Publications by authors named "William Grobman"

460 Publications

FIGO good practice recommendations on progestogens for prevention of preterm delivery.

Int J Gynaecol Obstet 2021 Oct;155(1):16-18

Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Women at high risk of preterm birth (either a previous spontaneous preterm birth and/or sonographic short cervix) with a singleton gestation should be offered daily vaginal progesterone or weekly 17-OHPC treatment to prevent preterm birth. Benefit is most significant in those with prior history of preterm birth and a short cervix. For women with a previous spontaneous preterm birth and a cervix ≥30 mm the effectiveness of progesterone is uncertain. In asymptomatic women with no prior history of previous preterm birth, no mid-trimester loss, or no short cervical length, progesterone therapy is not recommended for the prevention of preterm birth. For those with unselected multiple pregnancies, progesterone therapy is not recommended for the prevention of preterm birth. Daily vaginal progesterone or weekly 17-OHPC treatment can be used for the prevention of preterm birth. The preparation used should be decided by the woman and her clinician. There is no evidence of neurological or developmental benefit or harm in babies whose mothers use progestogens for preterm birth prevention antenatally.
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http://dx.doi.org/10.1002/ijgo.13852DOI Listing
October 2021

FIGO good practice recommendations on cervical cerclage for prevention of preterm birth.

Int J Gynaecol Obstet 2021 Oct;155(1):19-22

Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.

Cervical cerclage is an intervention which when given to the right women can prevent preterm birth and second-trimester fetal losses. A history-indicated cerclage should be offered to women who have had three or more preterm deliveries and/or mid-trimester losses. An ultrasound-indicated cerclage should be offered to women with a cervical length <25 mm if they have had one or more spontaneous preterm birth and/or mid-trimester loss. In high-risk women who have not had a previous mid-trimester loss or preterm birth, an ultrasound-indicated cerclage does not have a clear benefit in women with a short cervix. However, for twins, the advantage seems more likely at shorter cervical lengths (<15 mm). In women who present with exposed membranes prolapsing through the cervical os, a rescue cerclage can be considered on an individual case basis, taking into account the high risk of infective morbidity to mother and baby. An abdominal cerclage can be offered in women who have had a failed cerclage (delivery before 28 weeks after a history or ultrasound-indicated [but not rescue] cerclage). If preterm birth has not occurred, removal is considered at 36-37 weeks in women anticipating a vaginal delivery.
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http://dx.doi.org/10.1002/ijgo.13835DOI Listing
October 2021

FIGO good practice recommendations on reduction of preterm birth in pregnancies conceived by assisted reproductive technologies.

Int J Gynaecol Obstet 2021 Oct;155(1):13-15

Bill and Melinda Gates Foundation, Seattle, Washington, USA.

FIGO (the International Federation of Gynecology and Obstetrics) supports assisted reproductive technologies (ART) to achieve pregnancy and supports their availability in all nations. However, the increased frequency of preterm birth must be taken into account. Therefore, before in vitro fertilization (IVF) is started, other approaches, including expectant management, should be considered. Single embryo transfer is the best approach to ensure a live, healthy child. However, increased risks for preterm birth are also associated with a singleton IVF pregnancy and should be discussed and contrasted with spontaneous conception. Increased preterm birth and other adverse pregnancy outcomes in singleton IVF cycles warrant investigations to elucidate and mitigate. Minimizing embryo manipulation during cell culture is recommended. Increased risk of preterm birth and other pregnancy complications in ART could reflect the underlying reasons for infertility. This information should be discussed and further explored.
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http://dx.doi.org/10.1002/ijgo.13834DOI Listing
October 2021

FIGO good practice recommendations on the use of pessary for reducing the frequency and improving outcomes of preterm birth.

Int J Gynaecol Obstet 2021 Oct;155(1):23-25

Department of Women and Children's Health, King's College, London, UK.

A pessary is a device made of synthetic material that is placed in the vagina and has been used for prevention of preterm birth. It has been suggested that a potential mechanism of the pessary is alteration of the cervico-uterine angle to a more posterior position, which reduces cervical compression in women with a singleton pregnancy and a short cervical length. Pessaries should not be used in routine clinical care to reduce the frequency of preterm birth or to improve outcomes (e.g. neonatal outcomes) related to preterm birth. In women with a twin pregnancy-regardless of cervical length-pessaries should not be used in routine clinical care to reduce the frequency of preterm birth or to improve outcomes (e.g. neonatal outcomes) related to preterm birth. Presently there is no sufficient evidence suggesting that pessaries should be used as a standard treatment to prevent preterm birth; their use should be reserved for study populations.
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http://dx.doi.org/10.1002/ijgo.13837DOI Listing
October 2021

FIGO good practice recommendations on the use of pessary for reducing the frequency and improving outcomes of preterm birth.

Int J Gynaecol Obstet 2021 Oct;155(1):23-25

Department of Women and Children's Health, King's College, London, UK.

A pessary is a device made of synthetic material that is placed in the vagina and has been used for prevention of preterm birth. It has been suggested that a potential mechanism of the pessary is alteration of the cervico-uterine angle to a more posterior position, which reduces cervical compression in women with a singleton pregnancy and a short cervical length. Pessaries should not be used in routine clinical care to reduce the frequency of preterm birth or to improve outcomes (e.g. neonatal outcomes) related to preterm birth. In women with a twin pregnancy-regardless of cervical length-pessaries should not be used in routine clinical care to reduce the frequency of preterm birth or to improve outcomes (e.g. neonatal outcomes) related to preterm birth. Presently there is no sufficient evidence suggesting that pessaries should be used as a standard treatment to prevent preterm birth; their use should be reserved for study populations.
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http://dx.doi.org/10.1002/ijgo.13837DOI Listing
October 2021

Enhancing information and choice after prior cesarean.

Am J Obstet Gynecol 2021 Sep 2. Epub 2021 Sep 2.

Feinberg School of Medicine, Northwestern University, Chicago, IL. Electronic address:

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http://dx.doi.org/10.1016/j.ajog.2021.08.046DOI Listing
September 2021

Using principle component analysis to examine associations of early pregnancy inflammatory biomarker profiles and adverse birth outcomes.

Am J Reprod Immunol 2021 Sep 3. Epub 2021 Sep 3.

Department of Obstetrics and Gynecology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Northwestern University Center for Healthcare Studies - Institute for Public Health and Medicine, Evanston, IL, USA.

Objective: Inflammation as a risk factor for preterm birth is well-established. The primary objective of this analysis was to examine whether individual cytokines versus a composite indicator of mid-pregnancy inflammation are significantly associated with risk for adverse birth outcomes.

Study Design: A multi-site prospective study was conducted in a socio-demographically diverse cohort of 610 pregnant participants. At a study visit between 12 and 20 6/7 weeks' gestation, low-grade inflammation was measured via log-transformed serum concentrations of the biomarkers IFN-γ, IL-10, IL-13, IL-6, IL-8, TNF-α, and CRP. Principal component analysis (PCA) was used to identify underlying dimensions of inflammatory activity from the seven biomarkers measured. Gestational age and birth weight at delivery were obtained from medical chart review. The associations between inflammatory profiles and birth outcomes were assessed via linear and logistic regression models. Results were compared with those from individual inflammatory biomarkers, and model fit was assessed using Akaike's Information Criterion (AIC).

Results: PCA analysis yielded a two-factor solution, with the first factor (IF1) composed of IL-8, IL-10, IL-13, IFN-ɣ, and TNF-α, and the second factor (IF2) containing IL-6 and CRP. When adjusted for race, education, BMI, smoking status, gestational age at time of blood draw, and study site, a one standard deviation (SD) increase in IF1 remained significantly associated with a decrease in standardized gestational age (β = -0.13, 95% CI: -0.21, -0.05) and an increase in odds of preterm delivery (OR = 1.46, 95% CI: 1.13, 1.88) (Table 3). A one SD increase in IF2 was similarly associated with a decrease in standardized gestational age at delivery (β = -0.13, 95% CI: -0.23, -0.04) and an increase in odds of preterm delivery (OR: 1.46, 95% CI: 1.04, 2.05). Neither IF1 nor IF2 was associated with measures of fetal growth. AIC identified that IL-6 was a slightly better fit for length of gestation compared to either composite measure, though all performed similarly.

Conclusion: Independent of known sociodemographic risk factors, an elevated mid-pregnancy inflammatory profile was associated with a nearly 50% increase in odds of preterm delivery. The composite performed similarly to IL-6. These results suggest that maternal low-grade inflammation is a risk factor for preterm delivery, and that mid-pregnancy inflammatory biomarkers may be useful in predicting risk for preterm delivery. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/aji.13497DOI Listing
September 2021

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

Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes.

JAMA Netw Open 2021 Sep 1;4(9):e2122576. Epub 2021 Sep 1.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Importance: Health literacy is considered an important social determinant of health that may underlie many health disparities, but it is unclear whether inadequate health literacy among pregnant individuals is associated with adverse maternal and neonatal outcomes.

Objective: To assess the association between maternal health literacy and maternal and neonatal outcomes among nulliparous individuals.

Design, Setting, And Participants: This was a secondary analysis of a large, multicenter cohort study of 10 038 nulliparous individuals in the US (2010-2013). Participants underwent 3 antenatal study visits and had detailed maternal and neonatal data abstracted. Data analysis was performed from July to December 2019.

Exposures: Between 16 and 21 weeks of gestation, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Short Form, a validated 7-item word recognition test. In accordance with standard scoring, results were dichotomized as inadequate vs adequate health literacy.

Main Outcomes And Measures: On the basis of theoretical causal pathways between health literacy and health outcomes, a priori maternal and neonatal outcomes (determined via medical records) were selected for this analysis. Multivariable Poisson regression models were constructed to estimate the associations between health literacy and outcomes. Sensitivity analyses in which education was removed from models and that excluded individuals who spoke English as a second language were performed.

Results: Of 9341 participants who completed the Rapid Estimate of Adult Literacy in Medicine-Short Form, the mean (SD) age was 27.0 (5.6) years, and 2540 (27.4%) had publicly funded prenatal care. Overall, 1638 participants (17.5%) had scores indicative of inadequate health literacy. Participants with inadequate health literacy were more likely to be younger (mean [SD] age, 22.9 [5.0] vs 27.9 [5.3] years), have less educational attainment (some college education or greater, 1149 participants [73.9%] vs 5279 participants [94.5%]), have publicly funded insurance (1008 participants [62.2%] vs 1532 participants [20.0%]), and report they were a member of an underrepresented racial or ethnic group (non-Hispanic Black, 506 participants [30.9%] vs 780 participants [10.1%]; Hispanic, 516 participants [31.5%] vs 948 participants [12.3%]) compared with those with adequate health literacy. Participants who had inadequate health literacy had greater risk of cesarean delivery (adjusted risk ratio [aRR], 1.11; 95% CI, 1.01-1.23) and major perineal laceration (aRR, 1.44; 95% CI, 1.03-2.01). The adjusted risks of small-for-gestational-age status (aRR, 1.34; 95% CI, 1.14-1.58), low birth weight (aRR, 1.33; 95% CI, 1.07-1.65), and 5-minute Apgar score less than 4 (aRR, 2.78; 95% CI, 1.16-6.65) were greater for neonates born to participants with inadequate health literacy. Sensitivity analyses confirmed these findings.

Conclusions And Relevance: These findings suggest that inadequate maternal health literacy is associated with a variety of adverse maternal and neonatal outcomes.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.22576DOI Listing
September 2021

Gestational Diabetes and Overweight/Obesity: Analysis of Nulliparous Women in the U.S., 2011-2019.

Am J Prev Med 2021 Aug 23. Epub 2021 Aug 23.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Electronic address:

Introduction: The rates of gestational diabetes mellitus are increasing in parallel with the rates of overweight and obesity. This analysis examines nationwide trends in the population-attributable fraction for gestational diabetes mellitus associated with prepregnancy overweight and obesity.

Methods: A serial, cross-sectional study was performed using U.S. population-based birth data files maintained by the National Center for Health Statistics between 2011 and 2019. Live singleton births to nulliparous women aged 15-44 years were included, and all analyses were stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian). Prevalences of prepregnancy overweight (25.0-29.9 kg/m and 23.0-27.4 kg/m) and obesity (≥30.0 kg/m and ≥27.5 kg/m) based on standard and Asian-specific BMI categories, respectively, were quantified. Logistic regression estimated the adjusted associations between prepregnancy overweight and obesity and gestational diabetes mellitus, with normal weight (18.0-24.9 kg/mand 18.0-22.9 kg/m) as the ref. Annual population-attributable fractions for gestational diabetes mellitus associated with prepregnancy overweight and obesity were calculated, which account for both the prevalence of the risk factor and the associated risk of gestational diabetes mellitus.

Results: Among 11,950,881 included women, the mean maternal age was 26.3 years. From 2011 to 2019, the population-attributable fractions for gestational diabetes mellitus associated with overweight were stable (Hispanic: 12.0%-11.3%, non-Hispanic Asian: 12.1%-11.6%, p≥0.20) or decreased (non-Hispanic White: 10.8%-9.4%, non-Hispanic Black: 12.3%-9.2%, p<0.002); the population-attributable fractions for gestational diabetes mellitus associated with obesity were stable (non-Hispanic Black: 36.3%-37.9%, p=0.11) or increased (non-Hispanic White: 30.9%-33.3%, Hispanic: 27.2%-33.3%, non-Hispanic Asian 12.2%-15.4%, p<0.001).

Conclusions: The population-attributable fractions for gestational diabetes mellitus associated with obesity largely increased in the past decade, underscoring the importance of optimizing weight before pregnancy.
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http://dx.doi.org/10.1016/j.amepre.2021.05.036DOI Listing
August 2021

Trends in Prepregnancy Obesity and Association With Adverse Pregnancy Outcomes in the United States, 2013 to 2018.

J Am Heart Assoc 2021 Sep 25;10(17):e020717. Epub 2021 Aug 25.

Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL.

Background The prevalence of obesity in the population has increased in parallel with increasing rates of adverse pregnancy outcomes (APOs). Quantifying contemporary trends in prepregnancy obesity and associations with interrelated APOs (preterm birth, low birth weight, and pregnancy-associated hypertension) together and individually can inform prevention strategies to optimize cardiometabolic health in women and offspring. Methods and Results We performed a serial, cross-sectional study using National Center for Health Statistics birth certificate data including women aged 15 to 44 years with live singleton births between 2013 and 2018, stratified by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian). We quantified the annual prevalence of prepregnancy obesity (body mass index ≥30.0 kg/m; body mass index ≥27.5 kg/m if non-Hispanic Asian). We then estimated adjusted associations using multivariable logistic regression (odds ratios and population attributable fractions) for obesity-related APOs compared with normal body mass index (18.5-24.9 kg/m; 18.5-22.9 kg/m if non-Hispanic Asian). Among 20 139 891 women, the prevalence of prepregnancy obesity increased between 2013 and 2018: non-Hispanic White (21.6%-24.8%), non-Hispanic Black (32.5%-36.2%), Hispanic (26.0%-30.5%), and non-Hispanic Asian (15.3%-18.6%) women (-trend < 0.001 for all). Adjusted odds ratios (95% CI) for APOs associated with obesity increased between 2013 and 2018, and by 2018, ranged from 1.27 (1.25-1.29) in non-Hispanic Black to 1.94 (1.92-1.96) in non-Hispanic White women. Obesity was most strongly associated with pregnancy-associated hypertension and inconsistently associated with preterm birth and low birth weight. Population attributable fractions of obesity-related APOs increased over the study period: non-Hispanic White (10.6%-14.7%), non-Hispanic Black (3.7%-6.9%), Hispanic (7.0%-10.4%), and non-Hispanic Asian (7.4%-9.7%) women (-trend < 0.01 for all). Conclusions The prevalence of prepregnancy obesity and burden of obesity-related APOs have increased, driven primarily by pregnancy-associated hypertension, and vary across racial/ethnic subgroups.
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http://dx.doi.org/10.1161/JAHA.120.020717DOI Listing
September 2021

The association between the COVID-19 pandemic and postpartum care provision.

Am J Obstet Gynecol MFM 2021 Aug 14;3(6):100460. Epub 2021 Aug 14.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Grobman and Miller).

Background: The COVID-19 pandemic led to a rapid transformation in the healthcare system to mitigate viral exposure. In the perinatal context, one change included altering the prenatal visit cadence and increasing the utilization of telehealth methods. Whether this approach had inadvertent negative implications for postpartum care, including postpartum depression screening and contraceptive utilization, is unknown.

Objective: This study aimed to examine whether preventative health service utilization, including postpartum depression screening and contraceptive utilization, differed during the COVID-19 pandemic when compared with the prepandemic period.

Study Design: This retrospective cohort study included all pregnant patients who received prenatal care at 1 of 5 academic obstetrical practices and who delivered at Northwestern Memorial Hospital either before (delivery from September 1, 2018, to January 1, 2019) or during (delivery from February 1, 2020, to May 15, 2020) the COVID-19 pandemic. Completion of postpartum depression screening was assessed by reviewing standardized fields in the documentation associated with the screening in the electronic health record system. The method of contraception used was ascertained from the postpartum clinical documentation. Patients were classified as initiating long-acting reversible contraception use if they received NEXPLANON (etonogestrel implant) or an intrauterine device during the hospitalization for delivery or within 3 months following delivery. Bivariable and multivariable analyses were performed.

Results: Of the 2375 pregnant patients included in this study, 1120 (47%) delivered during the COVID-19 pandemic. Pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to have undergone postpartum depression screening (45.5% vs 86.2%; P<.01); this association persisted after adjusting for potential confounders (adjusted odds ratio, 0.13; 95% confidence interval, 0.11-0.16). Pregnant patients who delivered during the COVID-19 pandemic also were significantly less likely to initiate long-acting reversible contraception use within 3 months of delivery (13.5% vs 19.6%; adjusted odds ratio, 0.67; 95% confidence interval, 0.53-0.84).

Conclusion: The onset of the COVID-19 pandemic was associated with a decrease in the completion of postpartum depression screenings and fewer patients initiating long-acting reversible contraception use overall. These results can inform adaptations in healthcare delivery in the midst of the ongoing COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364402PMC
August 2021

Trends in Gestational Diabetes at First Live Birth by Race and Ethnicity in the US, 2011-2019.

JAMA 2021 08;326(7):660-669

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Importance: Gestational diabetes is associated with adverse maternal and offspring outcomes.

Objective: To determine whether rates of gestational diabetes among individuals at first live birth changed from 2011 to 2019 and how these rates differ by race and ethnicity in the US.

Design, Setting, And Participants: Serial cross-sectional analysis using National Center for Health Statistics data for 12 610 235 individuals aged 15 to 44 years with singleton first live births from 2011 to 2019 in the US.

Exposures: Gestational diabetes data stratified by the following race and ethnicity groups: Hispanic/Latina (including Central and South American, Cuban, Mexican, and Puerto Rican); non-Hispanic Asian/Pacific Islander (including Asian Indian, Chinese, Filipina, Japanese, Korean, and Vietnamese); non-Hispanic Black; and non-Hispanic White.

Main Outcomes And Measures: The primary outcomes were age-standardized rates of gestational diabetes (per 1000 live births) and respective mean annual percent change and rate ratios (RRs) of gestational diabetes in non-Hispanic Asian/Pacific Islander (overall and in subgroups), non-Hispanic Black, and Hispanic/Latina (overall and in subgroups) individuals relative to non-Hispanic White individuals (referent group).

Results: Among the 12 610 235 included individuals (mean [SD] age, 26.3 [5.8] years), the overall age-standardized gestational diabetes rate significantly increased from 47.6 (95% CI, 47.1-48.0) to 63.5 (95% CI, 63.1-64.0) per 1000 live births from 2011 to 2019, a mean annual percent change of 3.7% (95% CI, 2.8%-4.6%) per year. Of the 12 610 235 participants, 21% were Hispanic/Latina (2019 gestational diabetes rate, 66.6 [95% CI, 65.6-67.7]; RR, 1.15 [95% CI, 1.13-1.18]), 8% were non-Hispanic Asian/Pacific Islander (2019 gestational diabetes rate, 102.7 [95% CI, 100.7-104.7]; RR, 1.78 [95% CI, 1.74-1.82]), 14% were non-Hispanic Black (2019 gestational diabetes rate, 55.7 [95% CI, 54.5-57.0]; RR, 0.97 [95% CI, 0.94-0.99]), and 56% were non-Hispanic White (2019 gestational diabetes rate, 57.7 [95% CI, 57.2-58.3]; referent group). Gestational diabetes rates were highest in Asian Indian participants (2019 gestational diabetes rate, 129.1 [95% CI, 100.7-104.7]; RR, 2.24 [95% CI, 2.15-2.33]). Among Hispanic/Latina participants, gestational diabetes rates were highest among Puerto Rican individuals (2019 gestational diabetes rate, 75.8 [95% CI, 71.8-79.9]; RR, 1.31 [95% CI, 1.24-1.39]). Gestational diabetes rates increased among all race and ethnicity subgroups and across all age groups.

Conclusions And Relevance: Among individuals with a singleton first live birth in the US from 2011 to 2019, rates of gestational diabetes increased across all racial and ethnic subgroups. Differences in absolute gestational diabetes rates were observed across race and ethnicity subgroups.
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http://dx.doi.org/10.1001/jama.2021.7217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8371572PMC
August 2021

Trends in prepregnancy cardiovascular health in the United States, 2011-2019.

Am J Prev Cardiol 2021 Sep 31;7:100229. Epub 2021 Jul 31.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA.

Objective: To evaluate contemporary patterns in prepregnancy cardiovascular health (CVH) in the United States (US).

Methods: We conducted a serial, cross-sectional study of National Center for Health Statistics Natality Data representing all live births in the US from 2011 to 2019. We assigned 1 point for each of four ideal prepregnancy metrics (nonsmoking and ideal body mass index [18.5-24.9 kg/m] provided by maternal self-report, and absence of hypertension and diabetes ascertained by the healthcare professional at delivery) to construct a prepregnancy clinical CVH score ranging from 0 to 4. We described the distribution of prepregnancy CVH, overall and stratified by self-reported race/ethnicity, age, insurance status, and receipt of the Women, Infants, and Children program (WIC) for supplemental nutrition. We examined trends by calculating average annual percent changes (AAPCs) in optimal prepregnancy CVH (score of 4).

Results: Of 31,643,982 live births analyzed between 2011 and 2019, 53.6% were to non-Hispanic White, 14.5% non-Hispanic Black, 23.3% Hispanic, and 6.6% non-Hispanic Asian women. The mean age (SD) was 28.5 (5.8) years. The prevalence (per 100 live births) of optimal prepregnancy CVH score of 4 declined from 42.1 to 37.7 from 2011 to 2019, with an AAPC (95% CI) of -1.4% per year (-1.3,-1.5). While the relative decline was observed across all race/ethnicity, insurance, and WIC subgroups, significant disparities persisted by race, insurance status, and receipt of WIC. In 2019, non-Hispanic Black women (28.7 per 100 live births), those on Medicaid (30.4), and those receiving WIC (29.1) had the lowest prevalence of optimal CVH.

Conclusions: Overall, less than half of pregnant women had optimal prepregnancy CVH, and optimal prepregnancy CVH declined in each race/ethnicity, age, insurance, and WIC subgroup between 2011-2019 in the US. However, there were persistent disparities by race/ethnicity and socioeconomic status.
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http://dx.doi.org/10.1016/j.ajpc.2021.100229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8353467PMC
September 2021

Serum cotinine and adverse cardiovascular outcomes: a cross-sectional secondary analysis of the nuMoM2b Heart Health Study.

Am J Perinatol 2021 Aug 6. Epub 2021 Aug 6.

Obstetrics & Gynecology, University of Utah School of Medicine, Salt Lake City, United States.

Objective: Women with adverse pregnancy outcomes (APOs) have increased risks for cardiovascular disease. Smoking is a source of confounding that may be difficult to assess by self-report. We aimed to estimate odds of cardiovascular outcomes by smoking status using serum cotinine versus self-report and to assess whether the association between APOs and cardiovascular outcomes varies by smoking status.

Study Design: We conducted a cross-sectional study of the nuMoM2b Heart Health Study wherein women attended an in-person visit 2-7 years following their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine levels. Outcomes included incident chronic hypertension, metabolic syndrome, and dyslipidemia. Multivariable logistic regression estimated odds ratios for each outcome by smoking status.

Results: Of the 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as having secondhand smoke exposure, and 720 as smokers. After adjustment for APOs, smoking defined by serum cotinine levels was associated with metabolic syndrome (adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI) 1.21, 1.91) and dyslipidemia (aOR 1.28, 95% CI 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR 1.64, 95% CI 1.32, 2.03) and stage 2 hypertension (aOR 2.92, 95% CI 2.17, 3.93), metabolic syndrome (aOR 1.76, 95% CI 1.42, 2.18), and dyslipidemia (aOR 1.55, 95% CI 1.25, 1.91) relative to women with no APO. Similar findings were obtained using self-report to define smoking exposure.

Conclusion: Smoking and APOs are independently associated with subsequent cardiovascular outcomes in reproductive-age women. Smoking is associated with metabolic syndrome and dyslipidemia, whether smoking status is obtained by serum cotinine or self-report. Among nonsmokers, a history of APO is associated with hypertension, metabolic syndrome, and dyslipidemia compared to women without APOs.
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http://dx.doi.org/10.1055/a-1580-3155DOI Listing
August 2021

Maternal and Neonatal Outcomes in Nulliparous Participants Undergoing Labor Induction by Cervical Ripening Method.

Am J Perinatol 2021 Aug 5. Epub 2021 Aug 5.

Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania.

Objective:  This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals.

Study Design:  This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (L&D) stay. Multivariable analysis was used to adjust for patient characteristics.

Results:  Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96-1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92-1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83-1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16-0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29-0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40-1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter L&D stay (adjusted mean difference = -1.97 hours, 95% CI: -3.45 to -0.49 and -5.92 hours, 95% CI: -7.07 to -4.77, respectively), compared with PGE.

Conclusion:  In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of L&D stay was the shortest with concurrent Foley-oxytocin.

Key Points: · Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.. · Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.. · The use of Foley alone, or in combination with other agents, appears to be beneficial..
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August 2021

A Multivariable Predictive Model for Success of External Cephalic Version.

Obstet Gynecol 2021 Sep;138(3):426-433

Department of Obstetrics and Gynecology, Division of Biostatistics, and the Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, and the Feinberg School of Medicine, Northwestern University, Chicago Illinois; and the Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven Connecticut.

Objective: To create a prediction model for external cephalic version (ECV) success using objective patient characteristics.

Methods: This retrospective study included pregnant individuals of at least 18 years of age with a nonanomalous, singleton gestation who underwent an ECV attempt between 2006 and 2016 at a single quaternary care hospital. Variables assessed included maternal age, height, weight, body mass index (BMI), parity, fetal sex, gestational age, estimated fetal weight, type of fetal malpresentation, placental location, and amniotic fluid volume. Univariable and multivariable logistic regression models were used to determine the association of patient characteristics with ECV success. Estimated odds ratios and corresponding 95% CIs were calculated for each variable, and backward elimination and bootstrapping were used to find a parsimonious model for ECV success with the highest discriminatory capacity (as determined by the area under the receiver operating characteristic curve [AUC]). This model was evaluated with a calibration curve across deciles of success.

Results: A total of 1,138 individuals underwent an ECV attempt and were included in this analysis. The overall ECV success frequency was 40.6%. Factors significantly associated with ECV success were maternal age, parity, placental location, estimated fetal weight, and type of fetal malpresentation. A final model with BMI, parity, placental location, and type of fetal malpresentation had the highest AUC (0.667 [95% CI 0.634-0.701]), resulted in good calibration, and is represented by the following equation: 1/[1+e-x] where x=1.1726-0.0314 (BMI)-0.9299 (nulliparity)+1.0218 (transverse or oblique presentation at ECV)-0.5113 (anterior placenta). An interactive version of this equation was created and can be accessed at www.ecvcalculator.com.

Conclusion: A prediction model that estimates the probability of ECV success was created and internally validated. This model incorporates easily obtainable and objective patient factors known before ECV and may be used in decision making and patient counseling about ECV.
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http://dx.doi.org/10.1097/AOG.0000000000004518DOI Listing
September 2021

Association between gestational PFAS exposure and Children's adiposity in a diverse population.

Environ Res 2021 Jul 31;203:111820. Epub 2021 Jul 31.

Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.

Perfluoroalkyl substances (PFAS) are widely distributed suspected obesogens that cross the placenta. However, few data are available to assess potential fetal effects of PFAS exposure on children's adiposity in diverse populations. To address the data gap, we estimated associations between gestational PFAS concentrations and childhood adiposity in a diverse mother-child cohort. We considered 6 PFAS in first trimester blood plasma, measured using ultra-high-performance liquid chromatography with tandem mass spectrometry, collected from non-smoking women with low-risk singleton pregnancies (n = 803). Body mass index (BMI), waist circumference (WC), fat mass, fat-free mass, and % body fat were ascertained in 4-8 year old children as measures of adiposity. We estimated associations of individual gestational PFAS with children's adiposity and overweight/obesity, adjusted for confounders. There were more non-Hispanic Black (31.7 %) and Hispanic (42.6 %) children with overweight/obesity, than non-Hispanic white (18.2 %) and Asian/Pacific Islander (16.4 %) children (p < 0.0001). Perfluorooctane sulfonate (PFOS; 5.3 ng/mL) and perfluorooctanoic acid (2.0 ng/mL) had the highest median concentrations in maternal blood. Among women without obesity (n = 667), greater perfluoroundecanoic acid (PFUnDA) was associated with their children having higher WC z-score (β = 0.08, 95%CI: 0.01, 0.14; p = 0.02), fat mass (β = 0.55 kg, 95%CI: 0.21, 0.90; p = 0.002), and % body fat (β = 0.01 %; 95%CI: 0.003, 0.01; p = 0.004), although the association of PFUnDA with fat mass attenuated at the highest concentrations. Among women without obesity, the associations of PFAS and their children's adiposity varied significantly by self-reported race-ethnicity, although the direction of the associations was inconsistent. In contrast, among the children of women with obesity, greater, PFOS, perfluorononanoic acid, and perfluorodecanoic acid concentrations were associated with less adiposity (n = 136). Our results suggest that specific PFAS may be developmental obesogens, and that maternal race-ethnicity may be an important modifier of the associations among women without obesity.
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July 2021

Implementation of a text-based postpartum blood pressure monitoring program at 3 different academic sites.

Am J Obstet Gynecol MFM 2021 Jul 28;3(6):100446. Epub 2021 Jul 28.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA (Drs Janssen, Srinivas, and Hirshberg).

Background: Up to 30% of patients with hypertensive disorders of pregnancy continue to have elevated blood pressures after delivery, often necessitating medication titration or hospital evaluation in the weeks following hospital discharge. A previous randomized controlled trial demonstrated that remote blood pressure monitoring programs led to an increase in the number of blood pressure measurements obtained and increased compliance with clinical guidelines regarding the monitoring of patients for persistent or worsening postpartum hypertension.

Objective: The aims of this study were to measure the program participant response rates during the first 10 days after hospital discharge, to assess the replicability and scalability of the program, and to evaluate patient satisfaction at 3 distinct sites.

Study Design: We conducted a prospective observational cohort study across 3 US academic medical centers during which postpartum participants with hypertensive disorders of pregnancy were enrolled in a previously validated, remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood. English-speaking patients with access to a text message-enabled cell phone and with a diagnosis of hypertensive disorders of pregnancy were candidates for enrollment in the study. Each study site planned to enroll approximately 66 participants in this pilot implementation phase. All the enrolled participants received a validated blood pressure cuff, education on proper use of the device, and were sent text messages as a reminder to check their blood pressures twice daily for 10 days after discharge. They were asked to reply via text message with their blood pressure readings. All blood pressure readings were reviewed via a web-based platform by a physician. Physicians communicated with patients whose blood pressure levels exceeded 160 mm Hg systolic or 100 mm Hg diastolic to determine the next management steps. Enrollees were texted a survey at the end of the 10 days and the responses were recorded. The proportion of eligible parturients who were enrolled, the number of measured blood pressure values, and the postprogram survey results were measured. We assessed the number of patients who reported elevated blood pressures, required antihypertensive medication, and were readmitted for blood pressure control during the program duration.

Results: A total of 199 participants were enrolled in the program: 66 at site A, 67 at site B, and 66 at site C. In the 10 days after hospital discharge, 192 (97%) participants submitted at least 1 blood pressure measurement via text message. More enrolled patients submitted a blood pressure measurement on postpartum days 7 to 10 (171, 86%) than on days 1 to 4 (134, 67%). A total of 126 (63%) participants submitted blood pressures during both time frames. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery. The end-of-program survey was completed by 98 (49%) of the participants. Of those who completed the survey, 93% agreed that the program helped them to monitor their blood pressure (89% at site A; 88% at site B, and 100% at site C), and 93% would recommend it to friends or family members (94% at site A, 96% at site, and 88% at site C).

Conclusion: Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100446DOI Listing
July 2021

Provider Perspectives on Barriers and Facilitators to Postpartum Care for Low-Income Individuals.

Womens Health Rep (New Rochelle) 2021 16;2(1):254-262. Epub 2021 Jul 16.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Recent paradigm shifts in postpartum care have conceptualized the "fourth trimester" as a critical transitional period requiring tailored, ongoing health care. However, this concept presents challenges for providers, especially in low-resource settings. Our objective was to understand providers' perspectives on challenges in postpartum care to highlight strategies for optimizing care. Focus groups were conducted using a semistructured interview guide to elicit perspectives on barriers and facilitators to postpartum care. Participants included physicians, nurses, and social workers who care for low-income postpartum individuals. Interviews explored the provider experience of postpartum care, with a focus on barriers experienced by patients and providers, and tools for maintaining engagement. Analysis was performed using the constant comparative method and framed by the Social Ecological Model. Participants ( = 26) all acknowledged the importance of the "fourth trimester" but identified multiple barriers to providing optimal postpartum care. Challenges providers perceived for patients and those they perceived for themselves often overlapped, including difficulty with appointment scheduling, insurance limitations, lack of provider continuity, and knowledge gaps. Providers identified ease of referrals to specialists, access to tangible services (, contraception), and enhanced care coordination (, patient navigation) as potential facilitators of improved postpartum care. Obstetric providers recognize the importance of postpartum care yet highlighted significant systems- and patient-based barriers to achieving optimal care. The development and implementation of postpartum care delivery system redesign, such as the use of patient navigators to improve health care utilization and resource attainment, may enhance care during this critical time. Clinical Trial No.: NCT03922334.
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http://dx.doi.org/10.1089/whr.2021.0009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310741PMC
July 2021

Association of pre-pregnancy cardiovascular risk factor burden with adverse maternal and offspring outcomes.

Eur J Prev Cardiol 2021 Jul 20. Epub 2021 Jul 20.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive Ste. 1400, Chicago, IL 60611, USA.

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July 2021

Trajectories of antenatal depression and adverse pregnancy outcomes.

Am J Obstet Gynecol 2021 Jul 17. Epub 2021 Jul 17.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL.

Background: Antenatal depression affects approximately 1 of 7 pregnancies, with an increasing prevalence across gestation. Data regarding the associations between antenatal depression and adverse pregnancy outcomes yielded conflicting results. However, previous studies evaluated the cross-sectional prevalence of depression at various time points and not the depressive symptom trajectory across gestation.

Objective: This study aimed to identify whether the trajectory of antenatal depressive symptoms is associated with different risks of adverse pregnancy outcomes.

Study Design: This was a secondary analysis of a large multisite prospective cohort of nulliparous women across the United States. The Edinburgh Postpartum Depression Scale was administered at 2 study visits: between 6 and 14 weeks' gestation and between 22 and 30 weeks' gestation. The Edinburgh Postpartum Depression Scale score trajectories were categorized as improved, stable, or worsened based on whether the scores changed by at least 1 standard deviation between the 2 visits. The frequencies of adverse pregnancy outcomes (hypertensive disorders of pregnancy, abruption, cesarean delivery, preterm birth [ie, <37 weeks' gestation], small for gestational age neonates, neonatal intensive care unit admission, and maternal readmission) were compared with depression trajectories across gestation in bivariable and multivariable analyses. Secondary analyses evaluated the frequencies of spontaneous and medically indicated preterm births and frequencies of spontaneous and medically indicated preterm births before 35, 32, and 28 weeks' gestation.

Results: Of the 8784 women who completed the 2 antenatal Edinburgh Postpartum Depression Scale screens, 1141 (13.0%) had improved, 6663 (75.9%) had stable, and 980 (11.2%) had worsened depressive symptom trajectories across gestation. Compared with women with improved or stable depressive symptoms, those with worsened symptoms were more likely to experience preterm birth (8.3% vs 7.4% vs 9.9%, respectively; P=.018). After controlling for potential confounders, worsened depressive symptoms remained associated with more frequent preterm birth (adjusted odds ratio, 1.68; 95% confidence interval, 1.10-2.57).

Conclusion: Women with depression symptoms that worsen as pregnancy progresses have increased odds of preterm birth. Future research is warranted to optimize and implement effective prevention, screening, and treatment protocols for antenatal depressive symptoms as a strategy to prevent preterm birth.
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July 2021

Racial differences across pregnancy in maternal pro-inflammatory immune responsivity and its regulation by glucocorticoids.

Psychoneuroendocrinology 2021 Sep 18;131:105333. Epub 2021 Jun 18.

Development, Health and Disease Research Program, University of California, School of Medicine, Irvine, CA, United States; Department of Pediatrics, University of California, School of Medicine, Irvine, CA, United States; Department of Psychiatry and Human Behavior, University of California, School of Medicine, Irvine, CA, United States; Department of Obstetrics and Gynecology, University of California, School of Medicine, Irvine, CA, United States; Department of Epidemiology, University of California, School of Medicine, Irvine, CA, United States. Electronic address:

Background: The distribution of adverse pregnancy, birth and subsequent child developmental and health outcomes in the U.S. is characterized by pronounced racial (particularly Black-white) disparities. In this context, chronic stress exposure represents a variable of considerable importance, and the immune/inflammatory system represents a leading candidate biological pathway of interest. Previous pregnancy studies examining racial disparities in immune processes have largely utilized circulating cytokine levels, and have yielded null or mixed results. Circulating cytokines primarily represent basal secretion and do not necessarily represent functional features of immune responsivity and regulation. Thus, in order to conduct a more in-depth characterization of racial differences in functional immune properties during pregnancy, we utilized an ex vivo stimulation assay, a dynamic measure of immune function at the cellular level, to investigate Black-white racial differences in in mid- and late-gestation in i) pro-inflammatory (IL-6) responsivity of leukocytes to antigen [lipopolysaccharide (LPS)] challenge, and ii) regulation (dampening) of this pro-inflammatory response by glucocorticoids.

Method: 177 women (N = 42 Black (24%), n = 135 white (76%)) with a singleton, intrauterine pregnancy provided 20 mL venous blood in mid- (16.6 ± 2.4 wks) and late (33.3 ± 1.1 wks) pregnancy. Maternal pro-inflammatory responsivity of leukocytes was quantified by assessing the release of the pro-inflammatory cytokine IL-6 in response to LPS stimulation, and regulation of the pro-inflammatory response was quantified by assessing the suppression of the stimulated IL-6 response after co-incubation with progressively increasing levels of dexamethasone [10, 10, 10 M] (i.e., glucocorticoid receptor resistance (GRR)). A priori model covariates included maternal age, parity, SES (socioeconomic status), and pre-pregnancy BMI.

Results: Maternal pro-inflammatory responsivity (LPS-stimulated IL-6) and GRR increased significantly across mid- and late gestation (adjusted β = 0.157, p = 0.007; β = 0.627, p < 0.001, respectively). Across both time points in pregnancy Black women exhibited significantly higher LPS-stimulated IL-6 release and reduced glucocorticoid regulation of the IL-6 response (i.e., higher GRR) relative to white women, before and after adjusting for covariates (β = 0.381, p = 0.0030; β = 0.391, p = 0.0075, respectively). There was no racial difference in the concentrations of circulating IL-6 (p = 0.9199).

Conclusion: Our findings support the hypothesis postulating significant racial (Black-white) differences in key functional properties of the maternal immune system in pregnancy, which were not apparent using circulating cytokine measures. These data elucidate a potentially important physiological mechanism underlying the transduction of environmental conditions into racial disparities in reproductive and subsequent child health outcomes, and the use of these ex vivo measures should be considered in future studies.
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September 2021

Dietary Fat and Fatty Acid Intake in Nulliparous Women: Associations with Preterm Birth and Distinctions by Maternal BMI.

Curr Dev Nutr 2021 Jun 8;5(6):nzab074. Epub 2021 May 8.

Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Evidence documenting whether diet quality, particularly dietary fatty acids, is associated with preterm birth (PTB) is limited.

Objective: The aim was to measure associations between dietary fatty acid intake prior to pregnancy, specifically n-3 (ɷ-3) PUFAs and odds of PTB in US women and determine if associations differed by prepregnancy BMI.

Methods: We designed a secondary analysis of dietary intake in nulliparous women enrolled in a longitudinal cohort (NCT01322529). Participants completed an FFQ, modified to assess detailed PUFA intake, during the 3 mo preceding pregnancy. Inclusion in this analytic cohort required total energy intake within 2 SDs of the group mean. Prepregnancy BMI was categorized as underweight, normal, overweight, or obese. The primary exposure was estimated intake of EPA and DHA (combined EPA+DHA), in the context of a recommended intake of 250 mg. The primary outcome was PTB (<37 wk). Adjusted regression models controlled for maternal factors relevant to PTB and evaluated associations with PUFAs. Interaction terms estimated effect modification of BMI. A false discovery rate (FDR) correction accounted for multiple comparisons.

Results: Median daily intake of combined EPA+DHA in 7365 women was 70 mg (IQR: 32, 145 mg). A significant interaction term indicated the effects of EPA+DHA on odds of PTB were different for different BMI categories (< 0.01). Specifically, higher intake of combined EPA+DHA was nominally associated with reduced odds of PTB in women with underweight (OR: 0.67; 95% CI: 0.46-0.98) and normal BMI (OR: 0.87; 95% CI: 0.78-0.96), yet was associated with increased odds of overweight BMI (OR: 1.21; 95% CI: 1.02-1.44). Associations remained significant after FDR correction.

Conclusions: Based on a cohort of US women designed to identify predictors of adverse pregnancy outcomes, dietary intake of combined EPA+DHA was considerably lower than recommended. Associations between intake of these recommended n-3 fatty acids and risk of PTB differ by maternal BMI.
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http://dx.doi.org/10.1093/cdn/nzab074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178106PMC
June 2021

Interpregnancy Interval and Severe Maternal Morbidity in Iowa, 2009 to 2014.

Womens Health Issues 2021 Jun 1. Epub 2021 Jun 1.

Division of Epidemiology and Biostatistics, University of Illinois Chicago, School of Public Health, Chicago, Illinois.

Introduction: Maternal mortality and morbidity rates have risen significantly yet, little research has focused on how severe maternal morbidity (SMM) is associated with future reproductive health, such as birth spacing or the likelihood of subsequent SMM. This study focuses on the risk of SMM recurrence and the association of interpregnancy intervals with SMM.

Methods: This population-based, retrospective cohort study used Iowa hospital discharge data longitudinally linked to birth certificate data between 2009 and 2014. To examine recurrence of SMM, crude and adjusted multivariable logistic regression models were generated. The associations between varying interpregnancy intervals and subsequent SMM were examined. Crude, stratified, and adjusted risk ratios and their associated 95% confidence intervals were estimated.

Results: A total of 36,190 women were included in this study. Women with SMM in the index delivery had significantly higher odds of SMM in the subsequent delivery (adjusted odds ratio, 8.16; 95% confidence interval, 5.45-12.24) compared with women without SMM. Women with an interpregnancy interval of less than 6 months compared with 18 months or longer were more likely to experience SMM during their subsequent delivery, although the difference was not statistically significant (adjusted odds ratio, 1.41; 95% confidence interval-0.99, 2.03).

Conclusions: This study demonstrates that women who experience SMM are at markedly increased risk of subsequent SMM. Further investigation is necessary to inform optimal interpregnancy interval recommendations based on prior maternal health outcomes.
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http://dx.doi.org/10.1016/j.whi.2021.04.005DOI Listing
June 2021

Associations of the Neighborhood Built Environment with Gestational Weight Gain.

Am J Perinatol 2021 Jun 3. Epub 2021 Jun 3.

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Objective:  This study aimed to determine whether specific factors of the built environment related to physical activity and diet are associated with inadequate and excessive gestational weight gain (GWG).

Study Design:  This analysis is based on data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be, a prospective cohort of nulliparous women who were followed from the beginning of their pregnancies through delivery. At each study visit, home addresses were recorded and geocoded. Locations were linked to several built-environment characteristics such as the census tract National Walkability Score (the 2010 Walkability Index) and the number of gyms, parks, and grocery stores within a 3-km radius of residential address. The primary outcome of GWG (calculated as the difference between prepregnancy weight and weight at delivery) was categorized as inadequate, appropriate, or excessive based on weight gained per week of gestation. Multinomial regression (generalized logit) models evaluated the relationship between each factor in the built environment and excessive or inadequate GWG.

Results:  Of the 8,182 women in the analytic sample, 5,819 (71.1%) had excessive GWG, 1,426 (17.4%) had appropriate GWG, and 937 (11.5%) had inadequate GWG. For the majority of variables examined, built environments more conducive to physical activity and healthful food availability were associated with a lower odds of excessive or inadequate GWG category. For example, a higher number of gyms or parks within 3 km of a participant's residential address was associated with lower odds of having excessive (gyms: adjusted odds ratio [aOR] = 0.93 [0.89-0.96], parks: 0.94 [0.90-0.98]) or inadequate GWG (gyms: 0.91 [0.86-0.96]; parks: 0.91 [0.86-0.97]). Similarly, a higher number of grocery stores was associated with lower odds of having excessive GWG (0.94 [0.91-0.97]).

Conclusion:  Among a diverse population of nulliparous women, multiple aspects of the built environment are associated with excessive and inadequate GWG.

Key Points: · There are little data on the association between the built environment and pregnancy outcomes.. · Multiple aspects of the built environment are associated with excessive and inadequate GWG.. · These results suggest the role that neighborhood investment may play in improving pregnancy outcomes..
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June 2021

Healthy dietary patterns and common pregnancy complications: a prospective and longitudinal study.

Am J Clin Nutr 2021 Sep;114(3):1229-1237

Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.

Background: Adherence to alternate Healthy Eating Index (AHEI), alternate Mediterranean diet (AMED), and Dietary Approaches to Stop Hypertension (DASH) has been linked to lower risks of chronic diseases. However, their associations with common pregnancy complications are unclear.

Objectives: This study investigates the associations of AHEI, AMED, and DASH during periconception and pregnancy with common pregnancy complication risks.

Methods: The study included 1887 pregnant women from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies-Singletons. Women responded to an FFQ at 8-13 gestational weeks, and they performed a 24-h dietary recall at 16-22 and 24-29 wk. Gestational diabetes (GDM), gestational hypertension, preeclampsia, and preterm delivery were ascertained using medical records.

Results: Healthier diet indicated by higher AHEI, AMED, and DASH scores was generally related to lower risks of pregnancy complications. Significant inverse associations were observed between AHEI score reported at 16-22 wk and GDM risk [adjusted RR (95% CI), highest (Q4) vs. lowest quartile (Q1): 0.32 (0.16, 0.66), P-trend = 0.002]; DASH score reported at both 8-13 [adjusted RR (95% CI), Q4 vs. Q1: 0.45 (0.17, 1.17), P-trend = 0.04] and 16-22 wk [adjusted RR (95% CI), Q4 vs. Q1: 0.19 (0.05, 0.65), P-trend = 0.01] and gestational hypertension risk; AHEI score reported at 24-29 wk and preeclampsia risk [adjusted RR (95% CI), Q4 vs. Q1: 0.31 (0.11, 0.87), P-trend = 0.03]; AMED score reported at 8-13 wk [adjusted RR (95% CI), Q4 vs. Q1: 0.50 (0.25, 1.01), P-trend = 0.03] and DASH score reported at 24-29 wk [adjusted RR (95% CI), Q4 vs. Q1: 0.50, (0.26, 0.96), P-trend = 0.03] and preterm delivery risk.

Conclusions: Adherence to AHEI, AMED, or DASH during periconception and pregnancy was related to lower risks of GDM, gestational hypertension, preeclampsia, and preterm delivery.This study was registered at ClinicalTrials.gov as NCT00912132.
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http://dx.doi.org/10.1093/ajcn/nqab145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8408886PMC
September 2021

Racial and Ethnic Disparities in Adverse Perinatal Outcomes at Term.

Am J Perinatol 2021 May 31. Epub 2021 May 31.

Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.

Objective:  This study aimed to evaluate whether racial and ethnic disparities in adverse perinatal outcomes exist at term.

Study Design:  We performed a secondary analysis of a multicenter observational study of 115,502 pregnant patients and their neonates (2008-2011). Singleton, nonanomalous pregnancies delivered from 37 to 41 weeks were included. Race and ethnicity were abstracted from the medical record and categorized as non-Hispanic White (White; referent), non-Hispanic Black (Black), non-Hispanic Asian (Asian), or Hispanic. The primary outcome was an adverse perinatal composite defined as perinatal death, Apgar score < 4 at 5 minutes, ventilator support, hypoxic-ischemic encephalopathy, subgaleal hemorrhage, skeletal fracture, infant stay greater than maternal stay (by ≥ 3 days), brachial plexus palsy, or facial nerve palsy.

Results:  Of the 72,117 patients included, 48% were White, 20% Black, 5% Asian, and 26% Hispanic. The unadjusted risk of the primary outcome was highest for neonates of Black patients (3.1%, unadjusted relative risk [uRR] = 1.16, 95% confidence interval [CI]: 1.04-1.30), lowest for neonates of Hispanic patients (2.1%, uRR = 0.80, 95% CI: 0.71-0.89), and no different for neonates of Asian (2.6%), compared with those of White patients (2.7%). In the adjusted model including age, body mass index (BMI), smoking, obstetric history, and high-risk pregnancy, differences in risk for the primary outcome were no longer observed for neonates of Black (adjusted relative risk [aRR] = 1.06, 95% CI: 0.94-1.19) and Hispanic (aRR = 0.92, 95% CI: 0.81-1.04) patients. Adding insurance to the model lowered the risk for both groups (aRR = 0.85, 95% CI: 0.75-0.96 for Black; aRR = 0.68, 95% CI: 0.59-0.78 for Hispanic).

Conclusion:  Although neonates of Black patients have the highest frequency of adverse perinatal outcomes at term, after adjustment for sociodemographic factors, this higher risk is no longer observed, suggesting the importance of developing strategies that address social determinants of health to lessen extant health disparities.

Key Points: · Term neonates of Black patients have the highest crude frequency of adverse perinatal outcomes.. · After adjustment for confounders, higher risk for neonates of Black patients is no longer observed.. · Disparities in outcomes are strongly related to insurance status..
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May 2021

Patient characteristics associated with complications of external cephalic version.

Am J Obstet Gynecol MFM 2021 09 29;3(5):100411. Epub 2021 May 29.

Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL (Drs Dahl, Son, Miller, Roy, and Grobman).

Background: Patient characteristics associated with external cephalic version success are well documented; however, the association between patient characteristics and the likelihood of external cephalic version complications is poorly understood.

Objective: This study aimed to assess the frequency of patient characteristics associated with complications that lead to unanticipated delivery during external cephalic version.

Study Design: This retrospective study included pregnant women aged at least 18 years with singleton gestations who underwent an external cephalic version attempt between 2006 and 2016 at a single quaternary care center. External cephalic version complications were defined as persistent nonreassuring fetal status, placental abruption, labor, spontaneous rupture of membranes, and umbilical cord prolapse. Complications were only considered if they led to unanticipated induction or cesarean delivery within 24 hours of external cephalic version. Patient characteristics including maternal age, height, weight, body mass index, parity, fetal sex, gestational age, estimated fetal weight, the type of fetal malpresentation, and placental location were analyzed for their association with external cephalic version complications using univariable analysis and multivariable logistic regressions.

Results: Among the 1138 patients included in this analysis, external cephalic version complications occurred in 6.7% (n=76). These complications (not mutually exclusive) included nonreassuring fetal status (4.8%, n=55), placental abruption (1.6%, n=18), labor (1.0%, n=11), spontaneous rupture of membranes (0.6%, n=7), and cord prolapse (0.1%, n=1). Neonatal outcomes for those with complications included intensive care unit admission (10.5%, n=8), 5-minute Apgar scores <5 (1.3%, n=1), cord arterial pH <7 (6.6%, n=5), head cooling (1.3%, n=1), and anemia (6.6%, n=5). There were no perinatal deaths. In multivariable analysis, higher body mass index (adjusted odds ratio, 0.90 per kg/m; 95% confidence interval, 0.84-0.97) and estimated fetal weight (adjusted odds ratio, 0.998 per gram; 95% confidence interval 0.998-0.999) were associated with decreased likelihood of experiencing external cephalic version complications, whereas greater gestational age at procedure (adjusted odds ratio, 1.95 per week; 95% confidence interval, 1.4-2.7) and anterior placental location (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.7) were associated with increased likelihood of experiencing external cephalic version complications.

Conclusion: In this large series, complications that led to delivery during external cephalic version occurred in 6.7% patients and were associated with body mass index, estimated fetal weight, gestational age, and placental location.
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September 2021

Is peripartum magnesium sulfate associated with a reduction in postpartum depressive symptoms?

Am J Obstet Gynecol MFM 2021 09 28;3(5):100407. Epub 2021 May 28.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Dr Miller, Ms Sakowicz, and Drs Roy, Grobman, and Yee).

Background: The prevention of postpartum depression is an important area of investigation given its association with major maternal and neonatal sequelae, yet few evidence-based treatments to reduce the frequency of postpartum depression are used. Recent data suggest that N-methyl-D-aspartate receptor antagonists may lead to rapid improvement of depressive symptoms lasting up to 2 weeks. We hypothesized that the N-methyl-D-aspartate receptor antagonist magnesium sulfate would elicit antidepressant effects subsequent to its receipt by women receiving peripartum seizure prophylaxis for a hypertensive disorder of pregnancy.

Objective: This study aimed to compare the frequency of depressive symptoms at 2 weeks and 6 weeks after delivery between women who did and did not receive peripartum magnesium sulfate for a hypertensive disorder of pregnancy.

Study Design: This prospective cohort study included women with a hypertensive disorder of pregnancy at ≥34 weeks' gestation with singleton gestations. Magnesium sulfate for seizure prophylaxis was administered at the obstetrician's discretion. The Quick Inventory of Depressive Symptomatology survey was administered before hospital discharge and again at 2 weeks and 6 weeks after delivery to assess for postpartum depressive symptoms. The primary outcome for this study was the change in Quick Inventory of Depressive Symptomatology score from baseline to 2 weeks after delivery, which was analyzed both continuously and categorically (any symptom worsening vs stability or improvement). Secondary outcomes included the change in Quick Inventory of Depressive Symptomatology score from baseline to 6 weeks after delivery and the proportion of women who experienced an increase in Quick Inventory of Depressive Symptomatology score at 6 weeks after delivery.

Results: Of the 342 women enrolled, 39% (n=134) received magnesium sulfate. Compared with women who did not receive magnesium, women who received magnesium had a significantly smaller change in their mean Quick Inventory of Depressive Symptomatology score (0.6±3.4 vs 1.6±3.0; P=.015) and also were less likely to have an increase in Quick Inventory of Depressive Symptomatology score at 2 weeks after delivery (52% vs 67%; P=.022). These differences were not present at 6 weeks after delivery. After controlling for potential confounders, women who received magnesium continued to have a lower odds of having an increased Quick Inventory of Depressive Symptomatology score from baseline at 2 weeks after delivery than women who did not receive magnesium (adjusted odds ratio, 0.88; 95% confidence interval, 0.78-0.98).

Conclusion: Peripartum magnesium was associated with less of an exacerbation in depressive symptoms in the immediate postpartum period. Given the implications of postpartum depression on maternal and child health and the lack of existing prophylaxis, randomized trials should examine this novel potential prophylactic therapy.
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September 2021
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