Introduction: Many digital tools are available to support healthy pregnancies. Far fewer focus on the postpartum period or have the explicit goal of reducing poor or inequitable maternal health outcomes. Yet, many pregnancy-related complications occur up to a year after labor and delivery. Here, we outline a healthequity-centered process, using multiple phases of data collection, which informed our design decisions when developing a comprehensive postpartum support app, Myana ("Mothers, you are not alone"). Methods: Drawing on a behavioral decision research approach and grounded in principles for developing equity-focused digital reproductive health tools, we iteratively designed and tested the Myana app. Our data collection included qualitative interviews, focus groups, and evaluations of an interactive experience prototype and app wireframes. Results: To illustrate our process, we highlight two unique features of Myana intended to address health inequities: a symptom triaging feature ("The Healing Check-in") and a tailored educational hub ("The Learning Center"). Results from our iterative development process shaped how we asked about and responded to symptoms reported in the Healing Check-in, the topics and framing of curated content in the Learning Center, the cadence of expected interaction with features in the app, as well as the app's overall tone and visual design. Discussion: We created a postpartum support app to help birthing parents make informed decisions about their health and well-being in the year postpartum, with the larger goal of improving health outcomes. The iterative design and development process integrated clinical and community perspectives while intentionally centering health disparities. This approach represents a new model for developing digital supports to supplement the formal healthcare system.

We sought to evaluate outcomes following implementation of a remote monitoring program for postpartum individuals with a hypertensive disorder of pregnancy (HDP). We evaluated the impact of engagement in a remote hypertension management program in a cohort of postpartum individuals with a HDP delivering from 1/2018 - 6/2023 at a single institution. We compared postpartum readmission, office visit within 6 weeks, BP measurement within 10 days, and postpartum initiation of antihypertensive medication among those who participated to controls who did not participate. Program participation was at the discretion of the care provider and patient. We performed multivariate logistic regression and conditional regression in a propensity score matched cohort. Adjustment variables were included in propensity score modeling likelihood of program participation. Propensity scores were assessed for even distribution by group and ensuring standardized bias < 10% after matching. We included 14,382 eligible individuals (6501 participants, 7881 controls). Program participants were more likely to be white, commercially insured, reside in a more disadvantaged neighborhood, have a higher BMI, have preeclampsia, and have higher prenatal and inpatient postpartum BPs. These factors were well-balanced after implementation of propensity score. Program participants had lower 6-week postpartum readmission rates, demonstrating 16 fewer readmissions for every 1000 individuals in the program [adjRD=-1.6 (-2.5, -0.80); aRR 0.77 (0.68, 0.88)]. For every 100 individuals in the program, 85 more had a BP recorded within 10 days [adjRD=85.9 (85.1, 86.8)] and 7 more were adherent with 6-week postpartum office visit [adjRD=7.9 (6.4, 9.5)]. Participants were 3-4 times more likely to initiate an antihypertensive medication postpartum [ajdRR=3.79 (3.42, 4.19)]. Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use after implementation.

Anti-PP1PK alloimmunization is rare given ubiquitous P1PK expression. Prevention of recurrent miscarriages and hemolytic disease of the fetus and newborn (HDFN) in pregnant individuals with anti-PP1PK antibodies has relied upon individual reports. Here, we demonstrate the successful management of maternal anti-PP1PK alloimmunization in a 23-year-old, G2P0010, with therapeutic plasma exchange (TPE), intravenous immunoglobulin (IVIG), and monitoring of anti-PP1Pk titers. Twice-weekly TPE (1.5 plasma volume [PV], 5% albumin replacement) with weekly titers and IVIG (1 g/kg) was initiated at 9 weeks of gestation (WG). The threshold titer was ≥16. Weekly middle cerebral artery-peak systolic velocities (MCA-PSV) for fetal anemia monitoring was initiated at 16 WG. PVs were adjusted throughout pregnancy based on treatment schedule, titers, and available albumin. Antigen-negative, ABO-compatible RBCs were obtained through the rare donor program and directed donation. An autologous blood autotransfusion system was reserved for delivery. Titers decreased from 128 to 8 by 10 WG. MCA-PSV remained stable. At 24 WG, TPE decreased to once weekly. After titers increased to 32, twice-weekly TPE resumed at 27 WG. Induction of labor was scheduled at 38 WG. Vaginal delivery of a 2950 g neonate (APGAR score: 9, 9) occurred without complication (Cord blood: 1+ IgG DAT; Anti-PP1Pk eluted). Newborn hemoglobin and bilirubin were unremarkable. Discharge occurred postpartum day 2. Anti-PP1Pk alloimmunization is rare but associated with recurrent miscarriages and HDFN. With multidisciplinary care, a successful pregnancy is possible with IVIG and TPE adjusted to PV and titers. We also propose a patient registry and comprehensive management plan.

OBJECTIVE: To evaluate differences in health care utilization and guideline adherence for postpartum individuals with hypertensive disorders of pregnancy (HDP) who are engaged in a remote monitoring program, compared with usual care. METHODS: This was a retrospective cohort study of postpartum individuals with HDP who delivered between March 2019 and June 2023 at a single institution. The primary exposure was enrollment in a remote hypertension management program that relies on patient home blood pressure (BP) measurement and centralized nursing team management. Patients enrolled in the program were compared with those receiving usual care. Outcomes included postpartum readmission, office visit within 6 weeks postpartum, BP measurement within 10 days, and initiation of antihypertensive medication. We performed multivariable logistic and conditional regression in a propensity score matched cohort. Propensity scores, generated by modeling likelihood of program participation, were assessed for even distribution by group, ensuring standardized bias of less than 10% after matching. RESULTS: Overall, 12,038 eligible individuals (6,556 participants, 5,482 in the control group) were included. Program participants were more likely to be White, commercially insured, be diagnosed with preeclampsia, and have higher prenatal and inpatient postpartum BPs. Differences in baseline factors were well-balanced after implementation of propensity score. Program enrollment was associated with lower 6-week postpartum readmission rates, demonstrating 1 fewer readmission for every 100 individuals in the program (propensity score–matched adjusted risk difference [aRD] −1.5, 95% CI, −2.6 to −0.46; adjusted risk ratio [aRR] 0.78, 95% CI, 0.65–0.93). For every 100 individuals enrolled in the program, 85 more had a BP recorded within 10 days (propensity score–matched aRD 85.4, 95% CI, 84.3–86.6), and six more had a 6-week postpartum office visit (propensity score–matched aRD 5.7, 95% CI, 3.9–7.6). Program enrollment was also associated with increased initiation of an antihypertensive medication postpartum (propensity score–matched aRR 4.44, 95% CI, 3.88–5.07). CONCLUSION: Participation in a postpartum remote BP monitoring program was associated with fewer postpartum hospital readmissions, higher attendance at postpartum visits, improved guideline adherence, and higher rates of antihypertensive use.

Objective While twin gestations are at increased risk of severe maternal morbidity (SMM), there is limited information about timing and causes of SMM in twins. Furthermore, existing data rely on screening definitions of SMM because a gold standard approach requires chart review. We sought to determine the timing and cause of SMM in twins using a gold standard definition outlined by the American College of Obstetricians and Gynecologists (ACOG). Study Design We used a perinatal database to identify all twin deliveries from 1998 to 2013 at a single academic medical center (n = 2,367). Deliveries were classified as screen positive for SMM if they met any of the following criteria: (1) one of the Centers for Disease Control and Prevention (CDC) International Classification of Diseases Ninth Revision diagnosis and procedure codes for SMM; (2) a prolonged postpartum length of stay (>3 standard deviations beyond mean length of stay by mode of delivery); or (3) maternal intensive care unit admission. We identified true cases of SMM through medical record review of all screen-positive deliveries using the definition of SMM outlined in the ACOG Obstetric Care Consensus. We also determined cause and timing of SMM. Results A total of 165 (7%) of twin deliveries screened positive for SMM. After chart review of all screen-positive cases, 2.4% (n = 56) were classified as a true case of SMM using the ACOG definition for a positive predictive value of 34%. The majority of SMM occurred postpartum (65%). Hemorrhage was the most common cause of SMM, followed by hypertensive and pulmonary etiologies. Conclusion Commonly used approaches to screen for SMM perform poorly in twins. This has important implications for quality initiatives and epidemiologic studies that rely on screening definitions of maternal morbidity. Our study demonstrates that the immediate postpartum period is a critical time for maternal health among women with twin pregnancies. Key Points

Women with hypertensive disorders of pregnancy (HDP) are at increased risk for chronic hypertension (cHTN). It is unclear whether postpartum blood pressures (BPs) differ among women who develop persistent HTN from those who do not. Among women with a HDP, we evaluated BP trajectories in the first 6 weeks postpartum, and compared women with persistent hypertension to those normotensive at 6-18 months postpartum. We used home BP data collected through a remote postpartum HTN monitoring program. Women who delivered between 2/2018-6/2019, without pre-pregnancy cHTN and with a follow up BP between 6-18 months postpartum were included. We compared BP trajectories and demographics by whether women had persistent hypertension (systolic BP ≥ 130 mmHg, diastolic BP ≥ 80 mmHg or anti-hypertensive medication use). We used repeated BP measures to fit mixed-effects linear regression models with participant identifier as random intercepts and weeks postpartum as a fixed effect expressed using restricted cubic splines. Adjusted models included pre-pregnancy body mass index (pBMI) and type of HDP. We included 368 women who contributed 5,958 BPs in the first 6 weeks postpartum. 182 (49.5%) were hypertensive at follow up, and 186 (50.5%) were normotensive at follow up a mean of 12.9 +/- 3.6 months postpartum. Women hypertensive at follow up had a higher pBMI. There was no difference by race, insurance status, maternal age or type of HDP. Despite no differences in BP at first prenatal visit, women with persistent hypertension had a slower decline in BP (p<0.01 for systolic and diastolic BP) in the first 6 weeks postpartum and had higher BPs at the postpartum visit. These differences persisted in multivariable models after adjustment for pBMI and type of HDP (p<0.01 for systolic and diastolic BP). BP trajectories in the first 6 weeks postpartum distinguish women with persistent hypertension at 6-18 months. Given insurance and long-term follow up limitations for many women, BP profiles in the first 6 weeks postpartum may identify women at higher risk for persistent hypertension.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Women of non-Hispanic black race are disproportionately impacted by hypertensive disorders of pregnancy (HDP), cardiovascular disease (CVD) and maternal morbidity and mortality. We sought to compare blood pressure (BP) trajectories following a HDP via home blood pressure monitoring in the first six weeks postpartum by race. We utilized home BP data collected through an ongoing postpartum remote hypertension monitoring program. Women are enrolled in the nursing call center-driven BP management program by their primary obstetric provider during their postpartum hospitalization and are prompted to report their BP via text message 3-5 times per week for the first six weeks postpartum. Demographic and obstetrical outcome data was obtained from the electronic medical record and compared by self-reported race (non-Hispanic black vs. all other races) in univariate and multivariable analysis using linear regression with adjustment for previously identified co-variates. 550 women were included; 116 non-Hispanic black (21.1%) and 434 white and other races (78.9%) who participated in the program between January 2018 and May 2019, with a total of 8,200 recorded blood pressures in the first 42 days postpartum. The postpartum decline of both systolic and diastolic BP was significantly lower among non-Hispanic black women compared to all other races; systolic BP -6.8 [95%CI -7.4, -6.3] vs. -4.2 [95%CI -5.5, -2.9] mmHg per week in the first 3 weeks postpartum. These findings remained significant in multivariable models adjusted for type of hypertensive disorder of pregnancy, anti-hypertensive medication use and BMI category (p< 0.0001). At each week postpartum among non-Hispanic black women, BP is higher with a slower decline over time than women of other races. These findings highlight physiologic differences that might contribute to disparities in postpartum morbidity and long-term CVD among black women. Importantly, our findings identify a potential therapeutic opportunity postpartum and highlight the importance of transitioning care to the primary care physician after a HDP.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Hypertensive disorders of pregnancy (HDP) are a major contributor to postpartum maternal morbidity and mortality. Historically, compliance with in-person postpartum visits is poor and innovative interventions to improve adherence to care in this period are needed. We sought to assess the impact of replacement of the in-office blood pressure (BP) check with a remote hypertension telehealth monitoring program in women with HDP. This is an ongoing quality improvement project utilizing nursing call center-driven BP management that included women with a HDP. Eligible women are enrolled by their primary obstetric provider while inpatient in the postpartum period into either a medication or non-medication group based on the need for medication at the time of discharge. Women are prompted to report BP via secure text message 3-5 times per week depending on the need for anti-hypertensive medication. If all BPs are at goal, the one week postpartum in-office BP check is canceled and the patient continues remote monitoring (Figure). We utilized Geocoding from patient's home addresses to an in-office BP check to assess the distance traveled and travel time saved through our remote monitoring program. A total of 550 women participated in the program between January 2018 and April 2019, with 351 women (63.8%) requiring an office BP check and 199 (36.2%) not requiring a visit. Women reported a median of 15 [7-20] BPs through the program. Compliance was 88.1% in the first week with 541 (98.4%) women reporting at least one BP in the first ten days postpartum. Women saved a median of 26.3 minutes [IQR 17.3-39.6] and 12.8 miles [IQR 7.4-26.1] one-way by averting an in-person BP assessment. Replacement of the in-office BP assessment with remote blood pressure monitoring saved an aggregate total of 11,008 miles and 15,489 minutes of travel time round-trip among 199 women. Remote monitoring programs for postpartum hypertension may reduce the travel time and burden related to in-office BP checks. Such programs may be particularly useful in reducing barriers to care in the postpartum period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Question Does postpartum blood pressure trajectory after a hypertensive disorder of pregnancy differ by race? Findings In this prospective cohort study that included 1077 women after a hypertensive disorder of pregnancy, blood pressure trajectories evaluated using mixed-effects linear regression models differed significantly by self-reported race. At the conclusion of the study, 68% of Black women and 51% of White women met the criteria for stage 1 or stage 2 hypertension. Meaning This study suggests that postpartum blood pressure trajectories indicate persistence of higher blood pressures among Black women in this cohort, which may have important implications for postpartum morbidity and mortality associated with hypertensive and cardiovascular conditions in this population. This cohort study describes the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and evaluates whether blood pressure trajectories differ by self-reported race. Importance Maternal morbidity and mortality are increasing in the United States, most of which occur post partum, with significant racial disparities, particularly associated with hypertensive disorders of pregnancy. Blood pressure trajectory after a hypertensive disorder of pregnancy has not been previously described. Objectives To describe the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and to evaluate whether blood pressure trajectories differ by self-reported race. Design, Setting, and Participants This prospective cohort study included deliveries between January 1, 2018, and December 31, 2019. Women with a clinical diagnosis of a hypertensive disorder of pregnancy were enrolled in a postpartum remote blood pressure monitoring program at the time of delivery and were followed up for 6 weeks. Statistical analysis was performed from April 6 to 17, 2020. Main Outcomes and Measures Mixed-effects regression models were used to display blood pressure trajectories in the first 6 weeks post partum. Results A total of 1077 women were included (mean [SD] age, 30.2 [5.6] years; 804 of 1017 White [79.1%] and 213 of 1017 Black [20.9%]). Systolic and diastolic blood pressures were found to decrease rapidly in the first 3 weeks post partum, with subsequent stabilization (at 6 days post partum: mean [SD] peak systolic blood pressure, 146 [13] mm Hg; mean [SD] peak diastolic blood pressure, 95 [10] mm Hg; and at 3 weeks post partum: mean [SD] peak systolic blood pressure, 130 [12] mm Hg; mean [SD] peak diastolic blood pressure, 85 [9] mm Hg). A significant difference was seen in blood pressure trajectory by race, with both systolic and diastolic blood pressure decreasing more slowly among Black women compared with White women (mean [SD] peak systolic blood pressure at 1 week post partum: White women, 143 [14] mm Hg vs Black women, 146 [13] mm Hg; P = .01; mean [SD] peak diastolic blood pressure at 1 week post partum: White women, 92 [9] mm Hg vs Black women, 94 [9] mm Hg; P = .02; and mean [SD] peak systolic blood pressure at 3 weeks post partum: White women, 129 [11] mm Hg vs Black women, 136 [15] mm Hg; P < .001; mean [SD] peak diastolic blood pressure at 3 weeks post partum: White women, 84 [8] mm Hg vs Black women, 91 [13] mm Hg; P < .001). At the conclusion of the program, 126 of 185 Black women (68.1%) compared with 393 of 764 White women (51.4%) met the criteria for stage 1 or stage 2 hypertension (P < .001). Conclusions and Relevance This study found that, in the postpartum period, blood pressure decreased rapidly in the first 3 weeks and subsequently stabilized. The study also found that, compared with White women, Black women had a less rapid decrease in blood pressure, resulting in higher blood pressure by the end of a 6-week program. Given the number of women with persistent hypertension at the conclusion of the program, these findings also appear to support the importance of ongoing postpartum care beyond the first 6 weeks after delivery.

The use of remote monitoring has been proposed to improve patient engagement and reduce maternal morbidity during the postpartum period. We sought to compare healthcare utilization in women enrolled in remote monitoring versus a historical cohort of women with a diagnosis of a hypertensive disorder of pregnancy (HDP). This project utilizes nursing call center-driven blood pressure management that includes women with HDP admitted to the postpartum unit of a single tertiary care hospital. Eligible women are enrolled in the program by their obstetric provider into either a medication or non-medication group based on the need for anti-hypertensive therapy at discharge. Women are prompted to take and report blood pressures via text-messaging enabled smartphones between 3-5 times per week. Electronic medical record review was performed on women in the remote monitoring program compared to a cohort of women with HDP six months prior to the onset of program enrollment. Maternal, obstetrical and healthcare utilization data were compared using univariate analysis with chi-square and student's t-tests. A total of 340 women were enrolled in the program between January 2018 and December 2018. Compared to the historical cohort, women in the remote monitoring group had a lower BMI, were more likely to have private insurance, and delivered at an earlier gestational age. 41 (12.2%) women in the remote monitoring group compared with 31 (8.0%) women in the historical cohort were readmitted within 56 days of delivery. Attendance at the postpartum appointment was significantly higher in the remote monitoring group (Figure). We demonstrate that women enrolled in a remote hypertension monitoring program are more likely to follow-up for their postpartum visit than those in the historical cohort. Additionally, there is a trend towards an increased number of hospital readmissions in this population. We hypothesize that this may be secondary to increased recognition of complications related to hypertension. However, further analyses are needed to ascertain a reduction in postpartum morbidity.

OBJECTIVE:To evaluate the feasibility, acceptability, and compliance of a remote blood pressure monitoring protocol implemented as a quality improvement measure at the hospital level for management of hypertension in postpartum women after hospital discharge.METHODS:This is an ongoing quality improvement project that included women admitted to the postpartum unit of a single tertiary care hospital. We designed nursing call center-driven blood pressure management and treatment algorithms, which were initiated after hospital discharge until 6 weeks postpartum. Women are eligible to participate if they have a diagnosis of chronic hypertension, superimposed preeclampsia, gestational hypertension, preeclampsia, or postpartum hypertension and have access to a text messaging-enabled smartphone device. After identification by an obstetric care provider, women are enrolled into the program, which is automatically indicated in the electronic medical record. Maternal, obstetric, and sociodemographic data were obtained from the electronic medical record.RESULTS:Between February 2018 and January 2019, we enrolled 499 patients. Here we report on the first 409 enrolled patients. Participants include 168 (41%) with gestational hypertension, 179 (44%) with preeclampsia with no history of chronic hypertension, 49 (12%) with chronic hypertension with superimposed preeclampsia, and 13 (3%) with postpartum preeclampsia. One hundred seventy-one (42%) participants had antihypertensives initiated or titrated through the program. Three hundred forty women (83%) continued the program beyond 3 weeks postpartum, and 360 (88%) attended an in-person 6-week postpartum visit. Two hundred thirty-five out of 250 women who completed a postprogram survey (94%) reported satisfaction with the program.CONCLUSION:In this study, we detail results from an ongoing remote blood pressure monitoring program. We demonstrate high compliance, retention, and patient satisfaction with the program. This is a feasible, scalable remote monitoring program connected to the electronic medical record.

Mirror syndrome is a rare pregnancy complication, life-threatening to mother and fetus. Increasing survival rates of congenital heart disease into reproductive age mean that complications like Mirror syndrome in this population may be more challenging to diagnose, given overlapping signs of edema in cases of heart failure exacerbation. We report a case of a pregnant woman with a history of unspecified congenital heart disease, presenting with swelling and distension, with diagnostic findings not consistent with preeclampsia. Her course was complicated by dyspnea, oliguria, and fetal hydrops. A cesarean delivery under neuraxial anesthesia was performed. We review the clinical manifestations of Mirror syndrome and discuss anesthetic and obstetric management considerations for this condition.

Telemedicine care is an innovative healthcare delivery approach to help overcome difficulties with access to care. We sought to compare pregnancy outcomes with in-person and telemedicine Maternal-Fetal Medicine consultation in women with gestational diabetes mellitus (GDM). This is a retrospective cohort study of 542 pregnant women with GDM who underwent Maternal-Fetal Medicine consultation between 2016 and 2017. GDM management included physician consultation, medical nutrition therapy counseling by a certified diabetes educator, and weekly glycemic surveillance for both telemedicine and in-person groups. We compared baseline maternal characteristics and pregnancy outcomes based on the type of care. Telemedicine management was performed in 88 (16%) of women with GDM. Women undergoing telemedicine management were younger (29.6 vs 32.2, p<0.001), more likely to be obese (71.6 vs 55%, p=0.02), and to actively smoke (22.7 vs 11.1, p=0.01), but there were no differences in gestational age at GDM diagnosis (23.7 vs 25.1 weeks, p=0.06). Need for pharmacologic therapy was similar in both groups (53.4 vs. 54.8%, p=0.8). Also, mean fasting (100.5 vs 98.7 mg/dL, p=0.4) and postprandial (130.8 vs 129.9 mg/dL, p=0.7) glucose values were similar in women undergoing telemedicine and in-person consultation. Pregnancy outcomes did not differ by management type including preterm birth, hypertensive disorders of pregnancy and cesarean delivery. Neonatal outcomes were similar including NICU admission (17.1 vs. 25.2%, p=0.1) and composite neonatal morbidity (52.3 vs. 45.2%, p=0.2) in women with GDM undergoing telemedicine and in-person management. We found no difference in pregnancy outcomes in women with GDM who underwent telemedicine or in-person management. Our findings suggest a potential role for telemedicine care in the management of women with GDM.

IntroductionWe have previously shown that miRNAs produced from the Chromosome 19 MiRNA Cluster (C19MC), which are expressed almost exclusively in primate trophoblasts and are released into the maternal circulation, reduce viral replication in non-placental cells and can modulate migratory behavior of extravillous trophoblast. We sought to define the expression pattern of C19MC miRNA in early pregnancy and in response to viral infection in vitro and in vivo.MethodsWe prospectively followed women undergoing in vitro fertilization (IVF) and determined their blood level of C19MC miRNA using RT-qPCR. To examine the effect of viral exposure on C19MC miRNAs expression, we used three systems: (1) a transgenic mouse overexpressing the C19MC cluster and exposed to Togaviridae during pregnancy, (2) cultured primary human trophoblasts exposed to Vesicular Stomatitis Virus in vitro, and (3) amniotic fluid from women exposed to cytomegalovirus during pregnancy.ResultsIn 27 IVF pregnancies, C19MC miRNAs were detected as early as 2 weeks after implantation, and their levels increased thereafter. There was no change in C19MC miRNA expression levels in the mouse placenta in response to viral exposure. Similarly, Vesicular Stomatitis Virus infection of primary human trophoblast did not selectively increase C19MC miRNA expression. C19MC miRNA expression in the amniotic fluid was not affected by vertical transmission of cytomegalovirus.DiscussionThe expression of C19MC miRNAs in maternal circulation very early in pregnancy suggests a role in the establishment of the maternal-fetal interface. The levels of C19MC miRNA are not influenced by diverse types of viral infection.

INTRODUCTION: Excess weight gain in pregnancy is associated with maternal and neonatal morbidity. Although the Institute of Medicine (IOM) issued revised guidelines in 2009 for weight gain in pregnancy, it is uncertain whether obstetric providers are discussing weight, and if these conversations adhere to these guidelines. We aim to describe the frequency of these discussions and adherence to IOM guidelines during first prenatal visits. METHODS: Data for this analysis came from a larger study involving audio-recorded initial prenatal visits and post-visit patient questionnaires assessing patients' recall of their encounters. Transcripts from a random sampling of 100 visits were qualitatively coded for weight discussions. Descriptive statistics were used to characterize the sample and frequency of weight discussions. Chi square tests examined associations between discussion occurrence and patient or provider characteristics. RESULTS: The mean BMI among our sample was 28.6 kg/m2±7.2 (39% obese). Gestational weight discussions were infrequent (26%), with 62% providing specific recommendations; 56% of recommendations were consistent with IOM guidelines. On post-visit questionnaires, 46% of patients reported concern regarding weight, 44% recalled discussing weight, and 65% reported a desire to discuss weight gain recommendations. Patients interested in discussing weight were more likely to have this discussion (P=.015). Providers were not more likely to discuss weight with obese women (P=.166). CONCLUSION: Discussions regarding gestational weight gain are infrequent and often do not adhere to IOM guidelines. Providers should become more familiar with recommendations regarding gestational weight gain in order to provide appropriate and meaningful patient counseling.

OBJECTIVE: The objective of the study was to compare the pharmacokinetics of 2 g and 3 g doses of cefazolin when used for perioperative prophylaxis in obese gravidae undergoing cesarean delivery.STUDY DESIGN: We performed a double-blinded, randomized controlled trial from August 2013 to April 2014. Twenty-six obese women were randomized to receive either 2 or 3 g intravenous cefazolin within 30 minutes of a skin incision. Serial maternal plasma samples were obtained at specific time points up to 8 hours after drug administration. Umbilical cord blood was obtained after placental delivery. Maternal adipose samples were obtained prior to fascial entry, after closure of the hysterotomy, and subsequent to fascial closure. Pharmacokinetic parameters were determined via non-compartmental analysis.RESULTS: The median area under the plasma concentration vs time curve was significantly greater in the 3 g group than in the 2 g group (27204 mg/mL per minute vs 14058 mg/mL per minute; P =.001). Maternal plasma concentrations had an impact by body mass index. For every 1 kg/m(2) increase in body mass index at the time of the cesarean delivery, there was an associated 13.77 mg/mL lower plasma concentration of cefazolin across all time points (P =.01). By the completion of cesarean delivery, cefazolin concentrations in maternal adipose were consistently above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria with both the 2 g and 3 g doses. The median umbilical cord blood concentrations were significantly higher in the 3 g vs the 2 g group (34.5 mg/mL and 21.4 mg/mL; P =.003).CONCLUSION: Cefazolin concentrations in maternal adipose both at time of hysterotomy closure and fascial closure were above the minimal inhibitory concentration for both Gram-positive and Gram-negative bacteria when either 2 g or 3 g cefazolin was administered as perioperative surgical prophylaxis. Maternal cefazolin concentrations in plasma and maternal adipose tissue are related to both dose and body mass index.