Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P \u3c .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk

Weight gain in early, mid, and late pregnancy and hypertensive disorders of pregnancy

Objective: To examine the relationship of weight change during early, mid, and late pregnancy with the development of a hypertensive disorder of pregnancy (HDP). Study design: These data are from a prospective cohort study of nulliparous women with live singleton pregnancies. "Early" weight change was defined as the difference between self-reported pre-pregnancy weight and weight at the first visit (between 6 and 13 weeks' gestation); "mid" weight change was defined as the weight change between the first and second visits (between 16 and 21 weeks' gestation); "late" weight change was defined as the weight change between the second and third visits (between 22 and 29 weeks' gestation). Weight change in each time period was further characterized as inadequate, adequate, or excessive based on the Institute of Medicine's (IOM's) trimester-specific weekly weight gain goals based on pre-pregnancy body mass index. Multivariable Poisson regression was performed to adjust for potential confounders. Main outcome measure: Development of any hypertensive disorder of pregnancy. Results: Of 8296 women, 1564 (18.9%) developed a HDP. Weight gain in excess of the IOM recommendations during the latter two time periods was significantly associated with HDP. Specifically, trimester-specific excessive weight gain in the mid period (aIRR 1.16, 95% CI 1.01-1.35) as well as in the late period (aIRR = 1.19, 95% CI = 1.02-1.40) was associated with increased risk of developing HDP. The weight gain preceded the onset of clinically apparent disease. Conclusions: Excessive weight gain as early as the early second trimester was associated with increased risks of development of HDP

Early Pregnancy Atherogenic Profile in a First Pregnancy and Hypertension Risk 2 to 7 Years After Delivery

Background: Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown. Methods and Results: Among 4471 primiparous women, we related first-trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high-sensitivity C-reactive protein [5.6 versus 4.0 nmol/L], and lower high-density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; P<0.05) than women without an APO/GDM. They were also more likely to develop hypertension after delivery (32.8% versus 18.1%, P<0.05). Accounting for confounders and factors routinely assessed antepartum, higher glucose (relative risk [RR] 1.03 [95% CI, 1.00-1.06] per 0.6 mmol/L), high-sensitivity C-reactive protein (RR, 1.06 [95% CI, 1.02-1.11] per 2-fold higher), and triglycerides (RR, 1.27 [95% CI, 1.14-1.41] per 2-fold higher) were associated with later hypertension. Higher physical activity was protective (RR, 0.93 [95% CI, 0.87-0.99] per 3 h/week). When evaluated as latent profiles, the nonobese group with higher lipids, high-sensitivity C-reactive protein, and insulin values (6.9% of the cohort) had increased risk of an APO/GDM and later hypertension. Among these factors, 7% to 15% of excess RR was related to APO/GDM. Conclusions: Individual and combined first-trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later

Obesity in Pregnancy: A Qualitative Approach to Inform an Intervention for Patients and Providers

Background: Interventions have not been effective in assisting obese women to meet gestational weight gain (GWG) recommendations. Culturally-tailored prenatal programs may be needed. Objective: To investigate the perceptions of minority pregnant women and their providers about obesity and GWG along with their motivations for and barriers to improving health behaviors during pregnancy and strategies to improve the management of obesity in pregnancy with an emphasis on group programs. Methods: Sixteen primarily non-Hispanic black pregnant women with a prepregnancy body mass index ≥30kg/m2 and 19 prenatal care providers participated in focus groups. Discussion topics included GWG goals, body image, health behaviors, stress management, and group prenatal care for the patients and providers with additional emphasis on education and training needs for the provider. Results: Women frequently stated a target GWG of >20lbs. Women described a body image not in line with clinical recommendations (“200 pounds is not that big.”). They avoided the term “obese” and more commonly used “thick.” They were interested in learning more about nutrition and culturally-specific healthy cooking resources. Women stated they would enjoy massage and exercise in a group setting, though definitions of “exercise” varied. Family members could be helpful, but generational differences posed challenges (Grandmothers would “curse them out” for exercising during pregnancy). As a result, most felt the need to “encourage myself” and “do this for me and the baby.” Providers expressed discomfort discussing GWG and difficulty finding the right words for obesity and this was partially attributed to their own body weight. They gave several examples of the challenges they faced in providing prenatal care to obese women including time constraints, cultural myths, and system issues. They believed that a group setting that provides social support would be an ideal environment to address health behaviors in obese women. Conclusions: Culturally-tailored programs that use acceptable terms for obesity, provide education regarding healthy eating and safe exercise, and encourage appropriate support from social networks may be effective in addressing GWG in obese minority women. Further provider training in communication skills is necessary to appropriately address obesity in pregnancy

Preparing for and Managing a Pregnancy After Bariatric Surgery

The number of bariatric surgeries performed in the United States has risen exponentially. Given that the majority of patients are female and of reproductive age, it is important for clinicians who manage women’s health issues to be aware of the surgery, its long term goals, and the potential effect on future pregnancies. Most pregnancies after bariatric surgery have successful outcomes with decreased occurrences of gestational diabetes and hypertension and lower birth weight compared with controls. Adherence to nutritional guidelines and supplementation in the event of deficiencies are critical in the provision of prenatal care to this unique population. Other important issues include a multidisciplinary team management, a different approach to screening for gestational diabetes, careful evaluation of any gastrointestinal complaints, and appropriate counseling for gravidas who still remain obese during pregnancy. Further research should investigate the long-term maternal outcomes in pregnancies after bariatric surgery as well as the effect on the offspring

A qualitative exploration of the challenges providers experience during peripartum management of patients with a body mass index ≥ 50 kg/m2 and recommendations for improvement.

BackgroundThe objective of this research was to conduct a qualitative study among a diverse group of providers to identify their clinical needs, barriers, and adverse safety events in the peripartum care of people with a body mass index (BMI) ≥ 50 kg/m2.MethodsObstetricians, anesthesiologists, certified nurse midwives, nurse practitioners, and nurses were invited to participate in focus group discussions if they were employed at the hospital for >6 months. Key concepts in the focus group guide included: (1) Discussion of challenging situations, (2) Current peripartum management approaches, (3) Patient and family knowledge and counseling, (4) Design and implementation of a guideline (e.g., checklist or toolkit) for peripartum care. The audiotaped focus groups were transcribed verbatim, uploaded to a qualitative analysis software program, and analyzed using inductive and constant comparative approaches. Emerging themes were summarized along with representative quotes.ResultsFive focus groups of 27 providers were completed in 2023. The themes included staffing (level of experience, nursing-patient ratios, safety concerns), equipment (limitations of transfer mats, need for larger sizes, location for blood pressure cuff, patient embarrassment), titrating oxytocin (lack of guidelines, range of uses), monitoring fetal heart rate and contractions, patient positioning, and communication (lack of patient feedback, need for bias training, need for interdisciplinary relationships). Providers gave examples of items to include in a "BMI cart" and suggestions for a guideline including designated rooms for patients with a BMI ≥ 50 kg/m2, defining nursing ratios and oxytocin titration plans, postpartum incentive spirometer, and touch points with providers (nursing, physicians) at every shift change.ConclusionsProviders discussed a range of challenges and described how current approaches to care may negatively affect the peripartum experience and pose threats to safety for patients with a BMI ≥ 50 kg/m2 and their providers. We gathered information on improving equipment and communication among providers

Perinatal Outcome in the Live-Born Infant with Prenatally Diagnosed Omphalocele

Objective: To compare perinatal outcomes between liveborn non-isolated and isolated omphaloceles diagnosed during a prenatal ultrasound. Study Design: Fetuses (n=86) with omphalocele were identified between 1995-2007 at a single institution. Inclusion criteria were an omphalocele >14 weeks gestation, available fetal and/or neonatal karyotype, and a liveborn infant (n=46). Perinatal outcomes were compared in non-isolated (n=23) and isolated omphaloceles (n=23). Results: For all omphaloceles, the majority delivered after 34 weeks by cesarean. Mean birth weight (2782 vs. 2704g), median length of stay (27 vs. 25 days), and mortality (2 in each group) was not different between the non-isolated and isolated groups, P>0.05. In the non-isolated group, 7 major anomalies were not confirmed postnatally. Of the prenatally diagnosed isolated omphaloceles, 8(35%) were diagnosed with a syndrome or other anomalies after birth. Conclusion The outcomes were similar in non-isolated and isolated prenatally diagnosed omphaloceles, but ultrasound did not always accurately determine the presence or absence of associated anomalies

Targeting obstetric providers in interventions for obesity and gestational weight gain: A systematic review.

BACKGROUND:Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care. OBJECTIVE:To identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review. SEARCH STRATEGY:A keyword search of databases was performed up to April 2017. SELECTION CRITERIA:Obstetric providers who participated in an intervention with the aim to change a provider's clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921. DATA COLLECTION AND ANALYSIS:Bias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness. MAIN RESULTS:Of the 6,821 abstracts screened, seven studies (4 quantitative, 3 mixed-methods) with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change. CONCLUSIONS:Given the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes

Maternal Obesity: Do Patients Understand the Risks?

Objective: To evaluate patient knowledge of the risks of maternal obesity and compare knowledge between non-obese and obese women. Study Design: A face-to-face survey was administered to 105 women at their first prenatal visit. The survey assessed their knowledge of obesity-related risks during pregnancy, weight history and goals, and health behaviors. Descriptive statistics described the entire sample. Student’s t and Chi-square tests compared knowledge between non-obese (BMI<30kg/m2) and obese (BMI≥30kg/m2) gravidas. Results: There were 56(54%) non-obese and 47(46%) obese participants. There were no significant differences between the weight groups with respect to age, race, insurance, education, tobacco use, and primigravity. Overall, 49% participants knew that obesity increases risk in pregnancy. The knowledge of specific risks was similar in the non-obese (60% correct) and obese (64% correct) groups, p=0.76. Obese patients were more aware of the risk for diabetes, 68% vs. 96%, p<0.001. Obese gravidas expressed more interest in weight loss prior to another pregnancy (61% vs. 81%, p=0.03); though the desired BMI's (22.1±2.3 vs. 26.2±3.0 kg/m2, p<0.001) were different for nonobese and obese women, respectively. Of all participants, 9% discussed the risks of maternal obesity with a provider prior to study participation and 75% wanted to participate in a study on weight loss prior to pregnancy to determine whether it leads to healthier pregnancies. 3 Kominiarek Obesity Survey Conclusions: Regardless of BMI category, patients require more knowledge about the risks of obesity in pregnancy, requested additional information, and were motivated to lose weight before future pregnancies. Because obese women underestimated their optimal weight loss goals, it is necessary to target this group for further education