were estimated through modified Poisson regression, adjusting for confounding factors. Multiple pregnancies for the same woman were accounted for through robust sandwich standard error estimation. RESULTS: Among 773 pregnancies, 29% (n = 224) had a CL <25 mm before 24 weeks. The number of prior PTBs was not associated with short CL, but a prior full-term delivery conferred a lower risk of short CL (absolute risk reduction or aRR 0.79, 95% CI 0.63-1.00). Earliest GA of prior spontaneous PTB was associated with short CL. The strongest association was observed in women with a prior PTB at 160/7 to 236/7weeks (aRR 1.98, 95% CI: 1.46-2.70), compared with those with deliveries at 340/7 to 366/7 weeks. Yet, even women whose earliest PTB was 340/7 to 366/7 weeks remained at risk for a short CL, as 21% had a CL <25 mm. The number of prior PTBs did not modify the effect of GA of the earliest prior PTB (interaction test: p = 0.70). CONCLUSION: GA of earliest spontaneous PTB, but not the number of prior PTBs, is associated with short CL. Nevertheless, women with a history of later PTBs remain at sufficiently high risk of having a short CL at <24 weeks gestation that we cannot recommend modifications to existing CL screening guidelines in this group of women. KEY POINTS: · Prior 16 to 236/7 weeks birth is a key risk factor for CL <25 mm.. · One in five women with prior late PTB had a short CL.. · Number of PTBs is a less important risk factor..

Intrahepatic cholestasis of pregnancy: risk factors for severe disease.

INTRODUCTION: Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-associated hepatic disorder characterized by pruritus in the setting of elevated serum bile acids (BA). Risk factors for the disease include preexisting hepatobiliary disease, personal or family history of ICP, and advanced maternal age. Recent data suggests that patients with severe ICP (BA ≥100 µmol/L) have a higher risk of adverse pregnancy outcomes including stillbirth. MATERIAL AND METHODS: This was a retrospective cohort study of patients diagnosed with ICP between 2012 and 2019 at a tertiary referral center. ICP was defined as symptomatic pruritus combined with serum BA >10 µmol/L. Maternal characteristics and outcomes were abstracted from electronic medical records. Baseline characteristics were compared between patients with mild (BA <40 µmol/L), moderate (BA 40-99 µmol/L) and severe (BA ≥100 µmol/L) ICP. Obstetrics and neonatal outcomes for patients in each category were then analyzed. Shapiro-Wilk test was used to test for normality for continuous variables, and ANOVA, Kruskal-Wallis, Chi-squared or Fisher's exact tests were used as appropriate. A p-value <.05 was considered statistically significant. RESULTS: 438 patients were included in the analysis. Individuals with pregestational diabetes (p < .01), history of ICP (p < .01), prior cholecystectomy (p < .01), and tobacco use (p < .05) were more likely to have severe disease. When compared to individuals with moderate and mild disease, individuals with severe disease were more likely to be diagnosed earlier (29w1d vs 34w1d vs 34w1d, p < .05), have gestational diabetes (50% vs 6% vs 13%, p < .01), hypertensive disorders of pregnancy (42% vs 10% vs 15%, p = .02), and abnormal aspartate aminotransferase (91% vs 65% vs 27%, p < .01) and alanine aminotransferase levels (91% vs 60% vs 26%, p < .01). There were no differences in preterm labor, meconium-stained amniotic fluid, or neonatal respiratory distress syndrome and no stillbirths in this cohort. CONCLUSIONS: In patients with ICP, those with pregestational diabetes, history of ICP, prior cholecystectomy, and tobacco use are more likely to develop severe disease. Given the adverse outcomes associated with severe disease, serial BA measurements to monitor for development of severe disease may be warranted in this population.

Optimal antenatal corticosteroid exposure in women with history of preterm birth and asymptomatic short cervical length.

BACKGROUND: A proposed benefit of cervical length assessment after 24 weeks' gestation in women with a history of preterm birth is to aid in the timing of antenatal corticosteroids in otherwise asymptomatic women. OBJECTIVE: We sought to investigate whether the use of an ultrasonographic short cervical length as an indication for antenatal corticosteroids in asymptomatic women results in optimal exposure compared with women receiving antenatal corticosteroids for preterm labor symptoms. STUDY DESIGN: Retrospective cohort study of all women with a previous spontaneous preterm birth and a singleton gestation who underwent serial cervical length assessment at a large academic tertiary medical center from 2011 to 2016. Patients were included in the analysis if they received antenatal corticosteroids for either an asymptomatic short cervical length or symptoms of preterm labor. The primary outcome was optimal antenatal corticosteroids exposure (latency to delivery of ≤7 days). PROPOSED CHANGE IN RESULTS: Poisson regression with robust error variance was used to calculate incidence rate ratios (IRR) and confidence intervals (CI) for primary and secondary outcomes adjusting for primary and secondary outcomes adjusting for race, earliest previous preterm birth, and current cerclage. RESULTS: There were 287 women meeting inclusion criteria, among whom 166 (57.8%) received antenatal corticosteroids for a short cervical length and 121 (42.2%) for preterm labor symptoms. Women who received antenatal corticosteroids for a short cervical length were less likely to have optimal exposure (1.2% vs 19.0%; incidence rate ratios, 0.06; confidence interval, 0.02-0.27) compared with women with preterm labor symptoms. They were also more likely to have exposure with eventual term delivery (43.2% vs 33.4%; incidence rate ratios, 1.6; confidence interval, 1.2-2.0). Importantly, women who received antenatal corticosteroids for a short cervical length were significantly less likely to receive either an initial or rescue antenatal corticosteroids course within 7 days of a preterm delivery of less than 34 weeks' gestation (42.9% vs 76.9%; incidence rate ratios, 0.52; confidence interval, 0.35-0.75). CONCLUSION: Women with a previous preterm birth who receive antenatal corticosteroids for an asymptomatic short cervical length are less likely to have optimal exposure than women with symptoms of preterm labor. These data challenge the practice of cervical length surveillance for the sole indication of timing antenatal corticosteroids administration.

Maternal transport: an opportunity to improve the system of risk-appropriate care.

OBJECTIVE: To assess how often maternal transport preceded pregnancy-related deaths and describe contributing factors and recommendations related to maternal transport. STUDY DESIGN: We used Ohio maternal mortality review committee (MMRC) data from 2010 to 2016. We defined two transport types among pregnancy-related deaths: field to hospital and hospital to hospital. We examined deaths determined by the MMRC to be potentially preventable by transfer to a higher level of care and described contributing factors and recommendations. RESULT: Among 136 pregnancy-related deaths, 56 (41.2%) were transported. Among 15 deaths identified as potentially preventable by transfer to a higher level of care, 5 were transported between hospitals. Contributing factors for 14 deaths included inadequate response by Emergency Medical Services and lack of transport to a higher level of care. CONCLUSION: Our results suggest opportunities for examining modification and adherence to existing protocols. Improving risk-appropriate maternal care systems is important for preventing pregnancy-related deaths.

The Importance of Clinical Presentation in Risk and Management of Recurrent Preterm Birth.

OBJECTIVE: This study aimed to compare the risk of recurrent spontaneous preterm birth (sPTB), as well as cerclage efficacy, between groups stratified by phenotype of the index sPTB. STUDY DESIGN: This is a retrospective cohort study of women with a history of sPTB. Included were women with a history of singleton sPTB who received progesterone in a subsequent pregnancy. Multifetal gestations and abdominal cerclage were excluded. Exposure groups were based upon the presenting symptom that preceded their first sPTB and included painless cervical dilation (PCD), preterm premature rupture of membranes (PPROM), and painful dilation (preterm labor [PTL]). Primary outcome was delivery <34 weeks in a subsequent pregnancy. Secondary outcomes included delivery <28 and <37 weeks. Rates were compared using the Chi-square test. Multivariable Poisson regression was used to adjust for confounders. RESULTS: A total of 723 women were included. A total of 114 (16%) presented with PCD, 305 (42%) with PPROM, and 304 (42%) with PTL in their first sPTB. Cerclage in subsequent pregnancy was highest in the PCD group (42%) when compared with the PPROM (16%) and PTL (12%) groups. Rates of sPTB <34 and 37 weeks were similar among the groups. After adjusting for confounders, PCD was found to significantly increase the risk of recurrent sPTB <28 weeks (incidence rate ratio: 3.46 [1.09-11.0]; p = 0.04). Of the 121 women who underwent cerclage, there were no significant differences in rates of sPTB between the clinical presentation groups. CONCLUSION: PCD as a specific phenotype of sPTB impacts recurrence of delivery before 28 weeks, but not at later gestational ages. In contrast, there was no significant association between clinical presentation of index sPTB and gestational latency in women who also underwent cerclage placement in a subsequent pregnancy. Our data suggest that clinical presentation is important with regards to recurrence of early sPTB, but not sPTB at later gestational ages. KEY POINTS: · Phenotype is critical to understanding PTB.. · Phenotype is associated with recurrent PTB.. · Painless dilation is associated with recurrent PTB..

Fetal renal artery impedance in pregnancies affected by preeclampsia.

Background Preeclampsia (PE) is a pregnancy-specific vascular endothelial disorder characterized by multi-organ system involvement. This includes the maternal kidneys, with changes such as continuous vasospasm of renal arteries and reduced renal blood flow. However, it is unclear whether similar renal vascular changes are seen in the fetus. This study sought to compare renal artery impedance in fetuses of women with and without PE. Methods This was a prospective Doppler assessment study of the fetal renal artery impedance in 48 singleton fetuses. The group with PE consisted of 24 appropriately grown fetuses in pregnancy complicated by both mild and severe PE and a control group of 24 uncomplicated pregnancies. Doppler studies included renal artery systolic/diastolic (S/D) ratio, pulsatility index (PI), resistance index (RI), and identification of end-diastolic blood flow. Results Fetuses of mothers with PE were more likely to have a lower renal artery Doppler S/D ratio (7.85 [6.4-10.2] vs. 10.8 [7.75-22.5], P = 0.03) and lower RI (0.875 [0.842-0.898] vs. 0.905 [0.872-0.957], P = 0.03). However, there was no statistically significant difference in PI. There was also no difference in the incidence of absent end-diastolic flow. Conclusion This study suggests that PE results in changes in blood flow to the renal arteries of the fetus. This may be associated with long-term adverse health effects later in adulthood.

Severe Maternal Morbidity, A Tale of 2 States Using Data for Action-Ohio and Massachusetts.

Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

Examination of a death due to cardiomyopathy by a maternal mortality review committee.

Deaths related to pregnancy were relatively common in the United States at the beginning of the twentieth century. A dramatic reduction of 99% in maternal mortality rate, from 850.0-7.5 per 100,000 live births from 1900-1982, is 1 of the most noteworthy public health success stories of the time period. This plateau continued until the late 1990s when the maternal mortality rate began to rise again. The reasons for this increase are unclear. Vital statistics data alone cannot answer the many questions surrounding this increase. The need for detailed and reliable information about causes of death and underlying factors has led to the development of state- and urban-based maternal death reviews. Although processes may vary, an expert panel is convened to review individual cases and make recommendations for systems change. Review of maternal deaths is considered to be a core public health function. There are multiple purposes for this article. The first goal is to highlight the components of a maternal mortality review. The second goal is to provide an example for new review committees. A mock case of cardiomyopathy is used to illustrate both the process and development of actionable recommendations for clinical intervention. Recommendations to address community- and system-level contributing factors and the social determinants of health are discussed. The third goal is to educate providers regarding presentation and management of cardiomyopathy. Fourth, it is hoped that policymakers in the area of maternal health and facilities that review maternal morbidity and mortality rates at the institutional level will find the article useful as well. Finally, the article provides facility-level committees with a process example for review of the circumstances of maternal deaths beyond clinical factors so that they may make recommendations to address nonclinical contributors to pregnancy-related deaths. Documenting both clinical and nonclinical contributors to maternal death are critical to influence public opinion, develop coalitions for collective impact, and engage at risk populations in proposing interventions.

Healthcare Experiences of Low-Income Women with Prior Gestational Diabetes.

Introduction An important yet understudied component of postpartum type 2 diabetes risk reduction among high risk women is experiences with the healthcare system. Our objective was to describe the healthcare experiences of a diverse, low-income sample of women with prior GDM, including their suggestions for improving care. Methods Focus groups were conducted among African American, Hispanic, and Appalachian women who were diagnosed with GDM within the past 10 years. Participants were recruited from community and medical resources. Twelve focus groups were conducted, four within each race-ethnic group. Results Three broad themes were identified around barriers to GDM care, management, and follow-up: (1) communication issues; (2) personal and environmental barriers; and (3) type and quality of healthcare. Many women felt communication with their provider could be improved, including more education on the severity of GDM, streamlining information to be less overwhelming, and providing additional support through referrals to community resources. Although women expressed interest in receiving more actionable advice for managing GDM during pregnancy and for preventing type 2 diabetes postpartum, few women reported changing behaviors. Barriers to behavior change were related to cost, transportation, and competing demands. Several opportunities for improved care were elucidated. Discussion Our findings suggest that across all racial and ethnic representations in our sample, low-income women with GDM experience similar communication, personal, and environmental barriers related to the healthcare they receive for their GDM. Considering the increased exposure to the health care system during a GDM-affected pregnancy, there are opportunities to address barriers among women with GDM across different race-ethnic groups.

State-based Review of Maternal Deaths: The Ohio Experience.

Ohio established a Pregnancy-Associated Mortality Review system in 2010 to ensure that all maternal deaths are identified and preventive actions developed. The need for detailed and reliable information to supplement vital statistics data has led to the development of state-based and urban-based maternal death reviews. Although processes vary from state to state, in general, an expert panel is convened to review individual cases and make recommendations for systems change. This article describes the development and operation of Ohio's state-based maternal death review including interventions developed and actions taken based on review data.

The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women.

Objectives To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.

Evidence for participation of neutrophil gelatinase-associated lipocalin/matrix metalloproteinase-9 (NGAL•MMP-9) complex in the inflammatory response to infection in pregnancies complicated by preterm birth.

PROBLEM: Neutrophil gelatinase-associated lipocalin (NGAL) is expressed in neutrophils and involved in innate immunity by sequestering iron. NGAL's ability to complex with matrix metalloproteinase-9 (MMP-9) and extend its gelatinolytic activity led us to investigate its role in pregnancies complicated by preterm birth (PTB) and intra-amniotic infection/inflammation (IAI). METHOD OF STUDY: We assayed the amniotic fluid (AF) levels of NGAL and MMP-9 in 308 women that had a clinically indicated amniocentesis and a normal pregnancy outcome or PTB. qRT-PCR was employed to determine NGAL mRNA expression of placental villous trophoblast and amniochorion. Immunohistochemistry was used for cellular localization. RESULTS: AF NGAL levels were gestational age-regulated. Women with IAI and PTB had significantly higher levels of NGAL, MMP-9 and NGAL•MMP-9 complex. CONCLUSION: The amniochorion is a source of NGAL and similarly to other inflammatory conditions, this protein may augment the collagenolytic effect of MMP-9 and modulate host-microbe interactions in pregnancies complicated by IAI.

Strategies associated with higher postpartum glucose tolerance screening rates for gestational diabetes mellitus patients.

BACKGROUND: Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. METHODS: This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. RESULTS: Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. CONCLUSIONS: Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Gestational diabetes mellitus and postpartum care practices of nurse-midwives.

INTRODUCTION: Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. METHODS: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening. RESULTS: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. DISCUSSION: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.