Publications by authors named "Torri D Metz"

77 Publications

Marijuana use, fetal growth, and uterine artery Dopplers.

J Matern Fetal Neonatal Med 2021 Sep 1:1-8. Epub 2021 Sep 1.

Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA.

Objective: Marijuana (MJ) use is associated with adverse effects on fetal growth. We aimed to investigate the timing of suboptimal fetal growth onset in MJ-exposed pregnancies. In addition, we aimed to explore the relationship between MJ-exposure and both abnormal uterine artery (UtA) Doppler parameters and small for gestational age (SGA).

Study Design: This was a secondary analysis of a prospective multicenter cohort that enrolled nulliparous individuals delivering non-anomalous fetuses beyond 20 weeks' gestation. Marijuana exposure was ascertained by self-report or clinical urine toxicology testing. Ultrasound estimated fetal weights (EFWs) were assessed in participants at both 16w0d-21w6d and 22w0d-29w6d. EFWs and birth weight (BW) were converted to weight percentiles (wPCT). EFW and BW wPCTs were calculated using population-based standards. Additionally, a customized standard designed to be applicable to both EFWs and BWs within the same model was also used to allow for EFW to BW percentile trajectories. The primary outcome, longitudinal wPCT, was compared between individuals with and without MJ use in a linear mixed-effects regression model adjusting for tobacco. For modeling, wPCT was smoothed across gestational age; MJ was estimated as an intercept and linear difference in the slope of gestational age. UtA Doppler notching, resistance index (RI), and pulsatility index (PI) at 16w0d-21w6d were compared using -test and . SGA at delivery was also compared.

Results: Nine thousand one hundred and sixty-three individuals met inclusion criteria; 136 (1.5%) used MJ during pregnancy. Individuals who used MJ were more likely to be younger, identify as non-Hispanic Black, and have had less education. Fetuses exposed to MJ had lower wPCT beginning at 28 weeks using population-based and customized standards, when compared to those without exposure. UtA notching, PI, and RI were similar between groups. SGA was more frequent in neonates exposed to MJ using both population-based (22 vs. 9%, <.001) and customized (25 vs. 14%, <.001) curves.

Conclusions: MJ-exposed fetuses were estimated to be smaller than unexposed fetuses starting at 28 weeks' gestation across both growth standards without a difference in UtA Doppler parameters.
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http://dx.doi.org/10.1080/14767058.2021.1960973DOI Listing
September 2021

Coronavirus Disease 2019 (COVID-19) and Pregnancy Outcomes: State of the Science.

Obstet Gynecol 2021 Aug 9. Epub 2021 Aug 9.

Naima Thavory Joseph is from the Department of Obstetrics and Gynecology at the Beth Israel Deaconess Medical Center, Boston, Massachusetts. Torri D. Metz is from the Department of Obstetrics and Gynecology at University of Utah Health, Salt Lake City, Utah; email:

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http://dx.doi.org/10.1097/AOG.0000000000004548DOI Listing
August 2021

SPECIAL REPORT: A standardized definition of placental infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a consensus statement from the National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NIH/NICHD) SARS-CoV-2 placental infection workshop.

Am J Obstet Gynecol 2021 Aug 5. Epub 2021 Aug 5.

University of Utah Health, Salt Lake City, UT 84132.

Pregnant individuals infected with SARS-CoV-2 have higher rates of ICU admission, oxygen requirement, need for mechanical ventilation and death than non-pregnant individuals. Increased COVID-19 disease severity may be associated with increased risk for viremia and placental infection. Maternal SARS-CoV-2 infection is also associated with pregnancy complications such as preeclampsia and preterm birth, that can be either placentally-mediated or reflected in the placenta. Maternal viremia followed by placental infection may lead to maternal-fetal transmission (vertical), which affects 1-3% of exposed newborns. However, there is no agreed-upon or standard definition of placental infection. NIH/NICHD convened a group of experts to propose a working definition of placental infection to inform ongoing studies of SARS-CoV-2 during pregnancy. Experts recommended that placental infection be defined using techniques that allow virus detection and localization in placental tissue by one or more of the following methods: in-situ hybridization with anti-sense probe (detects replication) and/or a sense probe (detects viral genome or immunohistochemistry to detect viral nucleocapsid (N) or spike (S) proteins. If the above methods are not possible, RT-PCR detection and/or quantification of viral RNA in placental homogenates, or electron microscopy are alternative approaches. A graded classification for the likelihood of placental infection as definitive, probable, possible, and unlikely was proposed. Manuscripts reporting placental infection should describe the sampling method (location and number of samples collected), method of preservation of tissue, and detection technique. Recommendations were made for the handling of the placenta, examination, and sampling, as well as the use of validated reagents and sample protocols (included as appendices).
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http://dx.doi.org/10.1016/j.ajog.2021.07.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8340595PMC
August 2021

The Term Newborn: Prenatal Substance Exposure.

Clin Perinatol 2021 Aug;48(3):631-646

Department of Pediatrics, University of Colorado, Children's Hospital Colorado, 860 N Potomac Circle, Aurora, CO 80011, USA; Pediatrics, Children's Hospital Colorado, Child Health Pavilion, 860 N Potomac Circle, Aurora, CO 80011, USA. Electronic address:

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.
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http://dx.doi.org/10.1016/j.clp.2021.05.011DOI Listing
August 2021

Association between pregnancy and long-term cardiac outcomes in individuals with congenital heart disease.

Am J Obstet Gynecol 2021 Jul 28. Epub 2021 Jul 28.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, UT.

Background: As early life interventions for congenital heart disease improve, more patients are living to adulthood and are considering pregnancy. Scoring and classification systems predict the maternal cardiovascular risk of pregnancy in the context of congenital heart disease, but these scoring systems do not assess the potential subsequent risks following pregnancy. Data on the long-term cardiac outcomes after pregnancy are unknown for most lesion types. This limits the ability of healthcare practitioners to thoroughly counsel patients who are considering pregnancy in the setting of congenital heart disease.

Objective: We aimed to evaluate the association between pregnancy and the subsequent long-term cardiovascular health of individuals with congenital heart disease.

Study Design: This was a retrospective longitudinal cohort study of individuals identifying as female who were receiving care in two adult congenital heart disease centers from 2014 to 2019. Patient data were abstracted longitudinally from a patient age of 15 years (or from the time of entry into the healthcare system) to the conclusion of the study, death, or exit from the healthcare system. The primary endpoint, a composite adverse cardiac outcome (death, stroke, heart failure, unanticipated cardiac surgery, or a requirement for a catheterized procedure), was compared between parous (at least one pregnancy >20 weeks' gestation) and nulliparous individuals. By accounting for differences in the follow-up, the effect of pregnancy was estimated based on the time to the composite adverse outcome in a proportional hazards regression model adjusted for the World Health Organization class, baseline cardiac medications, and number of previous sternotomies. Participants were also categorized according to their lesion type, including septal defects (ventricular septal defects, atrial septal defects, atrioventricular septal defects, or atrioventricular canal defects), right-sided valvular lesions, left-sided valvular lesions, complex cardiac anomalies, and aortopathies, to evaluate if there is a differential effect of pregnancy on the primary outcome when adjusting for lesion type in a sensitivity analysis.

Results: Overall, 711 individuals were eligible for inclusion; 209 were parous and 502 nulliparous. People were classified according to the World Health Organization classification system with 86 (12.3%) being classified as class I, 76 (10.9%) being classified as class II, 272 (38.9%) being classified as class II to III, 155 (22.1%) being classified as class III, and 26 (3.7%) being classified as class IV. Aortic stenosis, bicuspid aortic valve, dilated ascending aorta or aortic root, aortic regurgitation, and pulmonary insufficiency were more common in parous individuals, whereas dextro-transposition of the great arteries, Turner syndrome, hypoplastic right heart, left superior vena cava, and other cardiac diagnoses were more common in nulliparous individuals. In multivariable modeling, pregnancy was associated with the composite adverse cardiac outcome (36.4%% vs 26.1%%; hazard ratio, 1.83; 95% confidence interval, 1.25-2.66). Parous individuals were more likely to have unanticipated cardiac surgery (28.2% vs 18.1%; P=.003). No other individual components of the primary outcome were statistically different between parous and nulliparous individuals in cross-sectional comparisons. The association between pregnancy and the primary outcome was similar in a sensitivity analysis that adjusted for cardiac lesion type (hazard ratio, 1.61; 95% confidence interval, 1.10-2.36).

Conclusion: Among individuals with congenital heart disease, pregnancy was associated with an increase in subsequent long-term adverse cardiac outcomes. These data may inform counseling of individuals with congenital heart disease who are considering pregnancy.
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http://dx.doi.org/10.1016/j.ajog.2021.07.015DOI Listing
July 2021

Rigor, reproducibility, and transparency of randomized controlled trials in obstetrics and gynecology.

Am J Obstet Gynecol MFM 2021 Jul 26;3(6):100450. Epub 2021 Jul 26.

Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Drs Bruno, Einerson, and Metz, Ms Allshouse, and Drs Scott and Blue); Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT (Drs Bruno, Einerson, Metz, and Blue).

Background: Randomized controlled trials are considered the highest level of evidence but fewer than half are reproducible. A rigorous methodology improves trial quality, but reproducibility may be limited by a lack of transparency in reporting. The Consolidated Standards of Reporting Trials guidelines define reporting standards, and pretrial registration requires a predefined methodology and predefined outcomes.

Objective: We evaluated obstetrics and gynecology trials published in 6 journals in terms of their adherence to the Consolidated Standards of Reporting Trials guidelines. Second, we evaluated pretrial registration compliance and concordance between the registry and publication. Furthermore, we evaluated the differences in trial characteristics among randomized controlled trials with the highest level of compliance and those with lower levels of compliance and adherence to guidelines by journal type.

Study Design: This was a cross-sectional study of obstetrics and gynecology trials published between 2017 and 2019 in 6 journals (American Journal of Obstetrics & Gynecology, BJOG: An International Journal of Obstetrics and Gynaecology, Obstetrics & Gynecology, The Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine). Randomized controlled trials were identified via PubMed and manual journal archive searches. The primary outcome was adequate compliance with the Consolidated Standards of Reporting Trials guidelines defined as ≥80% of the checklist items present. Secondary outcomes included completion of pretrial registration and concordance between the pretrial registration and publication in terms of the outcomes and sample size. We compared the characteristics between trials with adequate compliance and those with inadequate compliance. Secondary analyses included comparisons of characteristics of the trials in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines with those of the trials in lower quartiles and compliance with guidelines in obstetrics-gynecology vs non-obstetrics-gynecology journals. In an exploratory analysis, trends in compliance with the Consolidated Standards of Reporting Trials guidelines across the study period were assessed. A post hoc sensitivity analysis evaluated the outcomes after the exclusion of 2 retracted trials.

Results: Of the 170 trials included, 80% (95% confidence interval, 74%-86%) were adequately compliant with the Consolidated Standards of Reporting Trials manuscript guidelines and 66% (95% confidence interval, 59%-73%) were compliant with the abstract guidelines. Nearly all trials (98%) reported pretrial registration. Concordance between pretrial registration and publication in terms of the primary outcomes was identified for 77% of the trials, concordance in terms of the secondary outcomes was observed in 32% of the trials, and concordance in terms of sample size was observed in 60% of the trials. Trials with adequate compliance were more likely to be preregistered, include an a priori power calculation, and use an intent to treat analysis. Trials in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines were more likely to be multicenter, international, and government funded. More trials from non-obstetrics-gynecology journals were in the top quartile for compliance with the Consolidated Standards of Reporting Trials guidelines than trials from obstetrics-gynecology journals (64.9% vs 25.7%; P<.001). No significant trends in adequate compliance were identified across the study period. Results did not differ significantly in the sensitivity analysis.

Conclusion: Of all the trials included, 20% of obstetrics-gynecology trials published in 6 high-impact journals were not compliant with the Consolidated Standards of Reporting Trials guidelines, and there were major discrepancies between pretrial registration and publication. Transparency, reproducibility, and scientific rigor in obstetrics and gynecology trial reporting needs to be improved.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100450DOI Listing
July 2021

Impact of the p-Value Threshold on Interpretation of Trial Outcomes in Obstetrics and Gynecology.

Am J Perinatol 2021 Jun 24. Epub 2021 Jun 24.

Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.

Objective:  Randomized controlled trials (RCTs) are considered the highest level of evidence to inform clinical practice. However, the reproducibility crisis has raised concerns about the scientific rigor of published RCT findings. Some advocate for a lower -value threshold. We aimed to review published OB/Gyn topical RCTs in three representative OB/Gyn journals and three high impact non-OB/Gyn journals to determine if their interpretations would change with adoption of a -value threshold for significance of 0.005. Secondarily, we evaluated if there were differences in methodologic characteristics between those that did and did not lose significance.

Study Design:  A manual search was performed to identify all OB/Gyn RCTs published in the selected journals between July 2017 and June 2019. Data were collected on primary outcome(s), methodology, and -values. We determined the proportion of primary outcomes that would remain statistically significant with adoption of a -value significance threshold of 0.005 versus be reinterpreted as "suggestive" (defined as -value between 0.005 and 0.05). Chi-square or Fisher's exact test were used to compare study characteristics.

Results:  Overall, 202 RCTs met inclusion criteria; 52% in obstetrics and 48% in gynecology. Of 90 studies considered significant with <0.05 at the time of publication, 54.4% ( = 49) would maintain significant ( < 0.005), while 45.6% ( = 41) would become suggestive using the lower threshold. Most RCTs utilized a single (90.1%) versus composite (8.9%) primary outcome type, used an intent-to-treat analysis (73.3%), and studied a drug intervention (46.5%). Methodologically, 23.7% did not prespecify analysis type, 28.2% did not meet the pre-determined sample size, and 9.4% did not report an a priori sample size calculation. Studies maintaining significance were more likely to be international and report a funding source.

Conclusion:  Adopting a -value significance threshold of 0.005 would require reinterpretation of almost half of RCT results in the OB/Gyn literature. Highly variable methodological quality was identified.

Key Points: · New p-value threshold results in reinterpretation of nearly half of RCT results in OB/Gyn literature.. · Highly variable methodological quality was identified.. · Reduced use of binary interpretations of significance is necessary..
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http://dx.doi.org/10.1055/s-0041-1731345DOI Listing
June 2021

Quantification of prenatal marijuana use: evaluation of the correlation between self-report, serum, urine and umbilical cord assays among women delivering at two urban Colorado hospitals.

Addiction 2021 Jun 17. Epub 2021 Jun 17.

University of Colorado School of Medicine, Aurora, CO, USA.

Background And Aims: To estimate during pregnancy correlations between frequency of self-reported use of marijuana and quantified marijuana metabolite in biospecimens including urine, sera and umbilical cord homogenate.

Design: Prospective cohort.

Setting: Two urban hospitals in Colorado with legal recreational and medicinal marijuana.

Participants: Pregnant women (<16 weeks gestation) self-reporting marijuana use.

Measurements: Participants completed a written self-report survey and provided biospecimens at <16 weeks gestation (n = 46), 18 to 22 weeks gestation (n = 43), 32 to 36 weeks gestation (n = 39), and delivery (n = 37). Self-reported marijuana use frequency was calculated based on past-month days of use multiplied by number of daily uses. Maternal urine and sera were tested for presence (>5 ng/mL) of 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH). Liquid chromatography tandem mass spectrometry quantified THC-COOH in umbilical cord homogenate (ng/g). Last marijuana use by any measure was recorded to evaluate the time frame over which THC-COOH remains detectable (>0.10 ng/g) in cord.

Findings: From December 2017 through May 2019, 51 pregnant women enrolled, and 46 were included in analyses (2 withdrew and 3 had a spontaneous abortion). The majority were normal weight, White or Black race, and insured by Medicaid. At the time of enrollment between 7 to 15 weeks' gestation, 87% had ongoing use by self-report, or positive urine or serum. The majority (33 [66%]) stopped using before delivery. Sera and urine results were strongly correlated with self-reported use frequency (Spearman correlation coefficient [r] range 0.70-0.87 across visits, P < 0.001), and with each other. There was only one positive cord result when use stopped before 22 weeks. Frequency of self-reported marijuana use at delivery had strong correlation with quantified cord THC-COOH (r = 0.80, 95% CI = 0.62-0.89).

Conclusions: Quantified umbilical cord THC-COOH appears to strongly correlate with frequency of maternal marijuana use in the last month of pregnancy. Earlier use can be measured by either quantitative urine or serum assay.
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http://dx.doi.org/10.1111/add.15606DOI Listing
June 2021

Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity.

Am J Obstet Gynecol 2021 May 24. Epub 2021 May 24.

Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH.

Background: Investigators have attempted to derive tools that could provide clinicians with an easily obtainable estimate of the chance of vaginal birth after cesarean delivery for those who undertake trial of labor after cesarean delivery. One tool that has been validated externally was derived from data from the Maternal-Fetal Medicine Units Cesarean Registry. However, concern has been raised that this tool includes the socially constructed variables of race and ethnicity.

Objective: This study aimed to develop an accurate tool to predict vaginal birth after cesarean delivery, using data easily obtainable early in pregnancy, without the inclusion of race and ethnicity.

Study Design: This was a secondary analysis of the Cesarean Registry of the Maternal-Fetal Medicine Units Network. The approach to the current analysis is similar to that of the analysis in which the previous vaginal birth after cesarean delivery prediction tool was derived. Specifically, individuals were included in this analysis if they were delivered on or after 37 0/7 weeks' gestation with a live singleton cephalic fetus at the time of labor and delivery admission, had a trial of labor after cesarean delivery, and had a history of 1 previous low-transverse cesarean delivery. Information was only considered for inclusion in the model if it was ascertainable at an initial prenatal visit. Model selection and internal validation were performed using a cross-validation procedure, with the dataset randomly and equally divided into a training set and a test set. The training set was used to identify factors associated with vaginal birth after cesarean delivery and build the logistic regression predictive model using stepwise backward elimination. A final model was generated that included all variables found to be significant (P<.05). The accuracy of the model to predict vaginal birth after cesarean delivery was assessed using the concordance index. The independent test set was used to estimate classification errors and validate the model that had been developed from the training set, and calibration was assessed. The final model was then applied to the overall analytical population.

Results: Of the 11,687 individuals who met the inclusion criteria for this secondary analysis, 8636 (74%) experienced vaginal birth after cesarean delivery. The backward elimination variable selection yielded a model from the training set that included maternal age, prepregnancy weight, height, indication for previous cesarean delivery, obstetrical history, and chronic hypertension. Vaginal birth after cesarean delivery was significantly more likely for women who were taller and had a previous vaginal birth, particularly if that vaginal birth had occurred after a previous cesarean delivery. Conversely, vaginal birth after cesarean delivery was significantly less likely for women whose age was older, whose weight was heavier, whose indication for previous cesarean delivery was arrest of dilation or descent, and who had a history of medication-treated chronic hypertension. The model had excellent calibration between predicted and empirical probabilities and, when applied to the overall analytical population, an area under the receiver operating characteristic curve of 0.75 (95% confidence interval, 0.74-0.77), which is similar to the area under the receiver operating characteristic curve of the previous model (0.75) that included race and ethnicity.

Conclusion: We successfully derived an accurate model (available at https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator), which did not include race or ethnicity, for the estimation of the probability of vaginal birth after cesarean delivery.
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http://dx.doi.org/10.1016/j.ajog.2021.05.021DOI Listing
May 2021

Is Exposure to Intrapartum Prostaglandins for Labor Induction Associated with a Lower Incidence of Neonatal Respiratory Distress Syndrome?

Am J Perinatol 2021 08 2;38(10):993-998. Epub 2021 May 2.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.

Objective: Respiratory distress syndrome (RDS) is implicated in 30% of neonatal deaths. Since prostaglandins promote surfactant secretion and labor is associated with a lower risk of RDS in term neonates, it is plausible that synthetic prostaglandin (sPG) exposure is associated with a lower risk of RDS. Thus, we evaluated the association between sPG exposure and RDS in neonates born after the induction of labor (IOL).

Study Design: Secondary analysis of women with singleton pregnancies undergoing IOL at 34 to 42 weeks in the nuMoM2b study, a multicenter prospective cohort of nulliparous women. RDS rates and secondary neonatal outcomes in neonates with intrapartum sPG exposure were compared with those who had IOL with non-sPG methods (e.g., balloon catheter, amniotomy, oxytocin, and laminaria). Logistic regression models estimated the association of sPG with RDS and with secondary outcomes after adjustment for clinical and demographic factors (including gestational age). A sensitivity analysis was performed in which analysis was restricted to those with an admission cervical dilation ≤2 cm.

Results: Of 10,038 women in the total cohort, 3,071 met inclusion criteria; 1,444 were exposed and 1,627 were unexposed to sPGs. Antenatal corticosteroid exposure rates were low (3.0%) and similar between groups. In univariable analysis, neonates with sPG exposure had higher rates of RDS (3.2 vs. 2.0%, odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.01-2.50). This relationship was similar by gestational age at delivery (term vs. preterm, interaction  = 0.14). After adjustment, the association between sPG and RDS was no longer significant (adjusted odds ratio: 1.4, 95% CI: 0.9-2.3). When analysis was restricted to subjects with admission cervical dilation of ≤2 cm, there was also no association between sPG exposure and RDS.

Conclusion: In pregnancies between 34 and 42 weeks of gestation, exposure to sPG for cervical ripening or labor induction was not associated with newborn RDS.

Key Points: · RDS is implicated in 30% of neonatal deaths.. · sPG exposure was not associated with RDS.. · Avoiding preterm birth remains crucial in RDS prevention..
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http://dx.doi.org/10.1055/s-0041-1728820DOI Listing
August 2021

Maternal-fetal medicine program director experience of exclusive virtual interviewing during the coronavirus disease 2019 pandemic.

Am J Obstet Gynecol MFM 2021 07 27;3(4):100344. Epub 2021 Feb 27.

Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI (Dr Lewkowitz).

Background: The coronavirus disease 2019 pandemic necessitated an abrupt transition to exclusive virtual interviewing for maternal-fetal medicine fellowship programs.

Objective: This study aimed to assess the maternal-fetal medicine fellowship program directors' approaches to exclusive virtual interviews and to obtain program director feedback on the virtual interview experience to guide future interview cycles.

Study Design: A novel cross-sectional online survey was distributed through the Society for Maternal-Fetal Medicine to program directors after the completion of the interview season, but before the results of the National Resident Matching Program on October 14, 2020. Survey data were collected anonymously and managed using secure Research Electronic Data Capture electronic data capture tools.

Results: Overall 71 of 89 program directors (80%) responded. All respondents completed their 2020 interviews 100% virtually. Nearly half of program directors (33 of 68, 49%) interviewed more candidates in 2020 than in 2019. Of those who interviewed more candidates in 2020, the mean number of additional candidates per fellowship position was 5.8 (standard deviation, ±3.8). Almost all program directors reported no (35 of 71, 49%) or minimal (34 of 71, 48%) negative impact of technical difficulties on their virtual interview processes. Most programs structured their interview to a half day (4 hours) or less for the candidates. Many programs were able to adapt their supplemental interview materials and events for the candidates into a virtual format, including a virtual social event hosted by 31 of 71 programs (44%). The virtual social event was most commonly casual and led by current fellows. Ultimately, all program directors reported that the virtual interview experience was as expected or better than expected. However, most program directors felt less able to provide candidates with a comprehensive and accurate representation of their program on a virtual platform compared with their previous in-person experiences (46 of 71 [65%] reported minimally, moderately, or significantly less than in-person). In addition, most program directors felt their ability to get to know candidates and assess their "fit" with the program was less than previous in-person years (44 of 71 [62%] reported minimally, moderately, or significantly less than in-person). In a hypothetical future year without any public health concerns, there were 23 of 71 respondents (32%) who prefer exclusive in-person interviews, 24 of 71 (34%) who prefer exclusive virtual interviews, and 24 of 71 (34%) who prefer a hybrid of virtual and in-person interviews.

Conclusion: The virtual interview experience was better than expected for most program directors. However, most program directors felt less able to present their programs and assess the candidates on a virtual platform compared with previous in-person experiences. Despite this, most program directors are interested in at least a component of virtual interviewing in future years. Future efforts are needed to refine the virtual interview process to optimize the experience for program directors and candidates.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100344DOI Listing
July 2021

Disease Severity and Perinatal Outcomes of Pregnant Patients With Coronavirus Disease 2019 (COVID-19).

Obstet Gynecol 2021 04;137(4):571-580

Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah, University of Texas Medical Branch at Galveston, Galveston, Texas, Northwestern University, Chicago, Illinois, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, Columbia University, New York, New York, University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, Texas, University of Pennsylvania, Philadelphia, Pennsylvania, Brown University, Providence, Rhode Island, University of Alabama at Birmingham, Birmingham, Alabama, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, The Ohio State University, Columbus, Ohio, University of Pittsburgh, Pittsburgh, Pennsylvania, and University of Texas at Austin, Austin, Texas; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To describe coronavirus disease 2019 (COVID-19) severity in pregnant patients and evaluate the association between disease severity and perinatal outcomes.

Methods: We conducted an observational cohort study of all pregnant patients with a singleton gestation and a positive test result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who delivered at 1 of 33 U.S. hospitals in 14 states from March 1 to July 31, 2020. Disease severity was classified by National Institutes of Health criteria. Maternal, fetal, and neonatal outcomes were abstracted by centrally trained and certified perinatal research staff. We evaluated trends in maternal characteristics and outcomes across COVID-19 severity classes and associations between severity and outcomes by multivariable modeling.

Results: A total of 1,219 patients were included: 47% asymptomatic, 27% mild, 14% moderate, 8% severe, 4% critical. Overall, 53% were Hispanic; there was no trend in race-ethnicity distribution by disease severity. Those with more severe illness had older mean age, higher median body mass index, and pre-existing medical comorbidities. Four maternal deaths (0.3%) were attributed to COVID-19. Frequency of perinatal death or a positive neonatal SARS-CoV-2 test result did not differ by severity. Adverse perinatal outcomes were more frequent among patients with more severe illness, including 6% (95% CI 2-11%) incidence of venous thromboembolism among those with severe-critical illness compared with 0.2% in mild-moderate and 0% in asymptomatic (P<.001 for trend across severity). In adjusted analyses, severe-critical COVID-19 was associated with increased risk of cesarean birth (59.6% vs 34.0%, adjusted relative risk [aRR] 1.57, 95% CI 1.30-1.90), hypertensive disorders of pregnancy (40.4% vs 18.8%, aRR 1.61, 95% CI 1.18-2.20), and preterm birth (41.8% vs 11.9%, aRR 3.53, 95% CI 2.42-5.14) compared with asymptomatic patients. Mild-moderate COVID-19 was not associated with adverse perinatal outcomes compared with asymptomatic patients.

Conclusion: Compared with pregnant patients with SARS-CoV-2 infection without symptoms, those with severe-critical COVID-19, but not those with mild-moderate COVID-19, were at increased risk of perinatal complications.
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http://dx.doi.org/10.1097/AOG.0000000000004339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984765PMC
April 2021

Effect of virtual interviewing on applicant approach to and perspective of the Maternal-Fetal Medicine Subspecialty Fellowship Match.

Am J Obstet Gynecol MFM 2021 05 3;3(3):100326. Epub 2021 Feb 3.

Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI (Dr Rhoades).

Background: The 2020 application cycle for the Maternal-Fetal Medicine Specialty Fellowship Match was the first to be exclusively virtual.

Objective: Our study was designed to compare approaches and perspectives of the MFM fellowship candidates who applied with virtual interviews with those of the current Maternal-Fetal Medicine fellows, who applied with in-person interviews in 2017, 2018, or 2019.

Study Design: A survey was developed by the Society for Maternal-Fetal Medicine Fellowship Affairs Committee to ascertain applicant approaches to and perspectives of the Maternal-Fetal Medicine Fellowship Match and was disseminated after 2020 Maternal-Fetal Medicine interviews ended and completed before Fellowship Match Day. Participants were contacted by means of active Listservs maintained by the Society for Maternal-Fetal Medicine. Current fellows were instructed to complete the survey using their experiences on the application cycle in which they successfully matched. Those who elected to participate entered their survey responses through the electronic link; answers were recorded in a secure Research Electronic Data Capture database. Outcomes were compared between those who applied during the virtual 2020 Maternal-Fetal Medicine interview cycle and those that applied during the in-person interview cycles in 2017, 2018, or 2019.

Results: Of the 140 completed surveys, 46 people participated in the 2020 Maternal-Fetal Medicine Match and were categorized as "virtual applicants," whereas the remaining 94 people participated in the 2017 (n=28), 2018 (n=33), or 2019 (n=33) Maternal-Fetal Medicine Match and were categorized as "in-person applicants." The overall distribution of number of programs to which each applicant applied differed between groups (P=.02); for example, nearly 75% of virtual applicants applied to at least 25 fellowship programs, compared with less than 50% of in-person applicants. Although the number of interviews received was similar between virtual and in-person applicants, virtual applicants were significantly less likely to cancel scheduled interviews (n=18 [39.1%] vs n=68 [72.3%]; P<.001). There were also differences between virtual and in-person applicants in terms of overall cost of the fellowship intervention process and total days away from work for interviewing (P<.001 for both). In particular, nearly two-thirds of virtual applicants reported spending less than $1000 in the Maternal-Fetal Medicine fellowship application process, compared with the nearly two-thirds of in-person applicants who reported spending more than $5000. Among the 46 virtual applicants, nearly 80% reported the experience was better or slightly better than expected, and none reported the experience was slightly worse or worse than expected. Nearly two-thirds of the virtual applicants reported that, compared with their in-person residency interviews, they received a comparable representation of Maternal-Fetal Medicine fellowship programs and could effectively assess their "fit" during interviews (60.9% and 63.0%, respectively). Only 20% of virtual Maternal-Fetal Medicine applicants would recommend returning to exclusive in-person interviews should that be possible in future Maternal-Fetal Medicine matches.

Conclusion: Virtual Maternal-Fetal Medicine fellowship interviewing was viewed favorably by applicants but corresponded with significant changes to their application approaches. The differences between virtual and in-person fellowship applicant tendencies identified in this study should inform next year's application cycle for Maternal-Fetal Medicine and possibly other obstetrics and gynecology subspecialty fellowships.
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May 2021

Society for Maternal-Fetal Medicine Special Statement: Grading of Recommendations Assessment, Development, and Evaluation (GRADE) update.

Am J Obstet Gynecol 2021 04 24;224(4):B24-B28. Epub 2020 Dec 24.

Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.

The Society for Maternal-Fetal Medicine Publications Committee first adopted the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system in 2013. This document provides an update on the Society for Maternal-Fetal Medicine Publications Committee process for creating evidence-based practice recommendations and describes the GRADE process as it is currently implemented in the SMFM Consult and Guidelines series.
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April 2021

What can we do to make the fellowship application process better?

Am J Obstet Gynecol MFM 2019 11 10;1(4):100054. Epub 2019 Oct 10.

Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT.

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November 2019

Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic cholestasis of pregnancy: Replaces Consult #13, April 2011.

Am J Obstet Gynecol 2021 02 13;224(2):B2-B9. Epub 2020 Nov 13.

Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.

Intrahepatic cholestasis of pregnancy is a hepatic disorder characterized by pruritus and an elevation in serum bile acid levels. Although intrahepatic cholestasis of pregnancy poses little risk for women, this condition carries a significant risk for the fetus, including complications such as preterm delivery, meconium-stained amniotic fluid, and stillbirth. The purpose of this Consult is to review the current literature on intrahepatic cholestasis of pregnancy and provide recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend measurement of serum bile acid and liver transaminase levels in patients with suspected intrahepatic cholestasis of pregnancy (GRADE 1B); (2) we recommend that ursodeoxycholic acid be used as the first-line agent for the treatment of maternal symptoms of intrahepatic cholestasis of pregnancy (GRADE 1A); (3) we suggest that patients with a diagnosis of intrahepatic cholestasis of pregnancy begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing results or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C); (4) we recommend that patients with total bile acid levels of ≥100 μmol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk of stillbirth increases substantially around this gestational age (GRADE 1B); (5) we recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels of <100 μmol/L (GRADE 1C); (6) we recommend administration of antenatal corticosteroids for fetal lung maturity for patients delivering before 37 0/7 weeks of gestation if not previously administered (GRADE 1A); (7) we recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of intrahepatic cholestasis of pregnancy without laboratory confirmation of elevated bile acid levels (GRADE 1B).
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February 2021

Are Canadian Cannabis Dispensaries Counselling Pregnant Women Appropriately?

J Obstet Gynaecol Can 2021 04 25;43(4):506-510.e2. Epub 2020 Aug 25.

Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON; The Research Institute, St. Joseph's Healthcare, Hamilton, ON. Electronic address:

Our objective was to examine the recommendations that Canadian dispensary employees are giving to women regarding cannabis use for nausea and vomiting of pregnancy (NVP) since the legalization of recreational cannabis in 2018. We conducted a nationwide cross-sectional study of licensed cannabis dispensaries in 2019, wherein a mystery caller stated they were 8 weeks pregnant and experiencing nausea and vomiting and asked for recommendations about cannabis. Our research was modeled after the primary study done in Colorado by Dickson and colleagues in 2018. An overwhelming majority of dispensaries (93%) in our study recommended against the use of a cannabis product for NVP, which contrasted significantly to the findings of the Colorado study, in which 70% of dispensaries recommended a cannabis product. These findings suggest that Canadian dispensary employees have been adequately educated about the dangers of cannabis use during pregnancy and are helpful from a public health lens.
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http://dx.doi.org/10.1016/j.jogc.2020.08.011DOI Listing
April 2021

Maternal Marijuana Exposure, Feto-Placental Weight Ratio, and Placental Histology.

Am J Perinatol 2020 Sep 24. Epub 2020 Sep 24.

University of Utah Health, Salt Lake City, Utah.

Objective:  Marijuana use is associated with placenta-mediated adverse pregnancy outcomes including fetal growth restriction, but the mechanism remains uncertain. The objective was to evaluate the association between maternal marijuana use and the feto-placental weight ratio (FPR). Secondarily, we aimed to compare placental histology of women who used marijuana to those who did not.

Study Design:  This was a secondary analysis of singleton pregnancies enrolled in a multicenter and case-control stillbirth study. Prior marijuana use was detected by electronic medical record abstraction or cord homogenate positive for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid. Prior tobacco use was detected by self-report or presence of maternal serum cotinine. Stillbirths and live births were considered separately. The primary outcome was FPR. Association of marijuana use with FPR was estimated with multivariable linear modeling adjusted for fetal sex, preterm birth, and tobacco use. Comparisons between groups for placental histology were made using Chi-square and stratified by live birth and stillbirth, term and preterm deliveries, and fetal sex.

Results:  Of 1,027 participants, 224 were stillbirths and 803 were live births. Overall, 41 (4%) women used marijuana during the pregnancy. The FPR ratio was lower among exposed offspring but reached statistical significance only for term stillbirths (mean 6.84 with marijuana use vs. mean 7.8 without use,  < 0.001). In multivariable modeling, marijuana use was not significantly associated with FPR ( = 0.09). There were no differences in histologic placental features among those with and without marijuana use overall or in stratified analyses.

Conclusion:  Exposure to marijuana may not be associated with FPR. Similarly, there were no placental histologic features associated with marijuana exposure. Further study of the influence of maternal marijuana use on placental development and function is warranted to better understand the association between prenatal marijuana use and poor fetal growth.

Key Points: · Maternal marijuana exposure was not associated with the feto-placental weight ratio.. · Marijuana exposure was not associated with differences in placental histology.. · Concerning trend toward lower feto-placental weight ratios among marijuana-exposed stillbirths..
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September 2020

Maternal Marijuana Exposure, Feto-Placental Weight Ratio, and Placental Histology.

Am J Perinatol 2020 Sep 24. Epub 2020 Sep 24.

University of Utah Health, Salt Lake City, Utah.

Objective:  Marijuana use is associated with placenta-mediated adverse pregnancy outcomes including fetal growth restriction, but the mechanism remains uncertain. The objective was to evaluate the association between maternal marijuana use and the feto-placental weight ratio (FPR). Secondarily, we aimed to compare placental histology of women who used marijuana to those who did not.

Study Design:  This was a secondary analysis of singleton pregnancies enrolled in a multicenter and case-control stillbirth study. Prior marijuana use was detected by electronic medical record abstraction or cord homogenate positive for 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid. Prior tobacco use was detected by self-report or presence of maternal serum cotinine. Stillbirths and live births were considered separately. The primary outcome was FPR. Association of marijuana use with FPR was estimated with multivariable linear modeling adjusted for fetal sex, preterm birth, and tobacco use. Comparisons between groups for placental histology were made using Chi-square and stratified by live birth and stillbirth, term and preterm deliveries, and fetal sex.

Results:  Of 1,027 participants, 224 were stillbirths and 803 were live births. Overall, 41 (4%) women used marijuana during the pregnancy. The FPR ratio was lower among exposed offspring but reached statistical significance only for term stillbirths (mean 6.84 with marijuana use vs. mean 7.8 without use,  < 0.001). In multivariable modeling, marijuana use was not significantly associated with FPR ( = 0.09). There were no differences in histologic placental features among those with and without marijuana use overall or in stratified analyses.

Conclusion:  Exposure to marijuana may not be associated with FPR. Similarly, there were no placental histologic features associated with marijuana exposure. Further study of the influence of maternal marijuana use on placental development and function is warranted to better understand the association between prenatal marijuana use and poor fetal growth.

Key Points: · Maternal marijuana exposure was not associated with the feto-placental weight ratio.. · Marijuana exposure was not associated with differences in placental histology.. · Concerning trend toward lower feto-placental weight ratios among marijuana-exposed stillbirths..
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September 2020

Safety and immunogenicity of an investigational maternal trivalent group B streptococcus vaccine in pregnant women and their infants: Results from a randomized placebo-controlled phase II trial.

Vaccine 2020 10 1;38(44):6930-6940. Epub 2020 Sep 1.

GSK, Rockville, MD, USA. Electronic address:

Background: This study evaluated the safety and immunogenicity of an investigational trivalent group B streptococcus (GBS) vaccine in US pregnant women, transplacental serotype-specific antibody transfer and persistence in infants, and serotype-specific antibodies in breast milk.

Methods: This randomized, observer-blind, placebo-controlled trial administered one dose of trivalent GBS vaccine (n = 49) or placebo (n = 26) to healthy pregnant 18-40-year-old women at 24-34 weeks' gestation. Women were enrolled from March 2014 to August 2015. Safety follow-up continued through postpartum day 180. Primary immunogenicity objectives were to evaluate serotype Ia/Ib/III-specific immunoglobulin G (IgG) levels in sera from women on day 1 (pre-vaccination), day 31, delivery and postpartum days 42 and 90, and from infants at birth (cord blood), days 42 and 90. Antibody transfer ratios (cord blood/maternal sera at delivery) and serotype-specific secretory immunoglobulin A (sIgA) and IgG in breast milk after delivery and on postpartum days 42 and 90 were evaluated. The planned sample size was not based on statistical assumptions for this descriptive study.

Results: Baseline characteristics were similar between groups. Serious adverse events were reported for 16% of GBS-vaccinated women and 15% of their infants, and 15% of placebo recipients and 12% of their infants; none were fatal or deemed vaccine-related. Serotype-specific IgG geometric mean concentrations (GMCs) were 13-23-fold higher in vaccine vs placebo recipients on day 31 and persisted until postpartum day 90. Median antibody concentrations were substantially higher in women with detectable pre-vaccination antibody concentrations. Antibody transfer ratios in the vaccine group were 0.62-0.82. Infant IgG GMCs and breast milk sIgA GMCs were higher in the vaccine vs the placebo group at all timepoints.

Conclusions: Maternal immunization with the trivalent GBS vaccine in US women had a favorable safety profile, elicited antibodies that were transplacentally transferred and persisted in infants for a minimum of 3 months.

Clinical Trial Registration: Clinicaltrials.gov, NCT02046148.
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October 2020

Maternal Mortality From Coronavirus Disease 2019 (COVID-19) in the United States.

Obstet Gynecol 2020 08;136(2):313-316

University of Utah Health, Salt Lake City, Utah; the University of Mississippi Medical Center, Jackson, Mississippi; and Baylor College of Medicine, Houston, Texas.

Individual state maternal mortality review committees aim to comprehensively review all maternal deaths to not only evaluate the cause of death, but also to assess preventability and make recommendations for action to prevent future deaths. The maternal mortality review committee process remains critical during the coronavirus disease 2019 (COVID-19) pandemic. Maternal deaths due to COVID-19 have been reported in the United States. Some state maternal mortality review committees may choose to expedite review of these deaths in an effort to quickly provide clinicians with information intended to prevent other deaths during the ongoing pandemic. If states opt to pursue rapid review, entry of data into the Maternal Mortality Review Information Application system for submission to the Centers for Disease Control and Prevention will allow for aggregation nationally without duplication. It will be important to review not only deaths directly attributed to COVID-19, but also those that may be indirectly related to the COVID-19 pandemic, such as those influenced by changes in care practices or delays in seeking care during the pandemic. Therefore, regardless of the timing of the review, maternal deaths that occur during the time of the COVID-19 pandemic must be evaluated within that framework to ensure that all factors contributing to the death are considered to better understand the context of each of these tragic events.
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http://dx.doi.org/10.1097/AOG.0000000000004024DOI Listing
August 2020

Cost of Elective Labor Induction Compared With Expectant Management in Nulliparous Women.

Obstet Gynecol 2020 07;136(1):19-25

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and the Division of Epidemiology, Department of Internal Medicine, University of Utah Health, Intermountain Healthcare, and the IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah; George Washington University Biostatistics Center, Washington, DC; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To compare the actual health-system cost of elective labor induction at 39 weeks of gestation with expectant management.

Methods: This was an economic analysis of patients enrolled in the five Utah hospitals participating in a multicenter randomized trial of elective labor induction at 39 weeks of gestation compared with expectant management in low-risk nulliparous women. The entire trial enrolled more than 6,000 patients. For this subset, 1,201 had cost data available. The primary outcome was relative direct health care costs of maternal and neonatal care from a health system perspective. Secondary outcomes included the costs of each phase of maternal and neonatal care. Direct health system costs of maternal and neonatal care were measured using advanced costing analytics from the time of randomization at 38 weeks of gestation until exit from the study up to 8 weeks postpartum. Costs in each randomization arm were compared using generalized linear models and reported as the relative cost of induction compared with expectant management. With a fixed sample size, we had adequate power to detect a 7.3% or greater difference in overall costs.

Results: The total cost of elective induction was no different than expectant management (mean difference +4.7%; 95% CI -2.1% to +12.0%; P=.18). Maternal outpatient antenatal care costs were 47.0% lower in the induction arm (95% CI -58.3% to -32.6%; P<.001). Maternal inpatient intrapartum and delivery care costs, conversely, were 16.9% higher among women undergoing labor induction (95% CI +5.5% to +29.5%; P=.003). Maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge did not differ between arms.

Conclusion: Total costs of elective labor induction and expectant management did not differ significantly. These results challenge the assumption that elective induction of labor leads to significant cost escalation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323797PMC
July 2020

Is Universal Testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Needed on All Labor and Delivery Units?

Authors:
Torri D Metz

Obstet Gynecol 2020 08;136(2):227-228

Published online ahead-of-print May 19, 2020. Dr. Metz is from University of Utah Health, Salt Lake City, Utah; email:

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August 2020

Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery.

Am J Obstet Gynecol 2020 08 28;223(2):B11-B17. Epub 2020 Apr 28.

Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.

Venous thromboembolism is a major cause of maternal morbidity and mortality. The risk of venous thromboembolism is particularly elevated during the postpartum period and especially after cesarean delivery. There is considerable variation in the approach to prophylaxis of venous thromboembolism in pregnancy, including after cesarean delivery. This Consult discusses the different guidelines on prophylaxis of venous thromboembolism after cesarean delivery and provides recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that all women who undergo cesarean delivery receive sequential compression devices starting before surgery and that the compression devices be used continuously until the patient is fully ambulatory (GRADE 1C); (2) we suggest that women with a previous personal history of deep venous thrombosis or pulmonary embolism who undergo cesarean delivery receive both mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks postoperatively) prophylaxis (GRADE 2C); (3) we suggest that women with a personal history of an inherited thrombophilia (high-risk or low-risk) but no previous thrombosis who undergo cesarean delivery receive both mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks postoperatively) prophylaxis (GRADE 2C); (4) we recommend the use of low-molecular-weight heparin as the preferred thromboprophylactic agent in pregnancy and the postpartum period (GRADE 1C); (5) when pharmacologic thromboprophylaxis is needed in pregnant women with class III obesity, we suggest the use of intermediate doses of enoxaparin (GRADE 2C); and (6) we recommend that each institution develop a patient safety bundle with an institutional protocol for venous thromboembolism prophylaxis among women who undergo cesarean delivery (Best Practice).
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August 2020

Cannabis use during pregnancy in the United States: The role of depression.

Drug Alcohol Depend 2020 05 3;210:107881. Epub 2020 Mar 3.

Department of Psychology, College of Liberal Arts, Pennsylvania State University, University Park, PA 16802, USA.

Background: Cannabis use is increasing in the United States. Prior work suggests tobacco use in pregnancy is much more common among those with depression. It is not known whether cannabis use is also more common among this especially vulnerable group. Identifying those at highest risk for cannabis use is required to direct prevention and intervention efforts.

Methods: Data were drawn from the 2005-2018 National Survey on Drug Use and Health (NSDUH), an annual, cross-sectional sample of persons ages 12 and older representative of the US. The prevalence of past-30-day cannabis use by depression status (past-12-month) and by sociodemographic factors and perception of risk associated with cannabis use was estimated among pregnant women.

Results: Cannabis use was significantly more common among pregnant women with, compared to without, depression (12.7 % vs. 3.7 %; odds ratio (OR) = 3.8 (95 % confidence interval 2.8, 5.0)). This was the case across all sociodemographic subgroups. The relationship between depression and cannabis use was significantly stronger among those who perceived moderate-great risk (OR = 6.9 (3.7, 13.0)) compared with no risk (OR = 1.6 (1.1, 2.4); P = 0.0003) associated with regular use.

Conclusions: Women with depression are more than three times more likely to use cannabis during pregnancy. Disparities in cannabis use among pregnant women by depression status appear to be echoing trends in tobacco use. Education about risks associated with cannabis use in pregnancy and prevention, akin to those for prenatal tobacco use, may be needed among pregnant women who are depressed to stem this increase and potentially growing disparity.
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May 2020

Obstetric Care Consensus #10: Management of Stillbirth: (Replaces Practice Bulletin Number 102, March 2009).

Am J Obstet Gynecol 2020 Mar 29;222(3):B2-B20. Epub 2020 Jan 29.

Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.

Stillbirth is one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the United States. In developed countries, the most prevalent risk factors associated with stillbirth are non-Hispanic black race, nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, smoking, alcohol use, having a pregnancy using assisted reproductive technology, multiple gestation, male fetal sex, unmarried status, and past obstetric history. Although some of these factors may be modifiable (such as smoking), many are not. The study of specific causes of stillbirth has been hampered by the lack of uniform protocols to evaluate and classify stillbirths and by decreasing autopsy rates. In any specific case, it may be difficult to assign a definite cause to a stillbirth. A significant proportion of stillbirths remains unexplained, even after a thorough evaluation. Evaluation of a stillbirth should include fetal autopsy; gross and histologic examination of the placenta, umbilical cord, and membranes; and genetic evaluation. The method and timing of delivery after a stillbirth depend on the gestational age at which the death occurred, maternal obstetric history (eg, previous hysterotomy), and maternal preference. Health care providers should weigh the risks and benefits of each strategy in a given clinical scenario and consider available institutional expertise. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, peer support group, or mental health professional may be advisable for management of grief and depression.
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March 2020

Maternal cardiovascular complications at the time of delivery and subsequent re-hospitalization in the USA, 2010-16.

Eur Heart J Qual Care Clin Outcomes 2021 May;7(3):304-311

Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 N. 1900 E. Room 4A100, Salt Lake City, UT 84132, USA.

Aims: Cardiovascular (CV) complications are the leading cause of maternal morbidity and mortality. The objective was to estimate trends in the incidence of peripartum CV complications in the USA between 2010 and 2016.

Methods And Results: This was a retrospective analyses using data from the Healthcare Cost and Utilization Project. We included women with delivery codes consistent with delivery, weighted to a national estimate. The primary outcome was the age-adjusted incidence of CV complications among all deliveries, including complications that occurred during re-hospitalizations. Complications were identified using International Classification of Diseases (ICD) codes. Joinpoint regression was used to evaluate time trends and complications were stratified by type. The secondary outcome was in-hospital maternal death among women with a CV complication. We identified a weighted estimate of 27 408 652 women hospitalized for delivery from 2010 to 2016. Including all years, the complication incidence was 7.36/1000 births [95% confidence interval (CI) 7.18-7.54], with an estimated annual percentage change of 5.8% (95% CI 3.7-7.8%). Cardiac dysrhythmia was the most common complication [3.98/1000 births (95% CI 3.88-4.08)] and acute myocardial infarction was the least common complication [0.11/1000 births (95% CI 0.10-0.11)]. The incidence of hypertension, acute myocardial infarction, and cardiac arrest increased over time, the incidence of congestive heart failure and acute cerebrovascular disease remained stable, the incidence of pulmonary heart disease increased from 2015 onward, and the incidence of cardiac dysrhythmia decreased in 2016. Complications during re-hospitalization accounted for 13.6% (95% CI 13.2-14.1%) of all complications and was highest for acute myocardial infarction [28.1% (95% CI 23.2-33.1)]. Among women with any complication, the mortality rate was 1.20 (95% CI 1.11-1.29) per 100 complications.

Conclusion: Our analyses suggest the rate of peripartum CV complications are increasing in the USA, which highlights the need for active efforts in research and prevention.
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http://dx.doi.org/10.1093/ehjqcco/qcz056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092990PMC
May 2021

Impact of Marijuana Legalization on Prevalence of Maternal Marijuana Use and Perinatal Outcomes.

Am J Perinatol 2020 01 6;37(1):59-65. Epub 2019 Sep 6.

Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.

Objective: We aimed to assess whether marijuana legalization was associated with a difference in prevalence of prenatal use or an increase in incidence of adverse perinatal outcomes.

Study Design: The present study is a retrospective cohort of September and October deliveries in the years 2012 through 2015 at a tertiary center in Colorado. Primary outcome of the study was use of marijuana, defined by self-report or biodetection. Secondary outcomes of the study included growth restriction, spontaneous preterm birth, stillbirth, preeclampsia, and neonatal or maternal death. Marijuana use prevalence was compared by year, and secondary outcomes between two periods, before and after the opening of the first recreational dispensary.

Results: A total of 2,392 pregnant women were included (1,165 before legalization and 1,227 after). More women used marijuana over the period of legalization (trend  = 0.01). Odds of marijuana use were higher after legalization versus before (adjusted odds ratio [aOR] = 1.8, 95% confidence interval [CI]: 1.2-2.6). Incidence of growth restriction was higher after legalization (2.9 vs. 5.1%,  = 0.0084). This difference persisted after adjustment for ethnicity and other drugs in multivariable modeling (aOR = 1.9, 95%CI: 1.2-3.0).

Conclusion: The prevalence of prenatal marijuana use increased over the time of legalization. Further investigation into the population impact of legalization on obstetrical outcomes is warranted given the observed increase in growth restriction.
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http://dx.doi.org/10.1055/s-0039-1696719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957332PMC
January 2020

Is Increasing Frequency of Marijuana Use Among Women of Reproductive Age a Cause for Alarm?

JAMA Netw Open 2019 07 3;2(7):e196464. Epub 2019 Jul 3.

Denver Health and Hospital, Denver, Colorado.

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http://dx.doi.org/10.1001/jamanetworkopen.2019.6464DOI Listing
July 2019
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