Kara M. Rood

Objective: To test the hypothesis that breastfeeding is associated with improved neurodevelopmental outcomes among children delivered late preterm. Study design: Secondary analysis of a prospective, follow‐up study of ≥6‐year‐old children enrolled in the Antenatal Late Preterm Steroid (ALPS) Trial, a multicenter study that assessed betamethasone administration in pregnancies deemed to be at imminent risk of late preterm birth (34–36 weeks). Term births and those with missing breastfeeding data were excluded. The primary exposure was breastfeeding (exclusive or partial) at 3 months of life collected via maternal interviews. Any breastfeeding at 6 months was examined as a secondary exposure. The primary outcome was cognitive function at age ≥6, measured by the Differential Ability Scales, 2nd Edition (DAS‐II) core components of the General Conceptual Ability (GCA) that includes verbal, non‐verbal reasoning, and spatial abilities. Secondary outcomes included Gross Motor Function Classification System level, Social Responsiveness Scale, and Child Behavior Checklist scores. Multivariable analyses were adjusted for prespecified baseline characteristics (maternal age and education, gestational age at birth, child age, sex, tobacco use in pregnancy, ALPS study group, study center). Results: Of 797 mothers included in the analysis, 414 (51.9%) were breastfeeding 3 months after giving birth. Participants who breastfed were older, of lower body mass index (BMI), and were more likely to be White, have a college degree, be married, have private insurance, and less likely to have used tobacco in pregnancy. Children of participants who breastfed were also older at follow‐up. There were no differences in birth weight or gestational age at birth by breastfeeding status. The primary outcome, DAS‐II GCA, was higher among children who were breastfed at 3 months, 100.5 ± 13.7 vs. 93.2 ± 13.2, mean difference of 7.27 (95% confidence interval [CI], 5.32, 9.22; adjusted mean difference, 2.54; 95% CI, 0.70, 4.37). In secondary analyses, differences in the overall GCA appeared to be driven by increased scores for spatial ability and nonverbal reasoning. There were no differences in secondary outcomes. Conclusions: Among children born late preterm at 34–36 weeks, breastfeeding (exclusive or partial) at 3 months of life was associated with improved neurodevelopmental outcomes at age 6 or older. Breastfeeding for ≥3 months was associated with a modest increase in GCA score (2.5 points; 0.17 SD), the clinical significance of which is likely greater at the population than individual level.

Introduction: In the past decade, hepatitis C virus (HCV) infections among pregnant women increased dramatically in the United States, rising in parallel with the opioid crisis and increasing the number of children at risk for HCV. People with HCV infection that remains untreated are also at increased risk of cirrhosis, liver cancer, and death. Objective: To describe timing of HCV testing during pregnancy and postpartum HCV treatment among women with opioid use disorder (OUD). Methods: This analysis draws from the MATernaL and Infant clinical NetworK (MAT‐LINK) surveillance system's cohort of women with OUD during pregnancy, which is collected from electronic health records of seven healthcare systems. Women were included if they had OUD during pregnancy and a known pregnancy outcome during January 1, 2014–August 31, 2021. Antenatal HCV testing was examined by characteristics of pregnant women (including age, race, ethnicity, insurance, urbanicity, parity, and medication for OUD) using multinomial regression. Hepatitis C diagnosis (positive antibody or nucleic acid test or diagnostic code) and postpartum treatment were also examined. Results: Among the 5533 pregnancies in this cohort, 1506 (27.2%) had no testing or diagnostic code for hepatitis C including 1296 who received prenatal care. Among 910 pregnancies with no prenatal care, 700 (76.9%) had HCV testing or diagnostic codes. Among pregnancies with HCV testing or diagnostic codes, 55.8% had a hepatitis C diagnosis. Women were more likely to have HCV testing if they were White or Hispanic, had government‐funded insurance, or received medication for OUD during the pregnancy. From five clinical sites with prescription information available, 9.7% ( n = 81/836) of those with a detectable viral load had a direct‐acting antiviral prescription in the first year postpartum. Conclusion: Women with OUD during pregnancy have a high burden of hepatitis C. Despite national recommendations, gaps remain in HCV testing during pregnancy and HCV treatment postpartum. HCV testing among women with no prenatal care indicates that testing is occurring outside of traditional prenatal care settings. Receiving medication for OUD was associated with being tested for HCV during pregnancy. Improved HCV testing, treatment, and management for pregnant women with OUD represent opportunities for improving overall health and eliminating HCV infection.

Objective: To examine the likelihood of experiencing an overdose among women receiving any buprenorphine (with or without naloxone) compared to women receiving methadone during pregnancy. Methods: Data from the MATernaL and Infant clinical NetworK (MAT‐LINK), a longitudinal surveillance system of pregnant woman–child dyads using electronic health records (EHRs), were analyzed. Women from geographically diverse US clinical sites who had a diagnosis of opioid use disorder (OUD) during pregnancy, were prescribed medication for opioid use disorder (MOUD), and had a known birth outcome occurring between January 1, 2014 and August 31, 2021 were included. The Andersen–Gill Cox regression model for recurrent events with robust standard errors was used to model the effect of MOUD type by trimester on time to overdose or date of pregnancy outcome and calculate adjusted hazard ratios (aHRs). Results: Among the 3682 pregnancies included in this analysis, 46 (1.2%) had at least one EHR‐documented overdose. None of the overdoses were fatal. In adjusted models, no differences in overdose were observed between pregnancies in which buprenorphine was prescribed or administered compared to pregnancies in which methadone was prescribed or administered (any drug overdose: aHR, 0.62; 95% CI, 0.31–1.23; opioid‐involved overdose: aHR, 0.49; 95% CI, 0.18–1.30). In a trimester‐specific sub‐analysis of pregnancies with at least two MOUD prescriptions or administrations, taking buprenorphine in the third trimester resulted in a decreased likelihood of any drug overdose (aHR, 0.43; 95% CI, 0.20–0.93) and opioid‐involved overdose (aHR, 0.32; 95% CI, 0.11–0.92) compared with methadone. Conclusion: It is important that women with OUD are initiated on the medication that works best for them as early as possible during pregnancy and that reinforcement of the importance of MOUD occurs throughout pregnancy, paying special attention to disruptions in treatment during the third trimester that might increase risk for overdose.

Objective: To identify predictors of postpartum hemorrhage (PPH) treatment success with the JADA intrauterine vacuum‐induced hemorrhage‐control device in post‐market settings. Methods: We performed a retrospective cohort study of PPH managed using the JADA system across 16 centers in the United States (NCT04995887). Treatment success was defined as no treatment escalation or PPH recurrence after device placement. Multivariable logistic regression was used to determine significant predictors of PPH treatment success with a stepwise model selection technique. Selection of the best performing model was determined using area under the receiver operating characteristic (AUC) curves, Akaike information criterion (AIC), and data completeness. In exploratory analyses, we assessed differences in treatment success by cause of bleeding and difference in time to device insertion by self‐reported race, including an interaction term between race and insertion time. Results: From October 2020 to March 2022, 800 individuals had PPH managed with the JADA device. Most individuals delivered vaginally ( n = 530, 66.3%), self‐identified as White ( n = 463, 58.7%), and had a body mass index at delivery ≥35 kg/m ² ( n = 322, 40.2%). Cumulative blood loss (CBL) ≥1000 mL before device insertion occurred in 59.5% of individuals, and 65.9% experienced isolated uterine atony. Overall, the treatment success rate was 89.5%, varying across the top predictors. Device success ranged from 90.0% to 94.3% when CBL was p value range: 0.00001–0.05924). Multiple causes of bleeding (atony and non‐atony) were associated with lower treatment success compared to isolated atony (81.9% vs. 92.6%, p < 0.001), but not with only non‐atony bleeding causes (91.3%, p = 0.12). Individuals who identified as White had shorter time to insertion compared to non‐White (38.5 vs. 54.0 min, p < 0.01); however, the interaction between race and insertion time was not significant ( p = 0.52). Conclusion: The two most important predictors of treatment success with JADA device were CBL prior to device insertion and the etiology of the bleeding. Understanding these factors may guide PPH treatment algorithms.

Background: Cesarean delivery is a major risk factor for postpartum hemorrhage. A priority for postpartum hemorrhage safety bundles is the assessment of hemorrhage and transfusion risk following cesarean delivery and the identification of patients at increased risk for postpartum hemorrhage requiring red blood cell transfusion. A prediction model based on antenatal and intrapartum risk factors could be used in a standardized manner among all patients when considering crossmatch or other preparatory measures prior to cesarean delivery. Objective: To develop a multivariable prediction model for red blood cell transfusion associated with cesarean delivery using a prospective contemporary cohort. Methods: Secondary analysis of a multicenter trial of tranexamic acid (TXA) versus placebo for the prevention of red blood cell transfusion after cesarean delivery was performed. The primary outcome for this analysis was transfusion of packed red blood cells by hospital discharge or 7 days postpartum, whichever came first. Maternal characteristics and risk factors related to labor were compared between patients who received a transfusion and those who did not. Any of the characteristics that differed with a p value k ‐fold cross‐validation. Using backward elimination, variables that remained significant at p < 0.05 were retained in each model. The final model was chosen based on the highest area under the receiver operating characteristic curve (ROC) in the validation set. Results: A total of 418 of 10,961 patients (3.8%) received a red blood cell transfusion. Factors associated with transfusion and retained in the final model included gestational age at delivery <34 weeks or ≥41 weeks, chorioamnionitis, aspirin use in the week before delivery, preoperative hemoglobin level, preoperative platelet count <100,000, oxytocin duration, and cesarean delivery during the second stage of labor. The final multivariable model had excellent discrimination with an area under the curve (AUC) of 0.79 (95% confidence interval [CI], 0.76, 0.81). Using the same set of seven factors identified in the prediction model for transfusion, the AUC was 0.62 (95% CI, 0.60, 0.65) for differentiating patients who did and did not require surgical/radiological interventions in response to bleeding. Conclusion: We identified several factors associated with risk of red blood cell transfusion during/after cesarean delivery and a model with excellent predictive ability. Risk factors in this model, including lower preoperative hemoglobin level, aspirin use <7 days before delivery, and delivery during the second stage of labor, may be used to risk‐stratify patients for preparation for transfusion to reduce postoperative complications that result from bleeding.

Purpose This study aimed to address an evidentiary gap by exploring caregivers’ lived experiences of spontaneous preterm birth (sPTB) resulting from spontaneous preterm labor (sPTL) and characterize the most relevant health-related quality of life (HRQoL) impacts. Insights were used to develop a conceptual model. Methods Qualitative concept elicitation interviews were conducted with 24 primary caregivers in the United States, diagnosed with sPTB between 23 and 36 weeks’ gestational age (GA) resulting from sPTL. Interview transcripts were thematically analyzed. Results During pregnancy, caregivers commonly reported physical and emotional changes, and limited awareness of sPTL. Many did not recognize their signs and symptoms of sPTL onset as indicative of labor, and described a lack of choice regarding sPTL treatment. Caregivers consistently described neonatal outcomes as central to maternal HRQoL. Those who gave birth at lower GAs typically reported more frequent short-term and longer-term neonatal health or developmental problems, longer NICU stays, and worse NICU experiences. Maternal HRQoL impacts persisted well beyond the neonatal period, with emotional wellbeing remaining the most impacted domain in both the short-term (from delivery to 28 days following caregivers’ estimated date of delivery [EDD]) and longer-term (from 28 days to two years post-EDD). Conclusion This study centralizes the caregiver perspective, which is imperative to improving maternal outcomes. Caregivers’ experiences (particularly of neonatal outcomes such as length of NICU stay) are integral to shaping maternal HRQoL. Increased awareness of sPTL signs and symptoms, and enhanced sPTL management strategies, are needed to improve both maternal and neonatal outcomes.

Background: Sexual abuse before the age of 10 is reported by 2.7% of US women. Chronic pain has been linked to sexual abuse, but little is known about acute postoperative pain in those with a sexual abuse history and no history of chronic pain. We hypothesized that those who report prepubertal sexual abuse experience more pain at 7 days after hospital discharge from a cesarean delivery. Objective: To evaluate whether patients who report prepubertal sexual abuse experience more pain 7 days after hospital discharge from a cesarean delivery. Study Design: Secondary analysis of a multicenter randomized trial of individuals who underwent cesarean at 31 US hospitals (2020–2022). Participants were excluded if they had chronic pain or were missing sexual abuse data. The primary outcome was moderate‐to‐severe worst pain (≥4 on a scale from 0 to 10), as assessed by the Brief Pain Inventory (BPI), 7 days after discharge. Secondary outcomes included BPI at 2 weeks post‐discharge and 6 weeks and 90 days postpartum, Pain Catastrophizing Scale (PCS) and Physical Function (PF) scores at 6 weeks, Milligram Morphine Equivalents (MME) use in 24 h before discharge, and opioid use measured at 90 days (number of prescriptions beyond discharge and total number of tablets taken after discharge). Maternal characteristics were compared between those with and without prepubertal sexual abuse. Multivariable modeling was performed adjusting for prepregnancy body mass index (BMI), family history of substance use disorders, and Edinburgh depression score ≥13 at randomization. Results: Of the 4881 participants included in the analysis, 5.3% reported prepubertal sexual abuse. They were significantly more likely to have a BMI ≥30 (54% vs. 44%), a family history of substance use disorders (58% vs. 24%), and an Edinburgh depression score ≥ 13 (9% vs. 4%) (all p < 0.05). Multivariable models showed that a BPI score ≥ 4 was significantly higher 7 days post‐discharge (75% vs. 57%; adjusted relative risk [aRR], 1.3 [1.2, 1.4]) in those reporting prepubertal sexual abuse. BPI scores remained significantly higher through 6 weeks (2 weeks: 42% vs. 30%; aRR, 1.3 [1.1, 1.6]; 6 weeks: 14% vs. 10%; aRR, 1.5 [1.01, 2.1]; 90 days: 5% vs. 5%; aRR, 0.9 [0.4, 1.8]). PCS score ≥ 12 (15% vs. 12%) and PF score below average (64% vs. 56%) were not significantly different at 6 weeks. Opioid use in the 24 h before discharge (median MME 22.5% vs. 15, p < 0.01), additional opioid prescriptions after discharge (10% vs. 6%; aRR, 1.7 [1.1, 2.5]), and median total opioid tabs used after discharge (9% vs. 4 tabs, p < 0.01) were all significantly higher among individuals reporting prepubertal sexual abuse. Conclusion: In postpartum individuals who reported prepubertal sexual abuse, post‐cesarean pain through 6 weeks and prescription opioid use were significantly higher. These associations warrant further study.

BACKGROUND: Optimal dosing of nifedipine gastrointestinal therapeutic system (GITS) in pregnancies complicated by preeclampsia with severe features is unknown. We assessed whether nifedipine GITS 30 mg BID improved blood pressure control when compared with nifedipine GITS 60 mg daily. METHODS: Unblinded, randomized controlled trial, at a single academic hospital from December 2021 to December 2023. Individuals between 22 ^0/7 and 33 ^5/7 weeks of gestation diagnosed with preeclampsia with severe features were randomized to nifedipine GITS 60 mg QD or 30 mg BID once the decision to increase the total daily dose was made. The primary outcome was the percentage of suboptimal blood pressures on hours 24 to 48 after randomization, defined as the ratio of systolic ≥150 mm Hg and diastolic ≥100 mm Hg blood pressure episodes divided by the total number of blood pressures taken during the collection time period. RESULTS: The percentage of suboptimal blood pressure from hours 24 to 48 was similar between groups (60 mg daily: 34.2±29.4% versus 30 mg BID: 32.8±34.0%; P =0.87). The need for any emergent antihypertensive treatment during the blood pressure collection period was higher in the 60 mg daily group (46.2% versus 14.8%; P =0.03). Secondary outcomes including gestational age at delivery and number of increases in long-acting antihypertensive regimen were similar. CONCLUSIONS: Nifedipine GITS dosed 60 mg daily and 30 mg BID has similar rates of suboptimal blood pressure in individuals with preeclampsia with severe features. However, there is a reduction in the need for emergent antihypertensive treatment for severe range blood pressures with BID dosing, which would favor its use in this population.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality globally, and PPH rates in the United States are increasing. The current study describes treatment patterns and healthcare costs in abnormal postpartum uterine bleeding and PPH in the United States.Method: Utilizing data from the US Premier Hospital Database from January 2016 to March 2022, this study investigated treatment patterns for second‐line uterotonics and tranexamic acid (TXA), as well as the incidence of PPH and associated severe maternal morbidity (SMM) events, treatment patterns, and total healthcare costs. The analysis included 5,345,753 inpatient admissions for deliveries, identified PPH through ICD‐10 CM codes or administration of specified uterotonic medications beyond oxytocin.Results: A total of 787,964 (14.7%) individuals had PPH and/or received second‐line uterotonics beyond oxytocin (methylergonovine maleate, carboprost, misoprostol) and/or TXA. Rates of second‐line uterotonics/TXA and/or PPH increased from 12.1% in 2016 to 19.7% in 2022. Methylergonovine (51.9%) and misoprostol (47.0%) were the most used uterotonics. The mean ± SD SMM and nontransfusion SMM comorbidity scores were 6.8 ± 8.9 and 8.5 ± 12.4, respectively, and included common maternal risk factors such as advanced maternal age, anemia, prior cesarean delivery, and hypertensive disorders. Economic burden was high, particularly for individuals who required hysterectomy (vaginal births: $29,375 and cesarean births: $34,103), received uterine balloon tamponade (UBT; vaginal births: $12,605 and cesarean births: $20,188), and/or were treated with 3 or more second‐line uterotonics/TXA (vaginal births: $10,084 and cesarean births: $16,288). Intensive care unit admissions and hysterectomies were more common in the 3–4 uterotonics/TXA groups (4.4% and 2.2%) and among those who received UBT (9.4% and 4.4%) than those who received < 3 uterotonics/TXA.Conclusion: Using second‐line uterotonic/TXA use and PPH diagnosis codes, the observed rate of abnormal postpartum bleeding was higher than previously reported and associated with significant clinical and economic burden. Total costs increased with greater use of uterotonics/TXA, especially in cases involving UBT or SMM such as hysterectomy. Higher treatment intensity likely reflects escalation in response to more severe clinical presentations. These findings highlight the need for appropriate intervention, better treatment options, and preventive strategies to manage abnormal postpartum uterine bleeding and PPH.