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Objective The aim of the study is to determine the relation between education and adverse outcomes in individuals with pregestational or gestational diabetes. Study Design This population-based cohort study, using the U.S. vital statistics datasets, evaluated individuals with pregestational or gestational diabetes who delivered between 2016 and 2019. The primary outcome was composite neonatal adverse outcome including any of the following: large for gestational age (LGA), Apgar's score 6 hours, neonatal seizure, or neonatal death. The secondary outcome was composite maternal adverse outcomes including any of the following: admission to intensive care unit, transfusion, uterine rupture, or unplanned hysterectomy. Multivariable analysis was used to estimate adjusted relative risks (aRR) and 95% confidence intervals (CIs). Results Of 15,390,962 live births in the United States, 858,934 (5.6%) were eligible for this analysis. Compared with individuals with a college education and above, the risk of composite neonatal adverse outcome was higher in individuals with some college (aRR = 1.08, 95% CI = 1.07–1.09), high school (aRR = 1.06, 95% CI = 1.04–1.07), and less than high school (aRR = 1.05, 95% CI = 1.03–1.07) education. The components of composite neonatal adverse outcome that differed significantly between the groups were LGA, Apgar's score 6 hours. Infant death differed when stratified by education level. An increased risk of composite maternal adverse outcome was also found with a lower level of education. Conclusion Among individuals with diabetes, lower education was associated with a modestly higher risk of adverse neonatal and maternal outcomes. Key Points Education levels were associated with adverse outcomes among individuals with diabetes. Lower education is associated with multiple neonatal complications, including infant death. Individuals with varying levels of education are at higher risk for adverse maternal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To describe timing, antecedent events, and outcomes in pregnancy‐related stroke (PAS). Methods: Retrospective single‐center cohort of all PAS within 42 days of delivery from September 2010 to May 2021. Data were abstracted from medical records. Results: Among 51 500 births, we identified 91 cases of PAS, with a stroke rate of 177 per 100 000 births. Of all PAS, 62% (n = 56) were hemorrhagic, 56% (n = 51) occurred postpartum, 49% (n = 45) occurred in patients with hypertensive disorders of pregnancy (HDP), and 36% (n = 33) had surgical interventions. There were nine deaths, with a case fatality rate of 9.9%. Of the survivors (n = 82), 37 (45.1%) had residual deficits. Patients with HDP were more likely to have a postpartum stroke than those without HDP (crude relative risk 1.72, 95% confidence interval 1.16–2.55). Among patients with HDP, 89% had at least one severe range blood pressure (BP), with a peak systolic BP of 187.8 ± 27.9 mm Hg and a peak diastolic BP of 109.4 ± 18.4 mm Hg. There was no difference in presenting symptoms (P = 0.120), residual deficits (P = 0.609), or mortality (P = 0.739) between those with or without HDP. Conclusions: At a referral hospital, PAS was uncommon but was associated with a high mortality rate. An improved understanding of the modifiable risk factors is warranted to avert the sequelae of PAS. Synopsis: Pregnancy‐associated strokes are uncommon but associated with a high mortality rate. About half have postpartum presentation, half involve hypertensive disorder, and most present with headaches. [ABSTRACT FROM AUTHOR]

Objective The international consensus on continuous glucose monitoring (CGM) recommends time in range (TIR) target of >70% for pregnant people. Our aim was to compare outcomes between pregnant people with TIR ≤ versus >70%. Study Design This study was a retrospective study of all people using CGM during pregnancy from January 2017 to May 2021 at a tertiary care center. All people with pregestational diabetes who used CGM and delivered at our center were included in the analysis. Primary neonatal outcome included any of the following: large for gestational age, neonatal intensive care unit (NICU) admission, need for intravenous (IV) glucose, or respiratory distress syndrome (RDS). Maternal outcomes included hypertensive disorders of pregnancy and delivery outcomes. Logistic regression was used to estimate unadjusted and adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results Of 78 people managed with CGM, 65 (80%) met inclusion criteria. While 33 people (50.1%) had TIR ≤70%, 32 (49.2%) had TIR >70%. People with TIR ≤70% were more likely to be younger, have a lower body mass index, and have type 1 diabetes than those with TIR >70%. After multivariable regression, there was no difference in the composite neonatal outcome between the groups (aOR: 0.56, 95% CI: 0.16–1.92). However, neonates of people with TIR ≤70% were more likely to be admitted to the NICU (p = 0.035), to receive IV glucose (p = 0.005), to have RDS (p = 0.012), and had a longer hospital stay (p = 0.012) compared with people with TIR >70%. Furthermore, people with TIR ≤70% were more likely to develop hypertensive disorders (p = 0.04) than those with TIR >70%. Conclusion In this cohort, the target of TIR >70% was reached in about one out of two people with diabetes using CGM, which correlated with a reduction in neonatal and maternal complications. Key Points Among people with diabetes, 50% reached the recommended time in range using CGM. Time in range >70% was associated with reducing the rate of some neonatal complications. Time in range ≤70% was associated with increased risk for adverse maternal outcomes. [ABSTRACT FROM AUTHOR]

Background: Better understanding of the factors associated with formula feeding during the hospital stay can help in identifying potential lactation problems and promote early intervention. Our aim was to ascertain factors associated with exclusive formula feeding in newborns of low‐risk pregnancies. Methods: A population‐based, retrospective study using the United States vital statistics datasets (2014‐2018) evaluating low‐risk pregnancies with a nonanomalous singleton delivery from 37 to 41 weeks. People with hypertensive disorders, or diabetes, were excluded. Primary outcome was newborn feeding (breast vs exclusive formula feeding) during hospital stay. Adjusted relative risks (aRRs) with 95% confidence intervals (CI) were calculated. Results: Of the 19 623 195 live births during the study period, 11 605 242 (59.1%) met inclusion criteria and among them, 1 929 526 (16.6%) were formula fed. Factors associated with formula feeding included: age < 20 years (aRR 1.31 [95% CI 1.31‐1.32]), non‐Hispanic Black (1.42, 1.41‐1.42), high school education (1.69, 1.69‐1.70) or less than high school education (1.94, 1.93, 1.95), Medicaid insurance (1.52, 1.51, 1.52), body mass index (BMI) < 18.5 (1.10, 1.09‐1.10), BMI 25‐29.9 (1.09, 1.09‐1.09), BMI 30‐34.9 (1.19, 1.19‐1.20), BMI 35‐39.9 (1.31, 1.30‐1.31), BMI ≥ 40 (1.43, 1.42‐1.44), multiparity (1.29, 1.29‐1.30), lack of prenatal care (1.49, 1.48‐1.50), smoking (1.75, 1.74‐1.75), and gestational age (ranged from 37 weeks [1.44, 1.43‐1.45] to 40 weeks [1.11, 1.11‐1.12]). Conclusions: Using a large cohort of low‐risk pregnancies, we identified several modifiable factors associated with newborn feeding (eg, prepregnancy BMI, access to prenatal care, and smoking cessation). Improving the breast feeding initiation rate should be a priority in our current practice to ensure equitable care for all neonates. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether hypertensive disorders of pregnancy (HDP) among low‐risk nulliparous women expectantly managed at or after 39 weeks of gestation are associated with adverse outcomes. Design: Secondary analysis of a randomised trial. Setting: Multicentre, USA. Population: Individuals in the expectantly managed group who delivered on or after 39 weeks. Methods: Multivariable analysis to estimate adjusted relative risks (aRR) for binomial outcomes, adjusted odds ratios (aOR) for multinomial outcomes and 95% CI. Main outcome measures: Composite adverse maternal outcome including placental abruption, pulmonary oedema, postpartum haemorrhage, postpartum infection, venous thromboembolism or intensive care unit admission. Secondary outcomes included a composite of perinatal death or severe neonatal complications, mode of delivery, small and large for gestational age and neonatal intermediate or intensive unit length of stay. Results: Of the 3044 women randomised to expectant management in the original trial, 2718 (89.3%) were eligible for this analysis, of whom 373 (13.7%) developed HDP. Compared with participants who remained normotensive, those who developed HDP were more likely to experience the maternal composite (12% versus 6%, aRR 1.84, 95% CI 1.33–2.54) and caesarean delivery (29% versus 23%, aOR 1.32, 95% CI 1.01–1.71). Differences between the two groups were not significantly different for the adverse perinatal composite (7% versus 5%, aRR 1.38, 95% CI 0.92–2.07) or for other secondary outcomes. Conclusion: Almost 14% of low‐risk nulliparous individuals expectantly managed at 39 weeks developed HDP, and were more likely to experience adverse maternal outcomes compared with those who did not develop HDP. Almost 14% of low‐risk nulliparous individuals expectantly managed at 39 weeks developed hypertensive disorders of pregnancy, and were more likely to experience adverse maternal outcomes compared with those who did not develop hypertensive disorders. Almost 14% of low‐risk nulliparous individuals expectantly managed at 39 weeks developed hypertensive disorders of pregnancy, and were more likely to experience adverse maternal outcomes compared with those who did not develop hypertensive disorders. Linked article: This article is commented on by Gordon C. S. Smith, pp. 1404‐1405 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17080. [ABSTRACT FROM AUTHOR]

Objective  Women with placenta accreta spectrum (PAS) having an unplanned delivery may have worse outcome compared with women with a planned delivery. The primary objective of this study was to compare severe maternal morbidity among women with PAS who had a planned scheduled delivery versus an unplanned delivery. Secondary objective was to compare neonatal outcomes. Study Design  Retrospective cohort study at two tertiary centers (January 2009 to June 2019) of all women who underwent a hysterectomy with a histologic proven PAS. Primary outcome was severe maternal morbidity which defined as any of the following: transfusion of ≥4 RBC units or ureter/bowel injury. Neonatal outcome was a composite neonatal morbidity defined as any of the following: Apgar score's < 5 at 5 minutes, mechanical ventilation, or respiratory distress syndrome. Maternal demographic, clinical, and sonographic characteristics were compared between the two groups (planned vs. unplanned). Descriptive statistics were used as appropriate, and a statistical significance was established if p -value was < 0.05. Results  Of 109 women who underwent cesarean hysterectomy for PAS, 41 (37.6%) had an unplanned delivery. There was no significant difference in the number of previous cesarean deliveries or ultrasound findings between the two groups. Women with an unplanned delivery were more likely to bleed during pregnancy than those that had a planned delivery (p  = 0.04). Women with unplanned delivery had lower gestational age at delivery (30.3 vs. 33.8 weeks, p  = 0.001) had a 75% higher rate of the primary outcome (63 vs. 36%, p  = 0.007) and had a higher rate of intensive care unit admissions (39 vs. 17.7%, p  = 0.01) compared with women with a planned delivery. The neonatal morbidity did not differ between the two groups. Conclusion  Since unplanned cesarean hysterectomy among women with PAS occurs in 40% and is associated with significantly higher morbidity, interventions are needed to mitigate the rate of adverse outcomes. Key Points Only 60% of women with PAS reached planned delivery at 34 weeks. PAS unplanned delivery is associated with high morbidity. Some women with PAS may need a scheduled earlier delivery. [ABSTRACT FROM AUTHOR]

The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia. [ABSTRACT FROM AUTHOR]