Heather Straub

Postpartum weight retention risk factors and relationship to obesity at 1 year.

OBJECTIVE: To explore risk factors for postpartum weight retention at 1 year after delivery in predominantly low-income women. METHODS: Data were collected from 774 women with complete height and weight information from participants in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Community Child Health Network, a national five-site, prospective cohort study. Participants were enrolled primarily in the hospitals immediately after delivery. Maternal interviews conducted at 1, 6, and 12 months postpartum identified risk factors for weight retention and included direct measurement of height and weight at 6 and 12 months. Logistic regression assessed the independent contribution of postpartum weight retention on obesity. RESULTS: Women had a mean prepregnancy weight of 161.5 lbs (body mass index [BMI] 27.7). Women gained a mean of 32 lbs while pregnant and had a 1-year mean postpartum weight of 172.6 lbs (BMI 29.4). Approximately 75% of women were heavier 1 year postpartum than they were prepregnancy, including 47.4% retaining more than 10 lbs and 24.2% more than 20 lbs. Women retaining at least 20 lbs were more often African American, younger, poor, less educated, or on pubic insurance. Race and socioeconomic disparities were associated with high prepregnancy BMI and excessive weight gain during pregnancy, associations that were attenuated by breastfeeding at 6 months and moderate exercise. Of the 39.8 with normal prepregnancy BMI, one third became overweight or obese 1 year postpartum. CONCLUSION: Postpartum weight retention is a significant contributor to the risk for obesity 1 year postpartum, including for women of normal weight prepregnancy. Postpartum, potentially modifiable behaviors may lower the risk. LEVEL OF EVIDENCE: III

Antenatal depressive symptoms increase the likelihood of preterm birth.

OBJECTIVE We evaluated the relationship between antenatal depressive symptoms and preterm birth. STUDY DESIGN Patients completed the Edinburgh Postnatal Depression Scale between 24-28 weeks of gestation. A score ≥ 12 (or thoughts of self-harm) indicated an at-risk woman. Symptomatic women were compared to risk-negative patients for relevant demography, historical variables, and pregnancy outcome. RESULTS After screening 14,175 women we found a screen positive rate of 9.1% (n = 1298). At-risk women had a significant increase in preterm birth at <37, <34, <32, and <28 weeks of gestation. Multivariable analysis adjusting for maternal age, race/ethnicity, prior preterm delivery, and insurance status revealed a persistent association between antenatal depressive symptoms and preterm birth (adjusted odds ratio, 1.3; 95% confidence interval, 1.09-1.35), which was also observed after multiple gestations were excluded from the analysis (odds ratio, 1.7; 95% confidence interval, 1.38-1.99). CONCLUSION In this large cohort of prenatally screened women, those with depressive symptoms had an increased likelihood of preterm birth.

Stress and stress reduction.

Chronic stress contributes to preterm birth (PTB), through direct physiological mechanisms or behavioral pathways. This review identified interventions to prevent PTB through decreased maternal stress. Studies were grouped according to intervention: group prenatal care (11 studies), care coordination (8 studies), health insurance expansion (4 studies), expanded prenatal education/support in the clinic (8 studies), home visitation (9 studies), telephone contact (2 studies), or stress-reduction strategies (5 studies). Group prenatal care had the most evidence for PTB prevention. Comparative studies of PTB prevention through different models of prenatal care and maternal support, education, empowerment, stress-reduction, and coping strategies are needed.

Targeted obstetric haemorrhage programme improves incoming resident confidence and knowledge

Postpartum haemorrhage is an infrequent but potentially life-threatening obstetrical emergency amenable to simulation. An educational programme consisting of a lecture and high-fidelity simulation exercise was given to incoming obstetrics and gynaecology (OB) and family medicine (FM) residents. Residents reported pre- and post-intervention confidence scores on a 1–5 Likert scale and a subset completed a postpartum haemorrhage knowledge assessment. Residents reported significant improvements in confidence in parameters involved in diagnosis and management of postpartum haemorrhage. The postpartum haemorrhage test mean scores significantly increased (57.4 ± 9.6% vs 77.1 ± 7.9%, p < 0.01) and were significantly correlated to confidence scores (Spearmans coefficient of 0.651, p < 0.001). In conclusion, an education programme that incorporates high-fidelity simulation of postpartum haemorrhage improves the confidence and knowledge of incoming residents and appears to be an effective educational approach.

Preconception Detection of Undiagnosed or Poorly Controlled Diabetes by the Electronic Medical Record

INTRODUCTION: Poor preconception glucose control markedly increases adverse pregnancy outcome. We wished to determine whether undiagnosed diabetes or suboptimal glucose levels in nonpregnant women could be reliably identified using data from an integrated health systems electronic medical record. METHODS: An automated case-finding algorithm was applied to an electronic medical record-derived data warehouse to rapidly screen all nonobstetric outpatient visits for women of childbearing age by simultaneously analyzing multiple discrete data fields to determine both reproductive status and glycemic condition. Patients with hemoglobin A1C 6% or greater or serum glucose 200 mg/dL or greater were considered to have “provisional” diabetes. Detailed chart review of all algorithm-identified patients was used to confirm diagnoses. RESULTS: Of 107,339 female patient encounters screened between August 2010 and February 2012, 29,691 women were at risk for pregnancy and 373 met our criteria for provisional diabetes. Restricting cases to those with hemoglobin A1C 7% or greater, glucose greater than 200 mg/dL, or both yielded 241 of 373 (65%); 105 of these had hemoglobin A1C 8.0% or greater. The algorithm was effective across a spectrum of outpatient encounter types, including diagnostic visits (47%), medical and surgical consultations (32%), and emergency department evaluations (14%). Diabetes was entered as a discrete electronic medical record diagnosis in only 194 of 241 (80%) instances. Thus, the algorithm identified women not previously documented as being diabetic. CONCLUSION: Automated analysis of outpatient electronic medical record encounters identified 241 patients with undiagnosed or poorly controlled diabetes over 19 months. Such patients could potentially be offered diagnostic confirmation, treatment, and contraceptive counseling to optimize pregnancy timing. This screening strategy presents an opportunity to improve preconception glucose control and pregnancy outcome.