Faculty Bibliography

The objective of this study was to compare delivery outcomes among women in Northern Manhattan undergoing Centering versus routine prenatal care.This retrospective cohort study analyzed prenatal care and delivery hospitalizations among women receiving prenatal care at two ambulatory clinics in Northern Manhattan from 2013 to 2018. The exposure of interest was Centering versus routine prenatal care. The primary outcome of interest was preterm birth <37 weeks. Other clinical outcomes analyzed included number of prenatal visits, birth weight including very low birth weight (<1,500 g), cesarean versus vaginal delivery, and preterm birth at <32 weeks. Unadjusted and adjusted logistic regression models (accounting for demographic factors) were performed to analyze the association between the exposure of Centering prenatal care and the primary outcome with unadjusted (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI) as measures of association.A total of 714 women undergoing Centering prenatal care and 9,469 women undergoing traditional prenatal care were included in the analysis. Evaluating the primary outcome of preterm birth at <37 weeks, Centering was associated with a 5.9% risk of preterm birth compared to 7.1% with routine prenatal care (OR = 0.84, 95% CI: 0.53-1.30). Centering prenatal care was also not significantly associated with very low birth weight (OR = 0.4, 95% CI: 0.1-1.7), birth weight <2,500 g (OR = 0.65, 95% CI: 0.40, 1.06), or preterm birth at 32 to 36 weeks (OR = 1.0, 95% CI: 0.8, 1.2). Centering prenatal care was associated with lower odds of cesarean delivery (OR = 0.71, 95% CI: 0.60-0.84) and more frequent prenatal visits.Centering prenatal care was associated with lower likelihood of cesarean delivery and more frequent prenatal visits, while likelihood of preterm birth and low birth weight were not significantly more or less likely with Centering. · Centering prenatal care was associated with lower likelihood of cesarean delivery.. · Centering prenatal care was associated with more frequent prenatal visits.. · Preterm birth and low birth weight were not significantly more or less likely with Centering..

This study aimed to evaluate trends in placental abruption during delivery hospitalizations and associated risk factors and adverse outcomes.Delivery hospitalizations with and without placental abruption were identified using billing codes in the 2000 to 2020 National Inpatient Sample for this serial cross-sectional study. Temporal trends in abruption were analyzed with Joinpoint regression to determine the average annual percentage change (AAPC) in abruption. The association between hospital, demographic, and clinical factors and abruption was analyzed with adjusted logistic regression models with adjusted odds ratios (ORs) with 95% confidence interval (CI) as measures of association. Logistic regression models were then performed to assess the odds of adverse outcomes, including transfusion and severe maternal morbidity associated with abruption, accounting for demographic, hospital, and patient factors. Associations between changes in abruption and trends in the risk for adverse outcomes were then analyzed.Of 80.2 million deliveries from 2000 to 2020, 1.1 million had an abruption diagnosis. Placental abruption risk increased from 1.2% of deliveries in 2000 to 1.6% in 2020 (AAPC: 1.6%, 95% CI: 1.3%, 2.0%). Abruption was associated with multiple gestations, hypertensive diagnoses, diabetes, asthma, and Medicaid insurance. In adjusted analyses, abruption was associated with a range of adverse outcomes including transfusion (OR = 6.86, 95% CI: 6.70, 7.03), non-transfusion severe maternal morbidity (OR = 4.05, 95% CI: 3.93, 4.17), postpartum hemorrhage (OR = 1.76, 95% CI: 1.72, 1.80), disseminated intravascular coagulation (OR = 6.30, 95% CI: 6.00, 6.61), and critical care procedures (OR = 4.76, 95% CI: 4.26, 5.32). The increase in abruption accounted for 1.1% of the population change in transfusion risk over the study period.The risk for abruption increased over the study period and was associated with several adverse outcomes. Abruption accounted for a modest increase in population-level adverse outcomes. Given the increasing incidence, placental abruption will likely continue to be a significant source of adverse obstetric outcomes. · Abruption risk increased over the study period and was associated with several adverse outcomes.. · Abruption accounted for a modest increase in population-level adverse outcomes.. · Placental abruption will likely continue to be a significant source of adverse obstetric outcomes..

OBJECTIVE:To analyse the association between hypertensive diagnoses at delivery-both as a composite and individual diagnoses-and subsequent postpartum readmission for cardiovascular severe maternal morbidity (SMM). DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:2016-2022 Nationwide Readmissions Database. POPULATION OR SAMPLE/METHODS:Delivery hospitalisations with subsequent 6-month postpartum readmissions with cardiovascular SMM. METHODS:Multivariable logistic regression models were performed for postpartum cardiovascular SMM with delivery hospitalisation hypertensive diagnoses as the exposure of interest. Adjusted odds ratios (aORs) accounting for demographic, clinical and hospital factors were estimated as measures of association. An ancillary analysis restricted to deliveries with hypertensive diagnoses, excluding preterm prelabour rupture of membranes and preterm labour was performed to analyse the effect of gestational age at delivery. MAIN OUTCOME MEASURES/METHODS:Composite cardiovascular SMM. RESULTS:Among 12.0 million delivery hospitalisations, 1.8 million (15.4%) had an associated hypertensive diagnosis at delivery. Overall, 14 297 individuals (1.19 per 1000) were readmitted within 6 months postpartum with cardiovascular SMM, of whom 5912 (41.4%) had a hypertensive diagnosis at delivery. Hypertensive diagnoses were associated with increased odds for 6 months postpartum cardiovascular SMM readmission (aOR 2.8 95% CI 2.7-3.0). Evaluating individual diagnoses, superimposed preeclampsia (aOR 4.3, 95% CI 3.8-4.8), chronic hypertension (aOR 3.2, 95% CI 2.9-3.5), preeclampsia without severe features (aOR 3.1, 95% CI 2.8-3.5), preeclampsia with severe features (aOR 3.0, 95% CI 2.7-3.3) and gestational hypertension (aOR 2.1, CI 1.9-2.3) were all associated with significantly higher odds for postpartum cardiovascular SMM readmission compared to the absence of hypertensive diagnoses. In ancillary analysis restricted to patients with hypertensive disorders, delivery < 34 weeks was associated with higher odds for 6-month cardiovascular SMM postpartum readmission (aOR 1.4, 95% CI 1.2-1.6). CONCLUSIONS:Hypertensive diagnoses were associated with significantly increased odds for 6-month postpartum cardiovascular SMM readmission, with individual diagnoses demonstrating distinct odds. Among patients with hypertensive disorders, delivery < 34 weeks was particularly associated with increased odds. Hypertensive disorders are important risk factors for adverse cardio-obstetric outcomes postpartum and represent important factors to identify patient risk and improve the quality of postpartum care.

The use of continuous glucose monitors (CGM) and insulin pumps has revolutionized the care of patients with type 1 diabetes (T1D). Few data are available regarding the use of diabetes technology use in the pregnant T1D population. This study was conducted to evaluate temporal trends of diabetes technology use and predictors of use among pregnant individuals with TID in the United States from 2009 to 2020.MarketScan Research Databases from 2009 to 2020 were used to identify pregnant individuals with T1D who were and were not using CGM and/or insulin pumps. Joinpoint regression analysis was used to estimate the average annual percent change (AAPC) in diabetes technology use over time. Unadjusted and adjusted log-linear Poisson regression models were developed to assess the associations between the outcomes of CGM and insulin pump use and demographic and clinical predictors. Associations were reported as adjusted risk ratios (ARR) with 95% confidence intervals (CI).Among 9,201 pregnancies with T1D, CGM use increased from 2.3% in 2009 to 13.7% in 2020 (AAPC: 13.9%; 95% CI: 11.7-17.1), while insulin pump use remained unchanged from 10.9% in 2009 to 11.8% in 2020 (AAPC: -2.4%; 95% CI: -4.4 to 0.4). Medicaid insurance and obesity were associated with a lower likelihood of CGM use and insulin pump use, while a high obstetric comorbidity index score was associated with a higher likelihood of insulin pump use (ARR: 1.26; 95% CI: 1.05-1.51).From 2009 to 2020, CGM use among pregnant individuals with T1D increased, while insulin pump use remained unchanged. Use varied by patient demographic and clinical factors, most notable for lower likelihood of CGM use and insulin pump use with Medicaid insurance. Although CGM use increased over time, overall CGM use remained lower than expected despite the known benefits of CGM use in improving neonatal outcomes in pregnancies complicated by T1D. · CGM use in pregnant individuals with T1D increased from 2.3 to 13.7%, but pump use was stable.. · Medicaid and obesity were associated with lower CGM and pump use in pregnant individuals with T1D.. · Low CGM use in pregnant T1D individuals highlights barriers and the need for equitable access..

OBJECTIVE:To evaluate the association of vaginal versus caesarean birth with neonatal and maternal outcomes for breech, singleton deliveries at 22 0/7 to 25 6/7 weeks of gestation. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Hospital births in the United States. POPULATION/METHODS:This study analysed non-anomalous, singleton, breech live births at 22 0/7 to 25 6/7 weeks of gestation identified in the linked birth-infant death records data from 2016 to 2021. METHODS:A propensity score analysis was conducted to establish pseudo-randomization based on the mode of delivery, matching vaginal to caesarean deliveries at a ratio of 1:2 using greedy nearest-neighbour matching. The propensity score estimation included year of delivery, maternal age, race/ethnicity, pre-pregnancy body mass index, parity, marital status, maternal education, insurance status, attendant at delivery, smoking status, hypertensive disorders, diabetes mellitus, gestational age, induction of labour and whether a trial of labour was attempted. We estimated the risk differences (RD) and odds ratios (OR) and associated 95% CIs, taking the matching into consideration. Multiple imputation was used to account for missing data. MAIN OUTCOME MEASURES/METHODS:Composite adverse neonatal and maternal outcomes. RESULTS:Of 21,461 periviable breech singleton births, 34.0% (n = 7289) were delivered vaginally. The median gestational age was 24 (IQR: 23-25) and 23 (IQR: 22-24) weeks in the vaginal and caesarean delivery groups, respectively. Earlier gestational age was associated with vaginal birth, while later gestational age was associated with caesarean births. After propensity score matching, the distributions of baseline factors, except for gestational age, were balanced between the vaginal and caesarean delivery groups. A composite of adverse neonatal outcomes occurred among 99.0% (n = 7213) of vaginal and 96.8% (n = 13,716) of caesarean breech births (aRD 1.8%, 95% CI 1.3 to 2.4; aOR 2.25, 95% CI 1.59 to 3.17). Neonatal mortality rates were higher among vaginal compared to caesarean breech births (72.6% versus 36.2%; aRD 26.8%, 95% CI 25.0 to 28.6; aOR 3.15, 95% CI 2.85 to 3.48). A composite of adverse maternal outcomes occurred in 1.6% of vaginal breech and 3.1% of caesarean births (aRD -1.7%, 95% CI -2.2 to -1.1; aOR 0.47, 95% CI 0.35 to 0.63). CONCLUSIONS:Vaginal breech birth between 22 0/7 and 25 6/7 weeks of gestation is associated with a lower risk of adverse maternal outcomes but a higher risk of neonatal adverse outcomes and mortality.

OBJECTIVE:To assess trends in risk for obstetric venous thromboembolism (VTE). METHODS:This retrospective cohort study analyzed data from the 2008-2019 Merative MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 15-54 years with a delivery hospitalization and health care enrollment from 1 year before pregnancy to 60 days after delivery were identified. Risk for VTE during pregnancy from 2009 to 2019 was analyzed with joinpoint regression, with trends reported as the average annual percent change (APC). Venous thromboembolism events were identified with diagnosis codes along with pharmacy receipt of anticoagulants. Additionally, the association between risk factors for VTE and VTE events was evaluated with log-Poisson regression models with unadjusted and adjusted risk ratios (aRR) with 95% CIs as measures of association. RESULTS:Among 1,970,971 pregnancies, there were 5,270 VTE events, of which 35.5% (n=1,871) included a pulmonary embolism diagnosis and 64.5% (3,399) included a deep vein thrombosis diagnosis, alone. Risk for VTE increased significantly during pregnancy over the study period, with an APC of 9.2% (95% CI, 5.7-12.9%). Rates of VTE also increased individually during the antenatal period (APC 8.2%, 95% CI, 3.7-12.9%), during delivery hospitalizations (APC 12.2%, 95% CI, 7.4-17.3%), during the postpartum period (APC 8.4%, 95% CI, 5.9-11.0%), and individually for vaginal and cesarean delivery hospitalizations. Trends analyses individually for pulmonary embolism (APC 12.4%, 95% CI, 8.6-16.4%) and deep vein thrombosis (APC 7.6%, 95% CI, 4.0-11.3%) also demonstrated significant increases. In adjusted analyses for VTE, obesity (aRR 1.91, 95% CI, 1.78-2.05), chronic heart disease (aRR 3.14, 95% CI, 2.93-3.37), tobacco use (aRR 1.61, 95% CI, 1.34-1.95), asthma (aRR 1.46, 95% CI, 1.33-1.60), and preeclampsia (aRR 1.44, 95% CI, 1.31-1.58) were the factors associated the greatest increased adjusted relative risk. CONCLUSION/CONCLUSIONS:Risk for obstetric VTE increased significantly over the study period. Risk increased during the antenatal, delivery, and postpartum periods and for both cesarean and vaginal delivery.

BACKGROUND:Given the risks associated with congenital heart disease in the postpartum period, epidemiologic data identifying risk factors and timing of complications may be useful in improving postpartum care. OBJECTIVE:This study aimed to determine the timing of, risk factors for, and complications associated with 60-day postpartum readmissions following deliveries with maternal congenital heart disease. STUDY DESIGN/METHODS:The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions occurring within 60 days of delivery hospitalization discharge were ascertained. Clinical, demographic, and hospital risk factors associated with postpartum readmission were analyzed using logistic regression models, with unadjusted and adjusted odds ratios as measures of association. Among patients with congenital heart disease, the role of additional cardiac risk factors in the likelihood of readmission was analyzed. Risks for adverse maternal outcomes during readmission were analyzed, including severe maternal morbidity, cardiac severe maternal morbidity, and a critical care composite. RESULTS:Of an estimated 40,780,439 delivery hospitalizations, 35,242 had an associated congenital heart disease diagnosis (8.6 per 10,000), including 2279 (6.5%) with complex congenital heart disease and 32,963 (93.5%) with noncomplex congenital heart disease. The proportion of deliveries with a maternal congenital heart disease diagnosis increased significantly from 6.7 per 10,000 in 2010 to 11.8 in 2020. Overall risk for 60-day postpartum readmission was 1.6% among women without congenital heart disease and 3.1% among women with congenital heart disease (P<.01). Among women with congenital heart disease, 36.0% of 60-day postpartum readmissions occurred 1 to 5 days after discharge, 18.0% 5 to 10 days after discharge, and 14.5% 10 to 20 days after discharge. In adjusted models for the entire population, congenital heart disease retained a significant association with 60-day postpartum readmission (adjusted odds ratio, 1.73; 95% confidence interval, 1.55-1.94). When the cohort was restricted to deliveries with congenital heart disease, adjusted analyses demonstrated increased odds associated with additional cardiac risk factors (congestive heart failure: adjusted odds ratio, 1.72; 95% confidence interval, 1.13-2.62; arrhythmia: adjusted odds ratio, 1.68; 95% confidence interval, 1.27-2.21; pulmonary circulation disorders: adjusted odds ratio, 1.57; 95% confidence interval, 1.10-2.24; and chronic hypertension: adjusted odds ratio, 1.88; 95% confidence interval, 1.26-2.80), hypertensive disorders of pregnancy (adjusted odds ratio, 1.97; 95% confidence interval, 1.49-2.61), and cesarean delivery (primary adjusted odds ratio, 1.82; 95% confidence interval, 1.39-2.38; repeat cesarean: adjusted odds ratio, 1.91; 95% confidence interval, 1.42-2.55). The risk of adverse outcomes during readmissions was higher for women with congenital heart disease than for those without (severe maternal morbidity: 23.8% vs 16.1%; P<.01; cardiac severe maternal morbidity: 9.6% vs 4.9%; P<.01; and a critical care composite: 3.1% vs 1.8%; P<.01). CONCLUSION/CONCLUSIONS:Deliveries with congenital heart disease were associated with increased odds of postpartum readmission and complications during readmissions. Most readmissions occurred soon after delivery discharge. Among patients with congenital heart disease, risk for readmission was higher in the setting of additional cardiac risk factors, hypertensive disorders of pregnancy, and cesarean delivery.

In 2021, the severe acute respiratory syndrome coronavirus 2 Delta variant rapidly proliferated and became dominant. Some but not all research evidence supports that Delta was associated with increased maternal risk. The purpose of this study was to determine whether Delta was associated with risk for cardiac and respiratory complications in a national sample. Of an estimated 3,495,188 delivery hospitalizations in 2021, 1.8% of pre-Delta deliveries (n = 29,580; January-June) and 2.1% of Delta-period deliveries (n = 37,545; July-December) had a coronavirus disease 2019 (COVID-19) diagnosis. The Delta period was associated with increased adjusted odds of respiratory complications (adjusted odds ratio [aOR] = 1.54, 95% CI: 1.41, 1.69) and cardiac severe maternal morbidity (SMM; aOR = 1.54, 95% CI: 1.40, 1.69). Among deliveries with a COVID-19 diagnosis, the Delta period was associated with a higher incidence of respiratory complications (8.4 vs. 3.7%) and cardiac SMM (8.4 vs. 3.5%; p < 0.01 for both). These findings corroborate prior clinical studies suggesting that the Delta strain was associated with an increased maternal population-level clinical burden. · The Delta strain was associated with an increased maternal population-level clinical burden.. · The Delta period was associated with an increased risk for cardiac and respiratory complications.. · Among deliveries with a COVID-19 diagnosis, the Delta period was associated with increased risk..