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The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future. [ABSTRACT FROM AUTHOR]

Responding to Zika virus infections in Houston, Texas, USA, presented numerous challenges across the health system. As the nation's fourth-largest city, in a subtropical region with high travel volume to Latin America and the Caribbean, Houston was an ideal location for studying experiences encountered by clinicians and public health officials as they responded to the Zika virus crisis. To identify the challenges encountered in the response and to explore strategies to improve future responses to emerging infectious diseases, we interviewed 38 key stakeholders who were clinical, scientific, operational, and public health leaders. From the responses, we identified 4 key challenges: testing, travel screening, patient demographics and immigration status, and insufficient collaboration (between public health officials and clinicians and among clinical providers). We also identified 5 strategic areas as potential solutions: improved electronic health record support, specialty centers and referral systems, standardized forms, centralized testing databases, and joint academic/public health task forces. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Despite pregnant women's increased morbidity and mortality from influenza, vaccination rates remain low. This study intended to evaluate barriers to pregnant women's uptake of influenza vaccine. Study design: A survey was designed that assessed participant demographics, knowledge, beliefs, attitudes, and general experiences with seasonal and 2009 novel H1N1 influenza. Associations between patient characteristics and vaccine uptake were then assessed. Results: 88 women completed the survey. Women who correctly answered >75% of knowledge questions regarding influenza were significantly more likely to accept the influenza vaccine (seasonal: p =0.04, H1N1: p <0.01). Conversely, patients who declined the vaccine were more likely to hold false beliefs, such as perceiving that the vaccine was not protective (seasonal: p <0.01, H1N1: p <.01) and that they were not at risk for influenza (seasonal: p < 0.01). Conclusion: The reasons for influenza vaccine declination in pregnant patients include lower levels of knowledge and unfavorable attitudes regarding the safety and efficacy of the vaccine, and suggest the importance of education as a tool to improve vaccination uptake [Copyright &y& Elsevier]

Objective: To determine whether shock index (SI) is superior to traditional vital signs in predicting postpartum hemorrhage and need for intervention.Methods: Retrospective case-control study in an academic tertiary-care county hospital. Forty-one consecutive postpartum hemorrhage (PPH) cases and 41 controls were frequency-matched by mode of delivery and maternal weight. We measured four criteria: heart rate, systolic blood pressure (SBP), SI (HR/SBP), and delta-SI (peak SI - baseline SI). Using received operating characteristic curves, we compared the discrimination performance of each criterion to predict PPH, transfusion, and surgical intervention, and identified thresholds with the strongest classification.Results: SI ≤1.1 can be normal in peripartum. Peak SI and delta-SI were generally superior to heart rate (HR) and SBP in predicting PPH, transfusion, and surgical intervention. SI ≥1.143 and SI ≥1.412 were strong initial and "critical" thresholds. Delta-SI was the strongest classifier overall; both SI and delta-SI remain sensitive and specific when adjusted for potential confounders.Conclusions: SI and delta-SI appear to be superior to HR and SBP in predicting PPH and need for intervention. Utility of delta-SI should be prospectively explored. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has prompted expanded use of prone positioning for refractory hypoxemia. Clinical trials have demonstrated beneficial effects of early prone positioning for acute respiratory distress syndrome (ARDS), including decreased mortality. However, pregnant women were excluded from these trials. To address the need for low-cost, low-harm interventions in the face of a widespread viral syndrome wherein hypoxemia predominates, we developed an algorithm for prone positioning of both intubated and nonintubated pregnant women. This algorithm may be appropriate for a wide spectrum of hypoxemia severity among pregnant women. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus is responsible for the clinical manifestations of COVID-19. This syndrome can manifest as severe pneumonia complicated by hypoxemia and ARDS. Given the current global COVID-19 pandemic, with a large number of ARDS cases, there is renewed interest in the use of prone positioning to improve oxygenation in moderate or severe hypoxemia. Among the populations who can benefit from prone positioning are pregnant women experiencing severe respiratory distress, as long as the physiologic changes and risks of pregnancy are taken into account. [ABSTRACT FROM AUTHOR]

Objective: To assess whether recent anti-immigration rhetoric is significantly associated with inadequate prenatal care.Methods: This was a population-based cohort study (2011-2017). In their native language, patients were consented and queried regarding country of origin and time in the United States. Additional variables were collected or abstracted from the medical record, including documentation and timing of prenatal visits. Based on relevance and prevalence during the study period, publicly available Google search trends were mined for the terms "Make America Great Again," "Mexico Wall," and "Deportation" by geographic region. The time of first deviation from the mode Google search popularity value for each term was ascertained (mode inflection date). Perinatal data was averaged over 15 days moving windows, and the Adequacy of Prenatal Care Utilization Index was used to categorically define inadequate prenatal care by validated standards.Results: Twenty-four thousand nine hundred thirty-three deliveries occurred during the study period. A mode inflection date was extrapolated from Google trend analytics and used to define the period before change in trends use pre (before rhetoric) and post (after rhetoric). Coincident to the rhetoric change, there was a significant increase in days until the first prenatal visit, fewer prenatal visits, and a decreased trend of mean hemoglobin nadir among U.S. non-native Hispanic women (P<.001). Immigrant status was an independent predictor of inadequate prenatal care as defined by the Adequacy of Prenatal Care Utilization Index standard, with increased adjusted odds among Hispanic women (adjusted odds ratio 1.581, 95% CI 1.407-1.777 [1.4-1.8]) coincident with anti-immigration rhetoric.Conclusion: Our findings are of likely significant public health importance and suggest that recent anti-immigrant rhetoric is associated with adequate, timely, and regular access to prenatal care among nearly 25,000 deliveries in Houston, Texas. [ABSTRACT FROM AUTHOR]

Substance use disorders affect a significant number of pregnant persons in the USA and are associated with substantial maternal and neonatal morbidity and mortality. Treatment is complex and requires a comprehensive, interdisciplinary approach. Despite this, conventional perinatal medical systems are often without mental health and addiction medicine services and physically separated from established community treatment programs and resources. We outline an example of a multidisciplinary comprehensive care model integrating obstetrics, addiction psychiatry and psychology, neonatology, anesthesiology, social work and case management, established community services and resources, and the local legal system. Challenges with each component of the model are briefly described. Although outcome data is not available, the interdisciplinary clinic described represents a best practice approach based on existing interdisciplinary clinics aimed at improving substance use treatment engagement, maternal outcomes, and neonatal outcomes. Integration of addiction psychiatry/psychology, social work, and community services into prenatal care is crucial in achieving optimal outcomes for pregnant persons who use substances. We hope the recommendations based on identified challenges with establishing this model of care will help with program development across a variety of settings. Significance: What Is Already Known on This Subject? Although there are detailed accounts of interdisciplinary clinics focused on pregnant persons with substance use disorders, these authors are not aware of any published program overview that discusses integration of as many varied services for patient care and lessons learned within each specialty. What This Study Adds? There is a need for continued attention to best practice in care for pregnant persons with substance use disorders. The present article provides an outline for providers and medical facilities for development of interdisciplinary clinics to meet the needs of this vulnerable patient population. [ABSTRACT FROM AUTHOR]

The article discusses the implementation gap of Zika virus disease research evidence into clinical practice. It notes the barriers that impede the translation of recommendations into clinical practice, including lack of awareness of recommendations and agreement, patient preferences, lack of resources, and costs. It also discusses ways to address the barriers related to lack of awareness of Zika guidelines, including the role of associations such as the American Academy of Pediatrics.

Objective: In 2010, the American College of Obstetricians & Gynecologists (ACOG) published a new clinical practice guideline on trial of labor after cesarean (TOLAC) that was considered less restrictive. It allowed for offering TOLAC to women with two prior cesarean deliveries, even without a prior vaginal delivery, and for labor induction. As a result, our hospital, a public tertiary care academic center, updated our TOLAC practice guideline to reflect ACOG's new recommendations. We thus aim to evaluate maternal and neonatal outcomes for women undergoing TOLAC with 1 versus 2 prior cesareans, with and without a prior vaginal delivery, following these clinical practice changes at our hospital.Study design: This was a secondary analysis of a 2-year retrospective cohort following implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 0/7 weeks and 1 or 2 prior cesarean deliveries. Maternal and neonatal outcomes in women with one prior cesarean were compared to women with two prior cesareans. The primary outcome was composite maternal morbidity (uterine rupture, uterine dehiscence, hysterectomy, transfusion, postpartum venous thromboembolism, delivery/surgical injury, chorioamnionitis or endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity. The analysis was performed in SAS; p < .05 was considered significant.Results: Seven hundred women with one prior cesarean and 73 women with two prior cesareans underwent TOLAC after the 2011 guideline implementation. Post guideline maternal demographics, labor length, comorbid conditions, simplified Bishop score, and induced labor were similar between groups. Composite maternal morbidity was similar between groups (18.3 versus 23.3%, p = .30 for women with 1 versus 2 prior cesarean deliveries, respectively). The same was true when comparing women with 1 versus 2 prior cesareans who had never had a prior vaginal delivery (25.5 versus 33.3%, p = .28 for 1 versus 2 prior cesarean deliveries, respectively). There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were similar between groups (78.9% in women with 1 prior cesarean versus 74.0% in women with 2 prior cesareans, p=.33), even when only analyzing women without a prior vaginal delivery (69.4% in women with 1 prior cesarean versus 71.4% in women with 2 prior cesareans, p = .78).Conclusion: Adoption of ACOG's TOLAC practice changes, specifically offering TOLAC to women with two prior cesareans even without a prior vaginal delivery, and offering induction of labor regardless of cervical favorability, may increase VBAC rates without increasing maternal or neonatal morbidity from TOLAC. [ABSTRACT FROM AUTHOR]

Background: Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy‐induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery‐related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas. Methods: Delivery‐related hospitalizations among Texan women aged 15‐49 years were identified using the 2011‐2014 Texas all‐payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM. Results: SMM prevalence remained consistent between 2011 and 2014 (196.0‐197.0 per 10 000 deliveries, P >.05; n = 1 434 441). Nearly 40% of delivery‐related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42‐1.43). Conclusions: Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to compare patient outcomes between planned and emergent cesarean deliveries for placenta previa without morbidly adherent placenta.Study Design: All patients with confirmed, persistent placenta previa (without morbidly adherent placentation) who underwent the surgery between January 2010 and April 2016 were included in this retrospective study. Primary outcome was composite maternal morbidity defined as the presence of at least one of the followings: death, red blood cell (RBC) transfusion, hysterectomy, reoperation, hospital stay >7 d, ureteral injury, bowel injury, or cystotomy.Results: Three hundred and four patients with placenta previa were identified during the study period, of whom 154 (50.65%) had an antenatal and 10 (3.28%) had an intraoperative diagnosis of morbidly adherent placenta. One hundred and forty patients met the inclusion criteria. Eighty (57.1%) underwent planned cesarean delivery (planned cesarean delivery (PCD) group), and 60 (42.8%) required emergent cesarean delivery due to uterine contractions and/or bleeding (emergent cesarean delivery (ECD) group). Baseline characteristics were similar between the two groups except for the gestational age at delivery (36.0 weeks (36.0, 37.0) in PCD versus 34.0 weeks (32.0, 36.0) in ECP, p < .001). Composite maternal morbidity was not significantly different between two groups: 11 (18.3%) in ECD and 10 (12.5%) in PCD (p = .35) Conclusions: In our referral tertiary centre, emergent and planned cesarean deliveries for placenta previa without morbidly adherent placenta have similar maternal outcomes. In patients without significant hemorrhage, delivery may be safely deferred until 36-37 weeks. [ABSTRACT FROM AUTHOR]

Background: Cesarean delivery accounts for over one‐third of the ~400 000 annual births in Texas, with first‐time cesarean accounting for 20% of the overall cesareans. We examined associations of maternal medical comorbidities with cesarean delivery among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas. Methods: Nulliparous, term, singleton, vertex deliveries to women aged 15‐49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range 0‐4), including preexisting/gestational diabetes mellitus, preexisting/gestational hypertension/eclampsia, infertility treatment, smoking during pregnancy, and prepregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression analyses were conducted to examine associations between the categorized risk factor index and cesarean delivery, overall and by maternal race and ethnicity. Results: Among the 114 535 NTSV deliveries in Texas in 2015, 27.2% were by cesarean. The most prevalent maternal risk among all deliveries was prepregnancy overweight/obesity (42.4%). The odds of cesarean delivery increased significantly with increasing number of risk factors [one risk factor: 1.72 (95% CI 1.67‐1.78); two risk factors: 2.58 (95% CI 2.46‐2.71); and three or more risk factors: 3.91 (95% CI 3.45‐4.44)]. Discussion: In Texas in 2015, nearly half of NTSV deliveries had at least one maternal risk factor and the odds of cesarean delivery were significantly elevated for women with a higher risk index score. The findings from this study highlight the need for intervening during the preconception and interconception period as intrapartum care practices have an important influence on birth outcomes. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association of implementation of evidence-based bundles with surgical site infection rates after cesarean delivery.Data Sources: We searched MEDLINE through PubMed, EMBASE, Scopus, the Cochrane Database of Systematic Reviews, Google Scholar, and ClinicalTrials.gov.Methods Of Study Selection: We searched electronic databases for randomized controlled trials and observational studies comparing evidence-based infection prevention bundles for cesarean delivery, defined as implementation of three or more processes proven to prevent surgical site infection such as chlorhexidine skin preparation, antibiotic prophylaxis, and hair clipping, with usual care. The primary outcome was overall surgical site infection, defined using Centers for Disease Control and Prevention's National Healthcare Safety Network criteria. Secondary outcomes were superficial or deep surgical site infection and endometritis. Quality of studies and heterogeneity were assessed using validated measures. Pooled relative risks (RRs) with 95% CIs were calculated using random-effects models. Numbers needed to treat were estimated for outcomes with significant reduction.Tabulations, Integration, and Results: We found no randomized controlled trials. Fourteen preintervention and postintervention studies met inclusion criteria. Eight were full-text articles, and six were published abstracts. Quality of most of the primary studies was adequate with regard to the intervention, but modest in terms of implementation. The rate of surgical site infection was significantly lower after implementing an evidence-based bundle (14 studies: pooled rates 6.2% baseline compared with 2.0% intervention, pooled RR 0.33, 95% CI 0.25-0.43, number needed to treat=24). Evidence-based bundles were also associated with a lower rate of superficial or deep surgical site infection (six studies: pooled rate 5.9% baseline compared with 1.1% intervention, pooled RR 0.19, 95% CI 0.12-0.32, number needed to treat=21). The rate of endometritis was low at baseline and not significantly different after intervention (six studies: pooled rate 1.3% baseline compared with 0.9% intervention, pooled RR 0.57, 95% CI 0.31-1.06).Conclusion: Evidence-based bundles are associated with a significant reduction in surgical site infection after cesarean delivery. [ABSTRACT FROM AUTHOR]

Background: Red blood cell (RBC) antigen matching policies to prevent alloimmunization in females of childbearing potential (FCP) vary between centers. To inform transfusion centers responsible for making decisions about matching policies for FCPs, the causal stimulus of the antibodies implicated in severe hemolytic disease of the fetus and newborn (HDFN) must be determined.Study Design and Methods: We conducted a multinational retrospective study of women with offspring affected by severe HDFN requiring neonatal exchange transfusion and/or intrauterine transfusion. Mothers treated at centers that provide extended antigen-negative RBCs (MATCH, five centers) and those that do not (NoMATCH, nine centers) were compared.Results: A total of 293 mothers had at least one affected pregnancy: 179 at MATCH centers and 114 at NoMATCH centers. Most alloimmunization (83%) was attributed to previous pregnancy: 3% to transfusion (two cases at MATCH, six at NoMATCH centers) and 14% undetermined (both antecedent transfusion and pregnancy). Only 50 mothers had received transfusions; 13 had HDFN due to anti-K at MATCH and four at NoMATCH centers. Most (12/13, 92%) of the anti-K HDFN cases at MATCH centers had K+ paternal antigen status. Mothers at the MATCH centers do not appear to be protected from HDFN due to K, C, c, and E antibodies, although the low number of FCPs who received transfusions precluded drawing firm conclusions.Conclusion: The causal stimulus of antibodies that cause HDFN is predominantly from previous pregnancy. Although extended RBC matching for FCPs may impart some protection from allosensitization, we were unable to show a positive effect, possibly because matching policies are not uniform and there was a small number of mothers who previously received transfusions. [ABSTRACT FROM AUTHOR]

Objectives: To assess short-term neonatal respiratory morbidity from inductions of labor (IOL) in well-dated (WD) pregnancies (dating ultrasound [US] <20 0/7 weeks) versus non-well-dated (NWD) pregnancies when applying National Institutes of Health/Society for Maternal-Fetal Medicine/American College of Obstetricians and Gynecologists delivery recommendations at ≥34 0/7 weeks.Methods: Ours was a 1-year retrospective cohort of women with medically indicated IOL between 34 0/7 and 40 6/7 weeks with a live, cephalic, singleton gestation and no lethal anomaly. The primary outcome was a composite of neonatal respiratory morbidity (respiratory distress syndrome, transient tachypnea of the newborn, ventilator support, oxygen administration, and pneumonia).Results: A total of 476 WD and 231 NWD women underwent IOL during the study period. The groups had similar maternal characteristics, indications for IOL, and mode of delivery. There was no difference in the rate of primary outcome (8.7% in NWD group vs 8.8% in WD group; P = 0.95). This finding persisted after control for parity, gestational age (GA) at first US, operator of the dating US, and exposure to antenatal corticosteroids and magnesium sulfate. When stratified by GA at delivery and GA at first US, these findings persisted even when the dating US was performed at >35 weeks. There were no differences in maternal or other neonatal outcomes between the WD and NWD pregnancies.Conclusions: In our cohort of medically indicated IOL, a dating US before 20 weeks was not associated with a difference in neonatal respiratory morbidity. [ABSTRACT FROM AUTHOR]

Contemporaneous Zika virus (ZIKV) strains can cause congenital Zika syndrome (CZS). Current ZIKV clinical laboratory testing strategies are limited and include IgM serology (which may wane 12 weeks after initial exposure) and nucleic acid testing (NAT) of maternal serum, urine, and placenta for (+) strand ZIKV RNA (which is often transient). The objectives of this study were to determine if use of additional molecular tools, such as quantitative PCR and microscopy, would add to the diagnostic value of current standard placental ZIKV testing in cases with maternal endemic exposure and indeterminate testing. ZIKV RNA was quantified from dissected sections of placental villi, chorioamnion sections, and full cross-sections of umbilical cord in all cases examined. Quantitation with high-resolution automated electrophoresis determined relative amounts of precisely verified ZIKV (74-nt amplicons). In order to localize and visualize stable and actively replicating placental ZIKV in situ, labeling of flaviviridae glycoprotein, RNA ISH against both (+) and (−) ZIKV-specific ssRNA strands, and independent histologic examination for significant pathologic changes were employed. We demonstrate that the use of these molecular tools added to the diagnostic value of placental ZIKV testing among suspected cases of congenital Zika syndrome with poorly ascribed maternal endemic exposure. [ABSTRACT FROM AUTHOR]

Zika virus (ZIKV) is an emerging mosquito-borne (Aedes genus) arbovirus of the Flaviviridae family. Although ZIKV has been predominately associated with a mild or asymptomatic dengue-like disease, its appearance in the Americas has been accompanied by a multi-fold increase in reported incidence of fetal microcephaly and brain malformations. The source and mode of vertical transmission from mother to fetus is presumptively transplacental, although a causal link explaining the interval delay between maternal symptoms and observed fetal malformations following infection has been missing. In this study, we show that primary human placental trophoblasts from non-exposed donors (n = 20) can be infected by primary passage ZIKV-FLR isolate, and uniquely allowed for ZIKV viral RNA replication when compared to dengue virus (DENV). Consistent with their being permissive for ZIKV infection, primary trophoblasts expressed multiple putative ZIKV cell entry receptors, and cellular function and differentiation were preserved. These findings suggest that ZIKV-FLR strain can replicate in human placental trophoblasts without host cell destruction, thereby serving as a likely permissive reservoir and portal of fetal transmission with risk of latent microcephaly and malformations. [ABSTRACT FROM AUTHOR]

Zika virus (ZIKV) is an emerging mosquito-borne (Aedes genus) arbovirus of the Flaviviridae family. Although ZIKV has been predominately associated with a mild or asymptomatic dengue-like disease, its appearance in the Americas has been accompanied by a multi-fold increase in reported incidence of fetal microcephaly and brain malformations. The source and mode of vertical transmission from mother to fetus is presumptively transplacental, although a causal link explaining the interval delay between maternal symptoms and observed fetal malformations following infection has been missing. In this study, we show that primary human placental trophoblasts from non-exposed donors (n = 20) can be infected by primary passage ZIKV-FLR isolate, and uniquely allowed for ZIKV viral RNA replication when compared to dengue virus (DENV). Consistent with their being permissive for ZIKV infection, primary trophoblasts expressed multiple putative ZIKV cell entry receptors, and cellular function and differentiation were preserved. These findings suggest that ZIKV-FLR strain can replicate in human placental trophoblasts without host cell destruction, thereby serving as a likely permissive reservoir and portal of fetal transmission with risk of latent microcephaly and malformations. [ABSTRACT FROM AUTHOR]