Whitney Alexandra Booker

BACKGROUND: Isolated diastolic hypertension can precede combined systolic-diastolic hypertension, suggesting isolated diastolic hypertension may be a risk factor for adverse cardiovascular outcomes. Little is known about the prevalence of hypertensive subtypes (isolated diastolic, isolated systolic, or combined systolic-diastolic hypertension) in the years after first pregnancy, and whether these differ after hypertensive disorder of pregnancy. METHODS: This is a secondary analysis (conducted 2023–2024) of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study. Nulliparas were enrolled at 8 US clinical sites from 2010 to 2013; participants who completed the Heart Health Study visit 2 to 7 years after pregnancy were eligible. Blood pressures were elevated at the visit if systolic was ≥130 mm Hg and diastolic ≥80 mm Hg. Multinomial logistic regression relative risk models were adjusted for age, body mass index, race, and time from pregnancy to visit. RESULTS: Four thousand three hundred two participants were included. Mean age at Heart Health Study visit was 30.7 years (SD, 5.6 years); 812 (19%) had elevated blood pressure. Isolated diastolic hypertension was most prevalent (n=627; 15%). Compared with normotensive pregnancy, hypertensive disorders of pregnancy were associated with combined systolic-diastolic (adjusted risk ratio, 3.09 [95% CI, 2.21–4.31]) and isolated diastolic hypertension (adjusted risk ratio, 1.65 [95% CI, 1.36–2.00]). CONCLUSIONS: Isolated diastolic hypertension is the most prevalent hypertensive subtype after first pregnancy. Women with hypertensive disorders of pregnancy had increased risk of combined systolic-diastolic and isolated diastolic hypertension. Given the high prevalence of isolated diastolic hypertension found in this cohort, postpartum women represent a subgroup with opportunity for cardiovascular risk reduction. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02231398.

A didelphys uterus is a rare Müllerian duct anomaly (MDA) caused by the incomplete fusion of the Müllerian ducts, leading to the formation of two distinct uterine cavities. The occurrence of simultaneous twin pregnancies, with each fetus developing in a separate horn of a didelphys uterus, is estimated at approximately 1 in 1,000,000 cases. This case report describes a rare instance of a spontaneous dichorionic diamniotic twin pregnancy, with one fetus in each horn of a didelphys uterus. This is the case of a 35-year-old woman with unilateral renal agenesis who presented with a spontaneous dichorionic diamniotic twin pregnancy, with one fetus in each uterine cavity. This patient's pregnancy complications included intrahepatic cholestasis of pregnancy and rising creatinine levels, leading to a planned cesarean delivery at 36 weeks. The delivery was complicated by intrapartum hemorrhage and the postpartum course was further complicated by sepsis and endometritis. This case highlights the complexity of managing a dichorionic diamniotic twin pregnancy in a didelphys uterus with concomitant congenital unilateral renal agenesis. It contributes to the understanding of optimal management strategies for MDA presentations and highlights the necessity for ongoing research into complications and long-term outcomes associated with such anomalies. ^* Both authors contributed equally to this manuscript. Received: 19 December 2024 Accepted: 08 January 2025 Accepted Manuscript online: 19 March 2025 Article published online: 10 April 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

BACKGROUND: Preeclampsia is associated with autonomic dysregulation during pregnancy; however, less is known about autonomic function in the first week postpartum after preeclampsia. METHODS: We retrospectively analyzed data from a prospective cohort of women with and without preeclampsia. Continuous blood pressure and heart rate were measured with finger plethysmography within 7 days postpartum. Frequency-domain blood pressure and heart rate variability (HRV) were calculated using spectral analysis. Time-domain HRV was calculated as the root mean square of successive R–R interval differences. We compared results between those with and without preeclampsia, as well as between those with new-onset preeclampsia, chronic hypertension with superimposed preeclampsia, and normotensive participants. RESULTS: A total of 70 postpartum women were enrolled: 20 normotensive, 29 new-onset preeclampsia, and 21 superimposed preeclampsia. Both low- and high-frequency blood pressure variabilities were higher in those with preeclampsia compared with controls ( P =0.04 and P =0.02, respectively). This difference was driven by those with new-onset preeclampsia. The preeclampsia group had lower high-frequency HRV ( P P P =0.01); this difference was seen in those with and without chronic hypertension. CONCLUSIONS: Postpartum patients with preeclampsia with and without chronic hypertension had lower HRV compared with normotensive postpartum controls. Higher blood pressure variability was observed only in those with nonsuperimposed preeclampsia, suggesting that the autonomic profile of preeclampsia may differ in patients with chronic hypertension.

Traditionally, midline vertical skin incisions have been utilized during surgery for placenta accreta spectrum (PAS), as it is considered to maximize exposure and allow for a uterine incision to avoid the placenta. However, literature directly comparing outcomes of vertical versus transverse incisions in PAS is sparse. Our objective was to compare maternal outcomes between patients who underwent a vertical versus a transverse skin incision for PAS.Retrospective review of patients with pathologically confirmed PAS undergoing scheduled surgery at our institution between September 2019 and November 2023. Starting in October 2021, select patients were offered a transverse skin approach. Patients were eligible if the surgery was scheduled, and the placenta was not entirely covering the anterior uterine wall. The transverse skin incision was approximately 18 to 20 cm and used the patient's prior scar. Primary outcomes included the rate of maternal transfusion >4 units of packed red blood cells (PRBCs), the incidence of surgical complications, and the need for conversion to general anesthesia (GETA).Seventy patients underwent scheduled surgery for PAS. Thirty-three patients had a vertical skin incision, and 37 had a transverse incision. After initiation of the transverse incision approach, 37/43 (86%) had a transverse incision and none required conversion to a vertical incision intraoperatively. The two groups were similar with regard to age, body mass index (BMI; kg/m2), and severity of PAS. There was no difference in the rate of transfusion of >4 units of PRBCs (vertical 12% vs. transverse 22%, p = 0.29), or in the rate of intraoperative complications (i.e., cystotomy; vertical 3% vs. transverse 14%, p = 0.20). In patients with a transverse incision, a significantly lower number of patients required conversion to GETA intraoperatively (vertical 70% vs. transverse 24%, p < 0.001).In appropriately selected patients, a transverse skin incision was associated with lower conversion to GETA without any difference in intraoperative outcomes.

In this study, we piloted the use of continuous 24-hour blood pressure (BP) monitoring in postpartum patients with preeclampsia with severe features.We measured continuous BP for up to 24 hours using finger plethysmography. We also used an oscillometric device to measure brachial BP per usual clinical protocol (intermittent BP) during the same monitoring period. Using a paired t-test, we compared mean BP values assessed using intermittent and continuous methods, and using McNemar's test, we compared the proportion of patients with sustained severe-range BP using each BP measurement method.A total of 25 patients were included in this study. There was no difference in mean systolic BP (SBP) and mean arterial pressure between intermittent and continuous BP measurements. Intermittently recorded mean diastolic BP (DBP) was significantly higher than continuously recorded DBP. Eleven participants (44%) had sustained SBP ≥160 mm Hg using continuous monitoring compared with two using intermittent monitoring (p = 0.003). Of these 11 participants, 3 (37%) also recorded sustained DBP ≥110 mm Hg using continuous monitoring compared with none using intermittent monitoring.Continuous BP monitoring is a feasible and reliable method for detecting sustained severe-range BP in postpartum patients receiving treatment for preeclampsia with severe features.

Objective This study aimed to compare the effectiveness of oral short-acting (SA) nifedipine with intravenous (IV) labetalol for the treatment of postpartum (PP) severe hypertension. Study Design We conducted a retrospective cohort study of women who delivered at a tertiary care facility between January and December 2018, had not previously received antihypertensive medication, and required treatment for PP severe hypertension defined as systolic blood pressure (SBP) ≥ 160 mm Hg and/or diastolic blood pressure (DBP) ≥110 mm Hg. Exposure groups were defined by the receipt of either oral SA nifedipine or IV labetalol. The primary outcome was time (minutes) to BP control (SBP < 160 mm Hg and DBP st Annual Pregnancy Meeting, Society for Maternal-Fetal Medicine in Virtual Format. Received: 23 July 2024 Accepted: 26 September 2024 Article published online: 30 October 2024 © 2024. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

In 2021, the severe acute respiratory syndrome coronavirus 2 Delta variant rapidly proliferated and became dominant. Some but not all research evidence supports that Delta was associated with increased maternal risk. The purpose of this study was to determine whether Delta was associated with risk for cardiac and respiratory complications in a national sample. Of an estimated 3,495,188 delivery hospitalizations in 2021, 1.8% of pre-Delta deliveries (n = 29,580; January–June) and 2.1% of Delta-period deliveries (n = 37,545; July–December) had a coronavirus disease 2019 (COVID-19) diagnosis. The Delta period was associated with increased adjusted odds of respiratory complications (adjusted odds ratio [aOR] = 1.54, 95% CI: 1.41, 1.69) and cardiac severe maternal morbidity (SMM; aOR = 1.54, 95% CI: 1.40, 1.69). Among deliveries with a COVID-19 diagnosis, the Delta period was associated with a higher incidence of respiratory complications (8.4 vs. 3.7%) and cardiac SMM (8.4 vs. 3.5%; p < 0.01 for both). These findings corroborate prior clinical studies suggesting that the Delta strain was associated with an increased maternal population-level clinical burden.

Objective The American College of Obstetrics threshold for hypertension (≥140/90 mm Hg) differs from those of the American College of Cardiology (ACC) and the American Heart Association (AHA). It is unknown if ACC/AHA hypertension levels are associated with adverse pregnancy outcomes (APOs) after 20 weeks gestation. The purpose of this study is to analyze APOs in women with blood pressure (BP) in the elevated or stage 1 range after 20 weeks gestation. Study Design This was a secondary analysis of the nuMoM2b prospective cohort study of 10,038 nulliparous, singleton pregnancies between 2010 and 2014. BP was measured at three visits during the pregnancy using a standard protocol. Women without medical comorbidities, with normal BP by ACC/AHA guidelines (systolic BP [SBP] < 120 and diastolic BP [DBP] < 80 mm Hg) up to 22 weeks, were included. Exposure was BP between 22 and 29 weeks gestation: normal (SBP < 120 and DBP < 80 mm Hg), elevated (SBP: 120–129 and DBP < 80 mm Hg), and stage 1 (SBP: 130–139 or DBP: 80–89 mm Hg). The primary outcome was hypertensive disorder of pregnancy (HDP) at delivery. Secondary outcomes included fetal growth restriction (FGR), placental abruption, preterm delivery, and cesarean delivery. Multivariable-adjusted odds ratio (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. Results Of 4,460 patients that met inclusion criteria, 3,832 (85.9%) had BP in the normal range, 408 (9.1%) in elevated, and 220 (4.9%) in stage 1 range between 22 and 29 weeks. The likelihood of HDP was significantly higher in women with elevated BP (aOR: 1.71, 95%CI: 1.18,2.48), and stage 1 BP (aOR: 2.79, 95%CI: 1.84,4.23) compared to normal BP (p < 0.001). Stage 1 BP had twice odds of FGR (aOR: 2.33, 95%CI: 1.22,4.47) and elevated BP had three times odds of placental abruption (aOR: 3.03; 95%CI: 1.24,7.39). Conclusion Elevated or stage 1 BP >20 weeks of pregnancy are associated with HDP, FGR, and placental abruption. Key Points

Background: Intracerebral hemorrhage (ICH) is a major cause of maternal morbidity, but its pathophysiology is poorly characterized. We investigated characteristics of pregnancy‐associated ICH (P‐ICH), compared with ICH in similar aged nonpregnant adults of both sexes. Methods and Results: We performed a retrospective analysis of 134 adults aged 18 to 44 years admitted to our center with nontraumatic ICH from January 1, 2012, to December 31, 2021. We compared ICH characteristics among 3 groups: those with P‐ICH (pregnant or within 12 months of end of pregnancy); nonpregnant women; and men. We categorized ICH pathogenesis according to a modified scheme, SMASH‐UP (structural, medications, amyloid angiopathy, systemic, hypertension, undetermined, posterior reversible encephalopathy syndrome/reversible cerebral vasoconstriction syndrome), and calculated odds ratios and 95% CIs for primary (spontaneous small‐vessel) ICH versus secondary ICH (structural lesions or coagulopathy related), using nonpregnant women as the reference. We also compared specific ICH pathogenesis by SMASH‐UP criteria and functional outcomes between groups. Of 134 young adults with nontraumatic ICH, 25 (19%) had P‐ICH, of which 60% occurred postpartum. Those with P‐ICH had higher odds of primary ICH compared with nonpregnant women (adjusted odds ratio, 4.5 [95% CI, 1.4–14.7]). The odds of primary ICH did not differ between men and nonpregnant women. SMASH‐UP pathogenesis for ICH differed significantly between groups ( P <0.001). While the in‐hospital mortality rate was lowest in the P‐ICH group (4%) compared with nonpregnant women (13%) and men (24%), 1 in 4 patients with P‐ICH were bedbound and dependent at the time of discharge. Conclusions: In our cohort of young adults with ICH, 1 in 5 was pregnancy related. P‐ICH differed in pathogenesis compared with non–pregnancy‐related ICH in young adults, suggesting unique pathophysiology.