Elective induction of labor at 39 weeks among nulliparous women: The impact on maternal and neonatal risk

<div><p>Objective</p><p>Optimal management of pregnancies at 39 weeks gestational age is unknown. Therefore, we sought to perform a comparative effectiveness analysis of elective induction of labor (eIOL) at 39 weeks among nulliparous women with non-anomalous singleton, vertex fetuses as compared to expectant management (EM) which included IOL for medical or obstetric indications or at 41 weeks in undelivered mothers.</p><p>Materials and methods</p><p>A Monte Carlo micro-simulation model was constructed modeling two mutually exclusive health states: eIOL at 39 weeks, or EM with IOL for standard medical or obstetrical indications or at 41 weeks if undelivered. Health state distribution probabilities included maternal and perinatal outcomes and were informed by a review of the literature and data derived from the Consortium of Safe Labor. Analyses investigating preferences for maternal versus infant health were performed using weighted utilities. Primary outcome was determining which management strategy posed less maternal and neonatal risk. Secondary outcomes were rates of cesarean deliveries, maternal morbidity and mortality, stillbirth, neonatal morbidity and mortality, and preferences regarding the importance of maternal and perinatal health.</p><p>Results</p><p>A management strategy of eIOL at 39 weeks resulted in less maternal and neonatal risk as compared to EM with IOL at 41 weeks among undelivered patients. Cesarean section rates were higher in the EM arm (35.9% versus 13.9%, p<0.01). When analysis was performed only on patients with an unfavorable cervix, 39 week eIOL still resulted in fewer cesarean deliveries as compared to EM (8.0% versus 26.1%, p<0.01). There was no statistical difference in maternal mortality (eIOL 0% versus EM 0.01%, p = 0.32) but there was an increase in maternal morbidity among the EM arm (21.2% versus 16.5, p<0.01). There were more stillbirths (0.13% versus 0%, p<0.0003), neonatal deaths (0.25% versus 0.12%, p< 0.03), and neonatal morbidity (12.1% versus 9.4%, p<0.01) in the EM arm as compared to the eIOL arm. Preference modeling revealed that 39 week eIOL was favored over EM.</p><p>Conclusions and relevance</p><p>Mathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.</p></div

Associations of maternal preterm birth with subsequent risk for type 2 diabetes in women from the womens health initiative.

Preterm birth has been associated with insulin resistance and beta-cell dysfunction, a hallmark characteristic of type 2 diabetes. However, studies investigating the relationship between a personal history of being born preterm and type 2 diabetes are sparse. We sought to investigate the potential association between a personal history of being born preterm and risk for type 2 diabetes in a racially and ethnically diverse population. Baseline and incident data (&gt;16 years of follow-up) from the Womens Health Initiative (n = 85,356) were used to examine the association between personal history of being born preterm (born 1910-1940s) and prevalent (baseline enrollment; cross-sectional) or incident (prospective cohort) cases of type 2 diabetes. Logistic and Cox proportional hazards regression models were used to estimate odds and hazards ratios. Being born preterm was significantly, positively associated with odds for prevalent type 2 diabetes at enrollment (adjOR = 1.79, 95% CI 1.43-2.24; P &lt; 0.0001). Stratified regression models suggested the positive associations at baseline were consistent across race and ethnicity groups. However, being born preterm was not significantly associated with risk for incident type 2 diabetes. Regression models stratified by age at enrollment suggest the relationship between being born preterm and type 2 diabetes persists only among younger age groups. Preterm birth was associated with higher risk of type 2 diabetes but only in those diagnosed with type 2 diabetes prior to study enrollment, suggesting the association between preterm birth and type 2 diabetes may exist at earlier age of diagnosis but wane over time

Lower cesarean delivery rates among eIOL as compared to EM.

<p>Expectant management resutled in significantly higher cesarean delivery rates as compared to the elective induction of labor strategy: 35.9% versus 13.9%, p<0.01.</p

Elective induction of labor decision tree model.

<p>This model schematic demonstrates two mutually exclusive arms: elective induction (eIOL) of labor at 39 weeks or expectant management with induction of labor for medical and obstetrical indications or by 41 weeks for undelivered patients.</p

Breastfeeding practices among patients managed by a comprehensive cardio-obstetrics program

Objective: To evaluate breastfeeding intent, rates at discharge, and continued breastfeeding at follow-up in patients managed in a comprehensive cardio-obstetrics program stratified by severity of maternal cardiac disease. Study Design: Retrospective cohort of patients managed by a comprehensive cardio-obstetrics program at the University of Alabama at Birmingham (UAB). Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team and delivered at UAB. The primary outcome was the breastfeeding rate on discharge from the delivery-associated hospitalization. Secondary outcomes included intent to breastfeed on admission and breastfeeding at the postpartum visit. Baseline characteristics and rates were compared between patients with less severe (mWHO I – II/III) vs. more severe (mWHO III – IV) maternal cardiac disease. Results: 147 patients were included: 85 (57.8%) mWHO class I – II and 62 (42.2%) mWHO class III–IV. Patients with more severe maternal cardiac disease had higher rates of chronic hypertension (22.6% vs. 9.4%; p = 0.027), lower gestational age at delivery (36.4 vs 37.7 weeks; p = 0.008), and higher rates of NICU admission (31.2% vs. 14.1%; p = 0.013). There were no significant differences between mWHO class I-II vs. mWHO class III-IV in intent to breastfeed upon admission to the delivery-associated hospitalization (84.7% vs. 82.3%; p = 0.67), breastfeeding rates upon discharge from the delivery-associated hospitalization (90.6% vs. 87.1%; p = 0.50), or breastfeeding rates at the postpartum visit (54.1% vs. 48.5%; p = 0.60). Conclusions: Despite potential barriers in this high-risk population, over 85% of patients breastfed upon discharge from the delivery-associated hospitalization. However, breastfeeding rates dropped by 40% at the postpartum visit. Strategies to support breastfeeding in the post-partum period in patients with maternal cardiac disease are imperative.</p

Associations of maternal preterm birth with subsequent risk for type 2 diabetes in women from the women\u27s health initiative.

Preterm birth has been associated with insulin resistance and beta-cell dysfunction, a hallmark characteristic of type 2 diabetes. However, studies investigating the relationship between a personal history of being born preterm and type 2 diabetes are sparse. We sought to investigate the potential association between a personal history of being born preterm and risk for type 2 diabetes in a racially and ethnically diverse population. Baseline and incident data (\u3e16 years of follow-up) from the Women\u27s Health Initiative

Adverse pregnancy outcomes and risk of type 2 diabetes in postmenopausal women.

BACKGROUND: Although gestational diabetes mellitus and delivering high-birthweight infants are known to predict a higher risk of future type 2 diabetes mellitus, the association of hypertensive disorders of pregnancy and other adverse pregnancy outcomes with type 2 diabetes mellitus is not well established. OBJECTIVE: This study aimed to examine the associations between different types of adverse pregnancy outcomes and incident type 2 diabetes mellitus among postmenopausal women. STUDY DESIGN: The Womens Health Initiative, a nationwide cohort of postmenopausal women, collected self-reported history of adverse pregnancy outcomes, including gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm birth, and delivering low- birthweight (&lt;2500 g) or high-birthweight (&gt;4500 g) infants. Participants were followed up annually for self-reported incident type 2 diabetes mellitus treated with medication from baseline (1993-1998) to March 2021. This study used logistic regression to examine the associations of any and individual adverse pregnancy outcomes with diabetes mellitus. Stratified analyses were performed to assess effect modification by body mass index, race and ethnicity, education, parity, breastfeeding, and age at first birth. RESULTS: This analysis included 49,717 women without a history of diabetes mellitus at enrollment who had a least 1 pregnancy and responded to the questionnaire about adverse pregnancy outcomes. After adjusting for body mass index, demographic, lifestyle, and reproductive factors, gestational diabetes mellitus (odds ratio, 2.26; 95% confidence interval, 1.94-2.63), high birthweight (odds ratio, 1.30; 95% confidence interval, 1.18-1.44), and hypertensive disorders of pregnancy (odds ratio, 1.18; 95% confidence interval, 1.08-1.30) were independently associated with higher odds of type 2 diabetes mellitus, whereas preterm birth and low birthweight were not associated with diabetes mellitus risk. A history of ≥2 adverse pregnancy outcomes was associated with higher odds of type 2 diabetes mellitus (odds ratio, 1.55; 95% confidence interval, 1.28-1.88). This study further observed higher odds of type 2 diabetes mellitus (odds ratio, 3.69; 95% confidence interval, 2.38-5.70) among women with a history of both gestational diabetes mellitus and hypertensive disorders of pregnancy than those without any adverse pregnancy outcomes. CONCLUSION: Postmenopausal women with a history of gestational diabetes mellitus, those delivering high-birthweight infants, or those with hypertensive disorders of pregnancy are at risk of future type 2 diabetes mellitus. In addition, women with ≥2 conditions had an augmented risk and might be prioritized for screening and prevention efforts for type 2 diabetes mellitus