Faculty Bibliography

OBJECTIVE:This study aimed to determine whether receiving a proton-pump inhibitor (PPI) prescription during pregnancy was associated with decreased risk for preeclampsia. STUDY DESIGN:The Truven Health MarketScan database was used to determine whether receiving a PPI prescription was associated with risk for preeclampsia. Risk for preeclampsia was evaluated based on the presence or absence of receiving a PPI prescription (1) any time during pregnancy, and 2) individually during the 1st, 2nd, and 3rd trimesters. In addition to evaluating risk for all preeclampsia, severe preeclampsia and preterm severe preeclampsia were evaluated. Adjusted models including risk factors such as chronic hypertension, maternal age, multiple gestation, and diabetes were performed with adjusted risk ratios (aRR) with 95% confidence intervals [CIs] as measures of effect. RESULTS:A total of 2,755,885 women were included in the analysis of whom 69,249 were prescribed a PPI during pregnancy (2.5%). In adjusted models, receiving a PPI prescription anytime during pregnancy (aRR 1.28, 95% CI 1.24-1.32), the 1st trimester (aRR 1.12, 95% CI 1.04-1.22), the 2nd trimester (aRR 1.20, 95% CI 1.15-1.26), and the 3rd trimester (aRR 1.41, 95% CI 1.35-1.47) were all associated with increased risk for preeclampsia. Risk for severe preeclampsia was also significantly increased with receiving a PPI prescription anytime during pregnancy (aRR 1.21, 95% CI 1.15-1.27), during the 2nd trimester (aRR 1.14, 95% CI 1.06-1.23), and during the 3rd trimester (aRR 1.33, 95% CI 1.24-1.43), but not the first trimester (aRR 1.04, 95% CI 0.92-1.19). Evaluating the risk for preterm severe preeclampsia, adjusted risk was significantly increased with receiving a PPI prescription in the second trimester (aRR 1.35, 95% CI 1.21-1.52) but not the first trimester (aRR 1.06, 95% CI 0.86-1.32). CONCLUSION:In this analysis of payer data, receiving a PPI prescription during pregnancy was not associated with decreased risk for preeclampsia. Further empiric research is required to determine whether an effect may be present. KEY POINTS:· Proton pump inhibitors were not associated with decreased risk for preeclampsia.. · Proton pump inhibitors were not associated with decreased risk for severe preterm preeclampsia.. · Proton pump inhibitors are commonly prescribed during pregnancy..

OBJECTIVE:This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. STUDY DESIGN:The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. RESULTS:High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50-1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25-1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40-1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06-1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98-1.05; aRR: 0.95, 95% CI: 0.92-0.99). CONCLUSION:This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.

BACKGROUND:Chronic comorbid conditions increase the risk of influenza-related morbidity. Whether this holds for pregnant women who are at a high risk of complications from influenza remains to be determined. OBJECTIVE:This study aimed to determine whether chronic comorbid conditions are associated with an increased risk of severe maternal morbidity among pregnant women with an influenza diagnosis at delivery hospitalization. STUDY DESIGN:We performed a cross-sectional analysis of delivery hospitalizations complicated by an influenza diagnosis using the National Inpatient Sample from 2000 to 2015. We assessed 4 prevalent chronic comorbid conditions associated with increased influenza complications outside of pregnancy, obstructive lung disease (asthma and chronic obstructive pulmonary disease), chronic hypertension, obesity, and pregestational diabetes mellitus, overall and individually. The primary outcome was severe maternal morbidity, excluding transfusion as defined by the Centers for Disease Control and Prevention, and the secondary outcomes were specific severe maternal morbidity measures that were recognized as influenza-related complications, acute respiratory distress syndrome, mechanical intubation and ventilation, and sepsis and shock. Multivariable survey-weighted log-linear models were used, adjusting for patient, hospital, and clinical characteristics. RESULTS:Of 62.7 million delivery hospitalizations, 144,572 (0.2%) were complicated by an influenza diagnosis at delivery hospitalization (23 cases of influenza per 10,000 delivery hospitalizations) and 36,054 (24.9%) with ≥1 chronic comorbid conditions, of which 77.4% included obstructive lung disease. Pregnant women with an influenza diagnosis at delivery hospitalization with chronic comorbid conditions had a slightly higher risk of severe maternal morbidity than those without (2.6% vs 1.7%; adjusted risk ratio, 1.11; 95% confidence interval, 1.03-1.21) and acute respiratory distress syndrome (0.9% vs 0.5%; adjusted risk ratio, 1.42; 95% confidence interval, 1.23-1.64) and mechanical intubation and ventilation (0.2% vs 0.1%; adjusted risk ratio, 1.92; 95% confidence interval, 1.37-2.69) but a lower risk of sepsis and shock (0.2% vs 0.3%; adjusted risk ratio, 0.57; 95% confidence interval, 0.45-0.73). Regarding specific conditions, obstructive lung disease was associated with an increased risk of severe maternal morbidity (adjusted risk ratio, 1.21; 95% confidence interval, 1.11-1.32) and acute respiratory distress syndrome (adjusted risk ratio, 1.54; 95% confidence interval, 1.32-1.79) and mechanical intubation and ventilation (adjusted risk ratio, 2.80; 95% confidence interval, 2.00-3.91). Chronic hypertension was associated with an increased risk of acute respiratory distress syndrome (adjusted risk ratio, 1.70; 95% confidence interval, 1.16-2.49) but a lower risk of sepsis and shock (adjusted risk ratio, 0.34; 95% confidence interval, 0.13-0.85). Obesity was associated with a lower risk of severe maternal morbidity (adjusted risk ratio, 0.84; 95% confidence interval, 0.74-0.97). Pregestational diabetes mellitus was not associated with severe maternal morbidity. CONCLUSION:Among women with a diagnosis of influenza at delivery hospitalization, chronic comorbid conditions may increase the risk of severe maternal morbidity and particularly outcomes related to influenza. These results can inform efforts to increase influenza vaccination for all pregnant women, in particular those with chronic comorbidities.

BACKGROUND:It is currently unknown whether primary CDs performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement guidelines ("guideline-compliant") are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the guidelines ("guideline-noncompliant"). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD. METHODS:A retrospective cohort study of all primary CDs at one tertiary referral center in the calendar year following publication of the Consensus Statement. Logistic regression was performed to calculate the risk of adverse maternal and neonatal outcomes for guideline-compliant primary CDs, when compared to guideline-noncompliant and guideline-not addressed, and when adjusted for maternal age, BMI, hypertension, gestational age at delivery, insurance carrier, and provider practice. RESULTS:Eight hundred twenty-seven primary CDs were included during the study period, of which 34.8, 26.0, and 39.2% were guideline compliant, guideline-noncompliant, and guideline-not addressed. No statistically significant differences in the frequency of adverse maternal outcomes across these three groups were observed with the exception of maternal ICU admission, which was significantly associated with a guideline-not addressed primary CD (p = 0.0002). No statistical difference in rates of NICU admissions, 5 min APGAR < 5, or umbilical artery cord pH < 7 were observed between guideline-compliant and guideline-noncompliant primary CDs. CONCLUSION/CONCLUSIONS:Women undergoing guideline-compliant primary CDs were not significantly more likely to experience a maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs.

BACKGROUND:Women with liver transplants may be at increased risk for adverse outcomes. OBJECTIVE:The objectives of this study were to evaluate trends and provide recent data on outcomes for women with a liver transplant. STUDY DESIGN/METHODS:The National (Nationwide) Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project from 1998 to 2014 was used for this repeated cross-sectional analysis. Women aged between 15 and 54 years, with a history of liver transplant who underwent delivery, antepartum, or postpartum hospitalizations were identified. Temporal trends in deliveries of women with liver transplants were analyzed. The risk for severe maternal morbidity (SMM) excluding transfusion based on criteria from the Centers for Disease Control and Prevention (CDC), as well as for individual outcomes including hypertensive diseases of pregnancy, postpartum hemorrhage, placental abruption, liver rejection, cesarean delivery, preterm delivery, and coagulopathy during delivery hospitalizations were analyzed. Risks of SMM during antepartum and postpartum hospitalizations were also analyzed. An adjusted log-linear regression model for SMM during delivery hospitalizations including demographic factors, hospital characteristics, and underlying comorbidity was performed. The chi-squared or Fisher's exact test was used for comparisons. Temporal trends were analyzed with the Cochran-Armitage trend test. Population weights were applied to create national estimates. RESULTS: < .01). A diagnosis of liver rejection was present during 4.1% of delivery hospitalizations for women with liver transplant. In the adjusted analysis for severe morbidity excluding transfusion risk was retained with liver transplant associated with increased likelihood of this adverse outcome (aRR 8.49, 95% CI 5.59-12.87). Women with liver transplants were at significantly higher likelihood of undergoing antepartum and postpartum admissions, and of experiencing SMM during these hospitalizations. CONCLUSION/CONCLUSIONS:In this analysis of antepartum, delivery, and postpartum hospitalizations, women with liver transplant were at significantly higher risk for both SMM during all hospitalizations and for a range of adverse outcomes including placental abruption, hypertensive diseases of pregnancy, postpartum hemorrhage, cesarean delivery, and coagulopathy delivery during delivery hospitalizations. While deliveries to women with liver transplant were rare, these births became more frequent over the study period.

BACKGROUND:Placenta accreta spectrum (PAS) is a spectrum of conditions in which the placenta is abnormally adherent and invades the uterine wall. This invasion can cause life-threatening hemorrhage and lead to significant adverse maternal outcomes. Numerous studies have shown an association between treatment of PAS at high volume, specialized centers and improved maternal outcomes; however, little is known about how these data have influenced practice. OBJECTIVE:The objective of the study was to examine the patterns of care for women with placenta accreta spectrum over time. STUDY DESIGN/METHODS:Data from New York Statewide Planning and Research Cooperative System (SPARCS) from 2000 to 2017 was used for this analysis. The study cohort comprised of women aged 15-54 years with PAS who underwent a hysterectomy during their delivery hospitalization. Study outcomes included severe maternal morbidity as defined by the Centers for Disease Control and Prevention, surgical complications, and transfusion. Hospitals were stratified into tertiles based on the volume of PAS hysterectomy cases. Patient demographic and clinical characteristics were compared across volume tertiles. Random intercept log-linear regression models with Poisson distributions and log link functions were fit to examine the association between hospital PAS volume and the outcomes of interest. RESULTS:A total of 1958 women with PAS who underwent hysterectomy at 123 hospitals were identified. The number of hospitals providing care ranged from 46 centers in 2000 to 52 hospitals in 2016. The median hospital-level case volume of PAS was 1 (interquartile range [IQR], 1-2) in 2000 and rose slightly to 2 (IQR, 1-4) by 2016. The PAS volume cut-point for the top decile of hospitals was three cases in 2000 and increased to six cases in 2016. There was no significant change in the median travel distance for women with PAS over time. The rate of severe maternal morbidity increased significantly from 14.1% (95% CI: 7.8-24.0%) in 2000 to 19.0% (95% CI: 13.6-25.8%) in 2016. Transfusion occurred in 66.2% (95% CI: 54.6-76.1%) of cases in 2000 compared to 60.1% (95% CI: 52.3-67.4%) in 2016. Surgical complications occurred in 16.9% (95% CI: 9.9-27.3%) of cases in 2000 to 24.7% (95% CI: 18.6-32.0) in 2016. There was no difference in the adjusted rates of transfusion or surgical complications based on hospital volume. Compared to low-volume centers, the risk of severe maternal morbidity was reduced by 33% (aRR = 0.67; 95% CI: 0.50-0.90) at the intermediate volume centers. CONCLUSION/CONCLUSIONS:There has been little change in the patterns of care for women with PAS in New York State. While the volume of patients with PAS has increased at the highest volume centers, a large number of relatively low-volume centers still provide care for a significant number of women with PAS.

Importance:Limited data on vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and health outcomes of neonates born to mothers with symptomatic or asymptomatic coronavirus disease 2019 (COVID-19) are available. Studies are needed to inform evidence-based infection prevention and control (IP&C) policies. Objective:To describe the outcomes of neonates born to mothers with perinatal SARS-CoV-2 infection and the IP&C practices associated with these outcomes. Design, Setting, and Participants:This retrospective cohort analysis reviewed the medical records for maternal and newborn data for all 101 neonates born to 100 mothers positive for or with suspected SARS-CoV-2 infection from March 13 to April 24, 2020. Testing for SARS-CoV-2 was performed using Cobas (Roche Diagnostics) or Xpert Xpress (Cepheid) assays. Newborns were admitted to well-baby nurseries (WBNs) (82 infants) and neonatal intensive care units (NICUs) (19 infants) in 2 affiliate hospitals at a large academic medical center in New York, New York. Newborns from the WBNs roomed-in with their mothers, who were required to wear masks. Direct breastfeeding after appropriate hygiene was encouraged. Exposures:Perinatal exposure to maternal asymptomatic/mild vs severe/critical COVID-19. Main Outcomes and Measures:The primary outcome was newborn SARS-CoV-2 testing results. Maternal COVID-19 status was classified as asymptomatic/mildly symptomatic vs severe/critical. Newborn characteristics and clinical courses were compared across maternal COVID-19 severity. Results:In total, 141 tests were obtained from 101 newborns (54 girls [53.5%]) on 0 to 25 days of life (DOL-0 to DOL-25) (median, DOL-1; interquartile range [IQR], DOL-1 to DOL-3). Two newborns had indeterminate test results, indicative of low viral load (2.0%; 95% CI, 0.2%-7.0%); 1 newborn never underwent retesting but remained well on follow-up, and the other had negative results on retesting. Maternal severe/critical COVID-19 was associated with newborns born approximately 1 week earlier (median gestational age, 37.9 [IQR, 37.1-38.4] vs 39.1 [IQR, 38.3-40.2] weeks; P = .02) and at increased risk of requiring phototherapy (3 of 10 [30.0%] vs 6 of 91 [7.0%]; P = .04) compared with newborns of mothers with asymptomatic/mild COVID-19. Fifty-five newborns were followed up in a new COVID-19 Newborn Follow-up Clinic at DOL-3 to DOL-10 and remained well. Twenty of these newborns plus 3 newborns followed up elsewhere had 32 nonroutine encounters documented at DOL-3 to DOL-25, and none had evidence of SARS-CoV-2 infection, including 6 with negative retesting results. Conclusions and Relevance:No clinical evidence of vertical transmission was identified in 101 newborns of mothers positive for or with suspected SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices.

Background Racial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes. Methods and Results Using billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy-induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log-linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy-induced hypertension, black and Hispanic women had higher stroke risk compared with non-Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86-2.30; Hispanics: aRR, 2.19; 95% CI, 1.98-2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30-2.26; Hispanics: aRR, 1.75; 95% CI, 2.32-5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32-5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07-1.28). Conclusions Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non-Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy-induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.

OBJECTIVE:To characterize use of uterine tamponade and interventional radiology procedures. METHODS:This retrospective study analyzed uterine tamponade and interventional radiology procedures in a large administrative database. The primary outcomes were temporal trends in these procedures 1) during deliveries, 2) by hospital volume, and 3) before hysterectomy for uterine atony or delayed postpartum hemorrhage. Three 3-year periods were analyzed: 2006-2008, 2009-2011, and 2012-2014. Risk of morbidity in the setting of hysterectomy with uterine tamponade and interventional radiology procedures as the primary exposures was additionally analyzed in adjusted models. RESULTS:The study included 5,383,486 deliveries, which involved 6,675 uterine tamponade procedures, 1,199 interventional radiology procedures, and 1,937 hysterectomies. Interventional radiology procedures increased from 16.4 to 25.7 per 100,000 delivery hospitalizations from 2006-2008 to 2012-2014 (P<.01), and uterine tamponade increased from 86.3 to 158.1 (P<.01). Interventional radiology procedures use was highest (45.0/100,000 deliveries, 95% CI 41.0-48.9) in the highest and lowest (8.9/100,000, 95% CI 7.1-10.7) in the lowest volume quintile. Uterine tamponade procedures were most common in the fourth (209.8/100,000, 95% CI 201.1-218.5) and lowest in the third quintile (59.8/100,000, 95% CI 55.1-64.4). Interventional radiology procedures occurred before 3.3% of hysterectomies from 2006 to 2008 compared with 6.3% from 2012 to 2014 (P<.05), and uterine tamponade procedures increased from 3.6% to 20.1% (P<.01). Adjusted risks for morbidity in the setting of uterine tamponade and interventional radiology before hysterectomy were significantly higher (adjusted risk ratio [aRR] 1.63, 95% CI 1.47-1.81 and aRR 1.75 95% CI 1.51-2.03, respectively) compared with when these procedures were not performed. CONCLUSION:This analysis found that uterine tamponade and interventional radiology procedures became increasingly common over the study period, are used across obstetric volume settings, and in the setting of hysterectomy may be associated with increased risk of morbidity, although this relationship is not necessarily causal.