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Objective: Hypertensive disorders of pregnancy (HDP) are common complications associated with severe maternal and neonatal morbidity. One goal of prenatal care, especially at term, is to screen for HDP. As treatment of HDP centers on delivery when appropriate, timely diagnosis is crucial. We postulated that reduced in-person visits during the coronavirus disease 2019 (COVID-19) pandemic may have resulted in delayed diagnosis of HDP with concomitant higher rates of maternal morbidity. We sought to investigate the prevalence of HDP during the COVID-19 pandemic, as well as median gestational age at time of delivery as compared with the prepandemic median., Study Design: This was a retrospective cohort analysis comparing singleton deliveries at four large-volume hospitals during the COVID-19 pandemic (April-July 2020 during a statewide "stay-at-home" order) to those in a pre-COVID era (April-July 2019). Deliveries complicated by HDP were identified by International Classification of Disease, Tenth Revision codes. Rates of HDP and markers of severe disease were the primary outcomes compared between the groups; multivariate regression was used to calculate the odds ratio of severe disease among women with any diagnosis of HDP., Results: The cohort included 9,974 deliveries: 5,011 in 2020 and 4,963 in 2019. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ significantly between the groups. There was an increase in HDP during the COVID era (9.0 vs. 6.9%; p  < 0.01), which was significant even when controlling for patient parity (odds ratio = 1.41, 95% confidence interval: 1.20-1.66). Among women with HDP, gestational age at delivery did not differ between the cohorts, nor did the proportion of patients with severe disease., Conclusion: We found a statistically significant increase in the rate of HDP during the COVID-19 pandemic. However, there was no change in the proportion of severe disease, suggesting that this increase did not significantly impact clinical morbidity., Key Points: · Rates of HDP increased during the COVID-19 pandemic.. · There was no change in the proportion of severe HDP.. · HDP-related maternal/neonatal morbidity was unchanged.., Competing Interests: None declared., (Thieme. All rights reserved.)

The standard care model in the postpartum period is ripe for disruption and attention. Hypertensive disorders of pregnancy (HDPs) can continue to be a challenge for the postpartum person in the immediate postpartum period and is a harbinger of future health risks. The current care approach is inadequate to address the needs of these women. We propose a model for a multidisciplinary clinic and collaboration between internal medicine specialists and obstetric specialists to shepherd patients through this high-risk time and provide a bridge for lifelong care to mitigate the risks of a HDP. KEY POINTS: · HDPs are increasing in prevalence.. · The postpartum period can be more complex for women with HDPs.. · A multidisciplinary clinic could fill the postpartum care gap for women with HDP.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: We have previously described a model using maternal, antenatal, and ultrasonographic characteristics to assess the risk of delivery within 7 days following diagnosis of abnormal umbilical artery Doppler (UAD) in pregnancies affected by fetal growth restriction (FGR). Therefore, we sought to validate this model in an independent cohort., Study Design: Retrospective, single referral center study of liveborn singleton pregnancies from 2016 to 2019 complicated by FGR and abnormal UAD (systolic/diastolic ratio ≥95th percentile for gestational age [GA]). Prediction probabilities were calculated by applying the original model (Model 1) to the current cohort (Brigham and Women's Hospital [BWH] cohort). The variables of this model include GA at first abnormal UAD, severity of first abnormal UAD, oligohydramnios, preeclampsia, and prepregnancy body mass index. Model fit was assessed with area under the curve (AUC). Two alternative models (Models 2 and 3) were created to identify a model with better predictive characteristics than Model 1. The receiver operating characteristics curves were compared using the DeLong test., Results: A total of 306 patients were assessed for eligibility, 223 of whom were included in the BWH cohort. Median GA at eligibility was 31.3 weeks, and median interval from eligibility to delivery was 17 days (interquartile range: 3.5-33.5). Eighty-two (37%) patients delivered within 7 days of eligibility. Applying Model 1 to the BWH cohort resulted in an AUC of 0.865. Using the previously determined probability cutoff of 0.493, the model was 62% sensitive and 90% specific in predicting the primary outcome in this independent cohort. Models 2 and 3 did not perform better than Model 1 ( p  = 0.459)., Conclusion: A previously described prediction model to predict risk of delivery in patients with FGR and abnormal UAD performed well in an independent cohort. With high specificity, this model could assist in identifying low-risk patients and improve antenatal corticosteroid timing., Key Points: · Risk of delivery in 7 days can be predicted.. · Risk of delivery can inform corticosteroid timing.. · An externally validated clinical aid can be developed.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery., Study Design: We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t -tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test., Results: Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women ( p <0.001)., Conclusion: Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings., Key Points: · Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: The aim of the study is to analyze maternal morbidity in the second stage of labor in a manner that approximates clinical choice., Study Design: The study design comprises secondary analysis of the Consortium for Safe Labor, which included 228,688 deliveries at 19 hospitals between 2002 and 2008. We included the 107,675 women who were undergoing a trial of labor without a prior uterine scar or history of substance abuse, who reached the second stage, with a liveborn, nonanomalous, vertex, singleton, at term of at least 2,500 g. Maternal complications included postpartum fever, hemorrhage, blood transfusion, thrombosis, intensive care unit (ICU) admission, hysterectomy, and death. For maternal complications, we simulated the clinical choice by comparing operative vaginal or cesarean deliveries to continued expectant management at every hour in the second stage. For neonatal complications, we modeled the risk of severe neonatal complication by second stage duration for spontaneous vaginal deliveries only, adjusting for maternal demographics, comorbidities, and delivery hospital. Severe neonatal complications included death, asphyxia, hypoxic-ischemic encephalopathy (HIE), seizure, sepsis with prolonged stay, need for mechanical ventilation, and 5-minute Apgar score <4., Results: Maternal morbidity was higher with operative vaginal/cesarean delivery versus continued expectant management for every hour in the second stage, a difference that was statistically significant at hour 2 (18.4 vs. 14.7%; p <0.01). Overall, 951 (0.88%) deliveries were complicated by a severe neonatal complication. A second stage over 4 hours was associated with an adjusted odds of severe neonatal complication of 2.10 (95% confidence interval [CI]: 1.32-3.34) as compared with women who delivered in the first hour., Conclusion: There is a trade-off between maternal and neonatal morbidity in the second stage of labor. Serious neonatal complications rise throughout, however, there is no time at which maternal morbidity is improved with a cesarean or operative vaginal delivery. Strategies are needed to identify neonates at highest risk of complication for targeted intervention., Key Points: · Severe neonatal complications increase with every hour in the second stage.. · Shortening the second stage is associated with higher maternal complications at every hour.. · There is a trade-off between maternal and neonatal morbidity in the second stage.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Breast cancer is one of the most frequently diagnosed cancers in pregnancy and is commonly treated with chemotherapy. To date, studies examining effects of chemotherapy during pregnancy on fetal growth have yielded conflicting results, and most are limited by small sample sizes or are nonspecific with respect to cytotoxic regimen or type of cancer treated. We sought to evaluate the effect of chemotherapy for breast cancer in pregnancy on birthweight and small for gestational age infants., Study Design: This is a retrospective cohort study of 74 women diagnosed with pathologically confirmed breast cancer during pregnancy between 1997 and 2018 at one of three academic medical centers, who had a singleton birth with known birthweight. Forty-nine received chemotherapy and 25 did not receive chemotherapy. Linear regression modeling was used to compare birthweight (by gestational age and sex-specific z -score) by chemotherapy exposure. Subanalyses of specific chemotherapy regimen and duration of chemotherapy exposure were also performed. Placental, neonatal, and maternal outcomes were also analyzed by chemotherapy exposure., Results: In the adjusted model, chemotherapy exposure was associated with lower birthweight (Δ z -score = -0.49, p  = 0.03), but similar rates of small for gestational age (defined as birthweight <10th percentile for gestational age) infants (8.2 vs. 8.0%, p  = 1.0; Fisher's exact test). Each additional week of chemotherapy (Δ z -score = -0.05, p  = 0.03) was associated with decreased birthweight, although no association was found with specific chemotherapy regimen. Chemotherapy exposure was associated with lower median placental weight percentile by gestational age (9th vs. 75th, p  < 0.05). Secondary maternal outcomes were similar between the group that did and did not receive chemotherapy., Conclusion: Chemotherapy for breast cancer in pregnancy in this cohort is associated with lower birthweight but no difference in the rate of small for gestational age infants., Key Points: · Chemotherapy for breast cancer in pregnancy is associated with decreased birthweight but similar rates of small for gestational age infants.. · Birthweight did not differ according to chemotherapy regimen.. · There is no difference in the rate of small for gestational age infants.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: This study was aimed to assess whether the "39-week" rule is being extended to high-risk pregnancies and if so whether this has led to changes in neonatal morbidity or stillbirth., Study Design: Birth certificate data between 2010 and 2014 from 23 states (55% of births in the United States) were used. Pregnancies were classified as high risk if they had any one of the following: maternal age greater than or equal to 40 years, prepregnancy body mass index (BMI) greater than or equal to 40 kg/m 2 , chronic (prepregnancy) hypertension, or diabetes (pregestational or gestational). Delivery timing changes for all pregnancies at term (37 weeks or greater) were compared with changes in the high-risk population. Neonatal morbidities (neonatal intensive care unit [NICU] admission, need for assisted ventilation, 5-minute Apgar score, and macrosomia), maternal morbidities (intensive care unit [ICU] admission, cesarean delivery, operative vaginal delivery, chorioamnionitis, and severe perineal laceration), and stillbirth rates were compared across time periods. Multivariate logistic regression was used to analyze whether gestational age-specific morbidity changes were due to shifts in delivery timing., Results: For the overall population, there was a shift in delivery timing between 2010 and 2014, a 2.5% decrease in 38-week deliveries, and a 2.3% increase in 39-week deliveries ( p  < 0.01). This gestational age shift was identical in the high-risk population (2.7% decrease in 38-week deliveries and 2.9% increase in 39-week deliveries). For the high-risk population, NICU admission increased from 5.4 to 6.3% in 2014 ( p  < 0.01) and assisted ventilation rates declined from 3.8 to 2.9% ( p  < 0.01). These changes, however, were independent of changes in delivery timing. There was no increase in the rate of stillbirth (0.23% in 2010 and 0.23% in 2014; p  = 0.50)., Conclusion: There was a significant shift in delivery timing for high-risk pregnancies in the United States between 2010 and 2014. This shift, however, did not result in statistically significant changes in either neonatal morbidity or stillbirth., Key Points: · From 2010 to 2014, term deliveries for high-risk pregnancies shifted towards 39 weeks.. · The shift towards 39 weeks in high-risk pregnancies was not accompanied by any improvement in neonatal morbidity.. · The shift towards 39 weeks in high-risk pregnancies did not result in an increase in the stillbirth rate.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Preventing the first cesarean delivery (CD) is important as CD rates continue to rise. During the novel coronavirus disease 2019 (COVID-19) pandemic, quality improvement metrics at our hospital identified lower rates of CD. We sought to investigate this change and identify factors that may have contributed to the decrease., Study Design: We compared nulliparous singleton deliveries at a large academic hospital during the COVID-19 pandemic (April through July 2020 during a statewide "stay-at-home" order) to those in the same months 1 year prior to the pandemic (April through July 2019). The primary outcome, mode of delivery, was obtained from the electronic medical record system, along with indication for CD., Results: The cohort included 1,913 deliveries: 892 in 2019 and 1,021 in 2020. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ between the groups. Median gestational age at delivery was the same in both groups. The CD rate decreased significantly during the COVID-19 pandemic compared with prior (28.9 vs. 33.6%; p  = 0.03). There was a significant increase in the rate of labor induction (45.7 vs. 40.6%; p  = 0.02), but no difference in the proportion of inductions that were elective (19.5 vs. 20.7%; p  = 0.66). The rate of CD in labor was unchanged (15.9 vs. 16.3%; p  = 0.82); however, more women attempted a trial of labor (87.0 vs. 82.6%; p  = 0.01). Thus, the proportion of CD without a trial of labor decreased (25.1 vs. 33.0%; p  = 0.04)., Conclusion: There was a statistically significant decrease in CD during the COVID-19 pandemic at our hospital, driven by a decrease in CD without a trial of labor. The increased rate of attempted trial of labor suggests the presence of patient-level factors that warrant further investigation as potential targets for decreasing CD rates. Additionally, in a diverse and medically complex population, increased rates of labor induction were not associated with increased rates of CD., Key Points: · Primary CD rate fell during COVID-19 pandemic.. · Decrease was driven by more women attempting labor.. · Higher rate of induction without rise in CD rate was found.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population., Study Design: PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care., Results: A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10)., Conclusion: Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: To evaluate whether cervical dilation predicts the timing and likelihood of spontaneous labor at term., Study Design: This was a retrospective cohort of nulliparous women with singleton pregnancies who delivered at term from 2013 to 2015. Outpatient cervical examinations performed after 37 weeks and prior to labor onset were collected. Survival analysis was used to analyze time to spontaneous labor with cervical dilation as the primary predictor, modeled as continuous and categorical variables (<1 cm, 1 cm, >1 cm)., Results: Our cohort included 726 women; 407 (56%) spontaneously labored, 263 (36%) were induced, and 56 (8%) had an unlabored cesarean delivery. Women with >1-cm dilation were three times more likely to spontaneously labor (adjusted hazard ratio [aHR]: 3.1; 95% confidence interval [CI]: 2.4-4) than those with <1-cm dilation. At 39 weeks, 60% of women with >1-cm dilation went into spontaneous labor as compared with only 28% of those with <1-cm dilation (aHR: 2.9; 95% CI: 2-4.4)., Conclusion: In our cohort of nulliparous women at term, those with cervical dilation > 1 cm were significantly more likely to go into labor in the following week. This information can aid in counseling about elective induction of labor., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: The objective of this study was to investigate the relationship between preterm birth in a prior pregnancy and preterm birth in a twin pregnancy., Study Design: We performed a secondary analysis of a randomized controlled trial evaluating 17-α-hydroxyprogesterone caproate in twins. Women were classified as nulliparous, multiparous with a prior term birth, or multiparous with a prior preterm birth. We used logistic regression to examine the odds of spontaneous preterm birth of twins before 35 weeks according to past obstetric history., Results: Of the 653 women analyzed, 294 were nulliparas, 310 had a prior term birth, and 49 had a prior preterm birth. Prior preterm birth increased the likelihood of spontaneous delivery before 35 weeks (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.28-4.66), whereas prior term delivery decreased these odds (aOR: 0.55, 95% CI: 0.38-0.78) in the current twin pregnancy compared with the nulliparous reference group. This translated into a lower odds of composite neonatal morbidity (aOR: 0.38, 95% CI: 0.27-0.53) for women with a prior term delivery., Conclusion: For women carrying twins, a history of preterm birth increases the odds of spontaneous preterm birth, whereas a prior term birth decreases odds of spontaneous preterm birth and neonatal morbidity for the current twin pregnancy. These results offer risk stratification and reassurance for clinicians., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women., Study Design: A 4-year retrospective cohort. We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator., Results: Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p  < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p  = 0.02) and uterine rupture (1.9 vs. 0.0%; p  < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p  = 0.51), maternal, or immediate neonatal complications., Conclusion: Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective:  The objective of this study was to assess the association between the angle of progression (AoP) measured by transperineal ultrasound and mode of delivery and duration of the second stage., Study Design:  This is a prospective observational study of nulliparous women with a singleton gestation at term in which serial transperineal ultrasound examinations were obtained during the second stage of labor. Multivariable logistic regression and adjusted survival models were used for the analysis., Results:  A total of 137 patients were included in the analysis and median AoP for the study group was 153 degrees. The adjusted odds ratio (aOR) of requiring an operative delivery was 2.6 times higher for those patients who had an AoP < 153 degrees and the aOR of requiring a cesarean delivery was almost six times higher when compared with those patients who had an AoP ≥ 153 degrees (95% confidence interval [CI]: 1.0, 6.2; p  = 0.04; aOR: 5.8, 95% CI: 1.2-28.3; p  = 0.03, respectively). Those patients with an AoP < 153 degrees were at a higher hazard of staying pregnant longer (adjusted hazard ratio: 1.8, 95% CI: 1.2-2.8, p  = 0.005)., Conclusion:  The AoP has the potential to predict spontaneous vaginal delivery and the duration of the second stage of labor which may be useful in counseling patients and managing their labor., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective:  The objective of this study was to test whether hospitals experienced in twin delivery have lower rates of cesarean delivery for twins., Methods:  We divided obstetric hospitals in the 2011 National Inpatient Sample by quartile of annual twin deliveries and compared twin cesarean delivery rates between hospitals with weighted linear regression. We used Pearson's coefficients to correlate a hospital's twin cesarean delivery rate to its overall cesarean delivery and vaginal birth after cesarean (VBAC) rates., Results:  Annual twin delivery volume ranged from 1 to 506 across the 547 analyzed hospitals with a median of 10 and mode of 3. Adjusted rates of cesarean delivery were independent of delivery volume with a rate of 75.5 versus 74.8% in the lowest and highest volume hospitals ( p  = 0.09 across quartiles). A hospital's cesarean delivery rate for twins moderately correlated with the overall cesarean rate ( r  = 0.52, p  < 0.01) and inversely correlated with VBAC rate ( r  =  - 0.42, p  < 0.01)., Conclusion:  Most U.S. obstetrical units perform a low volume of twin deliveries with no decrease in cesarean delivery rates at higher volume hospitals. Twin cesarean delivery rates correlate with other obstetric parameters such as singleton cesarean delivery and VBAC rates suggesting twin cesarean delivery rate is more closely related to a hospital's general obstetric practice than its twin delivery volume., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: We assessed the impact of a policy preventing scheduled repeat cesarean deliveries at less than 39 weeks, accounting for potential inaccuracies in pregnancy dating., Study Design: We analyzed a cohort of repeat cesarean deliveries before and after the policy change and used chi-square testing to compare the proportion of deliveries at less than 39 weeks. We assessed whether the reduction in early-term deliveries was different if the gestational age was based on the documented estimated date of delivery (EDD) as compared with best obstetric dating., Results: Our cohort consisted of 213 women; 112 before the policy change and 101 after. Using the EDD assigned at delivery, there was a 12.1% absolute decrease in scheduled deliveries at less than 39 weeks (25.0-12.9%; p = 0.025). However, using the EDD by best obstetric dating, there was no significant change (32.1-25.7%; p = 0.305). Of the 85 discrepant EDDs, providers were more likely to assign an earlier EDD (63.5%; p = 0.013)., Conclusion: Our institution's policy change led to a 12.1% absolute reduction in documented, scheduled early-term deliveries, however only a 6.4% absolute decline using best obstetric dating. Policy initiatives to reduce early-term deliveries should consider the source and accuracy of the assigned pregnancy dating., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)