Faculty Bibliography

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.

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..

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..

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..

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.

Hypertensive disorders of pregnancy (HDP) may account for a considerable and growing clinical burden at rural hospitals which have been providing fewer obstetric services over the past two decades. The objectives of this analysis were to evaluate trends, risk factors, and outcomes associated with HDP during delivery hospitalizations at rural hospitals in the United States.The 2000 to 2020 National Inpatient Sample was used for this repeated-cross sectional analysis. Delivery hospitalizations at rural hospitals to women 15 to 54 years of age with and without HDP (including preeclampsia and gestational hypertension) were identified. Trends in HDP were characterized with joinpoint regression and estimated as the average annual percent change (AAPC) with 95% confidence intervals (CIs). The associations between (i) HDP risk factors and HDP and (ii) HDP and adverse maternal outcomes were estimated with adjusted logistic regression models.Among 8,885,683 deliveries that occurred at rural hospitals, the proportion with a HDP diagnosis increased significantly from 6.0% in 2000 to 11.1% in 2020 (AAPC: 3.1%; 95% CI: 2.8 and 3.4%). Preeclampsia with severe features (AAPC: 5.5%; 95% CI: 4.8 and 6.2%) and superimposed preeclampsia (AAPC: 6.5%; 95% CI: 5.6 and 7.5%) underwent the largest relative increases over the study period. Obesity, pregestational diabetes, chronic hypertension, multiple gestation, and chronic kidney disease were all associated with increased adjusted odds of HDP. HDP diagnoses were significantly associated with severe maternal morbidity (SMM), transfusion, stroke, and disseminated intravascular coagulation. The proportion of overall delivery SMM associated with HDP more than doubled from 11.3% in 2000 to 24.7% in 2020.Among delivery hospitalizations at rural hospitals, HDP, and associated risk factors increased significantly over the study period. Deliveries with HDP accounted for an increasing proportion of population-level SMM. HDP is a major, growing contributor to maternal risk and adverse outcomes during deliveries at rural hospitals. · Hypertensive disorders accounted for an increasing proportion of population-level severe morbidity.. · Hypertensive disorders increased among rural delivery hospitalizations.. · Risk factors associated with hypertensive disorders increased among rural delivery hospitalizations..