BackgroundThe “great obstetrical syndromes” of fetal growth restriction and hypertensive disorders of pregnancy can occur individually or be interrelated. Placental pathologic findings often overlap between these conditions, regardless of whether one or both diagnoses are present. Quantification of placental villous structures in each of these settings may identify distinct differences in developmental pathways.ObjectiveTo determine how quantity and surface area of placental villi and vessels differ between severe, early-onset fetal growth restriction with absent/reversed umbilical artery Doppler indices, hypertensive disorders of pregnancy, and the two conditions combined among subjects with disease severity warranting early preterm delivery. We hypothesize that trajectories of placental morphogenesis diverge after a common initiating insult of deep defective placentation. Specifically, we postulate that only villi are affected in pregnancy-related hypertension, whereas both villous and vascular structures are proportionally diminished in severe fetal growth restriction, with no additional effect when hypertension is concomitantly present.Study designIn this retrospective cohort study, paraffin-embedded placental tissue was obtained from four groups: [1] Severe fetal growth restriction with absent/reversed umbilical artery end-diastolic velocities and hypertensive disorders of pregnancy, [2] Severe fetal growth restriction with absent/reversed umbilical artery Doppler indices and no hypertension,[3] Gestational age-matched, appropriately grown pregnancies with hypertensive disease, and [4] Gestational age-matched, appropriately grown pregnancies without hypertension. Dual immunohistochemistry for cytokeratin-7 (trophoblast) and CD34 (endothelial cells) was performed followed by artificial intelligence-driven morphometric analyses. Number of villi, total villous area, number of fetoplacental vessels, and total vascular area across villi within a uniform region of interest were quantified. Quantitative analyses of placental structures were modeled with linear regression.ResultsPlacentas from pregnancies complicated by hypertensive disorders of pregnancy exhibited significantly fewer stem villi (-282 stem villi, 95% CI: [-467, -98], p<0.01), smaller stem villous area (-4.3 mm2, 95% CI: [-7.3, -1.2], p<0.01), and fewer stem villous vessels (-4967 stem villous vessels, 95% CI [-8501, -1433], p<0.01), with no difference in total vascular area. In contrast, placental abnormalities in severe growth restriction were limited to terminal villi, with global decreases in number of villi (-873 terminal villi, 95% CI: [-1501, -246], p<0.01), villous area (-1.5 mm2, 95% CI: [-2.7, -0.4], p<0.01), number of blood vessels (-5165 terminal villous vessels, 95% CI: [-8201, -2128], p<0.01), and vascular area (-0.6 mm2, 95% CI: [-1.1, -0.1], p=0.02). The combination of hypertension and growth restriction had no additional effect beyond the individual impact of each state.ConclusionPregnancies complicated by hypertensive disorders of pregnancy exhibited defects in the stem villi only, whereas placental abnormalities in severely growth restricted pregnancies with absent/reversed umbilical artery end-diastolic velocities were limited to the terminal villi. There were no significant statistical interactions with the combination of growth restriction and hypertension, suggesting that distinct pathophysiologic pathways downstream of the initial insult of defective placentation are involved in each entity and do not synergize to result in more severe pathologic consequences. Delineating mechanisms underlying the divergence in placental development after a common inciting event of defective deep placentation may shed light on new targets for prevention or treatment.

INTRODUCTION: This study assesses predictors of Child Protective Services (CPS) reporting among patients with a positive urine drug screening (UDS) during delivery hospitalization. METHODS: Patients receiving prenatal care and delivering at any UCHealth location between 2015 and 2022 with a positive UDS at delivery were included. Patient demographics, medical history, UDS, infant toxicology, and CPS reporting were collected from medical records. T-tests or nonparametric equivalents for continuous variables and χ2 or Fisher's exact tests for categorical variables were used to compare patients with and without CPS reporting. RESULTS: We found 523 patients with a positive UDS during their delivery hospitalization, with CPS reporting for 71%. CPS reporting was more common in younger patients (26 versus 28 years; P<.01), patients with prior CPS involvement (15% versus 5%; P<.01), patients with an antenatal UDS positive for any substance (46% versus 29%; P<.01), and any positive neonatal toxicology (87% versus 58%; P<.01). Patients positive for cannabis (78% versus 57%; P<.01) or amphetamines (6% versus 1%; P=.03) were more likely to be reported to CPS, while patients positive for barbiturates (12% versus 1%; P<.01) and benzodiazepines (6% versus 2%; P<.01) were less likely. Hospitals located in large (>400k pop.) or small cities (<100k pop.) were less likely to be reported to CPS than mid-sized cities (>100–399k pop.) (66% and 65% versus 76%; P=.03). CONCLUSION: Differences in CPS reporting depended on the substance that tested positive, infant positivity, and delivery location. Future research should explore reasons for no CPS reporting among patients with a positive UDS during delivery hospitalization.

This study aimed to synthesize current literature regarding the impact of social vulnerability on pregnancy-related substance use detection in the United States and highlight disparities in substance use detection practices. Clinicaltrials.gov, Google Scholar, PubMed (includes MEDLINE), and Cochrane Library databases were searched using the following Medical Subject Headings (MeSH): ([“pregnancy” or “prenatal”] AND [“substance use screening” or “urine toxicology testing” or “toxicology testing” or “urine drug screening” or “CRAFFT” or “4P's” or “4P's Plus” or “NIDA Quick Screen” or “DAST-10” or “SURP-P” or “WIDUS”], AND (“bias” or “disparities” or “social vulnerability”]). The search included systematic reviews, prospective and retrospective studies, randomized controlled trials, case studies, and qualitative and quantitative research from January 2014 through November 2023. Selected literature was limited to studies published in English, which included a study population of either pregnant individuals or pregnancy health care providers in the United States, and that were focused on inequities in pregnancy substance use detection. Using Covidence, three authors screened abstracts, and two screened full articles for inclusion. The included studies were evaluated for quality of evidence using the mixed methods appraisal tool. The search yielded 4,188 manuscripts; 37 were eligible for full review. A total of 18 manuscripts were included based on the relevancy of the topic. The most common social vulnerability domain identified was minority status (17/18), followed by socioeconomic status (11/18), household characteristics (8/18), and housing type (1/18). Social vulnerability plays a role in substance use detection among pregnant individuals. Most notably, race and ethnicity, age, and public insurance lead to increased rates of detection, though most individual factors need to be studied in greater depth. This study was registered with PROSPERO (PROSPERO ID CRD42022352598), the International Prospective Register of Systematic Reviews. Key Points

To leverage artificial intelligence (AI)-driven precision pathology to quantify the effects of severe FGR, pregnancy-related HTN, or their interaction on placental villus and vascular properties. We hypothesize that while only villi are affected in HTN, both villous and vascular structures are diminished in severe FGR with no additional effect of concomitant HTN. In this retrospective cohort study, paraffin-embedded placental sections were obtained from four groups: [1] Severe FGR with HTN (n=11) [2] Severe FGR with normotension (n=14) [3] Appropriately grown, gestational age (GA)-matched pregnancies with HTN (n=12) and [4] Appropriately grown, GA-matched pregnancies with normotension (n=14). These underwent immunodetection for cytokeratin-7 (trophoblast) and CD34 (endothelium) followed by AI-driven image analyses. Number of villi and placental vessels, total villous area and total vascular area were quantified. Outcomes were normally distributed, and quantitative analyses were modeled with linear regression models. Pregnancies with HTN exhibited significantly less stem villi (p< 0.01), stem villous area (p< 0.01), and stem villous vessels (p< 0.01), with no difference in vascular area. In contrast, abnormalities in severe FGR were limited to terminal villi, with fewer villi and vessels (p< 0.01) and decreased villous area (p< 0.01) and vascular area (p=0.02). No significant effects were found with the interaction of HTN and severe FGR. Pregnancy-related HTN and severe FGR are associated with stem and terminal villus anomalies, respectively, suggesting that perturbations in placental development may be occurring at different gestational periods for each condition.

INTRODUCTION: Preterm birth represents a leading cause of neonatal morbidity and mortality. Cerclage and progesterone supplementation are the two most frequently employed interventions to reduce the risk of prematurity. Guidelines for cerclage and progesterone have evolved as conflicting evidence for their use mounts, and combination therapy remains poorly understood. Our objective is to determine whether there is benefit to adjunct progesterone supplementation after cerclage placement. METHODS: This is a retrospective cohort review of all individuals who underwent transvaginal cerclage placement at a tertiary medical center between 2005 and 2021. The rate of delivery prior to 37 weeks was compared between participants with and without progesterone supplementation after cerclage. Several secondary maternal and neonatal outcomes were evaluated. Multivariate regression analysis accounted for cerclage indication, use of progesterone prior to cerclage, and other factors that affect prematurity risk. RESULTS: Of 451 participants, there were 160 history-indicated, 134 ultrasound-indicated, and 157 examination-indicated cerclages. Overall, 285 (63.2%) received postcerclage progesterone. Progesterone after cerclage did not decrease the rate of preterm delivery (adjusted odds ratio 1.1, 95% CI 0.4–2.6) for any indication of cerclage. Moreover, adjunct progesterone was associated with decreased latency between cerclage placement and delivery ( P =<.01). CONCLUSION: Prescribing patterns for progesterone after cerclage suggest clinical equipoise. We have found that adjunct progesterone does not decrease the preterm delivery rate and may in fact cause harm by decreasing latency from cerclage to delivery. These data do not support the use of progesterone after cerclage for any indication.

INTRODUCTION: The objective of this study was to compare unplanned cesarean deliveries, labor interventions, and maternal and neonatal adverse outcomes in low-risk pregnant patients receiving intrapartum care managed by obstetricians or midwives. METHODS: We conducted a retrospective cohort study using perinatal data from a single academic tertiary center from 2013 to 2018. The sample included healthy nulliparous and multiparous patients with a term, singleton, vertex fetus managed by obstetricians or midwives. We included both induced and spontaneous labor as well as trial of labor after cesarean. We excluded patients with planned cesarean delivery or any high-risk diagnosis requiring prelabor transfer from midwife to obstetrician care. RESULTS: Our cohort included 7,694 patients; 3,543 (46%) received care from an obstetrician and 4,151 (54%) from a midwife. The overall cesarean rate was 11.8%. Patients receiving midwifery care had significantly lower cesarean rates (8.9% versus 15.2%, P <.01), including when analyzed by parity. Patients receiving obstetrician care more frequently experienced induction/augmentation, neuraxial anesthesia, and operative vaginal delivery. Patients of obstetricians had a higher maternal adverse composite outcome (23% versus 18%, P <.01). Midwifery patients had higher rates of shoulder dystocia (3% versus 2%, P <.01). In logistic regression, midwifery care had lower adjusted odds of unplanned cesarean birth (adjusted odds ratio, 0.49 [0.40–0.60] 95% CI). CONCLUSION: Wider integration of midwifery care for low-risk labor and delivery may reduce rates of unplanned cesarean delivery and optimize effective patient-centered care. Additional studies are needed to identify the mechanisms underlying these findings and the implications for systems-based change to improve vaginal delivery rates in the U.S.

BACKGROUND: Severe COVID-19 infection in pregnancy has been associated with an increase in adverse perinatal outcomes, although studies differ regarding which outcomes are affected. Increased characterization of obstetrical and neonatal outcomes is needed, including details on indications for preterm delivery and additional neonatal adverse outcomes. OBJECTIVE: This study aimed to determine whether there is a higher rate of adverse perinatal outcomes with severe-to-critical COVID-19 infection compared with nonsevere COVID-19 diagnosed during pregnancy. STUDY DESIGN: This was a retrospective observational cohort study that compared rates of adverse perinatal outcomes between patients with severe-to-critical and those with nonsevere (asymptomatic, mild, or moderate) COVID-19 infection. Patients had singleton pregnancies and a positive laboratory polymerase chain reaction result for COVID-19. Primary outcomes included hypertensive disorders of pregnancy, cesarean delivery, fetal growth restriction, preterm birth, and neonatal intensive care unit admission. Additional neonatal outcomes analyzed included need for cardiopulmonary resuscitation, low birthweight (<2500 g), 1-or 5-minute Apgar score <7, need for supplemental oxygen, need for intubation, intraventricular hemorrhage, sepsis, respiratory distress syndrome, bronchopulmonary dysplasia, blood transfusion, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, birth trauma, or neonatal death. Appropriate bivariate analyses were used to compare groups. Logistic regression was used to examine primary outcomes while adjusting for confounders. RESULTS: A total of 441 participants were identified and confirmed via detailed chart review to be pregnant with a singleton pregnancy while diagnosed with COVID-19. Of these, 44 (10%) met National Institutes of Health criteria for severe-to-critical COVID-19 infection. The median gestational age at the time of maternal COVID-19 diagnosis was 36.4 weeks (interquartile range, 29.6-38.6). Severe-to-critical COVID-19 infection had a higher risk of a composite adverse neonatal outcome (36.4% vs 21.4%; P=.03). There was a high incidence of hypertensive disorders of pregnancy overall (20.6%), but this outcome was not higher in the severe-to-critical vs nonsevere group. There were no maternal deaths. There was a low incidence of neonatal COVID-19 test positivity among those tested (1.8%). When adjusting for presence of heart disease and gestational age at COVID-19 diagnosis, severe-to-critical COVID-19 was strongly associated with fetal growth restriction (adjusted odds ratio, 2.73; confidence interval, 1.03-7.25) and neonatal intensive care unit admission (adjusted odds ratio, 3.50; confidence interval, 1.56-7.87). Preterm delivery was more common but was no longer significant after adjustment (adjusted odds ratio, 2.23; confidence interval, 0.99-5.05). CONCLUSION: Severe-to-critical COVID-19 infection during pregnancy is associated with higher rates of adverse neonatal outcomes and strongly associated with neonatal intensive care unit admission and fetal growth restriction compared with nonsevere disease. There is a high rate of hypertensive disorders of pregnancy overall in all those affected by COVID-19, regardless of severity. Pregnant persons should be counseled on these risks to encourage vaccination, and those with infection during pregnancy should be monitored for fetal growth disorders.

Objective: To assess if distractions alter sonographers' perceptions of an obstetric sonogram's (OBS) quality and whether clinic policies mitigate this association. Materials and Methods: Members of the Society of Diagnostic Medical Sonography were surveyed regarding demographics, perceived distractions during OBS, clinic observer and/or recording policies, plus perceptions of OBS quality concerns. Distraction and OBS quality scores were calculated. Chi-squared tests were used for bivariate analysis. Logistic regression identified independent predictors of OBS quality concerns. Results: There were 805 surveys completed. Many respondents (68%) found more than 75% of behaviors distracting, which was associated with increased reports of OBS quality concerns (adjusted odds ratio [aOR] = 3.63, 95% confidence interval [CI]: 2.55, 5.15), despite respondents' demographics or clinic policies. More distracting behaviors (79%, P < .01) and quality concerns (40%, P = .04) were noted by sonographers who wanted, but did not have, recording policies at their clinic. Increased quality concerns correlated with disagreement concerning current recording policies (aOR = 2.89, 95% CI: 1.11, 8.00) and desired but absent observer policy (aOR = 2.24, 95% CI: 1.09, 4.59), regardless of respondent demographics or distraction score. Conclusion: Increased distraction scores are associated with more sonographer reports of OBS quality concerns. The lack of desired policies was associated with increased distractions and quality concerns. Further work is needed to understand the relationship between clinic policies, perceived distraction, and OBS quality.

Objective The aim of this retrospective study was to evaluate the maternal conditions for which preconception services are provided and the routine services and recommendations offered through the Maternal Fetal Medicine group at the University of Colorado (CU). The study sought to determine how services and recommendations differ by maternal condition, demographics, and reproductive health history. Materials and Methods Charts of patients who received preconception counseling through the CU MFM department during 2018 were reviewed to evaluate maternal conditions and the type of counseling patients received. Patients were grouped by their referral reason and subsequently by counseling recommendations to either proceed with immediate conception, defer immediate conception pending completion of further recommendations or to not conceive. Results Of the fifty-nine patients referred to preconception counseling, 52% (n = 31) of the women were referred for maternal disease, 40% (n = 24) for infertility, 32% (n = 19) for previous poor obstetric outcomes, 30% (n = 18) for advanced maternal age and finally, 15% (n = 9) for gynecologic anatomic abnormalities. Conclusion During the initial evaluation, 58% (n = 34) of patients were determined to have no concern for immediate conception while 7% (n = 4) were ultimately advised to not conceive. Using this data, we identified areas of preconception counseling that standardization will improve by ensuring patients receive comparable services and advice.

Objective The objective was to identify sonographer perceptions of distractions and policies for improving obstetric sonography examinations (OBUS). Materials and Methods A survey, with closed- and open-ended questions, was sent to OBUS practicing members of the Society of Diagnostic Medical Sonography (SDMS). Descriptive analyses, including frequency distributions overall and by various groups, were performed. Chi-square analyses were used to examine the relationships between categorical variables, including level of perceived distraction, and concordance with policies. Results Of the 3525 accessed e-mails, 807 responses were eligible for analysis. Over half (62%) of the respondents reported no observer policy. Sonographers reported strong agreement with observer policies and desired limits on observers. Policy disagreement themes included number of observers, children observers, patient satisfaction, and patient truthfulness. Most sonographers reported existence of (85%) and strong agreement (97%) with recording policies. Disagreements centered around the strictness of policies, policy enforcement and notification, distraction of recording, medico-legal issues, and finding anomalies while being recorded. Conclusion Discrepancies existed between policies regarding observers and recording in OBUS. Sonographers both desired and agreed with protocols to limit distractions. However, there were concerns regarding stringency, notification, and enforcement of policies. Further research is needed to determine if policies help limit distractions during OBUS.

Objective: Maternal infection during pregnancy is associated with psychiatric disorders among offspring. The aim of this study was to investigate associations between upper respiratory infection (URI) in pregnancy and measures of cognitive and behavioral outcomes in child offspring.Materials and methods: A longitudinal study of 534 mother-child pairs with information regarding prenatal exposures collected through an interview conducted on average one year after delivery and subsequent participation in a childhood cognitive and psychosocial assessment between the ages 5-12 years. Childhood cognition was measured using the Peabody Picture Vocabulary Test (PPVT-III) and the Beery-Buktenica Test of Visual Motor Integration-Fifth Edition (VMI-5) and behavioral function measured using the Child Behavior Checklist (CBCL) and teacher-report using the Teacher Report Form (TRF). Adjusted mean differences (adjMD) in outcome measures were calculated between mothers reporting the presence or absence of a URI during pregnancy.Results: URI during pregnancy was not associated with the two measures of cognition given to offspring, but was associated with modest increases in total behavioral problems reported by mothers (adjMD: 3.72; CI: 1.91-5.54) and teachers (adjMD: 2.74; CI: 0.97-4.50). We observed differences in CBCL and TRF scores based on timing of URI: infections in mid-pregnancy (lunar months 4-5) were associated with poorer scores than were infections in early pregnancy (lunar months 2-3).Conclusions: In general, URI in pregnancy was not associated with decrements in childhood cognition, but may be associated with behavior problems. (C) 2016 Elsevier Inc. All rights reserved.

On December 13, 2013, MMWR published a report describing three cases of sudden cardiac death associated with Lyme carditis. State public health departments and CDC conducted a follow-up investigation to determine 1) whether carditis was disproportionately common among certain demographic groups of patients diagnosed with Lyme disease, 2) the frequency of death among patients diagnosed with Lyme disease and Lyme carditis, and 3) whether any additional deaths potentially attributable to Lyme carditis could be identified. Lyme disease cases are reported to CDC through the Nationally Notifiable Disease Surveillance System; reporting of clinical features, including Lyme carditis, is optional. For surveillance purposes, Lyme carditis is defined as acute second-degree or third-degree atrioventricular conduction block accompanying a diagnosis of Lyme disease. During 2001-2010, a total of 256,373 Lyme disease case reports were submitted to CDC, of which 174,385 (68%) included clinical information. Among these, 1,876 (1.1%) were identified as cases of Lyme carditis. Median age of patients with Lyme carditis was 43 years (range = 1-99 years); 1,209 (65%) of the patients were male, which is disproportionately larger than the male proportion among patients with other clinical manifestations (p<0.001). Of cases with this information available, 69% were diagnosed during the months of June-August, and 42% patients had an accompanying erythema migrans, a characteristic rash. Relative to patients aged 55-59 years, carditis was more common among men aged 20-39 years, women aged 25-29 years, and persons aged ≥75 years.

A 63-year-old man was admitted to this hospital because of paresthesias, difficulty drinking liquids, and anxiety. Diagnostic procedures were performed.