Optimal timing of delivery for growth restricted fetuses with gastroschisis: A decision analysis.

Objective: Our objective was to determine the optimal timing of delivery of growth restricted fetuses with gastroschisis in the setting of normal umbilical artery (UA) Dopplers.

Methods: We designed a decision analytic model using TreeAge software for a hypothetical cohort of 2000 fetuses with isolated gastroschisis, fetal growth restriction (FGR), and normal UA Dopplers across 34-39 weeks of gestation. This model accounted for costs and quality adjusted life years (QALYs) for the pregnant individual and the neonate.

Differences in Perinatal Outcomes among Rural Women by County Composition.

Objective: We compared differences in perinatal outcomes among rural and nonrural women, stratified by maternal race/ethnicity. We also examined differences between majority minority rural counties with majority White rural counties.

Study Design: We conducted a retrospective cohort study with 2015 national vital statistics birth certificate data.

The Risk of Perinatal Mortality in Nulliparous Women Compared to Primiparous Women at Term.

Objective: The aim of this study was to determine the rate of perinatal mortality among nulliparous women compared with primiparous women at term and further characterize the risk of stillbirth by each week of gestation.

Study Design: This is a retrospective cohort study of all term, singleton, nonanomalous births comparing perinatal mortality (stillbirth and neonatal death [NND]) between primiparous (parity = 1, with no history of abortion) and nulliparous (parity = 0) women who delivered in California between 2007 and 2011. Chi-squared tests and multivariable logistic regression analyses were performed to determine the frequencies and strength of association of perinatal mortality with parity, adjusting for maternal age, race, body mass index, pregestational diabetes, chronic hypertension, fetal sex, smoking status, and socioeconomic status.

Long and short interpregnancy intervals increase severe maternal morbidity.

Background: Severe maternal morbidity is a composite variable that includes adverse maternal outcomes during pregnancy that are associated with maternal mortality. Previous literature has shown that interpregnancy interval is associated with preterm birth, fetal growth restriction, and low birthweight, but the association of interpregnancy interval and composite severe maternal morbidity is not well studied.

Objective: We sought to determine the relationship between interpregnancy interval (stratified as <6, 6-11, 12-17, 18-23, 24-59, and ≥60 months) and severe maternal morbidity, which we considered both with and without blood transfusion.

Severe maternal morbidity and Black-white differences in Washington State.

Objective: Rates of severe maternal morbidity (SMM) are significantly higher among Black women and some data suggests further worsening of these rates among hospitals with the highest proportion of Black deliveries. In this study, we sought to examine whether Black women have higher SMM in Washington State and whether this varied by hospital.

Methods: We conducted a retrospective cohort study using linked birth-hospital discharge data from Washington State.

Is Appropriate Administration of Antenatal Corticosteroids Associated with Maternal Race?

Objective: Antenatal corticosteroids (ACSs) improve outcomes for premature infants; however, not all pregnant women at risk for preterm delivery receive ACS. Racial minorities are less likely to receive adequate prenatal care and more likely to deliver preterm. The objective of this study was to determine if maternal race is associated with a lower rate of ACS administration in Washington for women at risk of preterm labor (between 23 and 34 weeks).

Obstetric management for stillbirth complicated by a prior cesarean delivery: a cost-effectiveness analysis.

Background: The primary concern for a trial of labor after cesarean (TOLAC) is a uterine rupture leading to neonatal injury or mortality and maternal mortality. In individuals who have a term stillbirth, the neonatal concern is absent, yet repeat cesarean delivery remains common in this setting. Given the increased maternal risks from cesarean, it is important to evaluate obstetric management options in the population of women who have a term stillbirth and prior cesarean delivery (CD).

Increased rates of adverse perinatal outcomes in women with gestational diabetes and depression.

Objective: We sought to examine the impact of depression on adverse perinatal outcomes in women with Gestational Diabetes Mellitus (GDM).

Methods: We performed a retrospective cohort study comparing the rates of perinatal complications among singleton, nonanomalous births to women with GDM and the diagnosis of depression compared to GDM women without depression between 2007 and 2011 in California. Perinatal outcomes were analyzed using chi-square and multivariable logistic regression to compare frequencies of characteristics and outcomes and to determine the strength of association of depression and adverse perinatal outcomes among women with GDM.

Association of Widespread Adoption of the 39-Week Rule With Overall Mortality Due to Stillbirth and Infant Death.

Importance: To improve neonatal morbidity, efforts have been made to reduce elective deliveries prior to 39 weeks' gestation, also known as the 39-week rule. Prolonging pregnancies also prolongs exposure to the risk of stillbirth. The true association of a 39-week rule with mortality is unknown and studies to date have shown conflicting results.

Timing of delivery in women with prior uterine rupture: a decision analysis.

Uterine rupture is an obstetric complication with high rates of associated maternal and neonatal morbidity and mortality. However, limited guidance for the timing of delivery in women with a history of prior uterine rupture exists. To determine the optimal gestational age of delivery in women with prior uterine rupture.

Fetal Malpresentation and Malposition: Diagnosis and Management.

Fetal malpresentation and fetal malposition are frequently interchanged; however, fetal malpresentation refers to a fetus with a fetal part other than the head engaging the maternal pelvis. Fetal malposition in labor includes occiput posterior and occiput transverse positions. Both fetal malposition and malpresentation are associated with significant maternal and neonatal morbidity, which have significant impact on patients and providers.

Fetal hydrops and the risk of severe preeclampsia.

Objective: To assess the incidence and severity of preeclampsia in pregnancies complicated by fetal hydrops.

Methods: We performed a retrospective cohort study of singleton gestations from 2005 to 2008 in California. The primary predictor was fetal hydrops and the primary outcome was preeclampsia.

The growth-restricted fetus: risk of mortality by each additional week of expectant management.

Objective: To compare fetal/infant mortality risk associated with each additional week of expectant management with the infant mortality risk of immediate delivery in growth-restricted pregnancies.

Methods: A retrospective cohort study was conducted of singleton, nonanomalous pregnancies from the 2005-2008 California Birth Registry comparing pregnancies affected and unaffected by growth restriction, defined using birth weights as a proxy for fetal growth restriction (FGR). Birth weights were subdivided as greater than the 90th percentile, between the 10th percentile and 90th percentile, and less than the 10th percentile.

Maternal and feto-placental phenotypes of early-onset severe preeclampsia.

Objective: To characterize maternal and feto-placental phenotypes of severe preeclampsia that trigger early-onset delivery.

Methods: A retrospective cohort review of pregnant women receiving care from 2000 to 2010. Subjects with early-onset severe preeclampsia delivering between 20 and 32 weeks were identified excluding multiple gestations or major anomalies.

The risk of fetal death in nonanomalous pregnancies affected by polyhydramnios.

Objective: The objective of the study was to evaluate the ongoing risk of intrauterine fetal demise (IUFD) in nonanomalous pregnancies affected by polyhydramnios.

Study Design: We analyzed a retrospective cohort of all singleton, nonanomalous births in California between 2005 and 2008 as recorded in a statewide birth certificate registry. We included all births between 24+0 and 41+6 weeks' gestational age, excluding multiple gestations, major congenital anomalies, and pregnancies affected by oligohydramnios.

The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies.

Objective: The objective of the study was to compare the fetal/infant mortality risk associated with each additional week of expectant management with the mortality risk of immediate delivery in women with twin gestations.

Study Design: A retrospective cohort study was performed utilizing 2006-2008 National linked birth certificate and death certificate data. The incidence of stillbirth and infant death were determined for each week of pregnancy from 32 0/7 weeks' through 40 6/7 weeks' gestation.

When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?

Objective: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.

Methods: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature.

The cost-effectiveness of repeat HIV testing during pregnancy in a resource-limited setting.

Objective: To estimate the cost-effectiveness of HIV screening strategies for the prevention of perinatal transmission in Uganda, a resource-limited country with high HIV prevalence and incidence.

Study Design: We designed a decision analytic model from a health care system perspective to assess the vertical transmission rates and cost-effectiveness of 4 different HIV screening strategies in pregnancy: (1) rapid HIV antibody (Ab) test at initial visit (current standard of care), (2) strategy 1 + HIV RNA at initial visit (adds detection of acute HIV), (3) strategy 1 + repeat HIV Ab at delivery (adds detection of incident HIV), and (4) strategy 3 + HIV RNA at delivery (adds detection of acute HIV at delivery). Model estimates were derived from the literature and local sources, and life years saved were discounted at a rate of 3% per year.

The risk of intrauterine fetal death in the small-for-gestational-age fetus.

Objective: We sought to evaluate the risk of intrauterine fetal death (IUFD) in small-for-gestational-age (SGA) fetuses.

Study Design: We analyzed a retrospective cohort of all births in the United States in 2005, as recorded in a national database. We calculated the risk of IUFD within 3 sets of SGA threshold categories as well as within non-SGA pregnancies using the number of at-risk fetuses as the denominator.