Publisher: Elsevier   (Total: 3204 journals)

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Showing 1 - 200 of 3204 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 39, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 27, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 106, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 29, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 46, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 8)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 6)
Acta Astronautica     Hybrid Journal   (Followers: 452, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 30, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 11, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 5, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 343, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 3, SJR: 1.793, CiteScore: 6)
Acta Psychologica     Hybrid Journal   (Followers: 26, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access   (Followers: 1)
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 14, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 198, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 13, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 20, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 30, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 12, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 12, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 35, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 6)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 11, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 11, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 27, SJR: 1.562, CiteScore: 3)
Advances in Clinical Radiology     Full-text available via subscription   (Followers: 2)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 21, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 15, SJR: 0.205, CiteScore: 1)
Advances in Cosmetic Surgery     Full-text available via subscription   (Followers: 2)
Advances in Dermatology     Full-text available via subscription   (Followers: 16)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 14)
Advances in Digestive Medicine     Open Access   (Followers: 14)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 44, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 31, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 9)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 51, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 2)
Advances in Family Practice Nursing     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 70, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 11, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 8, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 26)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 4, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 39, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 10, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 17, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 9, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 26)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Pathology     Hybrid Journal   (Followers: 1)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Ophthalmology and Optometry     Full-text available via subscription   (Followers: 1)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 6, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 19)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 10)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 71)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 7, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 3, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 7)
Advances in Space Research     Full-text available via subscription   (Followers: 435, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 6)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 36, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 57, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 399, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 481, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 32, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 47, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 6, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 8, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 12)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 2)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 12, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 56, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 5, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 5, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 59, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 67, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 48, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 13)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 17, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 41, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 35, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 37, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 51)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics & Gynecology MFM     Hybrid Journal   (Followers: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 276, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 68, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 33, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 29, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 69, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 27, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 6, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 224, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)

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Similar Journals
Journal Cover
American Journal of Obstetrics & Gynecology MFM
Number of Followers: 2  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 2589-9333
Published by Elsevier Homepage  [3204 journals]
  • COVID-19 in pregnancy: early lessons
    • Abstract: Publication date: Available online 27 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Noelle Breslin, Caitlin Baptiste, Russell Miller, Karin Fuchs, Dena Goffman, Cynthia Gyamfi-Bannerman, Mary D’Alton
       
  • Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19)
           during pregnancy: a systematic review and meta-analysis
    • Abstract: Publication date: Available online 25 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Daniele Di Mascio, Asma Khalil, Gabriele Saccone, Giuseppe Rizzo, Danilo Buca, Marco Liberati, Jacopo Vecchiet, Luigi Nappi, Giovanni Scambia, Vincenzo Berghella, Francesco D’Antonio
       
  • Extracorporeal membrane oxygenation in pregnant and postpartum women: a
           ten-year case series
    • Abstract: Publication date: Available online 25 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Carolyn M. Webster, Kathleen A. Smith, Tracy A. Manuck
       
  • Labor and Delivery Guidance for COVID-19
    • Abstract: Publication date: Available online 25 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Rupsa C. Boelig, Tracy Manuck, Emily A. Oliver, Daniele Di Mascio, Gabriele Saccone, Federica Bellussi, Vincenzo Berghella
       
  • Racial Disparities in Prematurity Persist among Women of High
           Socioeconomic Status
    • Abstract: Publication date: Available online 23 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Jasmine D. Johnson, Celeste A. Green, Catherine J. Vladutiu, Tracy A. Manuck
       
  • Morbidity in Pregnant Women with a Prosthetic Heart Valve
    • Abstract: Publication date: Available online 23 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Samuel C. Siu, Melody Lam, Britney Le, Pallav Garg, Candice K. Silversides, Joel G. Ray
       
  • The effect of intrauterine resuscitation by maternal hyperoxygenation on
           perinatal and maternal outcome; a randomized controlled trial
    • Abstract: Publication date: Available online 21 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Suzanne Moors, Lauren M. Bullens, Pieter J. Van Runnard Heimel, Jeanne P. Dieleman, Wim Kulik, Dirk L. Bakkeren, Edwin R. Van Den Heuvel, M. Beatrijs Van Der Hout- Van Der Jagt, S. Guid Oei
       
  • Association between long interpregnancy intervals and cesarean delivery
           due to arrest disorders
    • Abstract: Publication date: Available online 21 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Tetsuya Kawakita, Stephanie Franco, Atoosa Ghofranian, Alexandra Thomas, Helain J. Landy
       
  • MFM Guidance for COVID-19
    • Abstract: Publication date: Available online 19 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Rupsa C. Boelig, Gabriele Saccone, Federica Bellussi, Vincenzo Berghella
       
  • Wireless, remote solution for home fetal and maternal heart rate
           monitoring
    • Abstract: Publication date: Available online 17 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Muhammad Mhajna, Nadav Schwartz, Lorinne Levit-Rosen, Steven Warsof, Michal Lipschuetz, Martin Jakobs, Jack Rychik, Christof Sohn, Simcha Yagel
       
  • Early Prediction of Preeclampsia via Machine Learning
    • Abstract: Publication date: Available online 14 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Ivana Marić, Abraham Tsur, Nima Aghaeepour, Andrea Montanari, David K. Stevenson, Gary M. Shaw, Virginia D. Winn
       
  • Adding Perinatal Anxiety Screening to Depression Screening: Is It Worth
           It'
    • Abstract: Publication date: Available online 13 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Kate Lieb, Sarah Reinstein, Xianhong Xie, Peter S. Bernstein, Chavi Eve Karkowsky
       
  • Vaginal birth after cesarean: Does accuracy of predicted success change
           from prenatal intake to admission'
    • Abstract: Publication date: Available online 7 March 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Thoa K. Ha, Rashmi R. Rao, Melanie M. Maykin, Jenny Y. Mei, Alexandra L. Havard, Stephanie L. Gaw
       
  • Influence of Maternal Aerobic Exercise During Pregnancy on Fetal Cardiac
           Function and Outflow
    • Abstract: Publication date: Available online 27 February 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Linda E. May, Samantha McDonald, Lauren Forbes, Rebecca Jones, Edward Newton, Diana Strickland, Christy Isler, Kelly Haven, Dennis Steed, George Kelley, Lisa Chasan-Taber, Devon Kuehn
       
  • Intention to Treat: Obstetrical Management at the Threshold of Viability
    • Abstract: Publication date: Available online 27 February 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Tiffany R. Tonismae, Brownsyne Tucker Edmonds, Surya Sruthi Bhamidipalli, William F. Fadel, Christine Carlos, Bree Andrews, Katie A. Fritz, Steven R. Leuthner, Christin Lawrence, Naomi Laventhal, Drew Hayslett, Tasha Coleman, Mobolaji Famuyide, Dalia Feltman
       
  • New series of reviews on evidence-based L&D management and cesarean
           delivery!
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics & Gynecology MFM, Volume 2, Issue 1Author(s): Vincenzo Berghella
       
  • Social Media Committee
    • Abstract: Publication date: February 2020Source: American Journal of Obstetrics & Gynecology MFM, Volume 2, Issue 1Author(s):
       
  • Prolonged second stage of labor and risk of subsequent spontaneous preterm
           birth
    • Abstract: Publication date: Available online 20 February 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Nasim C. Sobhani, Arianna G. Cassidy, Marya G. Zlatnik, Melissa G. Rosenstein BackgroundPreterm birth is the leading cause of neonatal morbidity and mortality in the United States. While many risk factors for spontaneous preterm birth have been elucidated, some women with a prior term delivery experience spontaneous preterm birth in the absence of any identifiable risk factors. Cervical trauma during a prolonged second stage of labor has been postulated as a potential contributor to subsequent spontaneous preterm birth.ObjectiveThis study was designed to examine the relationship between the length of the second stage of labor in the first pregnancy and the risk of spontaneous preterm birth in the subsequent pregnancy.Study designThis was a retrospective cohort study of all women with two consecutive singleton deliveries at a single institution between July 2012 and June 2018, with the first delivery occurring at or beyond 37 weeks. Multiparous women and those who did not reach the second stage of labor in the first pregnancy were excluded. Prolonged second stage was defined as ≥ 4 hours, based on the 75th percentile for this cohort and on recommendations from the National Institute of Child Health and Human Development. Very prolonged second stage was defined as ≥ 7 hours, based on the 95th percentile for this cohort. The primary outcome was spontaneous preterm birth before 37 weeks in the subsequent pregnancy. The Kruskal-Wallis test compared median values for non-parametric continuous variables, Fisher’s exact tests compared proportions for categorical variables, and logistic regression generated odds ratios.ResultsA total of 1,032 women met criteria for study inclusion, with an overall subsequent spontaneous preterm birth rate of 3.1%. Prolonged second stage ≥ 4 hours was identified in 24.4% (252/1032) of the cohort, with 70.6% (178/252) of this group delivering vaginally. There was no statistically significant difference in rate of spontaneous preterm birth in those with and without prolonged second stage (4.4% (11/252) with vs 2.7% (21/780) without, P = 0.21, OR 1.6, 95% CI 0.8-3.5). Very prolonged second stage ≥ 7 hours was identified in 4.3% (44/1032) of the cohort, with 45.4% (20/44) of this group delivering vaginally. There was a significantly higher rate of spontaneous preterm birth in those with very prolonged second stage compared to those without (9.1% (4/44) with vs 2.8% (28/988) without, P = 0.04, OR 3.4, 95% CI 1.1-10.2), although this finding did not persist after controlling for mode of first delivery (adjusted OR 1.55, 95% CI 0.65-3.73). Spontaneous preterm birth after very prolonged second stage was identified in only four patients, all of whom had a cesarean delivery with the first pregnancy.ConclusionA second stage ≥ 4 hours in the first pregnancy was not associated with an increased risk of subsequent spontaneous preterm birth and was associated with a high rate (>70%) of vaginal birth. A second stage ≥ 7 hours did not appear to be associated with an increased risk of preterm birth, when adjusting for mode of first delivery. There was a non-significant increase in the risk of preterm birth in those who delivered via cesarean section after a second stage ≥ 7 hours.
       
  • Maternal stress, low cervicovaginal beta defensin, and spontaneous preterm
           birth
    • Abstract: Publication date: Available online 10 February 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Heather H. Burris, Valerie M. Riis, Isabel Schmidt, Kristin D. Gerson, Amy Brown, Michal A. Elovitz BackgroundSpontaneous preterm birth (sPTB) is a major contributor to infant mortality and its etiology remains poorly understood. Host immunity and maternal stress may play a role in the pathogenesis of sPTB but mechanisms are poorly delineated. Antimicrobial proteins in the cervicovaginal space, such as beta defensins, modulate immune responses to bacteria and have been shown to modulate the risk of sPTB from non-optimal microbiota. While stress is known to induce immunological changes, no study has examined the interplay between maternal stress and the immune response in association with sPTB.ObjectivesOur objectives were to determine whether psychosocial stress was associated with a mediator of the immune system in the cervicovaginal space, beta defensin-2, and to examine the combined impact of high stress and low cervicovaginal beta defensin-2 levels on the odds of sPTB.Study DesignFrom the Motherhood & Microbiome cohort study (n=2000), we performed a secondary, nested case-control study, frequency matched by race/ethnicity, of 519 pregnant women (110 sPTB and 409 term). Stress and cervicovaginal beta defensin-2 levels were measured at 16-20 weeks of gestation. Stress was dichotomized at a score of 30 on Cohen’s Perceived Stress Scale (PSS-14). We measured cervicovaginal beta defensin-2 levels with ELISA and dichotomized at the median. We modeled associations of high stress and low cervicovaginal beta defensin-2 levels using multivariable logistic regression. We also compared the proportion of women with high stress and low cervicovaginal beta defensin-2 levels among women with spontaneous preterm and term births using Chi-Square tests. We modeled adjusted associations of stress and cervicovaginal beta defensin-2 levels with odds of sPTB using logistic regression.ResultsThe majority of the study population was non-Hispanic black (72.8%), insured by Medicaid (51.1%), and had a PSS-14 score < 30 (80.2%). High stress was associated with reduced adjusted odds of low beta defensin-2 levels (aOR 0.63, 95% CI: 0.38 -0.99). In a model adjusted for race and smoking, both high stress (aOR 1.72, 95% CI: 1.03-2.90) and low beta defensin-2 (aOR 1.58, 95% CI: 1.004-2.49) were associated with increased odds of sPTB. We then built a model of the four possible combinations of low and high stress and low and high beta defensin-2 levels with the odds of sPTB. Women with either high stress (aOR 1.37, 95% CI: 0.68 - 2.78) or low beta defensin-2 (aOR 1.40, 95% CI: 0.83-2.34), had slightly elevated but not significantly increased odds of sPTB compared to women with neither exposure. However, women with both high stress and low beta defensin-2 had significantly elevated odds of sPTB compared to women with neither exposure (aOR 3.16, 95 % CI: 1.46 - 6.84).ConclusionHigh perceived stress and low cervicovaginal beta defensin-2 levels are associated with higher odds of sPTB, and when present concurrently, they result in the highest odds of sPTB in a largely non-Hispanic black cohort. Our findings warrant further work to examine social determinants of health and the host cervicovaginal immune responses that may modulate the pathogenesis of sPTB.
       
  • Patients’ perspectives regarding induction of labor in the absence of
           maternal and fetal indications: are our patients ready for the ARRIVE
           trial'
    • Abstract: Publication date: Available online 12 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Patience J. Gallagher, Elizabeth Liveright, Rebecca J. MercierBackgroundAfter careful review of the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) data, induction of labor prior to one’s due date in the absence of maternal and fetal indications (which the American College of Obstetricians and Gynecologists currently refers to as “elective”) is now endorsed as a “reasonable” option by the American College of Obstetricians and Gynecologists. As a result, there has been much discussion among providers regarding how best to operationalize this American College of Obstetricians and Gynecologists recommendation into shared decision making regarding delivery planning. However, we lack a formal understanding of the perspectives of patients themselves on this topic.ObjectiveTo assess patient understanding and preference for induction of labor prior to one’s due date.Materials and MethodsWe conducted an anonymous, cross-sectional survey of women in their third trimester of pregnancy presenting for routine obstetric care in August 2018. The survey included a series of questions designed to assess basic demographics, obstetric history, and patient understanding and opinions about the practice of induction of labor, with a focus on induction of labor prior to one’s due date in the absence of maternal and fetal indications.ResultsA total of 108 were approached for participation, and 100 women participated in this survey (93% participation). Of the participants, 99% were supportive of induction of labor for fetal indications, and 96% were supportive for maternal indications prior to one’s due date. In contrast, 54% of participants were not interested in induction of labor in the absence of maternal and fetal indications prior to one’s date. Women opposed to induction of labor in the absence of maternal and fetal indications were almost 4 times more likely to be concerned about the possibility that induction of labor in the absence of maternal and fetal indications could cause fetal harm (odds ratio, 3.9; confidence interval, 1.2–13.2).ConclusionNearly all women surveyed in our pilot study were interested in induction of labor prior to one’s due date for maternal or fetal indications. In all, 46% of those surveyed were interested in induction of labor in the absence of maternal and fetal indications prior to their due date. Concern about potential fetal harm was more likely among women opposed to induction of labor in the absence of maternal and fetal indications. As providers discuss delivery planning with their patients, these results may provide a useful context for operationalizing and individualizing the results of the ARRIVE trial for their patients.
       
  • Amniotic fluid embolism syndrome: Analysis of the Unites States
           International Registry
    • Abstract: Publication date: Available online 9 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Irene A. STAFFORD, Amirhossein MOADDAB, Gary A. DILDY, Ms. Miranda KLASSEN, Alexandra BERRA, Ms. Christine WATTERS, Michael A. BELFORT, Roberto ROMERO, Steven L. CLARK :BackgroundIncidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism (AFE) remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetrical morbidity and mortality.ObjectiveThe aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international AFE registry and (2) to investigate differences in demographic and obstetrical variables, clinical presentation, and outcomes between women with typical vs atypical AFE, using previously published and validated criteria for the research reporting of AFE.Study DesignThe AFE Registry is an international database established at Baylor College of Medicine, (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation, (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-AFE, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student’s t tests, chi-square tests, and ANOVA tables were used to compare the groups, as appropriate, using SAS/STAT® software, version 9.4 (Cary, NC).ResultsOne hundred and twenty-nine charts were available for review. Of these, 46% (59/129) represented typical AFE and 12% (15/129) atypical AFE, 21% (27/129) were non-AFE cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an AFE with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of women with typical AFE had a pregnancy complicated by placenta previa and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. Sixty-six percent (49/74) of women with AFE reported a history of atopy or latex, medication or food allergy compared to 34% of the obstetrical population delivered at our hospital over the study period (p = < .05).ConclusionOur data represent a series of women with AFE whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of AFE. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.
       
  • Risk of recurrent acute fatty liver of pregnancy: survey from a social
           media group
    • Abstract: Publication date: Available online 9 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Julie Glavind, Sidsel Boie, Emilie Glavind, Jens FuglsangBackgroundAcute fatty liver of pregnancy is a rare but serious complication in the last trimester of pregnancy or postpartum period. Data on the recurrence risk are largely unavailable, as only case reports or very small case series exist in which only 1 woman had recurrent acute fatty liver of pregnancy.ObjectiveWe aimed to estimate the risk of acute fatty liver of pregnancy recurrence and to compare disease severity and gestational age between primary and recurrent disease using patient-provided data from an acute fatty liver of pregnancy social media patient group.Materials and MethodsWe developed and distributed an electronic questionnaire through an international Facebook group called “Acute Fatty Liver of Pregnancy.” The data collection took place from June 11, 2018, to August 17, 2018, using REDCap. Our main outcome measures were recurrence of acute fatty liver of pregnancy, severity with recurrence, and gestational age at delivery.ResultsA total of 69 women with previous acute fatty liver of pregnancy completed the questionnaire; 24 women had a subsequent delivery, of whom 5 women were diagnosed with acute fatty liver of pregnancy again. In 4 of 5 of these women (80%), acute fatty liver of pregnancy took a milder course, whereas in 1 woman it worsened in the next pregnancy. Women with acute fatty liver of pregnancy recurrence delivered at a median gestational age at 265 days (interquartile range, 242−287 days) in their first pregnancy with acute fatty liver of pregnancy as compared to delivery by a prelabor cesarean delivery at 245 days (interquartile range, 235−261 days) in their second pregnancy with acute fatty liver of pregnancy. Male fetal sex was not associated with an increased risk of recurrent acute fatty liver of pregnancy.ConclusionOne in 5 women reported having had recurrent acute fatty liver of pregnancy, with most cases being milder, possibly because of an earlier gestational age at delivery.
       
  • PRETERM BIRTH PREDICTION IN ASYMPTOMATIC WOMEN AT MID-GESTATION USING A
           PANEL OF NOVEL PROTEIN BIOMARKERS: The Prediction of PreTerm Labor
           (PPeTaL) study
    • Abstract: Publication date: Available online 9 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): San Min LEOW, Megan K.W. DI QUINZIO, Zhen Long NG, Claire GRANT, Tal AMITAY, Ying WEI, Moshe HOD, Penelope M SHEEHAN, Shaun P. BRENNECKE, Nir ARBEL, Harry M. GEORGIOU BackgroundAccurate prediction of spontaneous preterm labor/preterm birth (PTL/B) in asymptomatic women remains an elusive clinical challenge due to the multi-etiological nature of PTB.ObjectiveThe aim is to develop and validate an immunoassay-based, multi-biomarker test to predict spontaneous PTB.Study DesignThis was an observational cohort study of women delivering from December 2017 to February 2019 at two maternity hospitals in Melbourne, Australia. Cervicovaginal fluid samples were collected from asymptomatic women at gestational week of 16+0-24+0 and biomarker concentrations were quantified by ELISA. Women were assigned to a training cohort (n = 136) and a validation cohort (n = 150) based on chronological delivery dates.ResultsSeven candidate biomarkers representing key pathways in utero-cervical remodeling were discovered by high throughput bioinformatic search and their significance in both in vivo and in vitro studies was assessed. Using a combination of the biomarkers for the first 136 women termed as the training cohort, we developed an algorithm to stratify term birth (n = 124) and spontaneous PTB (n = 12) samples with a sensitivity of 100% (95% CI: 76% to 100%) and a specificity of 74% (95% CI: 66% to 81%). The algorithm was further validated on a subsequent cohort of 150 women (n = 139 term birth and n = 11 PTB), achieving a sensitivity of 91% (95% CI: 62% to 100%) and a specificity of 78% (95% CI: 70% to 84%).ConclusionWe have identified a panel of biomarkers that yield clinically useful diagnostic values when combined in a multiplex algorithm. The early identification of asymptomatic women at risk of preterm birth would allow women to be triaged to specialist clinics for further assessment and appropriate preventative treatment.
       
  • Chromosomal microarray analysis in the investigation of prenatally
           diagnosed congenital heart disease
    • Abstract: Publication date: Available online 27 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Katherine M. Jacobs, Katelyn M. Tessier, Shanti L. Narasimhan, Alena N. Tofte, Allison R. McCarter, Sarah N. CrossBackgroundChromosomal microarray analysis has emerged as a primary diagnostic tool in prenatally diagnosed congenital heart disease and other structural anomalies in clinical practice.ObjectiveOur study aimed to investigate the diagnostic yield of microarray analysis as a first-tier test for chromosomal abnormalities in fetuses with both isolated and nonisolated congenital heart disease and to identify the association of different pathogenic chromosomal abnormalities with different subgroups of congenital heart disease.Study DesignRetrospective data from 217 pregnancies that were diagnosed with congenital heart disease between 2011 and 2016 were reviewed. All pregnancies were investigated with the use of microarray analysis during the study period. Classification of chromosomal abnormalities was done based on American College of Medical Genetics and Genomics guidelines into (1) pathogenic chromosomal abnormalities that included numeric chromosomal abnormalities (aneuploidy and partial aneuploidy) and pathogenic copy number variants (22q11.2 deletion and other microdeletions/microduplications), (2) variants of uncertain significance, and (3) normal findings.ResultsOur study found a detection rate for pathogenic chromosomal abnormalities (numeric and pathogenic copy number variants) of 36.9% in pregnancies (n=80) that were diagnosed prenatally with congenital heart disease who underwent invasive testing with chromosomal microarray. The detection rate for numeric abnormalities was 29.5% (n=64) and for pathogenic copy number variants was 7.4% (n=16) of which 4.2% were 22q11.2 deletion and 3.2% were other pathogenic copy number variants, most of which theoretically could have been missed by the use of conventional karyotype alone. Pathogenic copy number variants were most common in conotruncal defects (19.6%; 11/56) that included 42.9% in cases of interrupted aortic arch, 23.8% in cases of tetralogy of Fallot, 13.3% in cases of transposition of the great arteries, and 8.3% in cases of double outlet right ventricle. Of these changes, 81.8% were 22q11.2 deletion, and 18.2% were other microdeletions/microduplications. After conotruncal defects, pathogenic copy number variants were most common in right ventricular outflow tract and left ventricular outflow tract groups (8% and 2.2%, respectively) in which none were 22q11.2 deletion. Pathogenic chromosomal abnormalities (numeric and pathogenic copy number variants) detected by chromosomal microarray analysis were significantly more common in the nonisolated congenital heart disease group (64.5%; n=49) compared with the isolated group (22%; n=31; P
       
  • Induction of labor in women with a scarred uterus: does grand multiparity
           affect the risk of uterine rupture'
    • Abstract: Publication date: Available online 20 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Hila Hochler, Tamar Wainstock, Michal Lipschuetz, Eyal Sheiner, Yossef Ezra, Simcha Yagel, Asnat WalfischBackgroundPrevious cesarean delivery is the most important risk factor for subsequent uterine rupture. Data are inconsistent regarding grand multiparity (≥6th delivery) and a risk for uterine rupture. Specifically, no data exist regarding the risk that is associated with labor induction or augmentation in grand multiparous women after cesarean delivery.ObjectiveThis study aimed to examine whether grand multiparity elevates the risk for uterine rupture in trials of labor after 1 previous cesarean that involved induction or augmentation of labor.Study DesignA retrospective multicenter study was conducted that included all trials of labor after cesarean delivery at 24–42 gestational weeks with vertex presentation between the years 2003–2015. The study groups were defined in the following manner: (1) grand multiparous parturients (current delivery ≥6) who underwent labor induction or augmentation; (2) multiparous parturients (delivery 2–5) who underwent induction or augmentation; (3) grand multiparous parturients with no induction or augmentation of labor. The primary outcome was uterine rupture rate, which was defined as complete separation of all uterine layers. Secondary outcomes were obstetric and neonatal complications.ResultsA total of 12,679 labors were included in the study. The study group included 1304 labors of grand multiparous parturients after 1 previous cesarean delivery, of which 800 parturients underwent induction of labor and 504 parturients received labor augmentation. The multiparous group included 3681 parturients with either labor induction or augmentation. The third group included 7694 grand multiparous parturients without induction or augmentation. Incidence of uterine rupture was similar among the 3 study groups (0.3%, 0.3%, and 0.2%, respectively; P=.847). In the multivariable model that was adjusted for maternal age, ethnicity, diabetes mellitus, birthweight, and prolonged second stage of labor, no association was found between grand multiparity and uterine rupture in women with a scarred uterus who underwent labor induction or augmentation.ConclusionLabor induction/augmentation during trial of labor after cesarean delivery in grand multiparous parturients appears to be a reasonable option that has a similar uterine rupture risk as in multiparous parturients. Avoiding a mandatory cesarean delivery enables reduction of the risk for future multiple cesarean deliveries.
       
  • Implementation of an antenatal late-preterm corticosteroid protocol at a
           high-volume tertiary care center
    • Abstract: Publication date: Available online 17 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Nevert Badreldin, Grace G. Willert, Andrea A. Henricks, Alan Peaceman, Leslie A. Caldarelli, Lynn M. YeeBackgroundSince publication of the sentinel antenatal late-preterm steroids clinical trial, the use of antenatal steroids has become a routine aspect of the management of pregnancies at risk for late-preterm delivery. However, in practice, the administration of antenatal corticosteroids in the late-preterm period is widely varied across provider and institution, and the process of implementation of this new practice as well as outcomes associated with implementation are not well understood.ObjectiveThe objective was to evaluate institutional adherence to an antenatal late-preterm corticosteroid protocol and to assess neonatal outcomes associated with its introduction.Study DesignThis is a retrospective cohort study of all women with singleton pregnancies admitted between 34 and 36 5/7 weeks’ who presented in the year before (“preprotocol”: November 2012 to October 2013) and after implementation (“postprotocol”: April 2016 to March 2017). The protocol recommends corticosteroid administration to women 34 to 36 5/7 weeks’ gestation at risk for preterm birth who have not received prior corticosteroids. Women with fetal anomalies or pregestational or gestational diabetes were excluded from analysis. The frequency with which eligible women received corticosteroids and ineligible women were appropriately excluded (adherence) was calculated on a monthly basis. Neonatal outcomes of interest were hypoglycemia, receipt of dextrose, birthweight, 5-minute Apgar less than 7, receipt of surfactant, respiratory distress syndrome, transient tachypnea of the newborn, neonatal intensive care unit length of stay, intraventricular hemorrhage, necrotizing enterocolitis, culture-positive sepsis, bronchopulmonary dysplasia, and death. Bivariable and multivariable analyses were used to compare neonatal outcomes between (1) all women in the postprotocol cohort to those in the preprotocol cohort and (2) only women who received adherent care in the postprotocol cohort to all women in the preprotocol cohort.ResultsA total of 452 women were included in the preprotocol cohort and 451 in the postprotocol cohort. The majority of the postprotocol women (n = 366, 81.2%) received adherent care. Women in both cohorts were similar, with the exception that women in the postprotocol cohort were more likely to be nulliparous (P = .013). Compared to the preprotocol period, neonates of women in the postprotocol period had significantly higher odds of hypoglycemia
       
  • Delivery dose of methadone, but not buprenorphine, is associated with the
           risk and severity of neonatal opiate withdrawal syndrome
    • Abstract: Publication date: Available online 10 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): R. Lappen, Sydney Stark, Jennifer L. Bailit, Kelly S. GibsonBackgroundData on the relationship between the dose of opioid replacement therapy in pregnancy and the risk and severity of neonatal opioid withdrawal syndrome are conflicting and have methodological limitations.ObjectiveTo assess the association of methadone and buprenorphine dose at delivery with neonatal opioid withdrawal syndrome in a large cohort.Study DesignWe performed a retrospective cohort study using data from a comprehensive perinatal opioid dependency program from 2000 through 2016. Women with a history of opioid use disorder enrolled in a medication-assisted treatment program were included. Strict neonatal opioid withdrawal syndrome case definition and neonatal treatment guidelines were utilized throughout the study epoch. Comparisons were made between women on methadone and buprenorphine. The dose of opioid replacement at delivery and the risk and severity of neonatal opioid withdrawal syndrome were assessed with univariable analysis and multivariable logistic regression. In all analyses, methadone and buprenorphine dosing were evaluated as a continuous variable.ResultsFour hundred eighty two of 709 women (68.0%) met inclusion criteria including 344 on methadone (71.4%) and 138 on buprenorphine (28.6%). Nonopioid polysubstance abuse, body mass index, medication-assisted treatment compliance, birthweight, and other characteristics were similar between groups. Overall, the frequency of neonatal opioid withdrawal syndrome was not significantly different between the methadone and buprenorphine groups (56.8% vs 52.0%, P = .35). Dose at delivery ranged at 0–165 mg for methadone and 0–30 mg for buprenorphine. In a univariable analysis, methadone dose at delivery was associated with neonatal opioid withdrawal syndrome (83.0 ± 34.2 mg vs 71.9 ± 35.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P < .001), but buprenorphine dose at delivery was not (8.4 ± 4.4 vs 7.6 ± 4.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P = .30). Peak neonatal opioid withdrawal syndrome score, duration of neonatal opioid withdrawal syndrome treatment, and cumulative neonatal morphine exposure were significantly associated with delivery methadone dose but not buprenorphine dose. The association between delivery methadone dose and neonatal opioid withdrawal syndrome persisted in multivariable regression.ConclusionThe dose of methadone at the time of delivery is associated with the frequency and severity of neonatal opioid withdrawal syndrome, with higher doses associated with more severe neonatal opioid withdrawal syndrome when analyzed continuously. These data may inform future prospective studies on methadone dosing in pregnancy. While medication-assisted treatment agent and dose may have an impact on pertinent neonatal outcomes related to neonatal opioid withdrawal syndrome, the provision of medication-assisted treatment in pregnancy should reflect the goal of prevention of recidivism and maternal mortality and utilize an approach that balances fetal and maternal risk to optimize outcomes.
       
  • Effect of Antibiotic Treatment of Amniotic Fluid Sludge
    • Abstract: Publication date: Available online 22 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Ryan D. Cuff, Elliott Carter, Rosalea Taam, Evelyn Bruner, Sanjay Patwardhan, Roger B. Newman, Eugene Y. Chang, Scott A. SullivanBackgroundAmniotic fluid sludge refers to the sonographic presence of echogenic, free-floating aggregates of debris located within the amniotic cavity near the internal cervical os of women with intact membranes. Clinically, it is independently associated with increased obstetric, infectious, and neonatal morbidity, including: short cervix, chorioamnionitis, and an increased risk of preterm birth. It is thought to be infectious in nature and has been described as an intrauterine bacterial biofilm. There is little evidence on the impact of treatment with antibiotics on outcome.ObjectiveTo determine whether outpatient antibiotics administered to women with amniotic fluid sludge would reduce preterm birth risk compared to no antibiotic treatment.Materials and MethodsThis was a retrospective cohort study of all patients diagnosed with amniotic fluid sludge by transvaginal sonography between 15 and 25 weeks’ gestation in the outpatient ultrasound unit at a single academic center between 2010 and 2017. Patients were segregated according to whether they were treated with oral antibiotics at the time of diagnosis. Women with multiple gestation, fetal anomalies, preterm rupture of membranes prior to initial diagnosis of amniotic fluid sludge, and active preterm labor placenta previa and/or suspected accreta were excluded from analysis. Primary outcome of preterm birth at less than 37 weeks’ gestation was compared by univariate and regression analysis to control for potential co-linear and/or confounding variables. Additional outcomes were compared by univariate analysis.ResultsA total of 181 patients were initially identified, and 97 patients met inclusion criteria. Of these patients, 51 were treated with oral antibiotics (46 azithromycin and 5 moxifloxacin), and 46 were not treated. The overall incidence of preterm birth at
       
  • The use of longitudinal hemoglobin A1c values to predict adverse obstetric
           and neonatal outcomes in pregnancies complicated by pregestational
           diabetes
    • Abstract: Publication date: Available online 22 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Matthew M. Finneran, Miranda K. Kiefer, Courtney A. Ware, Elizabeth O. Buschur, Stephen F. Thung, Mark B. Landon, Steven G. GabbeBackgroundAlthough an elevated early pregnancy hemoglobin A1c has been associated with both spontaneous abortion and congenital anomalies, it is unclear whether A1c assessment is of value beyond the first trimester in pregnancies complicated by pregestational diabetes.ObjectiveWe sought to investigate the prognostic ability of longitudinal A1c assessment to predict obstetric and neonatal adverse outcomes based on degree of glycemic control in early and late pregnancy.Materials and MethodsThis was a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016 at The Ohio State University Wexner Medical Center with both an early A1c (26 weeks’ gestation) available for analysis. Patients were categorized by good (early and late A1c 6.5% and late A1c 6.5%) glycemic control. A multivariate regression model was used to calculate adjusted odds ratios [aOR] for each identified obstetric and neonatal outcome, controlling for maternal age, body mass index, race/ethnicity, type of diabetes, and gestational age at delivery compared to good control as the referent group.ResultsA total of 341 patients met inclusion criteria during the study period. The median A1c values improved from early to late gestation in the good (5.7% [interquartile range [IQR], 5.4−6.1%] versus 5.4%; [IQR 5.2−5.7%]), improved (7.5% [interquartile range, 6.7−8.5] versus 5.9% [interquartile range, 5.6−6.1%]) and poor (8.3% [interquartile range, 7.1−9.6%] versus 7.3% [interquartile range, 6.8−7.9%]) glycemic control groups. There were no statistically significant differences in the rate of adverse outcomes between the good and improved groups except for an increased rate of neonatal intensive care unit admissions in the improved group (adjusted odds ratio, 3.7; confidence interval [CI], 1.9−7.3). In contrast, the poor control group had an increased rate of shoulder dystocia (adjusted odds ratio, 6.8; confidence interval, 1.4−34.0), preterm delivery (adjusted odds ratio, 3.9; confidence interval, 2.1−7.3), neonatal intensive care unit admission (adjusted odds ratio, 2.8; confidence interval, 1.4−5.3), respiratory distress syndrome (adjusted odds ratio, 3.0; confidence interval, 1.1−8.0), hypoglycemia (adjusted odds ratio, 3.2; confidence interval, 1.5−6.9), large for gestational age weight at birth (adjusted odds ratio, 2.7; confidence interval, 1.5−4.9), neonatal length of stay>4 days (adjusted odds ratio, 3.1; confidence interval, 1.6−6.0) and preeclampsia (adjusted odds ratio, 2.4; confidence interval, 1.2−4.6). There were no differences in rates of cesarean delivery, umbilical artery pH
       
  • The impact of baseline proteinuria in pregnant women with pregestational
           diabetes mellitus
    • Abstract: Publication date: Available online 21 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Anne M. Ambia, Angela R. Seasely, Devin A. Macias, David B. Nelson, C. Edward Wells, Donald D. McIntire, F. Gary CunninghamBackgroundThe incidence of diabetes in pregnancy has increased dramatically with the rising rates of obesity. Because there are a number of recognized adverse maternal and fetal outcomes associated with diabetes, there have been several attempts to classify this disorder for perinatal risk stratification. One of the first classification systems for pregnancy was developed by White nearly 70 years ago. More recently, efforts to stratify diabetic disease severity according to vasculopathy have been adopted. Regardless of classification system, vasculopathy-associated effects have been associated with worsening pregnancy outcomes. Defining vasculopathy within an organ system, however, has not been consistent. For example, definitions of diabetic kidney disease differ from the previously used threshold of ≥500 mg/d by White for pregnancy to varying thresholds of albuminuria by the American Diabetes Association.ObjectiveTo evaluate a proteinuria threshold that was a relevant determinant of perinatal risk in a cohort of women with type 2 diabetes.Materials and MethodsThis was a retrospective cohort study of women with pregestational diabetes delivered of nonanomalous, singleton, liveborn infants. All women were assessed for baseline maternal disease burden with a 24-hour proteinuria quantification performed before 20 weeks’ gestation. Women with 300 mg/d.ResultsBetween 2009 and 2016, a total of 594 women with pregestational diabetes were found to meet study criteria. When analyzed according to protein excretion values 50–100, 101–200, 201–300, and 301–499 mg/d, there were no differences in maternal demographics. The rate of preeclampsia with severe features (P for trend = .02), preterm birth at 300 mg/d were significantly associated with preterm birth 300 mg/d was associated with preterm birth, preeclampsia with severe features, and birthweight
       
  • Choosing a hospital for obstetric, gynecologic, or reproductive
           healthcare: what matters most to patients'
    • Abstract: Publication date: Available online 16 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Luciana E. Hebert, Lori Freedman, Debra B. StulbergBackgroundDespite millions of U.S. women receiving obstetric/gynecologic or reproductive care in a hospital each year, little is known about which factors matter most to women in choosing a hospital for this care.Objective(s)To describe women’s reasons for choosing their hospital for obstetric/gynecologic or reproductive care, and to examine characteristics associated with reporting specific factors as important in hospital choice.Materials and MethodsWe conducted a nationally representative, cross-sectional survey of women aged 18–45 years. The 2016 survey recruited women from AmeriSpeak, a probability-based research panel. A total of 1430 women completed the survey. All data analysis used weighting and accounted for the complex survey design. We conducted bivariate and multinomial logistic regression modeling to assess associations.ResultsThree-fourths of women cited a hospital’s overall reputation/quality as a reason, and one-third named this as the most important reason for choosing a hospital. A total of 14% reported hospital religious affiliation as a reason. Compared to those with no prior deliveries, women who had delivered an infant were more likely to report that their top reason was specialty services/provider (relative risk ratio, 2.97; 95% confidence interval, 1.96–4.52) and were also more likely to report overall hospital quality/reputation as their top reason (relative risk ratio, 1.52; 95% confidence interval, 1.06–2.17), compared to logistical reasons. Metropolitan versus non-metropolitan residence was also a significant factor in hospital choice.ConclusionWomen endorse many factors when choosing a hospital for reproductive care, but perceived quality and reputation outweigh logistical concerns such as location and insurance.
       
  • Accuracy of estimated fetal weight assessment in fetuses with congenital
           diaphragmatic hernia
    • Abstract: Publication date: Available online 9 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Lisa C. Zuckerwise, Laura C. Ha, Sarah S. Osmundson, Emily W. Taylor, J NewtonBackgroundCongenital diaphragmatic hernia is a congenital anomaly in which fetal abdominal organs herniate into the thoracic cavity through a diaphragmatic defect, which can impede fetal lung development. Standard formulas for estimated fetal weight include measurement of fetal abdominal circumference, which may be inaccurate in fetuses with congenital diaphragmatic hernia because of displacement of abdominal contents into the thorax.ObjectivesThis study aimed to assess the accuracy of standard estimated fetal weight assessment in fetuses with congenital diaphragmatic hernia by comparing prenatal assessment of fetal weight with actual birthweight.Study DesignA retrospective cohort study of fetuses diagnosed with congenital diaphragmatic hernia was performed at a single center from 2012 to 2018. Fetuses with multiple anomalies or confirmed chromosome abnormalities were excluded. Estimated fetal weight was calculated using the Hadlock formula. Published estimates of fetal growth rate were used to establish a projected estimated fetal weight at birth from the final growth ultrasound, and the percentage difference between projected estimated fetal weight at birth and actual birthweight was calculated. A Wilcoxan rank-sum test was used to examine the difference between projected estimated fetal weight and birthweight.ResultsWe had complete data for 77 fetuses with congenital diaphragmatic hernia. The majority (76.6%, 55 of 77) had left-sided congenital diaphragmatic hernia. The median [interquartile range] projected estimated fetal weight was similar to median birthweight, at 3177 g [2691–3568] and 3180 g [2630–3500], respectively, which did not represent a statistically significant difference between projected estimated fetal weight and birthweight (P = .66). The median absolute percentage difference between projected birthweight and actual birthweight was 6.3% [3.2–7.0]. Estimated fetal weight was overall underestimated in a minority of cases (44.2%, 34 of 77).ConclusionIn fetuses with a congenital diaphragmatic hernia, standard measurements of fetal estimated fetal weight show accuracy that is at least comparable with previously established margins of error for ultrasound assessment of fetal weight. Standard estimated fetal weight assessment remains an appropriate method of estimating fetal weight in fetuses with congenital diaphragmatic hernia.
       
  • Outcomes of balloon occlusion in the University of California Morbidly
           Adherent Placenta Registry
    • Abstract: Publication date: Available online 9 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Andrew Y. Lee, Deddeh Ballah, Ismael Moreno, Paul R. Dong, Rory Cochran, Andrew Picel, Edward W. Lee, John Moriarty, Max Padgett, Kari Nelson, Maureen P. KohiBackgroundMorbidly adherent placenta, also known as placenta accreta spectrum, is associated with severe maternal morbidity and mortality. Multiple adjunctive procedures have been proposed to improve outcomes, and at many institutions, interventional radiologists will play a role in assisting obstetricians in these cases.ObjectiveThe objectrive of the study was to evaluate the outcomes of women with morbidly adherent placenta who underwent cesarean hysterectomy with aortic balloon occlusion or internal iliac artery balloon occlusion catheters, compared with cesarean hysterectomy with surgical ligation of the iliac arteries, or cesarean hysterectomy without adjunctive procedures.Study DesignA tetrospective review of women with morbidly adherent placenta treated with cesarean hysterectomy was performed at 5 institutions from May 2014 to April 2018. The balloon occlusion group had either prophylactic aortic or iliac balloons placed prior to cesarean hysterectomy. Comparison groups included those who underwent internal iliac artery ligation prior to hysterectomy or a control group if they underwent cesarean hysterectomy without adjuvant procedures. Evaluated outcomes include estimated blood loss, transfusion requirements, intensive care unit admission, and adverse event rates.ResultsThere were 171 women with morbidly adherent placenta included in the study. Twenty-eight had balloon placement prior to cesarean hysterectomy, 18 had intraoperative internal iliac artery ligation, and there were 125 control women who underwent cesarean hysterectomy without any adjunctive procedures. Compared with the women who underwent cesarean hysterectomy without adjunctive procedures, women who underwent aortic or iliac artery balloon occlusion prior to hysterectomy had significantly lower estimated blood loss (30.9% decrease, P < .001), transfusion requirements (76.8% decrease, P < .001), intensive care unit admission rates (0% vs 15.2%, P < .001), and intensive care unit stay lengths (0.0 vs 3.1 days, P < .001). Compared with women who underwent surgical ligation of the internal iliac arteries prior to hysterectomy, women who underwent aortic or iliac artery balloon occlusion prior to cesarean hysterectomy had lower estimated blood loss (54.2% decrease, P < .01), transfusion requirements (90.5% decrease, P < .001), operating room times (40.0% decrease, P < .01), intensive care unit admissions rates (0% vs 77.8%, P < .001), intensive care unit stay lengths (0.0 vs 1.4 days, P < .001), and adverse events (3.6% vs 44.4%, P < .01).ConclusionAortic and iliac artery balloon occlusion are associated with lower estimated blood loss, transfusion requirements, intensive care unit admission rates, and adverse event rates compared with women who underwent internal iliac artery ligation prior to cesarean hysterectomy or women who had no adjunctive interventions prior to cesarean hysterectomy for morbidly adherent placenta.
       
  • Intensive glycemic control in gestational diabetes mellitus: a randomized
           controlled clinical feasibility trial
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Christina M. Scifres, Carolyn Mead-Harvey, Hugh Nadeau, Sean Reid, Stephanie Pierce, Maisa Feghali, Dean Myers, David Fields, Julie A. StonerBackgroundOverweight and obese women with gestational diabetes mellitus are at increased risk for adverse perinatal outcomes, and they are also more likely to have suboptimal glycemic control. However, there is a paucity of data evaluating whether lower glycemic targets could improve outcomes.ObjectiveTo evaluate the feasibility of intensive glycemic control in overweight and obese women with gestational diabetes mellitus.Materials and MethodsWe randomized 60 overweight or obese women with gestational diabetes mellitus, diagnosed between 12 and 32 weeks’ gestation to either intensive (fasting
       
  • Opioid prescribing trends in postpartum women: a multicenter study
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Karissa B. Sanchez Traun, Charles W. Schauberger, Luis D. Ramirez, Cresta W. Jones, Alisha F. Lindberg, Ricardo A. Molero Bravo, Tricia E. Wright, Benjamin D. Traun, Suzanne E. Peterson, Vania P. RudolfBackgroundThe postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period.ObjectiveThe purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing.Study DesignData were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital.ResultsThe percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P 
       
  • Post−cesarean delivery outpatient opioid consumption and perception of
           pain control following implementation of a restrictive opioid prescription
           protocol
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Nisha Lakhi, Gabrielle Tricorico, Tomi Kanninen, Rahat Suddle, Jane Ponterio, Michael MorettiBackgroundCesarean delivery is the most common laparotomy performed in the United States and can be the first exposure to opioids for many women. Unnecessary consumption of opioids may lead to long-term addiction and further perpetuate this national health crisis.ObjectivesThe primary objective of the study was to assess whether a quality improvement initiative by means of a restrictive opioid prescription policy decreases opioid consumption and maintains patient satisfaction after cesarean delivery. A secondary objective is to correlate opioid consumption with demographic and perioperative factors.Materials and MethodsA Plan, Do, Check, Act model was used to implement a quality improvement initiative. A restrictive opioid prescribing policy was put in place in July 2017 preventing all physicians from prescribing opioids to their patients upon discharge after cesarean delivery; patients could call their providers from home to request additional analgesia (opioid or nonopioid) if pain was not sufficiently controlled. From August 2017 to February 2018, a postdischarge telephone interview assessing pain control satisfaction and opioid consumption was conducted for all English-speaking patients in our hospital who underwent a cesarean delivery. Statistical analysis was performed using IBM SPSS 22.0, with P < .05 reported as statistically significant.ResultsA total of 283 parturients were interviewed 8–33 days after cesarean delivery (mean, 16 days). After implementation of the restrictive opioid prescription policy, we observed a decrease in opioid prescriptions at discharge after cesarean delivery from 97.9% to 0%, with an 18% prescription rate after discharge. Patients reported high satisfaction with their pain control, with 89% (n = 253) stating that their pain was adequately controlled upon discharge. Although 90% (n = 256) reported that they did not need any pain medication other than ibuprofen or acetaminophen, opioids were prescribed to 18% of patients (n = 51) after discharge, with only 51% of these women (n = 27) consuming them. In response to the restrictive opioid prescribing policy, only 13% of the women (n = 37) reported that they wished that a stronger pain medication had been prescribed after hospital discharge. Factors associated with opioid consumption postdischarge included white race/ethnicity, multiparity, and opioid consumption during inpatient hospitalization.ConclusionFollowing implementation of the restrictive opioid prescribing policy, most women experienced adequate pain control after cesarean delivery. Patient satisfaction with pain control was high, showing that it is feasible to implement restrictive opioid prescription policies while maintaining a high satisfaction rate.
       
  • Role of early amniotomy with induced labor: a systematic review of
           literature and meta-analysis
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Sun Woo Kim, Dimitrios Nasioudis, Lisa D. LevineObjectiveThe aim of the present meta-analysis was to evaluate the efficacy and safety of early amniotomy performed during induction of labor.Data SourcesThe Medline, Embase, and Web-of-Science databases (from conception to end-of-search date, Dec. 31, 2018) were systematically searched.Study Eligibility CriteriaRandomized controlled trials that compared the performance of early amniotomy (performed before active phase of labor) to spontaneous or late amniotomy were eligible for inclusion. Eligible studies were limited to studies published as full articles available in the English language and included patients with a singleton viable fetus at term undergoing induction of labor for any indication.Study Appraisal and Synthesis MethodsData were pooled using the random-effects and fixed-effects models after assessing for the presence of heterogeneity. Risk of bias for each included study was assessed based on the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Primary outcomes were cesarean delivery and time to delivery. Secondary outcomes were intrapartum infectious morbidity, operative delivery, indication for cesarean, cord prolapse, uterine hyperstimulation, meconium-stained amniotic fluid, and neonatal intensive care unit admission. A subanalysis that included only nulliparous patients was performed for the primary outcomes.ResultsThere were a total of 7 studies identified that met the inclusion criteria and these studies reported on 1775 patients. The early and late/spontaneous amniotomy groups included 884 and 891 patients, respectively. Patients who had an early amniotomy had a shorter time to delivery (mean difference, –3.62 hours; 95% confidence interval, –.09 to –1.16). When limiting the analysis to the 866 nulliparous women, early amniotomy was associated with a 5 hour shorter time to delivery compared with late amniotomy (mean difference, –5.12 hours; 95% confidence interval, –8.47 to –1.76; I2, 89%). There was no difference in the rate of cesarean delivery (relative risk, 1.09; 95% confidence interval, 0.80–1.49) or intrapartum infectious morbidity (relative risk, 1.42; 95% confidence interval, 0.77–2.61) between the 2 groups. There were no differences in any of the other secondary outcomes evaluated.ConclusionEarly amniotomy during induction of labor is associated with faster time to delivery without any evidence of adverse perinatal outcomes.
       
  • Suture thickness and transvaginal cervical cerclage outcomes
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Ashley N. Battarbee, Abbey Pfister, Tracy A. ManuckBackgroundCervical cerclage placement has been shown to benefit women who have cervical insufficiency; however, the best type of suture to use for transvaginal cerclage placement is unknown.ObjectiveThe objective of the study was to evaluate the association between transvaginal cerclage suture thickness and pregnancy outcomes.Study DesignThis was a retrospective cohort study of women with a singleton, nonanomalous gestation who underwent history-, ultrasound-, or physical examination–indicated transvaginal cerclage at a single tertiary care center (2013–2016). The primary outcome was gestational age at delivery. Secondary outcomes included preterm birth less than 34 weeks, chorioamnionitis, neonatal intensive care unit admission, and composite neonatal morbidity. Baseline characteristics and outcomes were compared by thickness of suture material: thick 5 mm braided polyester fiber (Mersilene tape) vs thin polyester braided thread (Ethibond) or polypropylene nonbraided monofilament (Prolene) with selection of suture type at the discretion of the provider. The association between thick suture and gestational age at delivery was estimated using Cox proportional hazard regression. Multivariable logistic regression was used to estimate the association between thick suture and the secondary outcomes. Effect modification of cerclage indication was also assessed.ResultsA total of 203 women met inclusion criteria: 120 with thick suture (59%) and 83 with thin suture (41%). Of these, 130 women had history-indicated, 35 had ultrasound-indicated, and 38 had examination-indicated cerclages. Compared with women who had thin suture, women with thick suture were more likely to have had a history- or ultrasound-indicated cerclage, rather than examination-indicated cerclage, and more likely to have had a Shirodkar or cervicoisthmic approach, rather than McDonald. Women with thick suture were also more likely to have received progesterone and had placement at earlier gestational age, but there were no differences in cervical examination at placement. After adjusting for confounding factors, thick suture was associated with longer pregnancy duration among women with ultrasound-indicated cerclage (adjusted hazard risk, 0.61, 95% confidence interval, 0.41–0.91) and examination-indicated cerclage (adjusted hazard risk, 0.30, 95% confidence interval, 0.15–0.58) but not with history-indicated cerclage (adjusted hazard risk, 1.27, 95% confidence interval, 0.83–1.94). Thick suture was also associated with lower odds of preterm birth
       
  • The risk of spontaneous preterm birth in asymptomatic women with a short
           cervix (≤25 mm) at 23−28 weeks’ gestation
    • Abstract: Publication date: Available online 25 October 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Moti Gulersen, Michael Y. Divon, David Krantz, Frank A. Chervenak, Eran BornsteinBackgroundAsymptomatic short cervical length is an independent risk factor for spontaneous preterm birth. However, most studies have focused on the associated risk of a short cervical length when encountered between 16 and 23 weeks’ gestation. The relationship between cervical length and risk of spontaneous preterm birth after 23 weeks is not well known.ObjectiveTo evaluate the risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23–28 weeks’ gestation.Materials and MethodsA retrospective cohort study of women with asymptomatic short cervix (cervical length ≤25 mm) at extreme prematurity, defined as 23−28 weeks’ gestation, was performed at a single center from January 2015 to March 2018. Women with symptoms of preterm labor, multiple gestations, fetal or uterine anomalies, cervical cerclage, or those with incomplete data were excluded from the study. Demographic information as well as data on risk factors for spontaneous preterm birth were collected. Patients were divided into 4 groups based on the cervical length measurement (≤10 mm, 11−15 mm, 16−20 mm, and 21−25 mm). The primary outcome was time interval from enrollment to delivery. Secondary outcomes included delivery within 1 and 2 weeks of enrollment, gestational age at delivery, and delivery prior to 32, 34, and 37 weeks, respectively. Continuous variables were compared using Kruskal−Wallis test, whereas categorical variables were compared using the χ2 or Fisher exact test as appropriate. The Wilcoxon test for difference in survival time was used to compare gestational age at delivery among the 4 cervical length groups, with data stratified based on gestational age at enrollment.ResultsOf the 126 pregnancies that met inclusion criteria, 22 (17.4%) had a cervical length of ≤10 mm, 23 (18.3%) had a cervical length of 11−15 mm, 37 (29.4%) had a cervical length of 16−20 mm, and 44 (34.9%) had a cervical length of 21−25 mm. Baseline characteristics were similar among all 4 groups. The shorter cervical length group was associated with a shorter time interval from enrollment to delivery (cervical length ≤10 mm, 10 weeks; cervical length 11−15 mm, 12.7 weeks; cervical length of 16−20 mm, 13 weeks; cervical length of 21−25 mm, 13.2 weeks; P = .006). Regardless of the cervical length measurement, delivery within 2 weeks was extremely uncommon (1 patient; 0.8%). The prevalence of spontaneous preterm birth at
       
  • Institutional prevalence of class III obesity modifies risk of adverse
           obstetrical outcomes
    • Abstract: Publication date: Available online 25 October 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Jennifer L. Katz Eriksen, Vivienne L. Souter, Peter G. Napolitano, Suchitra ChandrasekaranBackgroundWomen with prepregnancy class III obesity (body mass index ≥40 kg/m2) are at an increased risk of perinatal complications and adverse obstetrical outcomes. Estimates of the magnitude of risk that these women face vary widely, which may reflect differences in institutional experience caring for women with obesity.ObjectiveWe sought to characterize the relationship between institutional prevalence of prepregnancy class III obesity and the risk of adverse perinatal outcomes among these women, hypothesizing that higher-prevalence institutions would have lower rates of adverse maternal and perinatal outcomes among this population.Study DesignWe conducted a retrospective cohort study using chart-abstracted data on births in Washington state from Jan. 1, 2012, to Dec. 31, 2017. The analysis was restricted to hospitals that delivered at least 1 patient per month with prepregnancy class III obesity. Institutional prevalence of prepregnancy class III obesity was calculated, and hospitals were classified as either high or low prevalence. We included nulliparous women with vertex-presenting singleton pregnancies at ≥37 weeks of gestation. We excluded births with missing initial body mass index. The primary outcome was the incidence of cesarean delivery. Secondary outcomes were induction of labor, postpartum complications, postpartum readmission, and neonatal intensive care unit admissions. We compared outcomes between women with prepregnancy class III and all obesity at high- and low-prevalence hospitals using the χ2 test or the Fishers exact test as appropriate. Binary logistic regression was performed to compare outcomes at high- and low-prevalence hospitals. A hospital-adjusted multivariable regression model that controlled for baseline institutional rates of each outcome and compared outcomes between high- and low-prevalence hospitals was developed. A final multivariable logistic regression that controlled for both baseline institutional variation as well as potential clinical confounders was performed.ResultsA total of 20,556 women at 6 hospitals were eligible for inclusion; the prevalence of prepregnancy class III obesity was 6.2% and 2.1% in high- and low-prevalence hospitals, respectively. Obese women, including those with class III obesity in a high-prevalence hospital, were more likely to be Latina and less likely to be of advanced maternal age and carry private insurance. After adjusting for the institutional cesarean delivery rate, women with prepregnancy class III obesity had significantly increased odds of cesarean delivery (odds ratio, 1.53, 95% confidence interval, 1.12–2.10); however, after adjusting for significant covariates, the association no longer achieved significance (odds ratio, 1.68, 95% confidence interval, 0.97–2.94). The hospital-adjusted odds of postpartum readmission were significantly increased for women with prepregnancy class III obesity when delivering in low-prevalence institutions (odds ratio, 6.61, 95% confidence interval, 1.93–22.56), and the association was further strengthened after controlling for significant covariates (odds ratio, 15.20, 95% confidence interval, 2.32–99.53). None of the models demonstrated significantly different odds of induction of labor, postpartum complications, or neonatal intensive care unit admission by institutional prevalence of prepregnancy class III obesity.ConclusionEven after controlling for underlying hospital and subject characteristics, women with prepregnancy class III obesity had significantly increased odds of postpartum readmission, and a trend toward increased odds of cesarean delivery, when delivering in institutions with less experience caring for women with obesity.
       
  • Management of Reproductive Health in Patients with Pulmonary Hypertension
    • Abstract: Publication date: Available online 23 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Sudeep R. Aryal, Hind Moussa, Rachel Sinkey, Rajat Dhungana, Jose A. Tallaj, Salpy V. Pamboukian, Maria Patarroyo-Aponte, Deepak Acharya, Navkaranbir S. Bajaj, Samyukta Bhattarai, Andrew Lenneman, Joanna M. Joly, Baha M. Sibai, Indranee N. Rajapreyar Pulmonary hypertension (PH) is characterized by elevated pulmonary artery pressure due to several clinical conditions affecting pulmonary vasculature. Morbidity and mortality in this condition is related to development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant PH patient resulting in increased morbidity and mortality. Current guidelines recommend that patients with known PH be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management and delivery planning.
       
  • Childhood neurodevelopment after spontaneous versus indicated preterm
           birth
    • Abstract: Publication date: Available online 7 January 2020Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Emily E. Nuss, Jessica Spiegelman, Amy L. Turitz, Cynthia Gyamfi-Bannerman BackgroundPreterm birth is the leading cause of neonatal morbidity and mortality. Individuals who survive preterm birth are at a higher risk for many long-term adverse effects, including neurodevelopmental deficits. There are many well-established risk factors for worse neurologic outcomes spanning the prenatal and postnatal periods, however, investigators have yet to assess whether the cause of preterm birth has an impact on neurodevelopment.ObjectiveOur objective was to assess whether neurologic outcomes differ by children born via indicated versus spontaneous preterm birth.Study DesignSecondary analysis of a multicenter trial assessing magnesium for neuroprotection in women at risk for preterm delivery from 24 to 31 weeks. We included women with live, nonanomalous, singleton gestations who delivered preterm; we excluded those whose children were missing 2-year follow-up information for reasons other than perinatal demise. The primary exposure was type of preterm birth: 1) spontaneous if the child’s mother presented with preterm labor or ruptured membranes or 2) indicated if the child was delivered preterm iatrogenically. The primary outcome was death (including stillbirths, NICU deaths, and deaths after discharge) or an abnormal Bayley II score by two years of age, defined as a Mental Developmental Index score or Psychomotor Developmental Index score 2 standard deviations below the mean. Secondary outcomes included death or Mental Developmental Index and Psychomotor Developmental Index scores ≤1 standard deviation and neonatal morbidities associated with prematurity. Bivariate analyses of baseline characteristics by exposure were conducted. We fit a logistic regression model to adjust for confounders.ResultsOf 1,678 subjects 1,631 (97.2%) underwent spontaneous preterm birth and 47 (2.8%) underwent indicated preterm birth. Baseline maternal demographics and gestational age at delivery were similar between groups (29.6 wks ±7.8 v. 28.8 wks ±2.5, p=0.07). A Psychomotor Developmental Index score ≤2 standard deviations or death occurred in 340 (20.9%) spontaneous preterm birth subjects and 17 (36.2%) indicated preterm birth subjects (p=0.01). When adjusting for confounders, there remained an increased probability of a Psychomotor Developmental Index scores ≤2 standard deviations or death in indicated preterm birth subjects (p=0.02). Though not statistically significant, indicated preterm birth was also associated with higher odds of Mental Developmental Index scores ≤2 standard deviations or death, Psychomotor Developmental scores ≤1 standard deviation or death, and Mental Developmental Index scores ≤1 standard deviation or death (1.76, 1.59, 1.45, respectively). Limiting the analysis to small for gestational age infants, there was no difference in neurologic outcomes. The same was true for when we excluded small for gestational age infants from our analysis. However, after adjusting for small for gestational age, the odds of a Psychomotor Developmental Index score ≤2 standard deviations or death remained significant higher in the indicated preterm birth group (aOR 1.98, 95% CI 1.01, 3.88).ConclusionIn this cohort of pregnancies who delivered preterm, indicated deliveries were associated with worse psychomotor development than spontaneous deliveries. Other outcomes appeared poor, but our numbers were limited. This finding should be confirmed in a larger cohort of women undergoing medically indicated preterm deliveries.
       
  • Evidence-based labor management: before labor (Part 1)
    • Abstract: Publication date: Available online 20 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Vincenzo Berghella, Daniele Di MascioIn preparation for labor and delivery, there is high-quality evidence for providers to recommend perineal massage with oil for 5–10 minutes daily starting at 34 weeks until labor; ≥1 daily sets of repeated voluntary contractions of the pelvic floor muscles, performed at least several days of the week starting at approximately 30–32 weeks gestation; no x-ray pelvimetry; sweeping of membranes weekly starting at 37–38 weeks gestation; for women with a risk factor for abnormal outcome plans should be made to deliver in a hospital setting; for low-risk women, alongside birth center birth is associated with maternal benefits and higher satisfaction, compared with hospital birth; midwife-led care for low-risk women; continuous support by a professional such as doula, midwife, or nurse during labor; and training of birth attendants in low- and middle-income countries.
       
  • Optimal timing of antenatal corticosteroid administration and preterm
           neonatal and early childhood outcomes
    • Abstract: Publication date: Available online 17 December 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Ashley N. Battarbee, Stephanie T. Ros, M. Sean Esplin, Joseph Biggio, Radek Bukowski, Samuel Parry, Heping Zhang, Hao Huang, William Andrews, George Saade, Yoel Sadovsky, Uma M. Reddy, Michael W. Varner, Tracy A. Manuck, National Institute of Child Health and Human Development (NICHD) Genomics and Proteomics Network for Preterm Birth Research (GPN-PBR)BackgroundAntenatal corticosteroids reduce morbidity and mortality among preterm neonates. However, the optimal timing of steroid administration with regard to severe neonatal and early childhood morbidity is uncertain.ObjectiveTo evaluate the association between the timing of antenatal corticosteroid administration and preterm outcomes. We hypothesized that neonates exposed to antenatal corticosteroids 2 to
       
  • Food insecurity during pregnancy and gestational weight gain
    • Abstract: Publication date: Available online 22 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Lindsay A. Cheu, Lynn M. Yee, Michelle A. KominiarekBackgroundLimited or uncertain availability of nutritionally adequate and safe food, known as food insecurity, has been associated with obesity and other adverse health outcomes, but has rarely been studied in pregnancy. Food insecurity may negatively affect behavioral and physiological changes during pregnancy and may be associated with poor perinatal outcomes including gestational weight gain.ObjectiveGiven the lack of information on the role of food insecurity in pregnancy and the possible relationship with perinatal outcomes such as gestational weight gain, the objective of this study was to examine the association between food insecurity and gestational weight gain in a diverse cohort of pregnant women.Materials and MethodsThis was an observational study of 299 English-speaking women who delivered live-born singleton gestations at ≥24 weeks at a single tertiary care center. During their postpartum hospitalizations, enrolled women completed a survey of food security status during pregnancy using the United States Department of Agriculture Household Food Security Survey Module. Scores were analyzed as inadequate (marginal, low, or very low) vs adequate (high) food security. Women without prepregnancy body mass index and gestational weight gain data were excluded. The primary outcome was gestational weight gain categorized as inadequate, adequate, or excessive based on 2009 National Academy of Medicine guidelines, which account for body mass index. Secondary outcomes included total gestational weight gain and other maternal and neonatal outcomes. Multivariable linear and multinomial logistic regressions were performed to assess the independent associations of food insecurity with gestational weight gain after controlling for potential confounding factors.ResultsOf the 299 women enrolled in the study, 11.0% (n = 33) reported inadequate food security during pregnancy. Women with inadequate food security were younger (P = .007), had a greater mean body mass index (P < .001), were more likely to be non-Hispanic black or Hispanic (P < .001) and publicly insured (P < .001), but were less likely to be employed (P < .001). Women with inadequate food security also had fewer prenatal visits (P < .001) and were less likely to have initiated prenatal care in the first trimester (P < .001). The occurrence of excessive gestational weight gain did not differ by food security status (33.3% inadequate food security vs. 43.6% adequate food security, an adjusted relative risk ratio of 0.42, 95% confidence interval 0.16−1.14). Median total gestational weight gain was lower for women with inadequate food security (9.2 kg, interquartile range 7.5−14.1) than for women with adequate food security (13.9 kg, interquartile range 10.6−16.7) (P < .001), and this difference persisted when controlling for potential confounders including prepregnancy body mass index (β = −2.5, 95% confidence interval − 5.0 to −0.21).ConclusionsIn this diverse, urban population, more than 1 in 10 women experienced food insecurity during pregnancy. Inadequate food security was associated with lower median total gestational weight gain, but not with excessive gestational weight gain as determined by the 2009 National Academy of Medicine categories.
       
  • Population-attributable fraction of risk factors for severe maternal
           morbidity
    • Abstract: Publication date: Available online 22 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Kyle E. Freese, Lisa M. Bodnar, Maria M. Brooks, Kathleen McTigue, Katherine P. HimesBackgroundSevere maternal morbidity is an important proxy for maternal mortality. The population-attributable fraction is the proportion of a disease that is attributable to a given risk factor and can be used to estimate the reduction in the disease that would be anticipated if a risk factor were reduced or eliminated.ObjectiveWe sought to determine the population-attributable fraction of potentially modifiable risk factors for severe maternal morbidity.Materials and MethodsWe used a retrospective cohort of 86,260 delivery hospitalizations from Magee-Womens Hospital, Pittsburgh, PA, for this analysis (2003−2012). Severe maternal morbidity was defined as any of the following: Centers for Disease Control and Prevention International Classification of Diseases 9th Revision diagnosis and procedure codes for the identification of maternal morbidity; prolonged postpartum length of stay (defined as>3 standard deviations beyond the mean length of stay:>3 days for vaginal deliveries and>5 days for cesarean deliveries); or maternal intensive care unit admission. We used multivariable logistic regression with generalized estimating equations to estimate the association of prepregnancy overweight or obesity, maternal age ≥35 years, preexisting hypertension, preexisting diabetes, excessive gestational weight gain, smoking, education, and marital status with severe maternal morbidity. We then calculated the population-attributable fraction for each risk factor. We also examined the impact of modest reductions and elimination of risk factors on the population-attributable fraction of severe maternal morbidity.ResultsThe overall rate of severe maternal morbidity was 2.0%. Overweight and obesity, maternal age ≥35 years, preexisting hypertension, excessive gestational weight gain, and lack of a college degree had population-attributable fractions ranging from 4.5% to 13%. If all risk factors had been eliminated, 36% of cases could have been prevented. Modest reductions in the prevalence of excessive body mass index and advanced maternal age had minimal impact on preventing severe maternal morbidity. Smoking during pregnancy and marital status were not associated with severe maternal morbidity.ConclusionOur data suggest that maternal morbidity can be reduced by modifying common, individual-level risk factors. Nevertheless, the majority of cases were not attributable to the patient-level risk factors that we examined. These data support the need for large studies of patient-, provider-, system-, and population-level factors to identify high-impact interventions to reduce maternal morbidity.
       
  • Preoperative cefazolin rather than clindamycin or metronidazole is
           associated with lower postpartum infection among women with
           chorioamnionitis delivering by cesarean delivery
    • Abstract: Publication date: Available online 22 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Kartik K. Venkatesh, Brenna L. Hughes, Chad A. Grotegut, Robert A. Strauss, David M. Stamilio, R. Philip Heine, Sarah K. Dotters-KatzBackgroundThe optimal antibiotic regimen to prevent maternal postpartum infection among high-risk women treated for chorioamnionitis delivering by cesarean delivery remains to be defined. Emerging data suggest that cefazolin decreases the risk of cesarean surgical site infection.ObjectiveTo investigate whether intrapartum antibiotic therapy with cefazolin versus the current standard clindamycin or metronidazole decreases the risk of postpartum infectious morbidity among women delivering by cesarean delivery who were receiving a base regimen of ampicillin or penicillin with gentamicin for chorioamnionitis.Materials and MethodsA secondary analysis from the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry. We included women who delivered by cesarean delivery with presumptive chorioamnionitis (intrapartum fever>100.4°F and receipt of intrapartum antibiotics). All women received a base regimen of penicillin or ampicillin with gentamicin. We compared antibiotic therapy with cefazolin versus clindamycin or metronidazole. The primary outcome was a composite of postpartum maternal infection, including endometritis and surgical site infection. Multivariable logistic regression was used, adjusting for age, parity, race/ethnicity, insurance, body mass index at delivery, tobacco use, pregestational diabetes, American Society of Anesthesiologists classification, trial of labor prior to cesarean delivery, and postpartum antibiotics.ResultsAmong 1105 women with presumptive chorioamnionitis who delivered by cesarean delivery, 22.0% (n = 244) received cefazolin and 77.9% (n = 861) received clindamycin or metronidazole. Most women were in labor prior to cesarean delivery (93.8%) and received postpartum antibiotics (88.4%). Almost one-tenth (9.5%) were diagnosed with a postpartum infection, most commonly endometritis (80.9%), followed by surgical site infection (20.9%) (not mutually exclusive). Women treated with cefazolin rather than clindamycin or metronidazole had lower odds of postpartum infectious morbidity (adjusted odds ratio, 0.49; 95% confidence interval, 0.26−0.90). This association held when the outcome was restricted to surgical site infection (adjusted odds ratio, 0.11; 95% confidence interval, 0.01−0.92) but not endometritis. Similar results were observed with propensity score analysis.ConclusionAmong women delivering by cesarean delivery who were treated for chorioamnionitis, additional antibiotic therapy with cefazolin decreased the risk of postpartum infection, primarily surgical site infection, compared to the current standard clindamycin or metronidazole.
       
  • A multidisciplinary approach to improving process and outcomes in
           unscheduled cesarean deliveries
    • Abstract: Publication date: Available online 16 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Hayley S. Quant, Rebecca F. Hamm, Nadav Schwartz, Sindhu K. SrinivasBackgroundEffective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes.ObjectiveTo evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes.Materials and MethodsThis was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score
       
  • Surgical errors and complications following cesarean delivery in the
           United States
    • Abstract: Publication date: Available online 16 November 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Manal S. Sheikh, Gregg Nelson, Stephen L. Wood, Amy MetcalfeBackgroundCesarean delivery is the most common inpatient surgery performed internationally. Although cesarean delivery is typically performed to prevent adverse maternal and fetal outcomes, there is still a risk of surgical errors and complications. This study examined maternal and hospital risk factors associated with errors and complications following cesarean delivery in the United States.ObjectiveTo determine the prevalence of, and associated individual- and hospital-level risk factors for, surgical errors and complications following cesarean delivery in the United States.Materials and MethodsData were obtained from the 2012–2014 National Inpatient Sample. Surgical errors (eg,. foreign body retained during surgery, anesthetic error) can be the result of human error, whereas complications (eg, mortality, postpartum hemorrhage) can be due to external factors such as pre-existing comorbidities. The overall prevalence of surgical errors and complications in cesarean delivery was calculated. Multilevel logistic regression models were used to examine the association between individual and hospital characteristics and surgical errors/complications.ResultsAmong 648,584 cesarean delivery hospitalizations, 1.98% (95% confidence interval, 1.95–2.01%) and 8.43% (95% confidence interval, 8.40–8.46%) of women had an error or complication, respectively. The most common errors were anesthetic errors, errors involving blood vessels, and errors involving the bladder. The most common complications were postpartum hemorrhage, infection, and hysterectomy. Both individual- and hospital-level factors were associated with errors and complications. Women with Medicaid insurance had increased odds of errors (odds ratio, 1.40; 95% confidence interval, 1.37–1.43) but lower odds of complications (odds ratio, 0.89; 95% confidence interval, 0.88–0.90) compared to women with private insurance. Compared to non-Hispanic white women, women of all races had lower odds of error, and only non-Hispanic black women had greater odds of complications (odds ratio, 1.14; 95% confidence interval, 1.13–1.16). Similarly, rural hospitals had lower odds of surgical errors (odds ratio, 0.59; 95% confidence interval, 0.56–0.62) and complications (odds ratio, 0.61; 95% confidence interval, 0.59–0.62), whereas hospitals with a large bed number had greater odds of errors and complications than medium–bed size hospitals, at 1.13 (95% confidence interval, 1.09–1.17), and 1.13 (95% confidence interval, 1.11–1.15), respectively.ConclusionThis study identified specific risk factors for errors and complications that can be further examined through quality improvement frameworks to reduce the prevalence of adverse maternal events during cesarean delivery.
       
  • Pharmacokinetics of 17 alpha hydroxyprogesterone caproate in singleton
           pregnancy and its influence of maternal body size measures
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Micaela Della Torre, Christopher Enakpene, Samath Ravangard, Laura DiGiovanni, Kelly Deyo, Anna Whelan, Monique Sutherland, James FischerBackgroundReducing spontaneous preterm deliveries is a worldwide public health priority. Although many interventions have been studied, 1 of the most effective treatments to decrease recurrent preterm birth is the use of weekly 17 alpha hydroxy progesterone caproate. Previous studies on the influence of excessive adipose tissue and obesity on the use of 17 alpha hydroxyprogesterone caproate for the prevention of recurrent spontaneous preterm deliveries have shown conflicting findings.ObjectiveTo estimate the pharmacokinetics of weekly17 alpha hydroxyprogesterone caproate in singleton and to evaluate the effect of maternal body size on the pharmacokinetics parameters.Study DesignA prospective, open-label, longitudinal design was implemented for this population pharmacokinetic study. Plasma samples and clinical variables were collected in pregnant women between 16 and 36 weeks’ gestational age, carrying a singleton pregnancy and receiving 17 alpha hydroxyprogesterone caproate, 250 mg intramuscularly weekly for the prevention of recurrent spontaneous preterm birth. Pharmacokinetics parameters and significant clinical covariates were estimated using mixed effect modeling. Four body size indicators were used in the model to predict pharmacokinetics parameters: lean body weight, total body weight, body mass index, and body surface area.ResultsA total of 56 pregnant women, aged 18−44 years with body mass index of 14.5−54.6 kg/m2, provided 114 17 alpha hydroxyprogesterone caproate plasma samples concentration for analysis. A 1-compartment model with first-order absorption satisfactorily described 17 alpha hydroxyprogesterone caproate pharmacokinetics. Compared to other body size indicators, lean body weight best explained intersubject variability. Age, race, and gestational age did not influence 17 alpha hydroxyprogesterone caproate pharmacokinetics. Lean body weight was the best descriptor for the influence of body size on 17 alpha hydroxyprogesterone caproate apparent clearance. Simulations showed that administration of a standard fixed dose of 250 mg intramuscularly produced substantially lower 17 alpha hydroxyprogesterone caproate plasma concentrations in pregnant women with body mass index>30 kg/m2 compared to those with body mass index 30 kg/m2 compared to women with lower body mass index. Administration of doses adjusted for lean body weight produced nearly identical 117 alpha hydroxyprogesterone caproate plasma concentrations in both the low− and high−body mass index groups.ConclusionPopulation pharmacokinetics analysis indicates the clearance significantly increases with increasing lean body mass. Higher 17 alpha hydroxyprogesterone caproate doses, adjusted by maternal lean body mass, may be required in patients with a body mass index>30 to achieve equivalent plasma concentrations in pregnant women with a body mass index
       
  • Vaginal cleansing with chlorhexidine gluconate or povidone-iodine prior to
           cesarean delivery: a randomized comparator-controlled trial
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Federico Migliorelli, Begoña Martinez De Tejada
       
  • Social Media Committee
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s):
       
  • AJOG MFM First Birthday!!!
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Vincenzo Berghella
       
  • Why is applying to fellowship so difficult'
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Aayushi Sardana, Nisha Kapani, Alex Gu, Scott M. Petersen, Alexis C. GimovskyStudents at all stages of their medical careers rely on the internet to research programs during the application process to help them learn and make educated decisions. In fact, studies with prospective emergency medicine residents have shown that the quality of information online can even impact an applicant decision to apply. Fellowship program information on institutional websites in the fields of pediatrics, orthopedics surgery, and sports medicine have been studied each highlighting poor content and accessibility of information within the domains of program information, application process and educational curriculum. In this call to action, we aim to shed light on the content and accessibility of information on Maternal Fetal Medicine (MFM) fellowship program websites and discuss the benefits of further centralizing and standardizing program information.
       
  • What can we do to make the fellowship application process better'
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Judith H. Chung, Joanne Stone, Cynthia Gyamfi-Bannerman, Torri D. Metz, Society for Maternal-Fetal Medicine Fellowship Affairs Committee
       
  • Fetal heart rate monitoring in nonobstetric surgery: a systematic review
           of the evidence
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Mary F. Higgins, Lindsay Pollard, Siobhan K. McGuinness, John C. KingdomObjectiveConcern for fetal well-being during maternal nonobstetric surgery may result in obstetricians and other maternity care providers being asked to perform intraoperative fetal heart rate (FHR) monitoring. We systematically reviewed the evidence regarding the use of FHR monitoring during nonobstetric surgery after potential fetal viability (>22 weeks gestational age), and examined the FHR patterns and outcomes reported.Data sourcesA systematic review of the evidence was performed. Sources included databases (MEDLINE, EMBASE, Cochrane, and CENTRAL), hand searching, guidelines, conference proceedings, and literature reviews. Online searching was performed to include literature published from 1966 to May 2019.Study eligibility criteriaAll studies reviewing care of pregnant women undergoing nonobstetric surgery where FHR monitoring was performed intraoperatively. Data were extracted from appropriate full-text articles using a data abstraction form.Study appraisal and synthesisCase reports and case series only were identified. A total of 74 cases were reviewed, encompassing maternal general surgery (n = 41, cardiovascular surgery (n = 13) and neurosurgery/orthopedics (n = 20). Median gestational age at time of maternal surgery was 30 weeks (range, 22−36 weeks). In 41 cases, findings of FHR monitoring were not reported. Abnormal tracings were observed in 29 cases, as either reduced variability (n = 13) or fetal bradycardia (n = 17). All but 3 bradycardias reported occurred during maternal cardiac surgery involving aortic clamping and cardiopulmonary bypass. In 1 case, FHR monitoring was not possible because of a surgical pneumoperitoneum; there was 1 fetal tachycardia associated with maternal pyrexia, and three cases in which FHR monitoring was deemed stable or normal. Three preterm infants were delivered simultaneously at the time of general surgery as a result of FHR abnormalities (at 30, 33, and 34 weeks respectively), 2 as a result of fetal bradycardia and 1 because of protracted reduced variablity.ConclusionThe evidence for intraoperative fetal monitoring is based on case reports and cases series. Maternal cardiac surgery involving cardiopulmonary bypass commonly results in fetal bradycardia, which may be challenging to interpret. Obstetricians should be aware of FHR pattern changes in response to anesthesia and surgery that do not justify iatrogenic preterm cesarean delivery.
       
  • Maternal body mass index and pregnancy outcomes: a systematic review and
           metaanalysis
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Rohan D’Souza, Ivan Horyn, Sureka Pavalagantharajah, Nusrat Zaffar, Claude-Emilie JacobObjective DataThe purpose of this study was to determine the effect of body mass index category on pregnancy outcomes.StudyFive databases (Medline, Embase, PubMed, www.clinicaltrials.gov, and Cochrane) were searched from inception until February 2019 for English or French publications that reported on pregnancy outcomes in women with body mass index ≥30 kg/m2. Reference lists of included articles were searched, and authors were contacted for missing data where necessary. Because no randomized trials were identified, we included single-center and population-based cohort studies that stratified pregnancy outcomes under the following body mass index categories: underweight, standard weight, overweight, and obese classes I–III, based on the World Health Organization international classification system.Study Appraisal and Synthesis MethodsStudy quality was appraised with the use of the Newcastle-Ottawa Scale Quality Assessment Scale for cohort studies. Because significant heterogeneity was anticipated among studies, we used random-effects metaanalysis to arrive at pooled estimates and 95% confidence intervals for pregnancy outcomes in each body mass index category and relative risks in relation to women with a standard body mass index.ResultsWe identified 10,258 studies, of which 13 studies with a low risk-of-bias that described 3,722,477 pregnancies that were included in the metaanalysis. Most adverse pregnancy outcomes increased steadily with increasing body mass index category. Compared with women with body mass index 18.5-24.9 kg/m2, women with body mass index>40 kg/m2 were at increased risk for gestational diabetes mellitus [17% vs 3.9%; relative risk, 4.6 [95% confidence interval, 3.6–5.9]), hypertensive disorders of pregnancy (15.9% vs 3.5%; relative risk, 4.6 [95% confidence interval, 3.4–6.0]), and cesarean delivery (47.7% vs 26.0%; relative risk, 1.86 [95% confidence interval, 1.75–1.97]). Babies were at increased risk for hypoglycemia (4.1% vs 1.4%; relative risk, 3.3 [95% confidence interval, 2.8–3.8]), macrosomia (12.9% vs 6.2%; relative risk, 2.6 [95% confidence interval, 1.4–4.7]), infection (2.8% vs 1.3%; relative risk, 2.3 [95% confidence interval, 1.6–3.3]), birth trauma (1.3% vs 0.9%; relative risk, 2.1 [95% confidence interval, 1.2–3.8]), respiratory distress (5.1% vs 2.7%; relative risk, 2.0 [95% confidence interval, 1.8–2.2]), death (1.4% vs 0.9%; relative risk, 1.8 [95% confidence interval, 1.2–2.9]), and neonatal intensive care unit admission (13.5% vs 9.5%; relative risk, 1.6 [95% confidence interval, 1.4–1.9]).ConclusionThere is a linear association between maternal body mass index and almost all adverse pregnancy outcomes. These risks, stratified by body mass index category as presented in this article, would facilitate counselling and encourage appropriate interventions to improve outcomes for mothers and babies.
       
  • Later sleep timing is associated with an increased risk of preterm birth
           in nulliparous women
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Francesca L. Facco, Corette B. Parker, Shannon Hunter, Kathryn J. Reid, Phyllis P. Zee, Robert M. Silver, Grace Pien, Judith H. Chung, Judette M. Louis, David M. Haas, Chia-Ling Nhan-Chang, Hyagriv N. Simhan, Samuel Parry, Ronald J. Wapner, George R. Saade, Brian M. Mercer, Melissa Bickus, Uma M. Reddy, William A. Grobman, NICHD NuMoM2b and NHLBI NuMoM2b Heart Health Study NetworksBackgroundAlthough uterine contractions have a diurnal periodicity and increase in frequency during hours of darkness, data on the relationship between sleep duration and sleep timing patterns and preterm birth are limited.ObjectiveWe sought to examine the relationship of self-reported sleep duration and timing in pregnancy with preterm birth.Study DesignIn the prospective Nulliparous Pregnancy Outcome Study: Monitoring Mothers-to-be cohort, women completed a survey of sleep patterns at 6–13 weeks gestation (visit 1) and again at 22–29 weeks gestation (visit 3). Additionally, at 16–21 weeks gestation (visit 2), a subgroup completed a weeklong actigraphy recording of their sleep. Weekly averages of self-reported sleep duration and sleep midpoint were calculated. A priori, sleep duration of 5 am) in early pregnancy had a preterm birth rate of 9.5%, compared with 6.9% for women with sleep midpoint ≤5 am (P=.005). Similarly, women with a late sleep midpoint had a higher rate of spontaneous preterm birth (6.2% vs 4.4%; P=.019). Comparable results were observed for women with a late sleep midpoint at visit 3 (all preterm birth 8.9% vs 6.6%; P=.009; spontaneous preterm birth 5.9% vs 4.3%; P=.023). All adjusted analyses on self-reported sleep midpoint (models 1 and 2) maintained statistical significance (P
       
  • Associations between unstable housing, obstetric outcomes, and perinatal
           health care utilization
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Matthew S. Pantell, Rebecca J. Baer, Jacqueline M. Torres, Jennifer N. Felder, Anu Manchikanti Gomez, Brittany D. Chambers, Jessilyn Dunn, Nisha I. Parikh, Tania Pacheco-Werner, Elizabeth E. Rogers, Sky K. Feuer, Kelli K. Ryckman, Nicole L. Novak, Karen M. Tabb, Jonathan Fuchs, Larry Rand, Laura L. Jelliffe-PawlowskiBackgroundWhile there is a growing interest in addressing social determinants of health in clinical settings, there are limited data on the relationship between unstable housing and both obstetric outcomes and health care utilization.ObjectiveThe objective of the study was to investigate the relationship between unstable housing, obstetric outcomes, and health care utilization after birth.Study DesignThis was a retrospective cohort study. Data were drawn from a database of liveborn neonates linked to their mothers’ hospital discharge records (2007–2012) maintained by the California Office of Statewide Health Planning and Development. The analytic sample included singleton pregnancies with both maternal and infant data available, restricted to births between the gestational age of 20 and 44 weeks, who presented at a hospital that documented at least 1 woman as having unstable housing using the International Classification of Diseases, ninth edition, codes (n = 2,898,035). Infants with chromosomal abnormalities and major birth defects were excluded. Women with unstable housing (lack of housing or inadequate housing) were identified using International Classification of Diseases, ninth edition, codes from clinical records. Outcomes of interest included preterm birth (2 days; cesarean delivery,>4 days), emergency department visit within 3 months and 1 year after delivery, and readmission within 3 months and 1 year after delivery. We used exact propensity score matching without replacement to select a reference population to compare with the sample of women with unstable housing using a one-to-one ratio, matching for maternal age, race/ethnicity, parity, prior preterm birth, body mass index, tobacco use during pregnancy, drug/alcohol abuse during pregnancy, hypertension, diabetes, mental health condition during pregnancy, adequacy of prenatal care, education, and type of hospital. Odds of an adverse obstetric outcome were estimated using logistic regression.ResultsOf 2794 women with unstable housing identified, 83.0% (n = 2318) had an exact propensity score–matched control. Women with an unstable housing code had higher odds of preterm birth (odds ratio, 1.2, 95% confidence interval, 1.0–1.4, P < .05), preterm labor (odds ratio, 1.4, 95% confidence interval, 1.2–1.6, P < .001), long length of stay (odds ratio, 1.6, 95% confidence interval, 1.4–1.8, P < .001), emergency department visits within 3 months (odds ratio, 2.4, 95% confidence interval, 2.1–2.8, P < .001) and 1 year after birth (odds ratio, 2.7, 95% confidence interval, 2.4–3.0, P < .001), and readmission within 3 months (odds ratio, 2.7, 95% confidence interval, 2.2–3.4, P < .0014) and 1 year after birth (odds ratio, 2.6, 95% confidence interval, 2.2–3.0, P < .001).ConclusionUnstable housing documentation is associated with adverse obstetric outcomes and high health care utilization. Housing and supplemental income for pregnant women should be explored as a potential intervention to prevent preterm birth and prevent increased health care utilization.
       
  • Reply
    • Abstract: Publication date: November 2019Source: American Journal of Obstetrics & Gynecology MFM, Volume 1, Issue 4Author(s): Nisha A. Lakhi
       
  • Maternal mortality: beyond overmedicalized solutions
    • Abstract: Publication date: Available online 27 September 2019Source: American Journal of Obstetrics & Gynecology MFMAuthor(s): Katie R. AllanMaternal deaths, particularly racial disparities in maternal deaths, represent a deeper problem than their medicalized solutions reflect—one deeply rooted in the devaluation of women’s well-being, institutional inequality, and racism. Most policy solutions for addressing maternal mortality involve actionable goals within the purview of healthcare providers, medical institutions, and insurance providers. Although we should continue studying the causes of maternal mortality through maternal mortality review committees, reducing racism in medicine with implicit bias training, and standardizing pregnancy care, there is a pressing need to challenge the processes and institutions that lead to health inequities. A woman’s income level, insurance status, housing stability, country of origin, gender identity, or skin color should not dictate how likely she is to die from a pregnancy-related cause.
       
 
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