Publications by authors named "Lisa D Levine"

75 Publications

Women with peripartum cardiomyopathy have normal ejection fraction, but abnormal systolic strain, during pregnancy.

ESC Heart Fail 2021 May 4. Epub 2021 May 4.

Division of Cardiology, Perelman Center for Advanced Medicine, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 2-East Pavilion, Philadelphia, PA, 19104, USA.

We report a case series of six women with peripartum cardiomyopathy (PPCM) who incidentally underwent echocardiography prior to the clinical presentation of PPCM. For comparison, we identified controls, matched 2:1 on age, race, body mass index, gestational age, and hypertensive disorder. Among the six cases, all were diagnosed with PPCM during the post-partum period. Pre-PPCM echocardiograms were performed between 17.7 weeks of gestation and 13 days post-partum. Baseline left ventricular ejection fraction and size were normal and similar to the 12 matched controls (60% ± 6.6% vs. 61.4% ± 6.3%, P = 0.63) or left ventricular end-diastolic dimension (4.6 cm ± 0.2 cm vs. 4.5 cm ± 0.4 cm, P = 0.689). There was a trend towards a less negative (more abnormal) mean global longitudinal strain in cases compared with controls (-14% ± 4% vs. -18.3% ± 4.5%, P = 0.0658). Mean global circumferential strain was significantly less negative (more abnormal) in cases compared with controls (-21.5% ± 5% vs. -29.3% ± 7.6%, P = 0.0329). We conclude that women who develop PPCM have normal left ventricular ejection fraction during gestation preceding PPCM, indicating that the disease develops acutely in the peripartum period. Abnormal strain can be detected, however, suggesting that strain imaging could represent a screening method in populations at high risk for PPCM if confirmed in future studies.
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http://dx.doi.org/10.1002/ehf2.13323DOI Listing
May 2021

Neighborhood education status drives racial disparities in clinical outcomes in PPCM.

Am Heart J 2021 Apr 24. Epub 2021 Apr 24.

Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Pennsylvania; Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania; Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia; Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania; Department of Pediatrics, Division of Oncology, Children's Hospital of Pennsylvania. Electronic address:

Importance: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM. The extent to which socioeconomic parameters contribute to these racial disparities is not known.

Objective: To quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes.

Design, Setting, And Participants: A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES.

Main Outcomes And Measures: Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified.

Results: Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17).

Conclusions: Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.
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http://dx.doi.org/10.1016/j.ahj.2021.03.013DOI Listing
April 2021

Genetic and Phenotypic Landscape of Peripartum Cardiomyopathy.

Circulation 2021 May 20;143(19):1852-1862. Epub 2021 Apr 20.

University of Pittsburgh Medical Center, PA (D.M.M.).

Background: Peripartum cardiomyopathy (PPCM) occurs in ≈1:2000 deliveries in the United States and worldwide. The genetic underpinnings of PPCM remain poorly defined. Approximately 10% of women with PPCM harbor truncating variants in (TTNtvs). Whether mutations in other genes can predispose to PPCM is not known. It is also not known if the presence of TTNtvs predicts clinical presentation or outcomes. Nor is it known if the prevalence of TTNtvs differs in women with PPCM and preeclampsia, the strongest risk factor for PPCM.

Methods: Women with PPCM were retrospectively identified from several US and international academic centers, and clinical information and DNA samples were acquired. Next-generation sequencing was performed on 67 genes, including , and evaluated for burden of truncating and missense variants. The impact of TTNtvs on the severity of clinical presentation, and on clinical outcomes, was evaluated.

Results: Four hundred sixty-nine women met inclusion criteria. Of the women with PPCM, 10.4% bore TTNtvs (odds ratio=9.4 compared with 1.2% in the reference population; Bonferroni-corrected [*]=1.2×10). We additionally identified overrepresentation of truncating variants in FLNC (odds ratio=24.8, *=7.0×10), DSP (odds ratio=14.9, *=1.0×10), and BAG3 (odds ratio=53.1, *=0.02), genes not previously associated with PPCM. This profile is highly similar to that found in nonischemic dilated cardiomyopathy. Women with TTNtvs had lower left ventricular ejection fraction on presentation than did women without TTNtvs (23.5% versus 29%, =2.5×10), but did not differ significantly in timing of presentation after delivery, in prevalence of preeclampsia, or in rates of clinical recovery.

Conclusions: This study provides the first extensive genetic and phenotypic landscape of PPCM and demonstrates that predisposition to heart failure is an important risk factor for PPCM. The work reveals a degree of genetic similarity between PPCM and dilated cardiomyopathy, suggesting that gene-specific therapeutic approaches being developed for dilated cardiomyopathy may also apply to PPCM, and that approaches to genetic testing in PPCM should mirror those taken in dilated cardiomyopathy. Last, the clarification of genotype/phenotype associations has important implications for genetic counseling.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.052395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113098PMC
May 2021

Neighborhood education status drives racial disparities in clinical outcomes in PPCM.

Am Heart J 2021 Apr 12. Epub 2021 Apr 12.

Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania.

Importance: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM. The extent to which socioeconomic parameters contribute to these racial disparities is not known.

Objective: To quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes.

Design, Setting, And Participants: A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES.

Main Outcomes And Measures: Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified.

Results: Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17).

Conclusions: Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.
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http://dx.doi.org/10.1016/j.ahj.2021.03.015DOI Listing
April 2021

Identifying the effective components of a standardized labor induction protocol: secondary analysis of a randomized, controlled trial.

J Matern Fetal Neonatal Med 2021 Apr 13:1-7. Epub 2021 Apr 13.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity.

Study Design: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome.

Results: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity.

Conclusions: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
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http://dx.doi.org/10.1080/14767058.2021.1909561DOI Listing
April 2021

Individual-Level and Neighborhood-Level Risk Factors for Severe Maternal Morbidity.

Obstet Gynecol 2021 05;137(5):847-854

Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, the Institute for Biomedical Informatics, the Center for Excellence in Environmental Toxicology, the Center for Public Health Initiatives, the Leonard Davis Institute for Health Economics, and the Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, and the Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and the Department of Statistics, University of South Carolina, Columbia, South Carolina.

Objective: To investigate the association between individual-level and neighborhood-level risk factors and severe maternal morbidity.

Methods: This was a retrospective cohort study of all pregnancies delivered between 2010 and 2017 in the University of Pennsylvania Health System. International Classification of Diseases codes classified severe maternal morbidity according to the Centers for Disease Control and Prevention guidelines. Logistic regression modeling evaluated individual-level risk factors for severe maternal morbidity, such as maternal age and preeclampsia diagnosis. Additionally, we used spatial autoregressive modeling to assess Census-tract, neighborhood-level risk factors for severe maternal morbidity such as violent crime and poverty.

Results: Overall, 63,334 pregnancies were included, with a severe maternal morbidity rate of 2.73%, or 272 deliveries with severe maternal morbidity per 10,000 delivery hospitalizations. In our multivariable model assessing individual-level risk factors for severe maternal morbidity, the magnitude of risk was highest for patients with a cesarean delivery (adjusted odds ratio [aOR] 3.50, 95% CI 3.15-3.89), stillbirth (aOR 4.60, 95% CI 3.31-6.24), and preeclampsia diagnosis (aOR 2.71, 95% CI 2.41-3.03). Identifying as White was associated with lower odds of severe maternal morbidity at delivery (aOR 0.73, 95% CI 0.61-0.87). In our final multivariable model assessing neighborhood-level risk factors for severe maternal morbidity, the rate of severe maternal morbidity increased by 2.4% (95% CI 0.37-4.4%) with every 10% increase in the percentage of individuals in a Census tract who identified as Black or African American when accounting for the number of violent crimes and percentage of people identifying as White.

Conclusion: Both individual-level and neighborhood-level risk factors were associated with severe maternal morbidity. These factors may contribute to rising severe maternal morbidity rates in the United States. Better characterization of risk factors for severe maternal morbidity is imperative for the design of clinical and public health interventions seeking to lower rates of severe maternal morbidity and maternal mortality.
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http://dx.doi.org/10.1097/AOG.0000000000004343DOI Listing
May 2021

Early Pregnancy Atherogenic Profile in a First Pregnancy and Hypertension Risk 2 to 7 Years After Delivery.

J Am Heart Assoc 2021 Feb 23;10(5):e017216. Epub 2021 Feb 23.

Northwestern University Feinberg School of Medicine Chicago IL.

Background Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown. Methods and Results Among 4471 primiparous women, we related first-trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high-sensitivity C-reactive protein [5.6 versus 4.0 nmol/L], and lower high-density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; <0.05) than women without an APO/GDM. They were also more likely to develop hypertension after delivery (32.8% versus 18.1%, <0.05). Accounting for confounders and factors routinely assessed antepartum, higher glucose (relative risk [RR] 1.03 [95% CI, 1.00-1.06] per 0.6 mmol/L), high-sensitivity C-reactive protein (RR, 1.06 [95% CI, 1.02-1.11] per 2-fold higher), and triglycerides (RR, 1.27 [95% CI, 1.14-1.41] per 2-fold higher) were associated with later hypertension. Higher physical activity was protective (RR, 0.93 [95% CI, 0.87-0.99] per 3 h/week). When evaluated as latent profiles, the nonobese group with higher lipids, high-sensitivity C-reactive protein, and insulin values (6.9% of the cohort) had increased risk of an APO/GDM and later hypertension. Among these factors, 7% to 15% of excess RR was related to APO/GDM. Conclusions Individual and combined first-trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02231398.
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http://dx.doi.org/10.1161/JAHA.120.017216DOI Listing
February 2021

Methodologic Concerns With Concluding a Link Between Epidural and Autism Spectrum Disorder.

JAMA Pediatr 2021 May;175(5):536-537

Maternal and Child Health Research Center, Perelman School of Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia.

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http://dx.doi.org/10.1001/jamapediatrics.2020.6692DOI Listing
May 2021

Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial.

Hypertension 2021 05 8;77(5):1517-1524. Epub 2021 Feb 8.

From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia.

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099047PMC
May 2021

Implementation of a calculator to predict cesarean delivery during labor induction: a qualitative evaluation of the clinician perspective.

Am J Obstet Gynecol MFM 2021 Jan 22;3(3):100321. Epub 2021 Jan 22.

Departments of Psychiatry, Medical Ethics and Health Policy, and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Dr Beidas); Penn Implementation Science Center (PISCE@LDI), Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Dr Beidas).

Background: We previously conducted a prospective cohort study (n=1610) demonstrating that the implementation of a validated calculator to predict likelihood of cesarean delivery during labor induction was associated with reduced maternal morbidity, reduced cesarean delivery rate, and improved birth satisfaction.

Objective: To optimize future implementation, we used qualitative interviews to understand the clinician perspective on: (1) the cesarean delivery risk calculator implementation and (2) the mechanisms by which the use of the calculator resulted in the observed improved outcomes.

Study Design: After completion of the prospective study (June 30, 2019), 20 trainees and attending clinicians (including nurse-midwives, obstetrical physicians, and family medicine physicians) at the study site participated in a single, brief semistructured interview from March 1, 2020, to June 30, 2020. Transcriptions were coded using a systematic approach.

Results: Overall, clinicians had favorable perspectives regarding the cesarean delivery risk calculator. Clinicians described the calculator as offering "objective data" and a "standardized snapshot of the labor trajectory." Concerns were raised regarding "overreliance" on calculator output. Barriers to use included time for patient counseling and "awkwardness" around the interactions and perceived patient misunderstanding of the calculator result. Although most senior clinicians (n=8) reported that the calculator did not impact patient management, trainee clinicians (n=12) more often felt that the calculator influenced care at the extremes of cesarean delivery risk. Furthermore, more senior clinicians felt "neutral" regarding any impact of counseling patients on cesarean delivery risk compared with trainee clinicians, who felt that the counseling "built [patient-clinician] trust."

Conclusion: This qualitative evaluation characterized the generally positive clinician perspective around the cesarean delivery risk calculator, while identifying specific facilitators and barriers to implementation. In addition, we elucidated potential mechanisms by which the calculator may have been related to clinician decision making and patient-clinician interactions, leading to reduced maternal morbidity and improved patient birth satisfaction. This information is important as widespread implementation of the cesarean delivery risk calculator begins.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100321DOI Listing
January 2021

Severe preterm preeclampsia: an examination of outcomes by race.

Am J Obstet Gynecol MFM 2020 11 22;2(4):100181. Epub 2020 Jul 22.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Background: Preeclampsia complicates 5% to 8% of all pregnancies. Previous studies have examined the maternal morbidity and mortality associated with preeclampsia and the expectant management of severe preterm preeclampsia. However, these studies either did not comment on outcomes by race or were primarily made up of nonblack participants.

Objective: This study aimed to determine whether maternal morbidity associated with the expectant management of severe preterm preeclampsia varied by race.

Study Design: We performed a retrospective cohort study of women with a diagnosis of severe preterm preeclampsia at <34 weeks' gestation between 2008 and 2017 at our institution. Severe preterm preeclampsia was defined by current American College of Obstetricians and Gynecologists guidelines. The primary outcome was a maternal morbidity composite, defined as experiencing ≥1 of the following: hemolysis, elevated liver enzymes, and low platelet count; eclampsia; pulmonary edema; severe renal dysfunction; abruption; maternal intensive care unit admission; venous thromboembolism; blood transfusion; hysterectomy; stroke; or death. Secondary outcomes included a composite of neonatal morbidity. Outcomes were compared between self-reported black and nonblack women.

Results: In this study, 275 women were included; among those women, 91 (33%) were nonblack, and 184 (67%) were black. In addition, 203 of 275 women (approximately 74%) underwent expectant management with no difference by race (75.8% of nonblack vs 72.8% of black women; P=.6). When examining maternal morbidity, 62 of the expectantly managed women (30.5%) developed the composite maternal morbidity outcome, with no difference by race (27.5% of nonblack vs 32.1% of black women; P=.5) even when adjusting for confounders such as maternal age, body mass index, and parity (adjusted odds ratio, 1.02; 95% confidence interval, 0.97-1.35). The median time from diagnosis to delivery (latency time) was 3 days, with no difference between the 2 groups (P=.9) and no difference in neonatal morbidity (60.9% nonblack vs 53% black; P=.3).

Conclusion: Within our population, there were no differences in maternal outcomes between black and nonblack women who were undergoing expectant management of severe preterm preeclampsia. More research is needed to determine if the known disparities in maternal morbidity among races are due to factors beyond the antepartum management of severe preterm preeclampsia.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753058PMC
November 2020

A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes.

Am J Obstet Gynecol MFM 2020 08 5;2(3):100148. Epub 2020 Jun 5.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: There are marked disparities between black and nonblack women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. Although the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in nonobstetrical populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization.

Objective: In this study, we aimed to evaluate the effect of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal and neonatal morbidity.

Study Design: We performed a prospective cohort study of women undergoing an induction from 2013 to 2015. Full-term (≥37 weeks' gestation) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were included. We compared the cesarean delivery rate and maternal and neonatal morbidity between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and (2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race.

Results: A significant reduction in cesarean delivery rate in black women managed with the induction protocol was noted when compared with those in the observational group (25.7% vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women (34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction, and Bishop score at induction start. In addition, a significant reduction in neonatal morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%; P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for either race.

Conclusion: A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity in black women undergoing induction. Further studies should determine whether implementation of induction protocols in diverse settings could reduce national racial disparities in obstetrical outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100148DOI Listing
August 2020

Role of early amniotomy with induced labor: a systematic review of literature and meta-analysis.

Am J Obstet Gynecol MFM 2019 11 28;1(4):100052. Epub 2019 Sep 28.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Objective: The aim of the present meta-analysis was to evaluate the efficacy and safety of early amniotomy performed during induction of labor.

Data Sources: The Medline, Embase, and Web-of-Science databases (from conception to end-of-search date, Dec. 31, 2018) were systematically searched.

Study Eligibility Criteria: Randomized controlled trials that compared the performance of early amniotomy (performed before active phase of labor) to spontaneous or late amniotomy were eligible for inclusion. Eligible studies were limited to studies published as full articles available in the English language and included patients with a singleton viable fetus at term undergoing induction of labor for any indication.

Study Appraisal And Synthesis Methods: Data were pooled using the random-effects and fixed-effects models after assessing for the presence of heterogeneity. Risk of bias for each included study was assessed based on the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Primary outcomes were cesarean delivery and time to delivery. Secondary outcomes were intrapartum infectious morbidity, operative delivery, indication for cesarean, cord prolapse, uterine hyperstimulation, meconium-stained amniotic fluid, and neonatal intensive care unit admission. A subanalysis that included only nulliparous patients was performed for the primary outcomes.

Results: There were a total of 7 studies identified that met the inclusion criteria and these studies reported on 1775 patients. The early and late/spontaneous amniotomy groups included 884 and 891 patients, respectively. Patients who had an early amniotomy had a shorter time to delivery (mean difference, -3.62 hours; 95% confidence interval, -.09 to -1.16). When limiting the analysis to the 866 nulliparous women, early amniotomy was associated with a 5 hour shorter time to delivery compared with late amniotomy (mean difference, -5.12 hours; 95% confidence interval, -8.47 to -1.76; I, 89%). There was no difference in the rate of cesarean delivery (relative risk, 1.09; 95% confidence interval, 0.80-1.49) or intrapartum infectious morbidity (relative risk, 1.42; 95% confidence interval, 0.77-2.61) between the 2 groups. There were no differences in any of the other secondary outcomes evaluated.

Conclusion: Early amniotomy during induction of labor is associated with faster time to delivery without any evidence of adverse perinatal outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100052DOI Listing
November 2019

Development and evaluation of MADDIE: Method to Acquire Delivery Date Information from Electronic health records.

Int J Med Inform 2021 01 6;145:104339. Epub 2020 Nov 6.

Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, United States; Institute for Biomedical Informatics, University of Pennsylvania, United States; Center for Excellence in Environmental Toxicology, University of Pennsylvania, United States; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, United States. Electronic address:

Objective: To develop an algorithm that infers patient delivery dates (PDDs) and delivery-specific details from Electronic Health Records (EHRs) with high accuracy; enabling pregnancy-level outcome studies in women's health.

Materials And Methods: We obtained EHR data from 1,060,100 female patients treated at Penn Medicine hospitals or outpatient clinics between 2010-2017. We developed an algorithm called MADDIE: Method to Acquire Delivery Date Information from Electronic Health Records that infers a PDD for distinct deliveries based on EHR encounter dates assigned a delivery code, the frequency of code usage, and the time differential between code assignments. We validated MADDIE's PDDs against a birth log independently maintained by the Department of Obstetrics and Gynecology.

Results: MADDIE identified 50,560 patients having 63,334 distinct deliveries. MADDIE was 98.6 % accurate (F-score 92.1 %) when compared to the birth log. The PDD was on average 0.68 days earlier than the true delivery date for patients with only one delivery (± 1.43 days) and 0.52 days earlier for patients with more than one delivery episode (± 1.11 days).

Discussion: MADDIE is the first algorithm to successfully infer PDD information using only structured delivery codes and identify multiple deliveries per patient. MADDIE is also the first to validate the accuracy of the PDD using an external gold standard of known delivery dates as opposed to manual chart review of a sample.

Conclusion: MADDIE augments the EHR with delivery-specific details extracted with high accuracy and relies only on structured EHR elements while harnessing temporal information and the frequency of code usage to identify accurate PDDs.
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http://dx.doi.org/10.1016/j.ijmedinf.2020.104339DOI Listing
January 2021

Valvular Heart Disease in Pregnancy.

Cardiol Clin 2021 Feb 2;39(1):151-161. Epub 2020 Nov 2.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104, USA.

Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.
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http://dx.doi.org/10.1016/j.ccl.2020.09.010DOI Listing
February 2021

Maternal Morbidity and Birth Satisfaction After Implementation of a Validated Calculator to Predict Cesarean Delivery During Labor Induction.

JAMA Netw Open 2020 11 2;3(11):e2025582. Epub 2020 Nov 2.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated.

Objective: To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction.

Design, Setting, And Participants: This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020.

Exposures: Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator.

Main Outcomes And Measures: The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss >1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale-Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity.

Results: A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], -6.3%; 95% CI, -9.7% to -2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20]; P = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, -8.5% [95% CI, -12.6% to -4.5%]). There were no significant differences in neonatal morbidity.

Conclusions And Relevance: These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666421PMC
November 2020

Successful in vitro fertilization in women with Fontan physiology.

J Assist Reprod Genet 2020 Dec 10;37(12):3017-3023. Epub 2020 Oct 10.

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Patients with single ventricle anatomy palliated with Fontan operation are at risk for thromboembolism, arrhythmia, and heart failure rendering pregnancy high risk or even contraindicated. Infertility and high rates of first trimester miscarriage are not uncommon. In vitro fertilization (IVF) with or without gestational surrogacy can be an option, but poses risks during ovarian stimulation, oocyte retrieval, and the post-procedural period. We present six cases of women with complex congenital heart disease status post Fontan operation who underwent successful IVF.

Methods: Case series from a single-center tertiary care setting.

Results: Indications for referral were cardiac or fertility concerns for pregnancy of the congenital cardiologist. One woman had mild volume overload after oocyte retrieval requiring furosemide and one experienced post-operative colitis. There were no thrombotic complications.

Conclusions: A multidisciplinary team-based approach can result in successful oocyte retrieval and IVF in women with complex congenital heart disease and Fontan physiology.
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http://dx.doi.org/10.1007/s10815-020-01969-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714836PMC
December 2020

Valvular Heart Disease in Pregnancy.

Clin Obstet Gynecol 2020 12;63(4):910-922

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.
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http://dx.doi.org/10.1097/GRF.0000000000000570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755297PMC
December 2020

Association of Obesity With Maternal and Cord Blood Penicillin Levels in Women With Group B Streptococcus Colonization.

Obstet Gynecol 2020 10;136(4):756-764

Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, and the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, the Division of Genetics and Metabolism, Children's Hospital of Philadelphia, and the Department of Pediatrics, Biochemistry, and Biophysics, University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: To compare maternal and cord blood penicillin concentrations in women with and without obesity who are receiving intrapartum group B streptococcus (GBS) prophylaxis.

Methods: We performed a prospective cohort study of term women receiving intrapartum penicillin prophylaxis for GBS colonization (determined by antenatal rectovaginal culture). The following outcomes were compared between obese (body mass index [BMI] 35 or higher at delivery) and nonobese (BMI less than 30 at delivery) groups: penicillin concentration in maternal blood (after two penicillin doses) and umbilical cord blood, GBS rectovaginal colonization status on admission and after two completed doses, and neonatal GBS colonization (using a postnatal ear swab). Fifty-five women were needed to detect a 0.75 SD difference in cord blood penicillin concentrations.

Results: Fifty-five women were enrolled and had all specimens collected; 49 had complete data for analysis (obese n=25, nonobese n=24). There was no difference in the median maternal penicillin concentration between groups (obese 4.2 micrograms/mL vs nonobese 4.0 micrograms/mL, P=.58). There was, however, a 60% lower median cord blood penicillin concentration in the obese compared with the nonobese group (2.7 micrograms/mL vs 6.7 micrograms/mL, respectively, P<.01), with no significant difference in time from last penicillin dose to delivery (obese 2.9 hours vs nonobese 1.7 hours, P=.07). The difference in cord blood concentrations remained significant after adjustment for nulliparity, hypertensive disorders, and time from last penicillin dose to delivery. Only 59.6% of women tested positive for GBS by rectovaginal culture on admission (obese 60.9% vs nonobese 58.3%, P=.86).

Conclusion: The median cord blood penicillin concentration was 60% lower in neonates born to women with obesity compared with those born to women without obesity. However, all concentrations exceeded the minimum inhibitory concentration. Maternal penicillin levels were not significantly different between groups. More than 40% of women who previously tested positive for GBS by antenatal culture tested negative for GBS on admission for delivery.
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http://dx.doi.org/10.1097/AOG.0000000000004020DOI Listing
October 2020

Patterns of Postpartum Ambulatory Care Follow-up Care Among Women With Hypertensive Disorders of Pregnancy.

J Am Heart Assoc 2020 09 27;9(17):e016357. Epub 2020 Aug 27.

Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center University of Pennsylvania Perelman School of Medicine Philadelphia PA.

Background Preeclampsia and gestational hypertension are hypertensive disorders of pregnancy (HDP) that identify an increased risk of developing chronic hypertension and cardiovascular disease later in life. Postpartum follow-up may facilitate early screening and treatment of cardiovascular risk factors. Our objective is to describe patterns of postpartum visits with primary care and women's health providers (eg, family medicine and obstetrics) among women with and without HDP in a nationally representative sample of commercially insured women. Methods and Results We conducted a retrospective cohort study using insurance claims from a US health insurance database to describe patterns in office visits in the 6 months after delivery. We identified 566 059 women with completed pregnancies between 2005 and 2014. At 6 months, 13% of women with normotensive pregnancies, 18% with HDP, and 23% with chronic hypertension had primary care visits (<0.0001 for comparing HDP and chronic hypertension groups with control participants). Only 58% of women with HDP had 6-month follow-up with any continuity provider compared with 47% of women without hypertension (<0.0001). In multivariable analysis, women with severe preeclampsia were 16% more likely to have postpartum continuity follow-up (adjusted odds ratio, 1.16; 95% CI, 1.2-1.21). Factors associated with a lower likelihood of any follow-up included age ≥30 years, Black race, Hispanic ethnicity, and having multiple gestations. Conclusions Rates of continuity care follow-up after a pregnancy complicated by hypertension were low. This represents a substantial missed opportunity to provide cardiovascular risk screening and management to women at increased risk of future cardiovascular disease.
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http://dx.doi.org/10.1161/JAHA.120.016357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660757PMC
September 2020

Compassionate use of remdesivir for treatment of severe coronavirus disease 2019 in pregnant women at a United States academic center.

Am J Obstet Gynecol MFM 2020 08 25;2(3):100164. Epub 2020 Jun 25.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajogmf.2020.100164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314679PMC
August 2020

Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial.

Am J Obstet Gynecol 2021 01 9;224(1):84.e1-84.e7. Epub 2020 Jul 9.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics.

Objective: We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia.

Study Design: We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05).

Results: A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes.

Conclusion: In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.
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http://dx.doi.org/10.1016/j.ajog.2020.07.007DOI Listing
January 2021

Labor and Delivery Outcomes with the Sequential Use of Misoprostol Followed by Cervical Foley Catheter.

Am J Perinatol 2020 Jun 28. Epub 2020 Jun 28.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective:  Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol.

Study Design:  Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann-Whitney -tests compared continuous variables.

Results:  Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours,  < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26-3.44,  = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%,  = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%,  = 0.1) and maternal morbidity (15 vs. 8%,  = 0.08) in the misoprostol followed by Foley catheter group.

Conclusion:  In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling.

Key Points: · Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.. · Nulliparas and dilation <1 cm increases need for Foley after misoprostol.. · Complications were more common in women requiring Foley after misoprostol..
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http://dx.doi.org/10.1055/s-0040-1713818DOI Listing
June 2020

Induction of labor in continuing pregnancies.

Best Pract Res Clin Obstet Gynaecol 2020 Aug 12;67:90-99. Epub 2020 May 12.

Fundared-Materna, Bogotá, Colombia; Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Director of Research, St. Luke's University Health Network, 701 Ostrum Street, Suite 303, Bethlehem, PA, 18015, USA; Global Network for Perinatal & Reproductive Health (GNPRH), Division of Maternal Fetal Medicine Oregon Health & Science University, Portland, OR, USA.

This chapter aims to provide an evidence-based approach to cervical-ripening methods and induction of labor in high-, middle-, and low-income countries. We will review the epidemiology of induction and will also review pharmacological and mechanical methods of cervical-ripening as well as oxytocin for induction. Lastly, we will review current guidelines of when to determine an induction to be failed.
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http://dx.doi.org/10.1016/j.bpobgyn.2020.04.004DOI Listing
August 2020

Care of critically ill pregnant patients with coronavirus disease 2019: a case series.

Am J Obstet Gynecol 2020 08 1;223(2):286-290. Epub 2020 May 1.

Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajog.2020.04.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252050PMC
August 2020

The Impact of Previous Obstetric History on the Risk of Spontaneous Preterm Birth in Women with a Sonographic Short Cervix.

Am J Perinatol 2020 10 20;37(12):1189-1194. Epub 2020 Mar 20.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: The natural history of women with a short cervix and a low-risk obstetric history remains poorly defined. In our study, we sought to better characterize the impact of previous obstetric history on the delivery outcomes in women diagnosed with a mid-trimester sonographic short cervix.

Study Design: We performed a retrospective cohort study of women with singleton gestations who underwent transvaginal cervical length screening between 16 and 24 weeks at two urban hospitals in Philadelphia between January 2013 and March 2018 and were found to have a short cervix (defined as ≤2 cm). Women were excluded from the cohort if there were major fetal anomalies noted or if delivery outcome information was not available. The cohort was then divided into three groups based on obstetric history: nulliparous, history of full-term birth only, or history of spontaneous preterm birth (sPTB). The primary outcome was sPTB <37 weeks, while the secondary outcome was sPTB <34 weeks.

Results: Our cohort included a total of 384 singleton pregnancies that were diagnosed with a sonographic short cervix: 165 women were nulliparous, 119 women had a history of full-term birth, and 100 women with a history of sPTB. We found that women with a short sonographic cervix had a sPTB rate of 39.6% with no differences found between the three groups. Only two-thirds of nulliparous women and women with a history of full-term birth received the recommended preventative treatment, compared with almost 100% of women with a history of sPTB.

Conclusion: Women with and without a history of sPTB are at comparable risk of sPTB in the presence of a sonographically short cervix. Preventative therapies should be recommended to both nulliparous women and women with a history of full-term birth since uptake in this population are not as high.
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http://dx.doi.org/10.1055/s-0040-1705169DOI Listing
October 2020

Preventive Health Care Utilization Among Mother-infant Dyads With Medicaid Insurance in the Year Following Birth.

Med Care 2020 06;58(6):519-525

Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia.

Background: Following birth, women may access preventive care in adult settings or, with their infants, in pediatric settings. Preventive care can improve future birth outcomes and long-term health, particularly for women with health risks.

Methods: This cohort study linked mother-infant Medicaid claims from 12 states for 2007-2011 births. Pregnancy claims identified health risk categories: maternal cardiovascular (diabetes, hypertension, pre-eclampsia, obesity), maternal mental health (depression, anxiety), and premature birth. Claims for 1 year following birth identified adult and pediatric preventive visits. Logistic regression assessed the relationship between visits and risks, adjusting for maternal demographics, perinatal health care utilization, year, and state.

Results: Of 594,888 mother-infant dyads with Medicaid eligibility for 1 year following birth, 36% had health risks. In total, 38% of all dyads, and 33% with health risks, had no adult preventive visits. Dyads had a median of 1 (IQR, 0-2) adult and 3 (IQR, 2-5) pediatric preventive visits. A total of 72% of dyads had more preventive visits in pediatric than adult settings. In regression, preterm birth was associated with lower odds of any adult preventive visits [odds ratio (OR), 0.97; 95% confidence interval (CI), 0.95-0.99], and maternal health risks with higher odds (cardiovascular OR, 1.19; 95% CI, 1.18-1.21; mental health OR, 1.87; 95% CI, 1.84-1.91), compared with dyads without risk.

Conclusions: Maternal health risks were associated with increased adult preventive visits, but 38% of dyads had no adult preventive visits in the year following birth. Most dyads had more opportunities for preventive care in pediatric settings than adult settings.
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http://dx.doi.org/10.1097/MLR.0000000000001310DOI Listing
June 2020

Postpartum blood pressure trends are impacted by race and BMI.

Pregnancy Hypertens 2020 Apr 26;20:14-18. Epub 2020 Feb 26.

Maternal and Child Health Research Center, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.

Objective: Our objective was to evaluate postpartum blood pressure trends, and time to resolution of hypertension among women with hypertensive disorders of pregnancy, specifically focusing on impact of race and BMI on these trends.

Methods: We performed a secondary analysis of a randomized trial that utilized a text-message based home blood pressure monitoring system. BPs for this study included both inpatient postpartum BPs as well as home BPs obtained from the text-based program. Women were followed from 12 h of delivery to 16 days postpartum. Outcomes were: (1) postpartum BP trend summaries from a linear mixed-effects regression model and (2) time to resolution of hypertension (defined as ≥ 48 h of BPs < 140/90) depicted using Kaplan Meier survival curves with hazard ratio estimates of association using Cox models.

Results: Eighty-four women were included, of which 63% were black. Non-black women with a BMI < 35 kg/m had steady decreases in systolic BP whereas other groups peaked around 6.5 days postpartum. BPs for women in the BMI < 35 group, regardless of race, remained in the normotensive range. Conversely, women with a BMI ≥ 35 had a systolic BP peak into the hypertensive range prior to declining. Diastolic BP peaked at an average of 8.5 days postpartum. Time to resolution of BPs differed by race and BMI groups (p = 0.012). Non-black women with a BMI < 35 had the shortest time to resolution and 81% of these women had resolution of hypertension. Only 49% of black women with a BMI < 35 had resolution of hypertension and approximately 40% of both black and non-black women with BMI ≥ 35 had resolution of hypertension.

Conclusion: We identified race and BMI to be determinants of postpartum BP trends and hypertension resolution. Further study is needed to determine if race and BMI targeted postpartum hypertension interventions may lead to faster blood pressure recovery and lower maternal morbidity postpartum.
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http://dx.doi.org/10.1016/j.preghy.2020.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918282PMC
April 2020

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

Obstet Gynecol 2020 03;135(3):542-549

Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania; the Department of Obstetrics and Gynecology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and the Department of Obstetrics and Gynecology, the Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective: To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor.

Methods: This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery.

Results: There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79).

Conclusions: In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.
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http://dx.doi.org/10.1097/AOG.0000000000003703DOI Listing
March 2020

Risk factors and racial disparities related to low maternal birth satisfaction with labor induction: a prospective, cohort study.

BMC Pregnancy Childbirth 2019 Dec 30;19(1):530. Epub 2019 Dec 30.

Department of Obstetrics & Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA.

Background: Decreased birth satisfaction has been associated with labor induction. Yet, there is a paucity of data evaluating risk factors for decreased satisfaction associated with labor induction. We aimed to determine what factors impact low birth satisfaction in labor induction and evaluate racial disparities in birth satisfaction.

Methods: We performed a prospective cohort study of women with term, singleton gestations undergoing labor induction at our institution from Jan 2018 to Jun 2018. Women completed the validated Birth Satisfaction Scale-Revised postpartum, which is subdivided into 3 domains: (1) quality of care provision, (2) women's personal attributes, and (3) stress experienced during labor. A total satisfaction score above the mean was classified as "satisfied", and below as "unsatisfied." Domain and item scores were compared by race.

Results: Three hundred thirty of 414 (79.7%) eligible women were included. There was no significant difference in birth satisfaction by age, body mass index, Bishop score, or labor induction agent. Black women were 75% more likely to be unsatisfied than non-Black women (54.0% vs. 37.2%, OR 1.75 [95% CI 1.11-2.76], p = 0.037), nulliparas were 71% more  likely to be unsatisfied than multiparas (54.2% vs. 40.9%, OR 1.71 [95% CI 1.09-2.67], p = 0.019), and women whose labor resulted in cesarean birth were almost 3 times more likely to be unsatisfied than women with a vaginal birth (67.4% vs. 42.3%, OR 2.82 [95% CI 1.69-4.70], p < 0.001). Additionally, increased labor length quartile was associated with decreased satisfaction >(p = 0.003). By race, domain 3 scores, which reflect preparedness for labor, were lower for Black women. No differences were seen for domain 1 or 2.

Conclusions: Black race, cesarean birth, and increasing labor length were identified as risk factors for low birth satisfaction among women who underwent labor induction. Further studies should explore interventions to target women at risk for low birth satisfaction.
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http://dx.doi.org/10.1186/s12884-019-2658-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6937753PMC
December 2019