Lisa Marie Korst

Background/Objectives: Prior studies using administrative data have found that antenatal anemia is a risk factor for severe maternal morbidity (SMM). However, administrative definitions, including the commonly used definition from the Centers for Disease Control and Prevention (CDC), have a poor positive predictive value for some SMM components. We tested the relationship between hemoglobin level at delivery admission and SMM, as defined by gold-standard chart review. Methods: This was a retrospective case–control study of deliveries at a high-acuity hospital in Los Angeles, California, from 2016 to 2019. Administrative data were screened to identify patients with CDC SMM. Control-patients were selected at random from screen-negative individuals. Medical records for all individuals were reviewed for gold-standard SMM criteria, and clinical data were abstracted. Confirmed-positive and confirmed-negative patients were compared using bivariate analyses. Multiple logistic regression models were developed to test the relationship between admission hemoglobin level and gold-standard SMM. Results: Of 4202 eligible individuals, 275 (6.5%) screened positive for SMM. Of these, 107 (38.5%) met gold-standard SMM criteria; 285 confirmed-negative controls were retained for analysis. Case-patients were more likely than control-patients to have anemia on delivery admission (43.9% vs. 24.2%, p < 0.01) and had lower admission hemoglobin levels (11.2 ± 1.7 g/dL vs. 11.9 ± 1.3 g/dL, p < 0.01). After controlling for covariates, admission hemoglobin was independently and inversely associated with gold-standard SMM (aOR = 0.76, 95% CI 0.60–0.96, p = 0.02). Conclusions: Lower hemoglobin level at delivery admission was associated with an increased risk of developing gold-standard SMM.

Background: Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.Objective: To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.Search methods: Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.”Selection criteria: Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.Data collection and analysis: Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.Main results: Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).Conclusions: The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Background: In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management. Objective: To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation. Study Design: This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD. Results: 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit. Conclusion: This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes.

Background: Optimal surgical management of monochorionic diamniotic twins complicated by selective intrauterine growth restriction (SIUGR) type II is unknown. Surgical management may involve selective laser photocoagulation of communicating vessels (SLPCV), which offers the possibility of dual twin survivors versus umbilical cord occlusion (UCO) of the SIUGR twin. Objective: To identify patient characteristics associated with SIUGR twin survival for those undergoing SLPCV. Study design: All patients studied were those who underwent fetal treatment for SIUGR type II at our center from 2006–2018. SIUGR type II was defined as an estimated fetal weight via SLPCV and nine via UCO. Of the 45 SLPCV cases, there were 16 (35.6%) with SIUGR twin (and dual) survival. SIUGR twin survival appeared associated with middle cerebral artery (MCA) peak systolic velocity (psv) post hoc analysis, we subsequently categorized patients as: SIUGR type IIa (N = 32 (71.1%)): normal MCA psv, and normal DV waveform, versus SIUGR type IIb (N = 13 (28.9%)): MCA psv ≥1.5 multiples of the median, and/or DV with absent or reversed atrial systolic flow. Thirty-day survival of the SIUGR twin was 50% for type IIa and 0% for type IIb. Conclusion: Over one-third of SIUGR type II patients experienced dual survival after treatment with laser surgery. Normal MCA psv and normal DV waveforms were associated with SIUGR type II survival of the SIUGR twin. Post hoc exploration and subclassification of SIUGR type II patients by preoperative Doppler indices created two groups, one (type IIa) with 50% survival and one (type IIb) with 0% survival of the SIUGR twin after laser surgery. Upon further confirmation, these findings may provide guidance for counseling patients and conducting fetal therapy.