Andrea R. Spence

Incidence and risk factors of sepsis mortality in labor, delivery and after birth: Population-based study in the USA

Maternal sepsis is one of the leading causes of maternal mortality around the world. The aim of this study was to estimate the incidence and mortality rate of sepsis, and the associated risk factors for their development during pregnancy, labor, delivery and the post‐partum period.

Incidence and causes of maternal mortality in the USA.

To characterize the most common causes and risk factors of maternal mortality in the USA and observe trends over the past 9 years.

Pregnancy outcomes in women with bariatric surgery as compared with morbidly obese women

Abstract Objective: Pregnancies among morbidly obese women are associated with serious adverse maternal and neonatal outcomes. Our study objective is to evaluate the effect of bariatric surgery on obstetrical outcomes. Methods: We carried out a retrospective cohort study using the healthcare cost and utilization project – Nationwide Inpatient Sample from 2003 to 2011 comparing outcome of births among women who had undergone bariatric surgery with births among women with morbid obesity. Logistic regression was used to estimate the adjusted effect of bariatric surgery on maternal and newborn outcomes. Results: There were 8 475 831 births during the study period (221 580 (2.6%) in morbidly obese women and 9587 (0.1%) in women with bariatric surgery). Women with bariatric surgery were more likely to be Caucasian and ≥35 years old as compared with morbidly obese women. As compared with women with morbid obesity, women with bariatric surgery had lower rates of hypertensive disorders, premature rupture of membrane, chorioamnionitis, cesarean delivery, instrumental delivery, postpartum hemorrhage, and postpartum infection. Induction of labor, postpartum blood transfusions, venous thromboembolisms, and intrauterine fetal growth restriction were more common in the bariatric surgery group. There were no differences observed in preterm births, fetal deaths, or reported congenital anomalies. Conclusion: In general, women who undergo bariatric surgery have improved pregnancy outcomes as compared with morbidly obese women. However, the bariatric surgery group was more likely to have venous thromboembolisms, to require a blood transfusion, to have their labor induced and to experience fetal growth restriction.

Pregnancy outcomes in liver transplant patients, a population-based study

Abstract Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies. Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients. Results: There were 7 288 712 deliveries and an estimated incidence of 2.1 LTs/100 000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0). Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.

Safety of splenectomy during pregnancy

Abstract Objective: The aim of our study is to evaluate the risk of morbidity and mortality of splenectomy in pregnant women compared with non-pregnant women. Materials and methods: We conducted a retrospective population-based matched cohort study using the Health Care Cost and Utilization Project, Nationwide Inpatient Sample database from 2003 to 2011. Pregnant women with splenectomy were age-matched to non-pregnant women with splenectomy. We compared risks of morbidity and mortality between pregnant and non-pregnant women using conditional logistic regression analysis. Results: The non-pregnant group had an excess of white patients and a greater proportion of Medicaid and private insurance users. There was a tendency for greater frequency of laparotomies in pregnant patients. Risk of VTE, portal vein thrombosis, renal failure and sepsis were comparable between the groups. Risk for transfusion was higher amongst pregnant women (OR 2.2, 95% CI (1.7–2.8)), as was the risk for a longer hospital stay (OR 1.7, 95% CI (1.4–2.1)). Conclusion: Caution should be taken when performing splenectomy during pregnancy as risk for complications and mortality may be increased. Additional measures should be undertaken to have blood units on reserve for this population.

Effect of Borderline Personality Disorder on Obstetrical and Neonatal Outcomes.

BACKGROUND Borderline personality disorder (BPD) is a serious mental disorder commonly associated with functional impairments and adverse health outcomes. Very little is known about BPD in pregnant women; hence, our study objective was to evaluate the effect of BPD on obstetrical and neonatal outcomes. METHODS We carried out a retrospective cohort study using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample from 2003 to 2012. We identified births using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes and classified women by BPD status. Multivariate logistic regression was used to evaluate the effect of BPD on obstetrical and neonatal outcomes, adjusted for subject baseline characteristics. FINDINGS During the study period, there were 989 births to women with BPD with an overall incidence of 11.65 in 100,000 births. Women with BPD were more likely younger, of lower socioeconomic status, smoked or used drugs, and had an underlying mental disorder. Unadjusted models revealed that BPD was associated with an increased risk of almost all adverse maternal and fetal outcomes we examined, the exception being post partum hemorrhage and instrumental delivery, which both had a null association with BPD, and induction of labor, which was negatively associated with BPD. Upon full adjustment, BPD was found to be associated with the following obstetrical and neonatal outcomes: gestational diabetes (odds ratio [OR], 1.45; 95% CI, 1.13-1.85), premature rupture of the membranes (OR, 1.40; 95% CI, 1.07-1.83), chorioamnionitis (OR, 1.65; 95% CI, 1.14-2.39), venous thromboembolism (OR, 2.11; 95% CI, 1.12-3.96), caesarian delivery (OR, 1.44; 95% CI, 1.26-1.64), and preterm birth (OR, 1.54; 95% CI, 1.29-1.83). CONCLUSION BPD is associated with several adverse obstetrical and neonatal outcomes. Hence, pregnant women who suffer from BPD should be monitored closely by a multidisciplinary health care team both before and during their pregnancies. This oversight would allow for the receipt of treatment for BPD and also interventions to help them to cease tobacco and drug use, which may ultimately decrease the incidence of poor obstetrical and neonatal outcomes.

Maternal and neonatal outcomes of pregnancies in women with Addison's disease: a population-based cohort study on 7.7 million births

To assess if pregnancies among women with Addisons disease (AD) are at higher risk of adverse maternal and neonatal outcomes.

Pregnancy outcomes in women with rheumatoid arthritis: a retrospective population-based cohort study

Abstract Purpose: To assess if pregnancies in women with rheumatoid arthritis (RA) are at a higher risk for adverse maternal and neonatal outcomes. Materials and methods: A retrospective cohort study was carried out using the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS) from the USA. All births that took place from 2004 to 2013 were identified and women were classified as having RA or not on the basis of ICD-9 coding. Unconditional logistic regression was used to evaluate the adjusted effect of RA on maternal and neonatal outcomes. Results: Of the total 8,417,607 births in our cohort, 6068 were among women with RA for an overall prevalence of 72 per 100,000 births. There was a steady increase in reported RA in pregnancy from 47 to 100 per 100,000 over the 10-year study period. Compared with women without RA, women with RA were more likely to develop pre-eclampsia/eclampsia, gestational diabetes, to present with preterm premature rupture of membranes(PPROM), to experience placental abruption and placenta previa, and to deliver by caesarean section. Postpartum, RA-complicated pregnancies were associated with wound complications and thromboembolisms. Congenital anomalies, small for gestational age and preterm birth were more common in neonates of women with RA. Conclusion: RA in pregnancy is associated with a greater likelihood of adverse maternal and neonatal outcomes. Women with RA should be made aware of these risks and be followed as a high risk pregnancy.

The effect of assisted reproductive technology on the incidence of birth defects among livebirths

PurposeOur study objective is to examine the association between births conceived with assisted reproductive technology (ART) and birth defects using a large database from the United States.MethodsUsing the Centers for Disease Control and Prevention’s Period-linked birth–infant death data files and fetal death database for 2011–2013, we conducted a retrospective cohort study comprised of live births that occurred in the USA during that time. Multivariate logistic regression was used to estimate the association between ART and birth defects, both overall and by specific defects.ResultsThere were 11,862,780 live births between 2011 and 2013. Of these births, 11,791,730 were spontaneous pregnancies and 71,050 were conceived by ART, with an increasing trend in incidence of ART during the study period and an overall increasing trend of birth defects. Overall, infants conceived by ART had a greater risk of having birth defects than did infants conceived spontaneously (77/10,000 vs 25/10,000, respectively, OR 2.14, 95% CI 1.94–2.35). The malformations most commonly associated with ART were cyanotic heart defects (OR 2.74, 95% CI 2.42–3.09), cleft lip and/or palate (OR 1.47, 95% CI 1.14–1.89), and hypospadias (OR 1.77, 95% CI 1.42–2.19). There were no differences in risk of omphalocele or neural tube defects between the two groups.ConclusionsThere is an overall and type-specific increased risk of birth defects in the ART population. Appropriate counseling and specialized ultrasound evaluations should be considered in pregnancies conceived by ART.

Maternal and neonatal outcomes among pregnant women with fibromyalgia: a population-based study of 12 million births

Abstract Purpose: Fibromyalgia (FM) is a rheumatologic disorder marked by chronic, widespread pain and associated comorbid conditions. The purpose of our study was to evaluate the effect of FM on maternal and neonatal outcomes. Methods: Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without FM. Results: Of 12 584 918 births during the 15-year study period, 7758 (0.06%) were to women with FM with rates increasing over the study period. Women with FM were more commonly older in age, overweight or obese, and users of alcohol, tobacco, and illicit drugs. They were more likely to experience anxiety, depression, and bipolar disorder. Women with FM were at greater risk of gestational diabetes, preterm premature rupture of membranes, and placental abruption. Women with FM more commonly had cesarean deliveries (odds ratios (OR): 1.11, 95% CI: 1.05–1.16) and births complicated by venous thromboembolism (OR: 2.34, 95% CI: 1.91–2.86). Infants of women with FM were more likely to be premature (OR: 1.35, 95% CI: 1.25–1.46) and have intrauterine growth restriction (OR: 1.48, 95% CI: 1.30–1.68). Conclusions: The prevalence of FM in pregnancy is rising in the US. FM is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes.