Women's Health Commons^™

Association Between Neighborhood Social Determinants Of Health And Stillbirth, Tetsuya Kawakita, Misa Hayasaka, Ann M. Harper, John Brush, George Saade

Department of Obstetrics & Gynecology Faculty Publications

OBJECTIVE:

To examine the association between neighborhood-level social determinants of health and stillbirth.

METHODS:

We performed a retrospective cohort study of deliveries that occurred at a gestational age of at least 20 weeks within a five-hospital system (2012-2022). Electronic health record data mapped to the Observational Medical Outcomes Partnership Common Data Model were geocoded using addresses at the time of delivery and linked to neighborhood health indices, which included the Area Deprivation Index (ADI), Maternal Vulnerability Index (MVI), and Social Vulnerability Index (SVI) at the Census tract level. Stillbirths were adjudicated by medical record review. Modified Poisson regression generated relative …

The Taper Sign: Sonographic Representation Of Uterine Dehiscence In Severe Cases Of Placenta Accreta Spectrum, Uma Deshmukh, Anna M. Modest, Alfred Abuhamad, Alireza A. Shamshirsaz, Jonathan L. Hecht, Scott A. Shainker

Department of Obstetrics & Gynecology Faculty Publications

Introduction: Prenatal diagnosis of placenta accreta spectrum (PAS) depends on reliable ultrasound markers and skilled image interpretation. Existing PAS markers emphasize placental features suggestive of abnormal adherence and require advanced image optimization. However, emerging hypotheses suggest that uterine dehiscence—not placental invasion—is the central mechanism underlying PAS, particularly in severe (Grade 3) disease. Despite this, few established ultrasound markers address this uterine dehiscence. We describe a novel ultrasound marker, the taper sign, which uniquely represents the uterine dehiscence in severe PAS with anterior placenta previa, and outline a standardized technique for image acquisition and interpretation.

Methods: This descriptive report details the …

Estetrol (E4) For The Treatment Of Moderate To Severe Vasomotor Symptoms In Postmenopausal Women - Efficacy And Safety Results From The Phase 3 E4comfort I Multicenter, Placebo-Controlled Study, Tommaso Simoncini, Céline Bouchard, Marie Cloes, Mélanie Taziaux, Santiago Palacios, Sebastião Freitas De Medeiros, Valeriu Vrabii, David F. Archer, Nick Panay

Department of Obstetrics & Gynecology Faculty Publications

Objective

To evaluate the efficacy and safety of estetrol in reducing moderate to severe vasomotor symptoms in postmenopausal women.

Methods

Multicenter, randomized, parallel group (1:1:1), placebo-controlled, double-blind, phase 3 study in hysterectomized and non-hysterectomized participants aged 40-65 years. A total of 640 participants with seven or more moderate to severe hot flashes daily or 50 weekly received estetrol 15 mg, estetrol 20 mg, or placebo for 12 weeks. Co-primary endpoints were the change in frequency and severity of moderate to severe vasomotor symptoms from baseline to weeks 4 and 12. Comparisons versus placebo were made using a mixed-effects model for …

Hungarian Validation Of The Pelvic Floor Distress Inventory - 20 (Pfdi-20) Questionnaire And The Pelvic Floor Impact Questionnaire - 7 (Pfiq - 7), Barbara Kozma, Bence Kozma, Peter Takacs, Dávid Rátonyi, Nelli Farkas, Attila G. Sipos, Balint Farkas

Department of Obstetrics & Gynecology Faculty Publications

Introduction and Hypotheses

Pelvic floor disorders (PFDs) affect women's quality of life through physical, psychological, and social domains. The Pelvic Floor Distress Inventory-20 (PFDI-20) and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) are validated tools for assessing symptom severity and quality of life impact. The current study aim to investigate the reliability and validity of the Hungarian versions of these questionnaires in women with PFD symptoms.

Methods

This validation study was carried out at the University of Debrecen among women with clinically confirmed pelvic floor disorders. The PFDI-20 and PFIQ-7 questionnaires were translated into Hungarian using independent native English speaker in …

Osmotic Dilators Vs. Foley Balloons: Bayesian Secondary Analyses Of The Dilafol Trial, Antonio F. Saad, Elenir B. C. Avritscher, Claudia Pedroza, Xiao Han, George R. Saade

Department of Obstetrics & Gynecology Faculty Publications

Background: Dilapan-S, a synthetic osmotic dilator used for pre-induction cervical ripening, has proven to be as effective as the Foley balloon in terms of vaginal versus cesarean delivery and has been associated with increased patient satisfaction. Nevertheless, its ability to lower cesarean rates and its cost-effectiveness remain poorly studied.

Objectives: To estimate the likelihood that synthetic osmotic dilators reduce cesarean deliveries and to evaluate their health system costs (2026 US$) and incremental cost-effectiveness compared to the Foley balloon during cervical ripening.

Study Design: Secondary Bayesian analyses were conducted using data from the single-center DILAFOL randomized controlled trial, which enrolled 419 …

The Association Between The Degree Of Social Vulnerability And Maternal Anemia And Other Adverse Perinatal Outcomes, Rubymel J. Knupp, Christina T. Blanchard, Ariann Nassel, Ashley Shea, Lindsay S. Robbins, Jeff M. Szychowski, Ashley N. Battarbee, Akila Subramaniam

Department of Obstetrics & Gynecology Faculty Publications

Objective

Maternal anemia in pregnancy is associated with many adverse maternal, fetal, and neonatal outcomes. The role of social determinants of health (SDOH) in the development of maternal anemia and other adverse outcomes is continually evolving. One such newer tool, the Social Vulnerability Index (SVI), measures an individual's community-level SDOH, with higher SVI denoting higher vulnerability. Our objective was to evaluate the association between SVI, maternal anemia, and other adverse perinatal outcomes.

Methods

Retrospective cohort study of pregnant individuals delivering singletons at a gestational age ≥23 weeks at a single center from 2014 to 2018. Patients with sickle cell disease, …

Risk Of Gestational Diabetes By Aerobic And Resistance Exercise During The First And Second Trimesters, Takaki Tanamoto, George Saade, Leryn J. Reynolds, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

Objective

While some studies have shown that exercise reduces the incidence of gestational diabetes mellitus (GDM), there is limited evidence on whether aerobic or resistance exercise is more beneficial. This study aimed to examine the rate of GDM according to the type of exercise during early pregnancy.

Study design

We analyzed data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective cohort of individuals enrolled during the first and second trimesters. We excluded participants with pregestational diabetes or delivery < 20 weeks. The primary exposure was either aerobic or resistance exercises in the first or second trimester. For each trimester, the metabolic equivalent of task hours per week (MET-h/week) was calculated for each exercise. Participants were grouped as follows: "Aerobic exercise" (≥7.5 MET-h/week from aerobic exercises), "Resistance exercise" (≥2 times/week from resistance exercises), "Both types of exercise" (≥7.5 MET-h/week from aerobic exercise and ≥2 times/week from resistance exercises), and "Insufficient exercise" (≤7.5 MET-h/week from aerobic exercise and ≤2 times/week from resistance exercises). Our primary outcome was GDM. Adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs) were calculated using modified Poisson regression, adjusting for potential confounders.

Results

In both the first and second trimesters, analyses included 9049 individuals. In the first trimester, individuals who performed …

The Association Between Social Vulnerability And Racial Disparities In Preterm Birth, Anita Pershad, Gabby Adams, Lindsay Robbins, George Saade, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

Objective

To evaluate the association between county-level social vulnerability and preterm birth and assess whether racial disparities vary across levels of vulnerability.

Methods

This cross-sectional study utilized restricted Centers for Disease Control and Prevention natality data from 2023. We included Black or White births with singleton pregnancies across 3123 US counties from 50 US states and the District of Columbia. Participants were grouped into quartiles based on the county-level Social Vulnerability Index (SVI), with quartile 4 representing the most socially vulnerable populations. The primary outcome was preterm birth, defined as delivery before 37 weeks. Secondary outcomes included small for gestational …

Prepregnancy Diet Quality Index And Adverse Pregnancy Outcomes, Ummayhany Bharmal, George Saade, Philip Greenland, Brenda J. Smith, Andrea C. Kozai, Stephanie A. Fisher, Lauren Theilen, William Grobman, Noel Bairey Merz, Uma Reddy, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

Introduction

Adverse pregnancy outcomes (APOs) are a major cause of maternal and neonatal morbidity.¹ Preconception diet quality is associated with APO risk,² but prior pregnancy-related indices had notable limitations.³ We developed the Prepregnancy Dietary Quality Index (PreP-DQI) to assess its association with APOs and cardiometabolic health.

Methods

This cohort study used data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (NuMoM2b) and the NuMoM2b-Heart Health Study (NuMoM2b-HHS),⁴,⁵ excluding individuals who delivered before 23 weeks of gestation, had fetal anomalies, missing dietary data, or had implausible caloric intake (below 1st percentile or above 99th percentile). All participants in the original studies …

Association Between The Social Vulnerability Index And Adverse Pregnancy Outcomes, Tetsuya Kawakita, Misa Hayasaka, Lindsay Robbins, Juliana Martins, George Saade

Department of Obstetrics & Gynecology Faculty Publications

Objective: To assess the association between the Social Vulnerability Index (SVI) and racial disparities in pregnancy outcomes across U.S. counties and to quantify these racial disparities.

Methods: This was a cross-sectional study using restricted Centers for Disease Control and Prevention data sets, including natality data sets, fetal death data sets, and all-cause mortality data sets from 2016 to 2021. We limited analyses to Black or White individuals aged 15-44 years from 3,114 U.S. counties. Participants were categorized into quartiles based on county-level SVI. The primary outcome was maternal mortality rate while pregnant or within 42 days of the end of …

Exposure To Phthalates And Replacements During Pregnancy In Association With Gestational Blood Pressure And Hypertensive Disorders Of Pregnancy, Erin E. Mcnell, Danielle R. Stevens, Barrett M. Welch, Emma M. Rosenthal, Suzanne Fenton, Antonia M. Calafat, Julianne Cook Botelho, Elena Sinkovskaya, Ann Przybylska, George Saade, Alfred Abuhamad, Kelly K. Ferguson

Department of Obstetrics & Gynecology Faculty Publications

Exposure to endocrine-disrupting chemicals such as phthalates may increase risk of hypertensive disorders of pregnancy (HDP). Prior studies lack investigation of chemical mixtures, phthalate replacements, or key periods of susceptibility including early pregnancy. In the present study, we used a longitudinal approach to evaluate gestational exposure to phthalates and replacements, as both single-pollutants and mixtures, in association with blood pressure and diagnosis of preeclampsia or any HDP. The Human Placenta and Phthalates prospective pregnancy cohort includes 291 participants recruited from two U.S. clinics. Urinary metabolites of ten phthalates and replacements were quantified at up to 8 time points per individual …

Methodological And Clinical Concerns In The Study On Postpartum Hypertension Management, Takaki Tanamoto, Kyosuke Kamijo, Yusuke Tsutsumi, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

[Introduction] We read with interest the recent study by Rosenfeld et al.¹ However, we have several clinical and methodological concerns about this study.¹

First, this study's propensity score matching (PSM) lacked key clinical confounders, including perinatal risk factors and the highest systolic/diastolic blood pressures. Smoking, alcohol use, and multifetal gestation, which influence blood pressure during pregnancy,²,³ potentially affect both primary and secondary outcomes. Additionally, the authors did not report standardized mean differences before and after PSM, which are essential for assessing balance.⁴

Longitudinal Assessment Of Intravillous Arterioles In Normal Pregnancy Using Superb Microvascular Imaging, R. Horgan, E. Sinkovskaya, G. Saade, E. Kalafat, A. Heeze, A. Abuhamad

Department of Obstetrics & Gynecology Faculty Publications

Objective

To use superb microvascular imaging (SMI) to longitudinally evaluate blood flow in intravillous arterioles (IVA) in pregnancy, and to develop reference ranges for IVA pulsatility index (PI) and peak systolic velocity (PSV) from 12 to 38 weeks' gestation.

Methods

The data for this study were obtained from the National Institutes of Health-funded Human Placenta Project. Eligible for inclusion were women aged 18-35 years, with a body mass index of <  30 kg/m², without comorbidities, with a singleton pregnancy conceived spontaneously and a gestational age of ≤ 13 + 6 weeks. Exclusion criteria were maternal or neonatal complications, fetal or umbilical cord anomalies, abnormal placental implantation and delivery <  37 weeks. Each participant underwent eight ultrasound examinations during pregnancy. Using SMI technology, the total number of IVA identified was recorded in a sagittal placental section at the level of cord insertion. The PI and PSV were measured in a total of six IVA (two in the central portion of the placenta, two peripherally towards the uterine fundal portion and two peripherally towards the lower uterine segment). Umbilical artery (UA)-PI was also obtained. Multilevel regression models were used to create reference ranges for IVA-PI and IVA-PSV at 12-38 weeks' gestation.

Results

A total of 90 women fulfilled the study criteria. IVA-PI decreased throughout pregnancy from a mean ± SD of 1.04 ± 0.23 in the first trimester (at 12-13 weeks) …

Association Between The Intensity Of Exercise In The First Trimester And Early Second Trimester And The Risk Of Gestational Diabetes, Takaki Tanamoto, Misa Hayasaka, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

Objective

Although some studies show that exercise decreases the incidence of gestational diabetes mellitus (GDM), the optimal exercise intensity during pregnancy remains unclear. We examined GDM risk according to exercise intensity in pregnant individuals.

Methods

We analyzed data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers‐to‐Be (nuMoM2b), a prospective study enrolling nulliparous individuals in the first trimester. Participants with pregestational diabetes or delivery before 20 weeks were excluded. Exercise intensity during the first (6–13 weeks’ gestation) and early second (16–21 weeks’ gestation) trimesters was categorized by metabolic equivalent of task hours per week (MET‐hr/week) as none, low intensity (< 7.5), moderate intensity (7.5–14.9), or high intensity (≥ 15). The primary outcome was GDM; secondary outcomes included preeclampsia, gestational hypertension, preterm birth, small‐for‐gestational‐age birth, and stillbirth. Adjusted relative risks (aRRs) with 95% confidence intervals (CIs) were calculated using a generalized linear mixed‐effects model with a Poisson distribution and robust error variance, controlling for the random effects of individuals and potential confounders.

Results …

Racial Disparities In Maternal Mortality Before, During, And After The Covid-19 Pandemic In The United States: A Difference-In-Difference Analysis, Kyosuke Kamijo, Misa Hayasaka, Tetsuya Kawakita

Department of Obstetrics & Gynecology Faculty Publications

Background

This study aimed to examine changes in racial disparities in pregnancy-related and maternal mortality before, during, and after the COVID-19 pandemic in the United States.

Methodology

This was a cross-sectional study using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) data from January 2018 to June 2024. We focused on pregnancy-related and maternal mortality among Black and White individuals to examine racial disparities. The study periods were defined as pre-pandemic (January 2018-March 2020), pandemic (April 2020-March 2022), and post-pandemic (April 2022-June 2024). We applied interrupted time series analysis and difference-in-difference (DID) models …

Association Of Mean Arterial, Systolic, And Diastolic Blood Pressure Trends In Early Pregnancy With Superimposed Preeclampsia With Severe Features In Pregnancies Complicated By Chronic Hypertension, Tetsuya Kawakita, Justin M. Leach, George R. Saade, Kim Boggess, Lorraine Dugoff, Brenna L. Hughes, Joseph Bell, Kjersti Aagaard, Rodney K. Edwards, Kelly Gibson, David M. Haas, Lauren Plante, Torri Metz, Brian Casey, Sherri Longo, Matthew K. Hoffman, Kara K. Hoppe, Methodius Tuuli, Michelle Y. Owens, Heather Frey, Todd Rosen, Uma M. Reddy, Wendy Kinzler, Emily Su, Iris Krishna, Mary E. Norton, Daniel Skupski, Yasser Y. El-Sayed, Ronald Librizzi, Mounira Habli, Shauna Williams, Gabriella Pridjian, David S. Mckenna, Sarah Osmundson, Joanne Quinones, Zorina Galis, Lorie Harper, Namasivayam Ambalavanan, Jeff M. Szychowski, Alan T.N. Tita

Department of Obstetrics & Gynecology Faculty Publications

OBJECTIVE: To evaluate the association of longitudinal systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in early pregnancy with later development of superimposed preeclampsia with severe features in pregnancies complicated by mild chronic hypertension.

METHODS: This secondary analysis used data from the CHAP (Chronic Hypertension and Pregnancy) trial, a multicenter randomized controlled trial that involved pregnant individuals with chronic hypertension. Participants were categorized based on the development of superimposed preeclampsia with severe features. Longitudinal blood pressure measurements from enrollment to the development of superimposed preeclampsia with severe features or delivery were assessed using regression models. …

Timing Of Delivery In Preeclampsia: Time To Reconsider?, Rebecca Horgan, Ahmed S. Z. Moustafa, Mackenzie Mchugh, Tetsuya Kawakita, Baha Sibai, George Saade

Department of Obstetrics & Gynecology Faculty Publications

The article discusses the need to reassess the timing of delivery in cases of preeclampsia, a condition affecting 2%–8% of pregnancies and linked to significant maternal and neonatal risks. It highlights that existing guidelines, primarily based on older studies, may not adequately reflect current clinical practices and advancements in neonatal care. The authors suggest that planned delivery at 34–36 weeks of gestation may offer maternal benefits without increasing short-term neonatal morbidity, while also emphasizing the importance of considering long-term outcomes for both mothers and infants. They advocate for further research, including large-scale randomized trials, to better understand the implications of …

Longitudinal Assessment Of Fetal Myocardial Performance Index In Normal Pregnancy Using Spectral Tissue Doppler, R. Horgan, E. Sinkovskaya, E. Kalafat, G. Saade, A. Abuhamad

Department of Obstetrics & Gynecology Faculty Publications

Objective

Although spectral tissue Doppler imaging is recognized as the optimal method for assessing the fetal myocardial performance index (MPI), longitudinal reference ranges for fetal MPI measured using spectral tissue Doppler have not been established. Our objective was to use spectral tissue Doppler data to establish gestational-age-specific reference ranges from 12–33 weeks for left and right ventricular fetal MPI.

Methods

This was a prospective longitudinal study of women aged 18–35 years, with a body mass index below 30 kg/m² and a singleton pregnancy conceived spontaneously. Fetal MPI measurements were obtained in the first, second and third trimesters and MPI was …

Association Between Adverse Pregnancy Outcomes And Awareness Of Cardiovascular Risk Factors: A Numom2b-Hhs Secondary Analysis, Elizabeth M. Wendl, Amanda A. Allshouse, Ashley Goodwin, Bri Hobbs, Philip Greenland, Lisa Levine, William Grobman, George R. Saade, Natalie Cameron, C. Noel Bairey Merz, Caroline Rouse, Sarah Rogan, Judith H. Chung, Lauren H. Theilen, National Heart, Lung, And Blood Institute Numom2b Heart Health Study Network

Department of Obstetrics & Gynecology Faculty Publications

Background

Adverse pregnancy outcomes (APOs) affect 10%-20% of pregnancies and are associated with increased risk of cardiovascular disease.

Objective

To determine whether the history of APO is associated with a person's awareness of their cardiovascular risk factors (CRF) 2-7 years postpartum.

Methods

This is a secondary analysis of a multicenter cohort study in which nulliparous pregnant people were enrolled in the first trimester and followed prospectively. Participants with a CRF (hypertension, dyslipidemia, and/or prediabetes/diabetes) at follow-up were included. We excluded participants with: pre-gestational diabetes, chronic hypertension, dyslipidemia during the index pregnancy or subsequent pregnancy, and non-fasting blood draws. The exposure …