Faculty Bibliography

INTRODUCTION/UNASSIGNED:Platelet hyperreactivity is linked to inflammation and cardiovascular risk in nonpregnant populations, but its relationship to placentally mediated pregnancy outcomes is undefined. We prospectively evaluated platelet hyperreactivity in pregnancy and subsequent ischemic placental disease (IPD), and examined aspirin's (ASA) effect on platelet activity by baseline platelet phenotype. METHODS/UNASSIGNED: RESULTS/UNASSIGNED:Of 66 pregnant participants recruited, 61 had first-trimester LTA; 20 (32.8%) had platelet hyperreactivity. Participants with hyperreactivity were more likely to develop IPD than those without (55% versus 24%, adjusted odds ratio [aOR] 3.77 (95% CI [1.05-13.53]), with consistent directionality across individual components despite low event frequencies. Participants with platelet hyperreactivity showed greater platelet aggregation to ADP, collagen, and low-dose AA. Platelet transcriptomic profiling distinguished participants with versus without platelet hyperreactivity and revealed differential expression of pathways related to platelet activity, energy metabolism, and immune regulation. Among 45 high-risk participants recommended ASA, those with hyperreactivity exhibited higher AA-induced aggregation (24% vs 12.5% platelet aggregation, p=0.01) despite similar serum TxB2 levels. CONCLUSION/UNASSIGNED:First-trimester platelet hyperreactivity was present in approximately one-third of participants and was independently associated with increased risk of IPD. Participants with platelet hyperreactivity demonstrated distinct transcriptomic signatures and greater platelet aggregation despite ASA use. Together, these findings support a contributory role for platelets in placental ischemic pathology and highlight the need to elucidate mechanisms and develop platelet-targeted preventive strategies.

OBJECTIVE:To evaluate the association between severe perioperative surgical morbidity with cesarean delivery and postpartum readmission. METHODS:This was a retrospective cross-sectional study using linked birth certificate and maternal discharge data for patients who underwent cesarean delivery in any California hospital between October 2015 and October 2021. Severe perioperative surgical morbidity is an index characterized by severe surgical complications occurring during hospitalization for cesarean delivery, identified using International Classification of Diseases, Tenth Revision diagnosis and procedure codes for severe surgical complications. The primary outcome was all-cause postpartum readmission within 42 days after hospital discharge. Readmission rates were quantified for patients with and without severe perioperative surgical morbidity, and generalized estimating equations were used to estimate adjusted relative risks (aRRs), adjusted risk differences (aRD), and 95% CIs, accounting for patient- and hospital-level factors. In secondary analysis, the association was assessed separately for prelabor and intrapartum cesarean deliveries. RESULTS:The study population included women who had undergone 703,079 cesarean deliveries. The readmission rate was higher among those with severe perioperative surgical morbidity compared with those without severe perioperative surgical morbidity (469.4/10,000 [95% CI, 428.0-511.0] vs 165.3/10,000 [95% CI, 162.3-168.3]). Severe perioperative surgical morbidity was associated with a twofold increased risk of readmission (aRR 2.22; 95% CI, 2.00-2.46). The aRD for patients with severe perioperative surgical morbidity was an excess of two readmissions (2.5; 95% CI, 2.1-3.0/100 cesarean deliveries) compared with patients without severe perioperative surgical morbidity. Wound infection was the most common diagnosis at readmission among patients with severe perioperative surgical morbidity (77/10,000; 95% CI, 60.5-95.3). The risk of readmission was similar among patients with severe perioperative surgical morbidity and without severe perioperative surgical morbidity who underwent intrapartum cesarean delivery (aRR 2.35; 95% CI, 2.09-2.65) and prelabor cesarean delivery (aRR 2.03; 95% CI, 1.72-2.40). CONCLUSION/CONCLUSIONS:Nearly 1 in 20 patients undergoing cesarean delivery who experience severe perioperative surgical morbidity undergoes postpartum readmission, with a twofold increased readmission risk at 42 days after discharge. Patients with severe perioperative surgical morbidity may benefit from targeted follow-up to reduce postpartum admission.

IMPORTANCE/UNASSIGNED:Insomnia and obstructive sleep apnea (OSA) are associated with pregnancy complications. OBJECTIVE/UNASSIGNED:To evaluate the association of insomnia and OSA during pregnancy with the risk of ischemic placental disease (IPD) and severe morbidity (SM) and to compare these risks between the 2 sleep disorders. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study included a statewide population-based sample of liveborn singleton births with linked birth certificates for birthing people and their infants in California from January 1, 2011, through December 31, 2020. The analysis was performed on July 22, 2024. EXPOSURES/UNASSIGNED:Insomnia and OSA. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcomes were IPD, defined as preeclampsia, placental abruption, and birth of a neonate small for gestational age (SGA), and SM, defined according to the Centers for Disease Control and Prevention definition. RESULTS/UNASSIGNED:During the study period, there were 4 145 096 singleton live births among birthing people aged 13 to 55 years; 4783 (0.1%) had insomnia, 5642 (0.1%) had OSA, and 4 134 671 (99.7%) had neither condition. The prevalence of insomnia and OSA was 116 and 136 cases per 1000 live births, respectively. Compared with patients without insomnia or OSA (738 660 [17.9%]), the adjusted relative risk (ARR) of any IPD was 1.42 (95% CI, 1.35-1.50) for those with insomnia (1406 patients [29.4%]) and 1.57 (95% CI, 1.50-1.64) for those with OSA (1848 [32.8%]). Compared with patients with neither disorder, the ARR of birth of an SGA neonate was higher for those with insomnia (1.23; 95% CI, 1.13-1.35) than for those with OSA. The ARR of preterm birth was 1.81 (95% CI, 1.68-1.95) for insomnia (711 patients [14.9%]) and 1.73 (95% CI, 1.62-1.85) for OSA (870 [15.4%]) vs neither disorder (279 364 [6.8%]). The ARR of SM was 2.26 (95% CI, 2.03-2.50) for insomnia (366 patients [7.7%]) and 2.81 (95% CI, 2.58-3.06) for OSA (545 [9.7%]) vs neither disorder (93 857 [2.3%]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study of singleton live births, pregnant individuals with insomnia or OSA were at increased risk for IPD, SM, and preterm birth compared with those without these sleep disorders. Further study is needed to determine the biological mechanisms for these risks and whether early identification and targeted preventive interventions may improve pregnancy outcomes.

OBJECTIVE:To investigate the relationship between platelet indices (count, size and production/immaturity) and hypertensive disorders of pregnancy. STUDY DESIGN/METHODS:This was a secondary analysis of a prospective cohort of pregnant individuals followed from first trimester through delivery at an academic tertiary care institution. Routine platelet indices obtained prospectively during prenatal care and delivery were compared between those who developed a hypertensive disorder of pregnancy and those who did not. We assessed platelet count (by trimester), mean platelet volume, and immature platelet fraction measured as percent (%) and absolute count. Data were analyzed using Fisher's Exact test, chi-square test, and multivariable logistic regression. P < 0.05 was considered statistically significant. RESULTS: = 0.01) compared to those without a hypertensive disorder of pregnancy, after adjusting for age, race/ethnicity, obesity, nulliparity, and chronic hypertension. The prevalence and likelihood of a hypertensive disorder of pregnancy increased with increasing mean platelet volume, as well as with both the percent and absolute immature platelet fraction. There was no difference between groups in platelet count in the first trimester, second trimester, or at delivery. CONCLUSIONS:An increase in platelet size and immaturity was observed in those with a hypertensive disorder of pregnancy. These data support further investigation of platelets in the mechanisms of the development of hypertensive disorders of pregnancy and the use of platelet indices to better identify high risk groups in pregnancy.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Healthcare is increasingly being delivered in the outpatient setting, but robust quality improvement programs and performance metrics are lacking in ambulatory care, particularly specialty-based ambulatory care. METHODS:To promote quality improvement in ambulatory care, we developed an infrastructure to create specialty-specific quality measures and dashboards that could be used to display providers' performance across relevant measures to individual providers and institutional leaders. RESULTS:The products of this program include a governance and infrastructure for specialty-specific ambulatory quality metrics as well as two distinct dashboards for data display. One dashboard is provider-facing, displaying provider's performance on specialty-specific measures as compared to institutional standards. The second dashboard is a leadership dashboard that provides overall and provider-level information on performance across measures. CONCLUSIONS:The Specialty-based Ambulatory Quality program reflects a systematic, institutionally-supported quality improvement framework that can be applied across diverse ambulatory specialties. As next steps, we plan to evaluate the program's impact on provider performance across measures and expand this program to other specialties practicing in the outpatient setting.

OBJECTIVE:Preterm induction of labor can be necessary for maternal and fetal wellbeing. Duration of cervical ripening balloon (CRB) use has been studied in only term inductions. Our study investigated duration of time in hours for CRB expulsion and vaginal delivery in preterm inductions of labor. METHODS:This was a single-institution retrospective cohort study of preterm (< 37 weeks) and term (≥ 37 weeks) inductions with CRB between 2010 and 2021. Cesarean deliveries were excluded. Primary outcome was insertion to expulsion time of CRB. Secondary outcomes included induction to delivery time, cervical dilation after expulsion, misoprostol, and Pitocin use. Institutional review board (IRB) approval was obtained prior to the study. RESULTS:Ninety-eight patients with vaginal delivery after preterm CRB use were identified and matched 1:1 on baseline characteristics (p > 0.05) to term patients with vaginal delivery after CRB use. Mean insertion to expulsion time was significantly shorter for term than preterm inductions (mean 7.2 ± 3.09 h versus 8.5 ± 3.38 h; p < 0.01). Mean induction to delivery time was significantly shorter for term than preterm inductions (18.4 ± 7.6 h versus 22.5 ± 9.01 h; p < 0.01). Increased use of misoprostol, Pitocin, and second CRB were noted among the preterm cohort. Among term patients, more CRB placement at start of induction and greater cervical dilation post-balloon were found in comparison to preterm patients. CONCLUSION/CONCLUSIONS:Among patients undergoing preterm induction, longer insertion to expulsion time of CRB, longer induction to delivery time, and increased interventions should be expected. Different standards for labor management should be considered for achieving vaginal delivery in preterm inductions.

BACKGROUND/UNASSIGNED:Coronary artery spasm is an established mechanism of myocardial infarction with non-obstructive coronary arteries (MINOCA). Various mechanisms have been proposed, ranging from vascular smooth muscle hyperreactivity to endothelial dysfunction, to autonomic nervous system dysregulation. CASE SUMMARY/UNASSIGNED:We report a case of a 37-year-old woman who presented with recurrent non-ST elevation myocardial infarction (NSTEMI), coinciding with her menstrual periods. Intracoronary acetylcholine provocation testing resulted in coronary spasm in the left anterior descending artery (LAD) that was relieved with nitroglycerine. Initiating calcium channel blockade and suppressing cyclical variation in sex hormones resulted in improvement of her symptoms and cessation of monthly NSTEMI events due to coronary spasm. DISCUSSION/UNASSIGNED:Initiating calcium channel blockade and suppressing cyclical variation in sex hormones resulted in improvement of her symptoms and cessation of monthly NSTEMI events due to coronary spasm. Catamenial coronary artery spasm is a rare, but clinically important, presentation of myocardial infarction with non-obstructive coronary arteries (MINOCA).

INTRODUCTION: Preterm induction of labor can be necessary for maternal and fetal wellbeing. Duration of cervical ripening balloon (CRB) use has been studied only in term inductions. Our study investigated duration of time for CRB expulsion and vaginal delivery in preterm inductions of labor.
METHOD(S): This was a single-institution retrospective cohort study of preterm (<37 weeks) and term (>=37 weeks) inductions with CRB between 2010 and 2021. Cesarean deliveries were excluded. Primary outcome was insertion to expulsion time (IET) of CRB. Secondary outcomes included induction to delivery time (IDT), cervical dilation after expulsion, and misoprostol and Pitocin use. Institutional review board approval was obtained prior to the study.
RESULT(S): A total of 98 patients with vaginal delivery after preterm CRB use were identified and matched 1:1 on baseline characteristics to patients with vaginal delivery after term CRB use. Mean IET was significantly shorter for term CRB than for preterm induction (mean 7.2+/-3.09 hours versus 8.5+/-3.38 hours; P=.004). Mean IDT was significantly shorter for term CRB than preterm CRB induction (18.4+/-7.6 hours versus 22.5+/-9.01 hours; P<.001). Increased use of misoprostol, Pitocin, and second CRB were noted among the preterm cohort compared to the term cohort. Among term patients, more CRB placement at start of induction and greater cervical dilation postballoon were found in comparison to preterm patients.
CONCLUSION(S): Among patients undergoing preterm induction, longer IET, longer IDT, and increased interventions should be expected. Different standards for labor management should be considered for achieving vaginal delivery in preterm inductions