BACKGROUND:Racial inequities in maternal morbidity and mortality persist in the postpartum period. Postpartum hospital use, including readmissions and emergency department visits, occurs in 5-9% of births, with rates among Black individuals at the higher end of this range. Risk-targeted interventions may improve efficiency and equity by directing resources to those at greatest risk postpartum and addressing structural barriers to care. Building on prior prediction model development and community-engaged intervention design, we conducted a pilot randomized controlled trial using a validated PHU risk calculator to identify and enroll high-risk participants into a postpartum education and patient navigation intervention. OBJECTIVES:To evaluate feasibility and engagement with a postpartum educational and patient navigation intervention and generate preliminary estimates of effectiveness in reducing postpartum hospital use within 30 days of delivery discharge. STUDY DESIGN:We conducted a randomized controlled trial among Black individuals who gave birth at a Philadelphia academic medical center between February 2024-April 2025. Recruitment was guided by a risk calculator derived from a previously validated prediction model for postpartum hospital use. Study coordinators abstracted predictor data from medical charts; self-identified Black individuals with ≥5.5% predicted postpartum hospital use were eligible (cut-point selected from validation). Participants were enrolled before discharge from delivery hospitalization and randomized 1:1 to receive a postpartum educational and patient navigation intervention or standard care. The intervention included bedside printed and electronic education materials, and patient navigation including an in-hospital educational session and support via text message and phone calls through 30 days postpartum. The primary outcome was hospital use within 30 days of discharge, ascertained via electronic medical record and self-report. Secondary outcomes included depressive symptoms, self-efficacy, and perceived access to care self-reported on surveys at three weeks postpartum. Feasibility measures including recruitment yield, retention, and implementation challenges identified from study logs and research team debriefs. RESULTS:Among 1,051 individuals screened, 616 (58.6%) were eligible and approached for enrollment, and 220 were enrolled and randomized (110 intervention, 110 control). Use of the risk calculator resulted in a high social vulnerability cohort: 50.0% with annual household income <$45,000 and 14.2% unhoused. Clinical risk scores were similar in intervention and control groups. Coordinators reported challenges to risk calculator use, including time-intensive abstraction, discrepancies between variable definitions in administrative data (model development) and medical records (recruitment), and missing data. The overall 30-day cumulative incidence of postpartum hospital use was 18.2%. Incidence was 20.0% among intervention participants and 16.4% among control participants (risk ratio [95% confidence interval] = 1.2 [0.7-2.0]). Secondary outcomes were similar between groups. Among intervention participants, 79% reported that the educational materials were helpful and 61% reviewed them more than once. CONCLUSIONS:Among Black participants at elevated risk, engagement with a postpartum patient navigation and education intervention was high, although preliminary estimates did not suggest reduced postpartum hospital use. Risk-based recruitment identified a cohort with elevated postpartum hospital use but posed challenges for real-time risk ascertainment. These findings can inform larger multisite trials of risk-targeted, multilevel postpartum interventions.
Gestational diabetes mellitus (GDM), traditionally defined as a disorder of hyperglycaemia with first onset or recognition during pregnancy, is a common condition which is complicated, costly, and controversial. Advances in understanding and awareness of GDM pathophysiology are resulting in an increasingly loud call for the application of personalised medicine approaches to both research in, and clinical care of, GDM. There is a shift away from viewing GDM as a condition to be diagnosed at 24 weeks of gestation and followed until 12 weeks postpartum, to a condition of metabolic vulnerability that precedes pregnancy, persists after pregnancy and requires a precision, life-course approach for health optimization facilitated by integrated, health system-wide supports. This article reviews emerging areas of focus in GDM with an emphasis on the relationship between the development of GDM and future health complications. The terms woman and women, mother and maternal are used in this paper to refer to all those, regardless of gender, who can or have become pregnant.
BACKGROUND:Early skin-to-skin contact and breastfeeding within the first hour after birth are recommended components of evidence-based intrapartum and immediate postpartum care and central elements of humanized childbirth models. These approaches emphasize uninterrupted mother-newborn contact, physiologic processes, and minimization of nonessential interventions immediately after birth. Despite these recommendations, early contact and breastfeeding are frequently interrupted in routine maternity care. Such interruptions may occur when newborn behavioral reflexes and maternal neuroendocrine pathways are most primed to support breastfeeding, potentially undermining practices intended to protect the early postpartum transition. OBJECTIVE:To identify provider-related and peripartum factors associated with longer uninterrupted skin-to-skin contact and breastfeeding within the first hour of life among low-risk term vaginal births. STUDY DESIGN:This is a secondary analysis of data from an open-label, parallel-group, 1:1 randomized clinical trial conducted at a tertiary maternity hospital [location withheld for double-anonymized peer review] between April and November 2019. The original trial compared physiological umbilical cord clamping after cessation of pulsation with delayed clamping at 1 to 3 minutes after birth. For the present analysis, candidate determinants included allocated clamping strategy, model of intrapartum care (midwifeled vs physician-led), and time of birth (night vs day). Outcomes were uninterrupted skin-to-skin contact duration and breastfeeding within the first hour of life. Determinants of skin-to-skin duration were evaluated using quantile regression, and determinants of breastfeeding were assessed using modified Poisson regression with robust variance estimation. RESULTS:Among 560 mother-infant dyads (physiological clamping 278, delayed 282), skin-to-skin contact occurred in 553 (98.8%). Median uninterrupted duration was 10.7 minutes (95% confidence interval, 10.0-12.2), and 67 dyads (12.0%) achieved ≥60 uninterrupted minutes. Breastfeeding data were available for 536 dyads (95.7%); 319 (59.5%) breastfed within the first hour. Physiological clamping and midwife-led care were independently associated with longer median skin-to-skin duration (adjusted median differences 8.65 and 4.86 minutes, respectively). In adjusted models, breastfeeding within the first hour was more likely with physiological clamping (adjusted risk ratio 1.41) and longer skin-to-skin duration (adjusted risk ratio 1.09 per 10 minutes) and less likely after night birth (adjusted risk ratio 0.81). CONCLUSION:In this low-risk trial cohort, skin-to-skin contact was nearly universal but typically brief. Physiological clamping and midwife-led care were associated with longer uninterrupted contact, and longer contact was strongly associated with breastfeeding within the first hour. Strategies that protect uninterrupted mother-newborn contact-particularly during night shifts-may improve early breastfeeding.
BACKGROUND:Non-English-speaking individuals have noted disparities in health outcomes in the United States, but the role of language in obstetric settings is not well characterized. OBJECTIVE:We examined the association between primary spoken (preferred) language and the risk of nulliparous, term, singleton vertex cesarean delivery. STUDY DESIGN:We conducted a retrospective cohort study of nulliparous, term, singleton vertex deliveries in California (2016-2021) using birth certificates linked to hospital discharge records. The primary outcome was the risk of cesarean delivery. Poisson log-linear regression was used to estimate the association between preferred language and cesarean delivery overall, adjusted for demographic, hospital, and obstetric factors. Analyses were stratified by labor type (pre-labor versus intrapartum), risk characteristics (standard versus high risk), and hospital characteristics (hospital type [academic versus nonacademic], setting [urban versus non-urban], and annual hospital cesarean delivery volume by sample tertiles). RESULTS:Among 721,263 birthing people in California, 87,538 (12.1%) indicated that their preferred language was not English and 359,988 (49.9%) had no measured medical comorbidities (termed standard risk). Non-English speaking patients had a decreased risk of cesarean delivery (adjusted relative risk 0.94, 95% confidence interval 0.92-0.96), including among Chinese- (adjusted relative risk 0.83, 95% confidence interval 0.79-0.86) and Spanish-speaking patients (adjusted relative risk 0.94, 95% confidence interval 0.93-0.97), although non-English speaking birthing people who preferred languages other than Spanish or Chinese had slightly higher risk of cesarean delivery (adjusted relative risk 1.06, 95% confidence interval 1.02-1.10). There was a decreased cesarean risk among non-English speaking patients across labor types (spontaneous labor or prelabor rupture of membranes: adjusted relative risk 0.94, 95% confidence interval 0.89-1.00; induced labor: adjusted relative risk 0.90, 95% confidence interval 0.87-0.93; no indication of either: adjusted relative risk 0.97, 95% confidence interval 0.95-1.00), among standard risk patients (adjusted relative risk 0.95, 95% confidence interval 0.92-0.97), and across hospital type, setting, and annual cesarean delivery volume tertile. A small decrease in cesarean risk was also observed in teaching (adjusted relative risk 0.93, 95% confidence interval 0.91-0.96) and non-teaching hospitals (adjusted relative risk 0.95, 95% confidence interval 0.92-0.97), urban settings (adjusted relative risk 0.93, 95% confidence interval 0.92-0.95), and highest volume tertile (adjusted relative risk 0.93, 95% confidence interval 0.91-0.95), though there was no increase risk in non-urban settings (adjusted relative risk 1.02, 95% confidence interval 0.95-1.11) and across lowest and middle volume tertiles (adjusted relative risk 1.01, 95% confidence interval 0.92-1.11; and adjusted relative risk 0.95, 95% confidence interval 0.91-0.98, respectively). CONCLUSION:Non-English language preference was associated with a slight decreased risk for cesarean delivery among nulliparous, term, singleton, and vertex presenting patients, and an increased risk among people who spoke other languages (i.e., not Chinese or Spanish). Our findings suggest that populations that speak less common non-English languages in California may be at elevated risk of disparate cesarean delivery outcomes.
OBJECTIVE:Twin pregnancies are 1 associated with greater maternal cardiovascular changes and a higher risk of hypertensive disorders of pregnancy (HDP) than singleton pregnancies.(1-4) However, the clinical utility of cardiac biomarkers in this population remains unclear. This study aimed to examine whether longitudinal changes in B-type natriuretic peptide (BNP), N-terminal pro-brain natriuretic peptide (NT-proBNP), and high-sensitivity cardiac troponin T (hs-cTnT) during pregnancy differ between women with and without HDP, and to assess the predictive performance and adjunctive diagnostic utility of BNP and NT-proBNP using previously established gestational age- specific reference ranges. (5) STUDY DESIGN: This study is a preplanned secondary analysis of a prospective single12 center cohort of women with twin pregnancies. Approval was granted by the Ethical Review Board of Osaka Women's and Children's Hospital. All participants provided written informed consent. The original study established gestational and postpartum reference ranges for cardiovascular biomarkers in uncomplicated twin pregnancies.Longitudinal trajectories of cardiac biomarkers were modeled using generalized additive models for location, scale, and shape. Predictive performance was assessed using samples obtained before HDP onset. Adjunctive diagnostic performance was evaluated using post-onset HDP samples collected at ≥30 weeks' gestation, excluding postpartum measurements. For adjunctive analyses, biomarker values were normalized as multiples of the median (MoM) using gestational age-specific reference ranges. Logistic regression models incorporating MoM values and gestational age were used to generate receiver operating characteristic (ROC) curves. Because 25 ROC-derived thresholds were clinically impractical, a pragmatic cutoff of 2.0 MoM was applied. Test characteristics, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated using samples obtained at 34-36 weeks' gestation. RESULTS:Overall, 205 twin pregnancies were included, 17 of which were discontinued owing to miscarriage or fetal death. Sixty-seven (36%) patients had HDP. Figure 1A-C shows the changes in biomarker levels corresponding to the presence or absence of HDP. In HDP cases, BNP and NT-proBNP levels began to increase around 25 weeks of gestation, peaked at 37 weeks, and decreased to the same level as in non-HDP cases at 4-5 days postpartum. Moreover, hs-cTnT levels were higher in HDP cases than in non- HDP cases from approximately 25 weeks and remained higher even at 4-5 days postpartum. Predictive performance was poor, with area under the curve (AUC) values ranging from 0.5 to 0.6 across gestation. In contrast, adjunctive diagnostic analyses in late gestation demonstrated moderate discrimination (AUC 0.81 for BNP and NT-proBNP). However, substantial overlap between HDP and non-HDP pregnancies resulted in clinically impractical ROC-derived thresholds.At a pragmatic cutoff of 2.0 MoM at 34-36 weeks' gestation, biomarkers demonstrated moderate sensitivity and specificity with relatively high negative predictive value but modest positive predictive value . CONCLUSION:Although cardiac biomarkers are elevated in twin pregnancies complicated by HDP, their predictive value is limited.
BACKGROUND:80% of patients presenting with threatened preterm labor do not deliver preterm. Currently, cervical length and cervicovaginal fluid fetal fibronectin are tools used to predict spontaneous preterm birth. However, fetal fibronectin testing has been discontinued worldwide. OBJECTIVES:This study aimed to compare the predictive performance of cervicovaginal fluid interleukin-6 (IL-6) and fetal fibronectin, combined with cervical characteristics (cervical length, sliding sign, and elastography) and other maternal characteristics, for predicting spontaneous preterm delivery in patients with threatened preterm labor. METHODS:This was a prospective study involving 249 singleton pregnancies presenting at 20-36 weeks with threatened preterm labor. Upon admission, cervical length, cervical elastrography, cervical sliding sign, quantitative cervicovaginal fluid fetal fibronectin, and IL-6 were measured. The predictive performance of individual and combined biomarkers for predicting spontaneous preterm delivery < 37 weeks was calculated. RESULTS:The prevalence of spontaneous preterm delivery at <37 weeks of gestation was 10.04% (25/249). The spontaneous preterm delivery group had a significant shorter mean cervical length but higher mean fetal fibronectin and IL-6 concentrations than the term delivery group [cervical length: 2.31 cm (1.90-3.18) vs. 3.41 cm (6.89-11.42); fetal fibronectin: 100 ng/mL (21.50-461.0) vs. 7.50 ng/mL (3.00-59.50); IL-6: 98.63 pg/mL (18.04-258.43) vs. 18.41 pg/mL (11.02-38.91); p<0.001 for all]. The combination of cervical length and IL-6 yielded the highest AUC of 0.78, with a sensitivity of 72% at a specificity of 77.2%, and positive and negative predictive values of 26.1% and 96.1%, respectively, for predicting spontaneous preterm birth at <37 weeks. Such performance is significantly greater than fetal fibronectin (p=0.02) or cervical length alone (p=0.016) but comparable to IL-6 alone (p=0.13). There are no differences in cervical elastrography score (p=0.23) and the presence of cervical sliding sign (p=0.14) between term and preterm birth groups. CONCLUSION:In patients with threatened preterm labor symptoms, cervical length in combination with IL-6 had a moderate sensitivity but high specificity and negative predictive value; thus, these tests may be used as a rule-out test for spontaneous preterm delivery <37 weeks. Cervical length, in combination with IL-6, or IL-6 alone, can replace the fibronectin test.
BACKGROUND:Conservative management of placenta accreta spectrum (PAS) is increasingly attempted to reduce maternal morbidity and preserve fertility. However, in a substantial proportion of cases, uterine preservation cannot be maintained and conversion to cesarean hysterectomy is required before skin closure, a distinct clinical event whose predictors and associated morbidity remain poorly described. OBJECTIVE:We aimed to determine the incidence of intraoperative conversion to cesarean hysterectomy during attempted conservative PAS management, to identify its preoperative predictors, and to characterize the associated maternal morbidity. METHODS:Retrospective multicenter cohort study conducted between January 2013 and December 2023 across three French tertiary PAS referral centers. Women with antenatal PAS suspicion in whom conservative management was attempted were included. Conservative management comprised leaving the placenta partially or completely in situ or performing focal resection of the invaded myometrium and adherent placenta, followed by uterine reconstruction. Intraoperative conversion was defined as cesarean hysterectomy performed before skin closure due to uncontrolled hemorrhage refractory to hemostatic measures. Preoperative predictors were identified by univariate and multivariable logistic regression analysis. RESULTS:Among 189 women with antenatal PAS suspicion, 101 in whom conservative management was initially attempted were included. Intraoperative conversion to cesarean hysterectomy occurred in 29 of 101 women (28.7%), corresponding to nearly one in three women undergoing attempted conservative management. In the conversion group, median estimated blood loss was 3,600 mL (IQR 2,500-6,000) versus 600 mL (IQR 300-1,525) in the successful group (P<.001), with bladder injuries in 13.8% versus 0% (P=.006), and requirement for conversion to general anesthesia in 82.8% versus 33.3% (P<.001). On multivariable analysis, antenatal vaginal bleeding was independently associated with intraoperative conversion (aOR 2.85, 95% CI 1.10-7.39; P=.031). The model had an AUC of 0.70 (95% CI 0.59-0.80), indicating modest discriminative ability. CONCLUSION:Intraoperative conversion to cesarean hysterectomy occurs in nearly one in three women undergoing attempted conservative PAS management and is associated with substantially higher maternal morbidity than successful uterine preservation. Antenatal vaginal bleeding independently predicts this event. It may help guide preoperative counseling and surgical planning.
BACKGROUND:In monochorionic diamniotic (MCDA) twin pregnancies with selective fetal growth restriction (sFGR), antenatal risk stratification relies primarily on umbilical artery (UA) Doppler assessment of the smaller twin. However, UA patterns may change, and placental sharing cannot be measured accurately. Umbilical venous (UV) diameter and flow may reflect each twin's oxygenated blood supply more directly. OBJECTIVES:To evaluate if intertwin differences in UV diameter and flow provide information on placental sharing and perinatal outcomes, in addition to established ultrasound markers. STUDY DESIGN:Prospective single-center cohort study of MCDA pregnancies with sFGR, (defined as estimated fetal weight discordance (EFW) of ≥20%). At diagnosis, intra-abdominal and free cord loop UV diameter and intra-abdominal UV flow, EFW, UA Doppler of the smaller twin, and cord insertion type were assessed. Placental sharing was determined by postnatal angiography. Adverse outcome was defined as fetal demise, neonatal loss, or birth <34 weeks of gestation. Associations were examined using uni- and multivariable regression analyses. Receiver operating characteristic analyses compared models with and without UV parameters. RESULTS:Of 114 sFGR pregnancies, 99 (87%) had placental angiography. Intertwin differences in UV parameters were strongly associated with placental sharing. After adjustment for EFW discordance, cord insertion type, and the smaller twin's UA Doppler pattern, the UV parameters remained independently associated with placental sharing. Intertwin differences in intra-abdominal UV diameter and flow were also independently associated with adverse outcomes. Adding UV parameters to models that included the smaller twin's UA Doppler pattern led to modest but consistent improvement in discrimination for unequal sharing and adverse perinatal outcome. This improvement was most pronounced for the UV flow with an area under the receiver operating characteristic curve (AUC) of 0.89 (0.82-0.96) versus 0.79 (0.70-0.88) (P=0.02) for unequal sharing and 0.82 (0.74-0.90) versus 0.74 (0.66-0.81) (P<0.01) for adverse outcomes, with and without the addition of UV flow, respectively. CONCLUSION:In MCDA twin pregnancies with sFGR, intertwin differences in UV diameter and flow reflect placental sharing and are independently associated with perinatal risk. These findings suggest that UV parameters may complement established ultrasound markers in the assessment of placental sharing and risk stratification.
BACKGROUND:Hypertensive disorders of pregnancy have continued to increase in prevalence among US women of reproductive age and are a leading cause of maternal morbidity and mortality. Digital health technologies may offer a novel approach in the detection and management of hypertensive disorders of pregnancy. OBJECTIVE:The purpose of this study is to report on the follow-up care and service linkages provided through a smartphone application (MOMitor™) developed to monitor postpartum participants with hypertensive disorders of pregnancy. STUDY DESIGN:This was a cohort study involving 861 pregnancies from a quaternary care institution in the southeastern United States. Postpartum participants with hypertensive disorders of pregnancy were asked to complete hypertension assessments through the MOMitor™ app for a 6-week period. Participants were evaluated through the app for need of follow-up care and service linkages. Primary outcomes were defined as counts of follow-up (nurse contacts following app triggers) and counts of service linkages by type. RESULTS:A total of 5,378 hypertension-related assessments were completed by 572 respondents. Follow-up calls by nurses were triggered 496 times, with the majority resulting in continued remote monitoring. Findings include: 2.3% (20/861) of participants were admitted to the hospital, 3.1% (27/861) were referred to labor and delivery or the emergency department, and 2.3% (20/861) were referred to clinic. Medication changes and nurse call requests each occurred in 0.2% (2/861) of cases. Continued monitoring was recommended for 18.5% (159/861) of participants, while 3.1% (27/861) could not be reached. Analysis of the 289 non-responders to the app assessments demonstrated that non-responders were more likely unmarried, Black, and had lower levels of education than responders. CONCLUSION:Our findings demonstrate the feasibility of app-based monitoring and how such programs can function within the existing postpartum care model. Real-time monitoring of participants with hypertensive disorders of pregnancy through MOMitor™ can assist clinical practice and reduce care burdens by providing increased follow-up and service care linkages to those at risk of maternal morbidity and mortality. Non-responders did not generate app triggers, and therefore their clinical outcomes could not be ascertained through this protocol. As this group showed characteristics associated with increased of morbidity and mortality, additional support, "nudges", incentives, and interventions may be needed.
