Faculty Bibliography

As of November, 2021 there have been more than 250 million coronavirus disease-2019 (COVID-19) cases worldwide and more than 5 million deaths. Obstetric patients have been a population of interest given that they may be at risk of more severe infection and adverse pregnancy outcomes. The purpose of this review is to assess current epidemiology and outcomes research related to COVID-19 for the obstetric population. This review covers the epidemiology of COVID-19, symptomatology, transmission, and current knowledge gaps related to outcomes for the obstetric population.

BACKGROUND/UNASSIGNED:Maternal race and socioeconomic status are predictors of obstetric morbidity and mortality in the U.S. A better understanding of the role that maternal education plays in these disparities could enable and target better interventions to improve obstetric outcomes. OBJECTIVE/UNASSIGNED:This study aims to assess the impact of the level of education on morbidity. STUDY DESIGN/UNASSIGNED:We conducted a retrospective nested cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Nulliparous women with live, non-anomalous singleton gestations who underwent primary cesarean section and had education status recorded were included. Education level was categorized as none, elementary, high school, some college, and a college degree. The primary outcome was a composite of maternal cesarean complications including hysterectomy, uterine atony, blood transfusion, surgical injury, arterial ligation, infection, wound complication, and ileus. A composite of neonatal morbidity was evaluated as a secondary outcome. We then created a multivariable logistic regression model adjusting for selected demographic and obstetric variables that may influence the likelihood of the primary outcome. RESULTS/UNASSIGNED:10,344 women met inclusion criteria with a 20.3% incidence of the primary outcome. After adjusting for potential confounding variables including race and medical co-morbidities, the incidence of maternal cesarean complications was found to be higher for women with only elementary (OR 1.34, 95% CI 1.01-1.78) and high school (OR 1.24, 95% CI 1.03-1.48) education, compared to women with a college degree. There was also higher neonatal morbidity among women with high school (OR 1.39, 95% CI 1.20-1.62) and some college (OR 1.23, 95% CI 1.04-1.46) education, compared to women with a college degree. CONCLUSION/UNASSIGNED:These findings suggest that efforts to alleviate adverse outcomes in obstetrics should target patient counseling and health literacy as differences in educational background are closely associated with disparities in maternal and neonatal morbidity.

INTRODUCTION/UNASSIGNED:17-alpha hydroxyprogesterone caproate (17 P) is a progestin commonly used during pregnancy to reduce risk of recurrent preterm birth. History of thromboembolism is a contraindication to 17 P and the package insert for 17 P recommends discontinuation in the setting of an acute VTE event. The objective of this study was to determine whether 17 P is associated with increased risk of VTE. STUDY DESIGN/UNASSIGNED:The MarketScan claims database was used to perform a retrospective cohort of women who underwent delivery from 4/2008 to 1/2015. We identified women who received 17 P during pregnancy based on pharmacy benefits. Risk for VTE including deep vein thrombosis, pulmonary embolism, or both was stratified based on the presence or absence of 17 P pharmacy receipt. Both antenatal and delivery hospitalization VTE events were asceratined and these periods were analyzed individually. Relative risk (RR) was determined based on 17 P receipt. RESULTS/UNASSIGNED: = 13,427) not receiving 17 P (RR 1.07, 95% 0.82-1.39). DISCUSSION/UNASSIGNED:No significant increased risk for VTE was noted with 17 P receipt. While new research has led to reconsideration of clinical use of 17 P for preterm birth prevention based on efficacy, findings from this analysis do not support major risk for thrombosis.

BACKGROUND:Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. OBJECTIVE:This study examined the association of maternal race with utilization of critical care interventions. STUDY DESIGN/METHODS:This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. RESULTS:73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. CONCLUSION/CONCLUSIONS:This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.

OBJECTIVE/UNASSIGNED:To determine risk for cardiac readmissions among women without cardiac diagnoses present at delivery up to 9 months after delivery hospitalization discharge. METHODS/UNASSIGNED:Delivery hospitalizations without cardiac diagnoses were identified from the 2010-2014 Nationwide Readmissions Database and linked with subsequent cardiac hospitalizations over the following 9 months. The temporality of new-onset cardiac hospitalizations was calculated for each 30-day interval from delivery discharge up to 9 months postpartum. Multivariable log-linear regression models were fit to identify risk factors for cardiac readmissions adjusting for patient, medical, and obstetrical factors with adjusted risk ratios as measures of effect (aRR). RESULTS/UNASSIGNED:Among 4.4 million delivery hospitalizations without a cardiac diagnosis, readmission for a cardiac condition within 9 months occurred in 26.8 per 10,000 women. Almost half of readmissions (45.9%) occurred within the first 30 days after delivery discharge with subsequent hospitalizations broadly distributed over the remaining 8 months. Factors such as hypertensive diseases of pregnancy (aRR 2.19, 95% CI 2.09, 2.30), severe maternal morbidity at delivery (aRR 2.06, 95% CI 1.79, 2.37), chronic hypertension (aRR 2.52, 95% CI 2.31, 2.74), lupus (aRR 4.62, 95% CI 3.82, 5.60), and venous thromboembolism during delivery (aRR 3.72, 95% CI 2.75, 5.02) were all associated with increased risk for 9-month postpartum cardiac admissions as were Medicaid (aRR 1.57, 95% CI 1.51, 1.64) and Medicare insurance (aRR 3.06, 95% CI 2.70, 3.46) compared to commercial insurance and maternal ages 35-39 and 40-54 years (aRR 1.24, 95% CI 1.17, 1.32, aRR 1.74, 95% CI 1.60, 1.90, respectively) compared to maternal age 25-29 years. CONCLUSIONS/UNASSIGNED:Among women without a cardiac diagnosis at delivery, multiple medical factors and obstetrical complications are associated with development of new cardiac disease requiring readmission in the postpartum period. Given that pregnancy complications and comorbidities may be associated with intermediate-term health outcomes, these findings support the importance of continued health care access after six weeks postpartum.

INTRODUCTION/UNASSIGNED:Obstetric venous thromboembolism (VTE) is a leading cause of maternal mortality. While hospital discharge data provide a readily accessible means of studying this relatively rare outcome, diagnosis codes are of limited validity. Prior studies have demonstrated that VTE billing codes may be subject to misclassification and false positives and overestimate obstetric VTE risk. Given the public health significance of accurately estimating obstetric VTE, the purpose of this study was to determine to what degree patients received anticoagulants after discharge from a delivery hospitalization associated with an acute VTE diagnosis as pharmacy claims may more accurately assess the incidence of obstetric VTE. STUDY DESIGN/UNASSIGNED:A retrospective cohort study using the MarketScan database was performed using 2008-2014 claims data. We identified women 15-54 years of age diagnosed with acute VTE during a delivery hospitalization. We determined the proportion of women with VTE that received anticoagulants within 60 days of delivery discharge. Only women with ≥60 days of pharmacy benefits after discharge were included. Receipt of low molecular weight and unfractionated heparin, warfarin, and Xa inhibitors was ascertained. Receipt of anticoagulants was analyzed individually based on diagnoses for deep vein thrombosis (DVT), pulmonary embolism (PE), or both. The Chi-square test was performed for categorical comparisons. RESULTS/UNASSIGNED:Of 2,664,951 delivery hospitalizations, 2112 women had a diagnosis of VTE (0.08%) including 236 women with PE alone, 1760 women with DVT alone, and 116 women with both DVT and PE. Of these women, 51.3% (95% CI 49.2-53.4%) received an anticoagulant including 49.5% of women with DVT (95% CI 47.2-51.8%), 50.0% of women with PE (95% CI 43.7-56.3%), and 81.9% of women with both DVT and PE (95% CI 73.9-87.9%). CONCLUSION/UNASSIGNED:This analysis of pharmacy claims found that estimates for the proportion of deliveries with acute VTE diagnoses that subsequently received anticoagulants was similar to chart-confirmed VTE, albeit in a large population. In addition to previous studies comparing database claims to chart review that showed that the prevalence of VTE was grossly overestimated, these findings support that the proportion of cases with VTE during delivery hospitalization may be approximately half that ascertained with billing codes.

OBJECTIVE:This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery. STUDY DESIGN:This unplanned secondary analysis of the Maternal-Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH ≤7.0, and Apgar score ≤4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or ≥50 minutes. As secondary outcomes umbilical cord pH ≤7.1, umbilical artery pH ≤7.0, and Apgar score ≤5 at 5 minutes were analyzed. RESULTS: = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals. CONCLUSION:Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean. KEY POINTS:· Shorter intervals likely occur with higher risk cases.. · Shorter intervals were associated with higher neonatal risk.. · Shorter intervals were associated with low cord pH..

BACKGROUND/UNASSIGNED:Maternal morbidity presents a growing challenge to the American healthcare system and increasing numbers of patients are requiring higher levels of care in pregnancy. Identifying patients at high risk for critical care interventions, including intensive care unit admission, during delivery hospitalizations may facilitate appropriate multidisciplinary planning and lead to improved maternal safety. Baseline risk factors for critical care in pregnancy have not been well-described previously. OBJECTIVE/UNASSIGNED:This study assesses baseline factors associated with critical care interventions that were present at admission for delivery. STUDY DESIGN/UNASSIGNED:This is a secondary analysis of a multicenter observational registry of pregnancy after prior uterine surgery and primary cesarean delivery. All women with known gestational age were included. The primary outcome measure was a composite of critical care interventions that included postpartum intensive care unit admission, mechanical ventilation, central intravenous access, and arterial line placement. Risk for this critical care outcome measure was compared by selected baseline and obstetric characteristics known at the time of hospital admission, including maternal age, pre-pregnancy BMI, race, maternal co-morbidities, parity, and plurality. We evaluated these potential predictors and fit a multivariable logistic regression model to ascertain the most significant risk factors for critical care during a delivery hospitalization. RESULTS/UNASSIGNED: < .01] (Table 2). Other predictors associated with increased risk included maternal age, African American race, smoking, diabetes, asthma, anemia, nulliparity, and twin pregnancy. CONCLUSION/UNASSIGNED:In this cohort, women with cardiac disease, renal disease, connective tissue disease and preeclampsia spectrum disorders were at increased risk for critical care interventions. Obstetric providers should assess patient risk routinely, ensure appropriate maternal level of care, and create multidisciplinary plans to improve maternal safety and reduce risk.