Prediction of Neonatal Birthweight associated with Maternal Obesity and Diabetes

Introduction: To design a model that will predict neonatal birth weight within obese mothers by diabetic status. Methods: A secondary data analysis of an RCT (NCT 02909582) was utilized to create a neonatal birth weight prediction model. Women (n=325) with a BMI \u3e 35 kg/m2 from a tertiary academic institution, 2016 – 2019, were included to estimate the risk of large for gestational age (LGA) infants and neonatal birth weight based on maternal prepregnancy BMI and diabetic status. LGA was defined as an infant birth weight \u3e 90th percentile. Analysis included Chi-square, t-test, multivariate logistic and linear regression. Results: Mean birthweight did not differ in obese mothers based on diabetic status. The frequency of large for gestational age infants was significantly greater for diabetic mothers (17% vs 7% without diabetes, p=0.024). Total pregnancy weight gain (continuous, lbs) (OR 1.03; 95% CI 1.01, 1.05; p=0.016) and pre-pregnancy BMI (continuous, OR 1.08; 95% CI 1.01, 1.15; p=0.018) were associated with the risk of LGA infants when accounting for demographics (model R2 = 0.074). The presence of diabetes (RR 146; 95% CI 24, 268; p=0.019), total weight gain (lbs) (RR 4; 95% CI 1, 7; p=0.015), and gestational age (RR 197; 95% CI 175, 220; p\u3c0.001) were associated with neonatal birth weight when accounting for demographics (model R2 = 0.550). Discussion: These models incorporate the joint effects of maternal obesity and diabetic status in predicting neonatal birthweight, thereby enabling clinicians to counsel their high-risk patients on risk for large for gestational age infants

Association Between Hypertensive Disorders and Fetal Growth Abnormalities in Class II and III Obese Women

Introduction: Studies have shown that hypertension in pregnancy can lead to small for gestational age newborns while obesity can lead to large for gestational age newborns. However, little research has been done to study the influence of both disorders on birthweight. Objective: To assess the effect of both maternal obesity and a hypertensive disorder on neonatal birthweight and to identify the specific growth abnormality(s) present if a discrepancy exists. We hypothesize that obese women diagnosed with hypertensive disorders are more likely to deliver neonates with growth abnormalities compared to obese women without hypertensive disorders. Methods: This is a nested prospective cohort study enrolling women who reached a body mass index of 35 kg/m2 during pregnancy from 2016-2018 at Thomas Jefferson University affiliated hospitals. Data on maternal hypertensive status and neonatal birthweight was obtained via chart abstraction. Categorical variables were analyzed via χ2 and continuous variables by independent samples t-test and ANOVA. Multiple logistic regression was performed to account for confounders. Results: Obese women diagnosed with gestational hypertension were less likely to have a newborn with a growth abnormality compared with normotensive obese women (OR .32, 95% CI 0.11, 0.92, p=0.035). Secondarily, there were a significant number of growth abnormalities in this cohort (n=70, 24%). Discussion: Obese women with gestational hypertension were less likely to deliver infants with growth abnormalities; however, this shouldn’t reduce standard fetal monitoring in these high-risk patients. The number of growth abnormalities found may indicate the need for more frequent ultrasounds for obese patients earlier in pregnancy

A Pilot Study for Enhancing Postpartum Discharge Instructions for Incision Care: Assessment of Comprehension

Literacy and Health Care • 14.5% of United States is illiterate 1 • Reading level of most medical forms is 10th grade 2 Improving Outcomes with a Visual Aid • Cesarean Surgical Site Infection (SSI) rate is 5% 3 • A patient with a SSI can be 2 times as expensive 4 • Visual aids improve information recall 8 and confidence in wound care 5 Study Objectives 1. To evaluate the readability of the cesarean wound care discharge instructions relative to the patient population’s reading level 2. To conduct a pilot Randomized Control Trial (RCT) to evaluate the effectiveness of a visual aid on improving comprehension of the cesarean wound care instructionshttps://jdc.jefferson.edu/cwicposters/1034/thumbnail.jp

External Cephalic Version for a Malpresenting First Twin Before Labor: A Prospective Case Series

Background: In twin pregnancies where the presenting twin is not cephalic, cesarean delivery is the standard of care. External cephalic version (ECV) has been used for malpresenting singleton pregnancies with low risk of complications. ECV in twin pregnancies is poorly studied. Objective: To assess feasibility and report any complications of ECV of a malpresenting twin before labor. Study design: This is a prospective cohort of twin pregnancies with malpresenting first twin. Inclusion criteria included English or Spanish speaking women. Exclusions included cases where there was a contraindication to vaginal delivery. ECV was performed according to the institutional singleton protocol. Fetal testing of both twins was performed before and after procedure. A vaginal hand was used during ECV as needed. The primary outcome was success of the procedure. Secondary outcomes included delivery characteristics and neonatal outcomes. Results: Five patients were enrolled in this study. Four patients underwent successful ECV and vaginal delivery occurred in 2 of the 4 patients. ECV procedure was performed at a mean gestational age of 36+0 weeks in the successful ECV group and 36+6/7 weeks for the unsuccessful group. Latency to delivery was 4.5 days in the successful ECV group and 1 day in the unsuccessful ECV group. No maternal or neonatal complications occurred in any participating women. Conclusion: ECV in twin pregnancies where the first twin is malpresenting was feasible in our cohort. More research is needed to better characterizer the safety and efficacy of this procedure in this patient population

Disparities in Contraception in Women with Cardiovascular Diseases in the Cardiac-Obstetrical Clinic

Objective - National Survey of Family Growth 2017-19 survey reported a 65.3% contraceptive use: 18% tubal, 5.6% vasectomy 18% hormonal therapy 8.4% intrauterine devices (IUD) 8.4% condoms - To evaluate postpartum contraception plans and use in pregnant women with cardiovascular disease (CVD) after visits to the combined cardio-obstetric clinichttps://jdc.jefferson.edu/obgynposters/1016/thumbnail.jp

Intraoperative fetal heart monitoring for non-obstetric surgery: A systematic review

Limited data are available on fetal monitoring during non-obstetric surgery in pregnancy. We performed a systematic review to evaluate the incidence of emergent cesarean delivery performed for non-reassuring fetal heart rate patterns during non-obstetric surgery. Electronic databases were searched from their inception until October 2018 without limit for language. We included studies evaluating at least five cases of intraoperative fetal heart rate monitoring -either with ultrasound or cardiotocography- during non-obstetric surgery in pregnant women at ≥22 weeks of gestation. The primary outcome was the incidence of intraoperative cesarean delivery performed for non-reassuring fetal heart rate monitoring. Non-reassuring fetal heart rate monitoring was defined by attendant personnel, meeting NICHD criteria for category II or III patterns. Data extracted regarded type of study, demographic characteristics, maternal and perinatal outcomes. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. Of 120 studies identified, 4 with 41 cases of intraoperative monitoring met criteria for inclusion and were analyzed. Most (66%) surgeries were indicated for neurological or abdominal maternal issues and were performed under general anesthesia (88%) at a mean gestational age of 28 weeks. Minimal or absent fetal heart variability was noted in most cases and a 10-25 beats per minutes decrease in fetal heart rate baseline was observed in cases with general anesthesia. No intraoperative cesarean deliveries were needed. The incidence of non-reassuring fetal heart rate monitoring was 4.9% (2/41) and were limited to fetal tachycardia during maternal fever. Two (4.9%) cases of non-reassuring fetal heart rate monitoring were noted within the immediate 48 h after surgery, necessitating cesarean delivery. A single case of intrauterine fetal demise occurred four days postoperatively in a woman who had neurosurgery and remained comatose. In conclusion, limited data exist regarding the clinical application of fetal heart rate monitoring at viable gestational ages during non-obstetric surgical procedures. Fetal heart rate monitoring during non-obstetric surgery at ≥22 weeks was not associated with need for intraoperative cesarean delivery, but two (4.9%) cesarean deliveries were performed for non-reassuring fetal heart rate monitoring within 48 h after surgery

Implementation Of A Screening Guideline For An Multidisciplinary Clinic Care of Pregnant Women With Underlying Cardiac Disease In An Urban Academic Healthcare System

Pregnancy-related maternal mortality is rising in the United States, with the most common underlying etiology now cardiac and hypertensive disease. Health care decisions in the diagnosis and treatment of cardiovascular disease have likewise been linked to maternal mortality. Implementation of a cardio-obstetrics program, including a guideline and multidisciplinary clinic, may standardize and optimize care. Methods: This study used a combination of retrospective and prospective cohorts as well as cross-sectional surveys of providers and patients to assess the implementation of the cardio-obstetrics program at Thomas Jefferson University. Prevalence of resting heart rates recorded for return prenatal care visits pre- and post-implementation of a guideline in January 2020 were compared. Staff perspective regarding implementation of the cardio-obstetrics program was solicited with a survey grounded in the Consolidated Framework for Implementation Research (CFIR) model. Patient experience with the multidisciplinary clinic started in March 2021 (consultations with both cardiology and maternal-fetal medicine (MFM) simultaneously) was captured using validated and published surveys, including the Patient Feedback on Consultation Skills (PFC) questionnaire. Utilization of transthoracic echo to screen for underlying heart disease in asymptomatic women at high risk for cardiac disease was assessed pre- and post-guideline implementation. Prevalence of clinically significant pathology was noted was well as cardiac and obstetric outcomes. Results: Prior to implementation of the guideline, 257 out of 1200 (21.4%) return prenatal visits had a resting heart rate routinely obtained during prenatal care. This was significantly different after implementation of the guideline (1541 out of 2278, 67.6%, p Conclusion: This study shows significant improvements in prevalence of heart rate screening and completion of transthoracic echocardiography after implementation of a cardio-obstetrics program. Staff and patients had overall positive experiences with implementation of this program. Additional adequately-powered prospective studies are needed to confirm improved patient outcomes

Weight Gain in Obese Pregnant Women and Risk for Cesarean Delivery by Class of Obesity

Objective: The objective of this study is to determine the influence of weight gain on the odds of cesarean delivery for obese women (as determined by pre-pregnancy BMI), by class of obesity. Materials and Methods: This is a secondary data analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS) in the United States. Specifically, the unadjusted odds of cesarean delivery were determined for each class of BMI (underweight, normal weight, overweight, class I obesity, class II obesity, and class III obesity). These odds were then adjusted by demographic and prenatal care factors influencing either weight gain during pregnancy or risk of cesarean delivery. Finally, the association of weight gain (insufficientlbs, appropriate 11-20 lbs, and excessive \u3e20 lbs) on the odds of cesarean delivery was noted via multivariate logistic regression analysis. Results: The adjusted odds of cesarean delivery by BMI are noted: underweight 0.92 (95% CI 0.83, 1.01), normal weight (referent group), overweight 1.38 (95% CI 1.32, 1.45), class I obesity 1.77 (95% CI 1.68, 1.88), class II obesity 2.17 (95% CI 2.02, 2.34), and class III obesity 3.07 (95% CI 2.82, 3.34). Class I and II obese women are more likely to have a cesarean with excessive weight gain, with class I odds ratio 1.20 (95% CI 1.06, 1.36) and class II odds ratio 1.24 (1.04,1.48) when compared to women in their same class of obesity with adequate weight gain. Conclusion: Although obesity is a known risk factor for cesarean delivery, this risk is thought to be mitigatable by appropriate weight gain during the pregnancy. Weight gain of 11-20 pounds was associated with the least risk of cesarean delivery among obese (particularly Class I and II) individuals. Presentation: 20:2

Implementation of a Screening Guideline for and Multidsciplinary Clinic Care of Pregnant Women with Underlying Cardiac Disease in an Urban Academic Healthcare System

Introduction: Pregnancy-related maternal mortality is rising in the United States, with the most common underlying etiology now cardiac and hypertensive disease. Health care decisions in the diagnosis and treatment of cardiovascular disease have likewise been linked to maternal mortality. Implementation of a cardio-obstetrics program, including a guideline and multidisciplinary clinic, may standardize and optimize care. Methods: This study used a combination of retrospective and prospective cohorts as well as cross-sectional surveys of providers and patients to assess the implementation of the cardio-obstetrics program at Thomas Jefferson University. Prevalence of resting heart rates recorded for return prenatal care visits pre- and post-implementation of a guideline in January 2020 were compared. Staff perspective regarding implementation of the cardio-obstetrics program was solicited with a survey grounded in the Consolidated Framework for Implementation Research (CFIR) model. Patient experience with the multidisciplinary clinic started in March 2021 (consultations with both cardiology and maternal-fetal medicine (MFM) simultaneously) was captured using validated and published surveys, including the Patient Feedback on Consultation Skills (PFC) questionnaire. Utilization of transthoracic echo to screen for underlying heart disease in asymptomatic women at high risk for cardiac disease was assessed pre- and post-guideline implementation. Prevalence of clinically significant pathology was noted was well as cardiac and obstetric outcomes. Results: Prior to implementation of the guideline, 257 out of 1200 (21.4%) return prenatal visits had a resting heart rate routinely obtained during prenatal care. This was significantly different after implementation of the guideline (1541 out of 2278, 67.6%, p \u3c 0.001). Staff members identified characteristics of individuals as potential domains of success during implementation. Among asymptomatic women obtaining consultations with maternal fetal medicine, women were much more likely to be recommended for a transthoracic echo post-guideline compared to pre-guideline (64 out of 80, 80.0%, versus 32 out of 91, 35.2%, respectively, p \u3c 0.001). Women were more likely to complete their transthoracic echocardiography screening post-guideline compared to pre-guideline (63 of 80, 78.8% versus 45 of 91, 49.5%, respectively, p \u3c 0.001). Of those who completed the echo, 31 out 108 (28.7%) had pathology identified on the screening echo. Among those seen in the cardio-obstetrics clinic, most agreed or strongly agreed that this clinic was more convenient (30 out of 32, 93.7%), more satisfying (31 out of 33, 93.9%), and more informative (28 out of 32, 87.5%). Obstetric and cardiac outcomes were not statistically different pre- versus post-guideline. Conclusion: This study shows significant improvements in prevalence of heart rate screening and completion of transthoracic echocardiography after implementation of a cardio-obstetrics program. Staff and patients had overall positive experiences with implementation of this program. Additional adequately-powered prospective studies are needed to confirm improved patient outcomes