Trends in Screening for Diabetes in Early Pregnancy in the United States

Objective: To characterize current diabetes screening practices in the first trimester of pregnancy in the United States, evaluate patient characteristics and risk factors associated with early diabetes screening, and compare perinatal outcomes by early diabetes screening. Methods: This was a retrospective cohort study of US medical claims data from patients diagnosed with a viable intrauterine pregnancy who presented for care before 14 weeks of gestation without pre-existing pre-gestational diabetes from the IBM MarketScan® database for the period of January 1, 2016, to December 31, 2018. Univariate and multivariate analyses were used to evaluate clinical factors and perinatal outcomes. Results: There were 400,588 pregnancies identified as eligible for inclusion, with 18.0% of women receiving early screening for diabetes. Of those with laboratory order claims, 53.1% had hemoglobin A1c, 30.0% fasting glucose, and 16.9% oral glucose tolerance tests. Compared to women who did not have early diabetes screening, those that did were more likely to be older, obese, have a history of gestational diabetes, chronic hypertension, polycystic ovarian syndrome, hyperlipidemia, and a family history of diabetes. In adjusted logistic regression, history of gestational diabetes (aOR 3.99, 95% CI 3.73-4.26) had the strongest association with early diabetes screening. Early diabetes screening irrespective of the screening result was also associated with adverse perinatal outcomes including a higher rate of cesarean delivery, preterm delivery, gestational hypertension, pre-eclampsia, and gestational diabetes. Conclusion: First trimester early diabetes screening was mostly commonly performed by hemoglobin A1c evaluation, and women that underwent early diabetes screening regardless of the result were more likely to experience adverse perinatal outcomes

The Incidence of Malignancy and the Preoperative Assessment of Women Undergoing Hysterectomy with Morcellation for Benign Indications

Background: The use of power morcellation in gynecologic surgery has come under scrutiny secondary to concerns for occult malignancy dissemination. The incidence of undiagnosed gynecologic malignancy when hysterectomy performed for benign indications is not definitive but has been quoted as high as 2.7% (1:37). There is not a standard recommended preoperative evaluation, and variation is anticipated by preoperative complaint or diagnosis. Objectives: To quantify the malignancy incidence in women undergoing hysterectomy for benign indications and to compare the preoperative evaluation of patients undergoing hysterectomy with and without morcellation. Methods: Retrospective cohort of women undergoing hysterectomies between October 2007 and June 2014 was identified by procedural codes through the hospital billing system. Exclusions included hysterectomies performed by gynecologic oncologists or non-gynecologic surgeons and surgeries performed outside the UMass healthcare system. Chart abstraction included demographics; pre-hysterectomy evaluation, including current cervical cytology, pathologic endometrial assessment (biopsy, dilation and curettage), and imaging (ultrasound, MRI, CT scan, sonohysterogram, or hysteroscopy); intraoperative factors; and final diagnosis. Results: Analytic cohort included 2,332 women undergoing hysterectomy with 396 (17.0%) including use of morcellation. The malignancy incidence on final pathology was 2.1% and was different between non-morcellated versus morcellated specimens (2.5% vs. 0.3%, p Conclusion: The incidence of malignancy at time ofhysterectomy performed by non­-oncology trained gynecologists was 2.1% overall, and 0.3% in morcellated cases. The pre-operative evaluation of patients undergoing hysterectomy with morcellation is similar to those without morcellation, except for lower rates of pathologic endometrial assessment. An argument could be made that a pathology assessment is indicated in this group due to risk of dissemination in the case of occult malignancy. The risk of occult malignancy is rare, but this should be discussed with patients and taken into account during the pre-operative evaluation

Effects of perinatal depression and anxiety on labor and delivery outcomes

INTRODUCTION: The purpose of this study was to determine how perinatal depression and anxiety effect obstetric outcomes and perceptions of labor and delivery experiences. METHODS: This prospective observational study examined the labor and delivery experiences of 25 high-risk and 25 low-risk women. The high-risk group was defined by symptoms during pregnancy as determined by the Edinburgh Postnatal Depression Scale, whereas the low-risk group reported no symptoms. Women in both groups were monitored with the Hamilton Rating Scales for depression and anxiety and filled out a questionnaire about their labor and delivery. RESULTS: The high-risk cohort had significantly more depressive symptoms than the low-risk cohort throughout pregnancy and into the postpartum period (P\u3c.001). Similarly, the high-risk cohort had significantly more anxiety symptoms than the low-risk cohort (P\u3c.001). The high-risk cohort was significantly more likely to report their labor and delivery was a traumatic experience (P=.046) and to have their labor induced (P=.018) as compared with the low-risk cohort. There was no significant difference in the rates of preterm labor (P=.149) or method of delivery (P=1.00) between both groups. CONCLUSIONS: Factors such as preterm labor, labor induction, and cesarean deliveries can cause women to report having traumatic deliveries. It is not known whether labor induction alone caused traumatic birth experiences or whether mood was a predisposing factor to a traumatic delivery. More research must be done to identify the mechanisms by which mood can influence labor and delivery outcomes

Screening test characteristics and comparison of diabetes outcomes among pregnant patients with prediabetes

This study sought to compare test characteristics of hemoglobin A1c, oral glucose tolerance test and fasting plasma glucose for the development of gestational diabetes among women with prediabetes. Diabetes outcomes were compared by screening test used for prediabetes diagnosis among a retrospective cohort of pregnant patients between 2017–2021. During the study, 8132 patients received diabetes screening and 14.0% met criteria for prediabetes. By screening test, 75.1% were screened with hemoglobin A1c, 10.0% with fasting plasma glucose and 14.9% with a 75-g oral glucose tolerance test. Hemoglobin A1c had the highest positive predictive value (67.2%). Use of hemoglobin A1c was significantly more likely to identify women with GDM than oral glucose tolerance test (aOR 3.94, 95% CI 2.30–6.73). In this study cohort, hemoglobin A1c was able to identify patients that were more likely to develop GDM in an at-risk population.IMPACT STATEMENT What is already known on this subject? Prediabetes is becoming more common in the general population; however little is known about prediabetes in pregnancy. Women with prediabetes in pregnancy appear to be at increased risk of developing gestational diabetes mellitus, however there is minimal information about various screening tests performance in pregnancy for detection of prediabetes and subsequent gestational diabetes. What do the results of this study add? The results of this study compare three commonly used screening tests for screening for diabetes. When identifying women with prediabetes, they are at increased risk for developing gestational diabetes mellitus if identified by hemoglobin A1c. What are the implications of these findings for clinical practice and/or further research? The clinical implication of this study is that women can be screened with hemoglobin A1c in early pregnancy for both overt diabetes, but also may be identified as high risk with prediabetes. Among women with prediabetes by hemoglobin A1c, they remain at high risk for developing gestational diabetes mellitus

Effects of Obstetric Complications on Adolescent Postpartum Contraception and Rapid Repeat Pregnancy

STUDY OBJECTIVE: To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with chi2 and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables. RESULTS: Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion (P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity (P = .002), parity (P = .003), number of previous spontaneous or therapeutic abortions (P = .026); they were also more like to have nonlive birth as a complication (P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups. CONCLUSION: Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy

Cardiac and Obstetric Outcomes Associated With Mitral Valve Prolapse

Mitral valve prolapse (MVP) is the most common valvular heart disease in women of reproductive age. Whether MVP increases the likelihood of adverse outcomes in pregnancy is unknown. The study objective was to examine the cardiac and obstetric outcomes associated with MVP in pregnant women. This retrospective cohort study, using the Healthcare Cost and Utilization Project National Readmission Sample database between 2010 and 2017, identified all pregnant women with MVP using the International Classification of Disease, Ninth and Tenth Revisions codes. The maternal cardiac and obstetric outcomes in pregnant women diagnosed with MVP were compared with women without MVP using multivariable logistic and Cox proportional hazard regression models adjusted for baseline demographic characteristics. There were 23,000 pregnancy admissions with MVP with an overall incidence of 16.9 cases per 10,000 pregnancy admissions. Pregnant women with MVP were more likely to die during pregnancy (adjusted hazard ratio 5.13, 95% confidence interval [CI] 1.09 to 24.16), develop cardiac arrest (adjusted odds ratio [aOR] 4.44, 95% CI 1.04 to 18.89), arrhythmia (aOR 10.96, 95% CI 9.17 to 13.12), stroke (aOR 6.90, 95% CI 1.26 to 37.58), heart failure (aOR 5.81, 95% CI 3.84 to 8.79), or suffer a coronary artery dissection (aOR 25.22, 95% CI 3.42 to 186.07) compared with women without MVP. Pregnancies with MVP were also associated with increased risks of preterm delivery (aOR 1.21, 95% CI 1.02 to 1.44) and preeclampsia/hemolysis, elevated liver enzymes, and low platelets syndrome (aOR 1.22, 95% CI 1.05 to 1.41). In conclusion, MVP in pregnancy is associated with adverse maternal cardiac outcomes and higher obstetric risks

Identifying barriers, facilitators, and interventions to support healthy eating in pregnant women with or at risk for hypertensive disorders of pregnancy

Background: Heart-healthy diets are important in the prevention and treatment of hypertension (HTN), including among pregnant women. Yet, the barriers, facilitators, and beliefs/preferences regarding healthy eating are not well described in this population. Objective: To identify barriers and facilitators to healthy diet, examine the prevalence of food insecurity, and determine interest in specific healthy diet interventions. Methods: Pregnant women, aged 18–50 years (N = 38), diagnosed with HTN, hypertensive disorders in pregnancy (HDP), or risk factors for HDP, were recruited from a large academic medical center in central Massachusetts between June 2020 and June 2022. Participants completed an electronic survey using a 5-point Likert scale (strongly disagree to strongly agree). Results: The mean age of participants was 31.6 years (SD 5.5) and 35.1% identified as Hispanic. Finances and time were major barriers to a healthy diet, reported by 42.1% and 28.9% of participants, respectively. Participants reported that their partners and families were supportive of healthy eating and preparing meals at home, though 30.0% of those with children considered their children’s diet a barrier to preparing healthy meals. Additionally, 40.5% of the sample were considered food insecure. Everyone agreed that healthy diet was important for maternal and fetal health, and the most popular interventions were healthy ingredient grocery deliveries (89.4%) and meal deliveries (84.2%). Conclusion: Time and cost emerged as major challenges to healthy eating in these pregnant women. Such barriers, facilitators, and preferences can aid in intervention development and policy-level changes to mitigate obstacles to healthy eating in this vulnerable patient population