( Am J Obstet Gynecol . 2019;221:271.e1–271.e10) An important strategy for improving maternal health is development of a tool that reliably identifies women at risk of severe maternal morbidity (SMM) and death. The obstetric comorbidity index (OB-CMI) summarizes the burden of maternal comorbidities and allows for the generation of a single numeric score to quantify risk assessment. While the OB-CMI was originally designed to address bias in research studies, the authors hypothesized it could be adapted for clinical use. The score is calculated from a 20-item list of comorbidities (eg, preeclampsia, multiple gestation, asthma, advanced maternal age). The comorbidities are weighted (eg, preeclampsia with severe features is 5 points, diabetes on insulin is 1 point). The points are summed for a total score. The aim of this study was to prospectively evaluate the performance of this comorbidity index as a screening tool to accurately identify laboring women at risk of SMM.
( BMJ . 2017;358:j3326) Neonatal abstinence syndrome is a recognized complication of intrauterine exposure to opioids. Neonatal abstinence syndrome can manifest in a number of different ways, from difficulty feeding and sleeping to more severe complications such as impaired thermoregulation, seizures, failure to thrive, and respiratory distress. Because pregnant women who are using an opioid often also use psychotropic medications, there are concerns about potential interactions between the opioid and psychotropic drugs leading to an increase in the occurrence and severity of neonatal drug withdrawal from. However, not much is known about how this risk varies by type of psychotropic medicine or about the risks associated with psychotropic polypharmacy. These investigators undertook the present study to determine whether the risk of neonatal drug withdrawal in newborns exposed in utero to one or more psychotropic medications in addition to opioids is greater and more severe than those exposed to opioids alone.
( Am J Obstet Gynecol. 2016;215(5):640.e1–640.e8) Peripartum hysterectomy can be a life-saving procedure for women with postpartum hemorrhage when other interventions have failed. The procedure itself, however, can be fatal with the risk of death ranging from 1% to 6%. Women with a suspected placenta accreta/percreta are considered to be at high-risk for peripartum hysterectomy, and are often referred to tertiary centers where this procedure is frequently performed.
( Anesthesiology . 2024;140:701–714. doi:10.1097/ALN.0000000000004900) Moderate or severe postsurgical pain is reported by a high number of patients following cesarean delivery (CD). Globally, it is the most common surgery performed, and higher pain levels after surgery are associated with persistent postsurgical pain and chronic opioid use. In addition, pain that is present before surgery is associated with worse postoperative pain and thus greater consumption of medications to manage pain. Current tools used to assess psychosocial factors associated with use of pain medication and postoperative pain levels include mainly dichotomous measures or extremely long comprehensive assessments. This study was designed to compare 3 sets of questionnaires that differ in length and detail to explain postoperative pain and opioid consumption variability after CD; first, a 3-item questionnaire (3-IQ); second, a 58-item long questionnaire with the 3-IQ; and third, a novel 19-item brief questionnaire in addition to the 3-IQ.
( Anesthesiology . 2019;130:446–461) As health care providers become more aware of acute fatty liver of pregnancy, more mild cases have been diagnosed and diagnosis is occurring earlier. Anesthesiologists must understand the pathophysiology and the obstetric impact to properly manage this condition.
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( Am J Obstet Gynecol. 2015;213(3):384.e1–e11) In the United States, 1.3 million women underwent cesarean delivery in 2012 alone. The fact that this is such a common surgery may have led to a heightened sense of safety surrounding the procedure despite the fact that it is associated with serious risks such as placenta accreta, which can result in major obstetric morbidity. The authors of this study investigated morbidity associated with both first and repeat cesarean deliveries with a special emphasis on placenta accreta. They also attempted to identify potential factors related to types of hospitals and patient demographics that might be associated with increased risk of such morbidity.
To determine whether outpatient exposure to calcium-channel blockers (CCBs) at the time of delivery is associated with an increased risk for postpartum haemorrhage (PPH).Cohort study.United States of America.Medicaid beneficiaries.We identified a cohort of 9750 patients with outpatient prescriptions for CCBs, methyldopa, or labetalol for pre-existing or gestational hypertension whose days of supply overlapped with delivery; 1226 were exposed to CCBs. The risk of PPH was compared in those exposed to CCBs to those exposed to methyldopa or labetalol. Propensity score matching and stratification were used to address potential confounding.The occurrence of PPH during the delivery hospitalisation.There were 27 patients exposed to CCBs (2.2%) and 232 patients exposed to methyldopa or labetalol (2.7%) who experienced PPH. After accounting for confounders, there was no meaningful association between CCB exposure and PPH in the propensity score matched (odds ratio 0.77, 95% CI 0.50-1.18) or stratified (odds ratio 0.79, 95% CI 0.53-1.19) analyses. Similar results were obtained across multiple sensitivity analyses.The outpatient use of CCBs in late pregnancy for the treatment of hypertension does not increase the risk of PPH.
( N Engl J Med . 2024;390(12):1069-1079. DOI: 10.1056/NEJMoa2309359) Maternal use of valproate during pregnancy has been linked to a heightened risk of neurodevelopmental disorders in children. While most studies on other antiseizure medications did not show increased risks of these disorders, insufficient and inconsistent data exist regarding the risk of autism spectrum disorder (ASD) associated with maternal topiramate use. A study conducted on maternal use of antiseizure medications during pregnancy, particularly focusing on the risk of ASD in children, revealed noteworthy findings.
To assess whether women with a genetic predisposition to medical conditions known to increase pre-eclampsia risk have an increased risk of pre-eclampsia in pregnancy.Case-control study.Pre-eclampsia cases (n = 498) and controls (n = 1864) in women of European ancestry from five US sites genotyped on a cardiovascular gene-centric array.Significant single-nucleotide polymorphisms (SNPs) from 21 traits in seven disease categories (cardiovascular, inflammatory/autoimmune, insulin resistance, liver, obesity, renal and thrombophilia) with published genome-wide association studies (GWAS) were used to create a genetic instrument for each trait. Multivariable logistic regression was used to test the association of each continuous scaled genetic instrument with pre-eclampsia. Odds of pre-eclampsia were compared across quartiles of the genetic instrument and evaluated for significance.Genetic predisposition to medical conditions and relationship with pre-eclampsia.An increasing burden of risk alleles for elevated diastolic blood pressure (DBP) and increased body mass index (BMI) were associated with an increased risk of pre-eclampsia (DBP, overall OR 1.11, 95% CI 1.01-1.21, P = 0.025; BMI, OR 1.10, 95% CI 1.00-1.20, P = 0.042), whereas alleles associated with elevated alkaline phosphatase (ALP) were protective (OR 0.89, 95% CI 0.82-0.97, P = 0.008), driven primarily by pleiotropic effects of variants in the FADS gene region. The effect of DBP genetic loci was even greater in early-onset pre-eclampsia cases (at <34 weeks of gestation, OR 1.30, 95% CI 1.08-1.56, P = 0.005). For other traits, there was no evidence of an association.These results suggest that the underlying genetic architecture of pre-eclampsia may be shared with other disorders, specifically hypertension and obesity.A genetic predisposition to increased diastolic blood pressure and obesity increases the risk of pre-eclampsia.
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