Patient Experience with Telehealth Medicine During the Ongoing COVID-19 Pandemic in New York City.

Background: The COVID-19 pandemic accelerated integration of telehealth services into OBGYN practices in New York City. Since then, studies have shown high patient satisfaction with OBGYN telehealth services. However, few studies have compared satisfaction between obstetric and gynecologic patients. The primary objective of this study was to compare satisfaction with telehealth services between obstetric and gynecologic patients. Methods: This was an institutional review board-approved cross-sectional survey study among patients who had a telehealth visit at NYU OBGYN Faculty Group Practice from March 2020 to March 2021. Results: Gynecologic patients had higher rates of being "completely satisfied" compared with obstetric patients (40% vs. 24%, p < 0.001). Gynecologic patients were more likely to opt for telehealth services than obstetric patients both during a pandemic (70% vs. 59%, p < 0.001) and in the absence of a pandemic (53% vs. 37%, p < 0.001). Discussion: Prior studies have demonstrated high satisfaction with OBGYN telehealth. However, obstetric patients were less likely than gynecologic patients to feel satisfied with and opt for telehealth services.

Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage.

OBJECTIVE: Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. STUDY DESIGN: A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. RESULTS: During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). CONCLUSION: Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. KEY POINTS: · Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..

Thromboelastography versus Standard Coagulation Assays in Patients with Postpartum Hemorrhage.

OBJECTIVE: Thromboelastography (TEG), a point-of-care test that measures blood's dynamic viscoelastic properties, is routinely used to guide resuscitation in surgical specialties with high hemorrhage risk. Patients with ongoing postpartum hemorrhage (PPH) often develop coagulopathy and hypofibrinogenemia. Timely assessment of fibrinogen is crucial because cryoprecipitate for repletion requires thawing time prior to administration. TEG may provide rapid assessment of coagulopathy in ongoing hemorrhage but this has not been thoroughly studied. Our objective was to determine if TEG accurately reflects coagulopathy in ongoing PPH when compared with standard assays. STUDY DESIGN: This was a retrospective cohort study of people with ongoing PPH (quantified blood loss >1,000 mL), from January 1, 2016, to December 31, 2019. TEG variables and standard coagulation parameters were compared in patients who had both assays drawn simultaneously. As a secondary analysis, patients who had TEG were compared with those who did not. The Mann-Whitney, Fisher's exact, Kruskal-Wallis, Spearman's rho, and logistic regression tests were used for analysis. Significance was set at p < 0.05. RESULTS: A total of 680 patients were included, 69 of whom had TEG and coagulation parameters drawn simultaneously and were included in the primary analysis. The remainder were included in the secondary analysis. TEG variables and coagulation assays correlated significantly-prolonged R with increased PTT (rho 0.25, p = 0.04), prolonged K and decreased α angle with decreased fibrinogen (rho -0.61, p < 0.001; rho 0.24, p < 0.001), and decreased maximum amplitude with decreased platelets (rho 0.62, p < 0.001). Those who had thromboelastographic assays had higher blood loss and need for interventions to manage hemorrhage than those who did not. CONCLUSION: TEG correlated significantly with standard laboratory assays in ongoing PPH, including for patients with hypofibrinogenemia. Given the point-of-care nature and rapid turnaround time, TEG should be considered for timely hemorrhage evaluation and directed resuscitation of coagulopathy. KEY POINTS: · TEG significantly correlates with standard laboratory measures of coagulopathy in postpartum hemorrhage, including in patients with hybofibrinogemia (fibrinogen <200).. · TEG is routinely used in nonobstetric hemorrhage, and should be considered in PPH.. · Due to the point-of-care nature, TEG may allow for rapid guided resuscitation, including fibrinogen..

Postpartum readmissions for hypertensive disorders in pregnancy during the COVID-19 pandemic.

BACKGROUND: Hypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2-infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown. OBJECTIVE: This study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic. STUDY DESIGN: This was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05. RESULTS: There was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0-6.0 days vs 6.0 days; interquartile range, 5.0-6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0-4.0 days vs 3.0 days; interquartile range, 2.0-4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths. CONCLUSION: These findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.

Prediction of Maternal Hemorrhage Using Machine Learning: Retrospective Cohort Study.

BACKGROUND: Postpartum hemorrhage remains one of the largest causes of maternal morbidity and mortality in the United States. OBJECTIVE: The aim of this paper is to use machine learning techniques to identify patients at risk for postpartum hemorrhage at obstetric delivery. METHODS: Women aged 18 to 55 years delivering at a major academic center from July 2013 to October 2018 were included for analysis (N=30,867). A total of 497 variables were collected from the electronic medical record including the following: demographic information; obstetric, medical, surgical, and family history; vital signs; laboratory results; labor medication exposures; and delivery outcomes. Postpartum hemorrhage was defined as a blood loss of ≥1000 mL at the time of delivery, regardless of delivery method, with 2179 (7.1%) positive cases observed. Supervised learning with regression-, tree-, and kernel-based machine learning methods was used to create classification models based upon training (21,606/30,867, 70%) and validation (4630/30,867, 15%) cohorts. Models were tuned using feature selection algorithms and domain knowledge. An independent test cohort (4631/30,867, 15%) determined final performance by assessing for accuracy, area under the receiver operating curve (AUROC), and sensitivity for proper classification of postpartum hemorrhage. Separate models were created using all collected data versus models limited to data available prior to the second stage of labor or at the time of decision to proceed with cesarean delivery. Additional models examined patients by mode of delivery. RESULTS: Gradient boosted decision trees achieved the best discrimination in the overall model. The model including all data mildly outperformed the second stage model (AUROC 0.979, 95% CI 0.971-0.986 vs AUROC 0.955, 95% CI 0.939-0.970). Optimal model accuracy was 98.1% with a sensitivity of 0.763 for positive prediction of postpartum hemorrhage. The second stage model achieved an accuracy of 98.0% with a sensitivity of 0.737. Other selected algorithms returned models that performed with decreased discrimination. Models stratified by mode of delivery achieved good to excellent discrimination but lacked the sensitivity necessary for clinical applicability. CONCLUSIONS: Machine learning methods can be used to identify women at risk for postpartum hemorrhage who may benefit from individualized preventative measures. Models limited to data available prior to delivery perform nearly as well as those with more complete data sets, supporting their potential utility in the clinical setting. Further work is necessary to create successful models based upon mode of delivery and to validate the findings of this study. An unbiased approach to hemorrhage risk prediction may be superior to human risk assessment and represents an area for future research.

Evaluating Expanded Noninvasive Prenatal Screening.

Public attention has been drawn recently to the commercial availability of noninvasive prenatal screening for rare genetic conditions, despite estimates that the positive predictive value of such tests is low. Many have focused on the importance of educating patients on the difference between screening and diagnostic testing so that they are adequately prepared for the possibility of a false-positive result. Even so, we question whether expanded noninvasive prenatal screening is ready to be used a screening tool. We argue that established public health criteria for evaluating the risks and benefits of a screening tool should be applied to expanded noninvasive prenatal screening. If a test fails to meet accepted standards, governmental agencies should consider regulating the accuracy and promotional claims of commercially available tests.

Society for Maternal-Fetal Medicine Special Statement: Updated checklists for management of monochorionic twin pregnancy.

Approximately 20% of twin pregnancies are monochorionic. The management of monochorionic twin pregnancy involves several additional interventions beyond the routine management of singletons or dichorionic twins. In 2015, the Society for Maternal-Fetal Medicine posted checklists for monochorionic/diamniotic twins and monochorionic/monoamniotic twins. The Society presents updated versions of these 2 checklists reflecting recent changes in practice recommendations. Suggestions for implementing the use of the checklists into antenatal care practices are also included.

Special statement: Proposed quality metrics to assess accuracy of prenatal detection of congenital heart defects.

Congenital heart defects are a leading cause of neonatal morbidity and mortality. Accurate prenatal diagnosis of congenital heart defects can reduce morbidity and mortality by improving prenatal care, facilitating predelivery pediatric cardiology consultation, and directing delivery to facilities with resources to manage the complex medical and surgical needs of newborns with congenital heart defects. Unfortunately, less than one half of congenital heart defect cases are detected prenatally, resulting in lost opportunities for counseling, shared decision-making, and delivery at an appropriate facility. Quality improvement initiatives to improve prenatal congenital heart defects detection depend on the ability to measure the rate of detection at the level of providers, facilities, or populations, but no standard metric exists for measuring the detection of congenital heart defects at any level. The need for such a metric was recognized at a Cooperative Workshop held at the 2016 Annual Meeting of the Society for Maternal-Fetal Medicine, which recommended the development of a quality metric to assess the rate of prenatal detection of clinically significant congenital heart defects. In this paper, we propose potential quality metrics to measure prenatal detection of critical congenital heart defects, defined as defects with a high rate of morbidity or mortality or that require surgery or tertiary follow-up. One metric is based on a retrospective approach, assessing whether postnatally diagnosed congenital heart defects had been identified prenatally. Other metrics are based on a prospective approach, assessing the sensitivity and specificity of prenatal diagnosis of congenital heart defects by comparing prenatal ultrasound findings with newborn findings. Potential applications, limitations, challenges, barriers, and value for both approaches are discussed. We conclude that future development of these metrics will depend on an expansion of the International Classification of Diseases system to include specific codes that distinguish fetal congenital heart defects from newborn congenital heart defects and on the development of record systems that facilitate the linkage of fetal records (in the maternal chart) with newborn records.

A case of fatal fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and persistent ventricular tachyarrhythmia associated with influenza A (H1N1) virus in a previously healthy pregnant woman.

Several studies have reported influenza A (H1N1) virus as a cause of fulminant myocarditis. We report the first fatal case of fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and ventricular tachyarrhythmia associated with influenza A (H1N1) in a previously healthy pregnant woman. A 38-year-old Asian woman, gravida 3, para 1-0-1-1, presented with flu-like symptoms. Initially, she developed wide-complex tachycardia requiring several defibrillations and was later intubated. Electrocardiogram showed ST-segment elevation. Coronary angiogram was negative and a pulmonary angiogram ruled out pulmonary embolism. Fetal compromise was noted on the monitor, and the patient underwent an emergent cesarean section. She subsequently expired. Autopsy confirmed severe myocarditis. Further testing confirmed influenza A (H1N1) virus. This case of a rare, yet lethal, complication of H1N1 infection underscores the importance of increased awareness among health care professionals to provide pregnant women with vaccination and prompt treatment.

Maternal-neonatal outcome with Staphylococcus aureus rectovaginal colonization.

OBJECTIVE: To estimate prevalence of rectovaginal colonization by Staphylococcus aureus among pregnant women with group B streptococcus (GBS) screening results and its association with maternal and infant outcomes. STUDY DESIGN: Cultures that detected both group B streptococcus (GBS) and S. aureus were obtained at > or = 35 weeks of gestation. Computerized database search and chart review determined invasive neonatal infection and maternal outcomes at the time of delivery through 6 months postpartum. RESULTS: A total of 6,626 GBS screening cultures met study criteria, and 769 (11.6%) GBS isolates and 67 (1.0%) S. aureus were identified. No maternal S. aureus-related outcomes were found. The rate of maternal methicillin-resistant S. aureus colonization was 0.1% (7 in 6,626). GBS-positive patients were twice as likely to be colonized with methicillin-susceptible S. aureus than GBS-negative patients. GBS-positive culture rates differed significantly by primary language: Spanish 10.0%, English 13.7%, Russian 26.9%, Cantonese 13.2%, Mandarin 11.5%, Arabic 15.9%, and other 17.8%. CONCLUSION: In our population, S. aureus colonization percentage (1.0%) was lower than the 7.5-8.2% reported by other medical centers, as was overall GBS carriage rate. S. aureus did not predispose to maternal or infant morbidity or mortality up to 6 months postpartum.

Intrathecal baclofen pump - a viable therapeutic option in pregnancy.

Baclofen, a gamma-aminobutyric acid analogue, is used as a muscle relaxant and antispasmodic to relieve symptoms in patients with intractable spasticity arising from cerebral or spinal aetiology such as in traumatic brain injury or multiple sclerosis. As it is often used in women of reproductive age, it is imperative to know the safety and associated maternal and fetal risks. The Food and Drug Administration has assigned the drug to Pregnancy Category C because of the lack of controlled data in humans. Animal studies have revealed an increased incidence of omphalocele if used in doses several times the recommended human dose. Baclofen should only be given during pregnancy when the benefits outweigh the risks. Baclofen is considered compatible with breast feeding by the American Academy of Pediatrics.

Vaginal radical trachelectomy: a valuable fertility-preserving option in the management of early-stage cervical cancer. A series of 50 pregnancies and review of the literature.

OBJECTIVE: To report the obstetrical results following vaginal radical trachelectomy (VRT), a fertility-preserving surgery in the treatment of early-stage cervical cancer. METHODS: Retrospective review of our first 72 patients treated by a laparoscopic pelvic lymphadenectomy followed by a VRT from October 1991 to October 2003 with regards to their reproductive function. RESULTS: Patients' median age was 32 years old (21-42) and 53 (74%) were nulligravida. A total of 50 pregnancies occurred in 31 women. The majority (66%) had only one pregnancy, 19% had 2 pregnancies and 16% had 3 pregnancies or more. The rate of first trimester miscarriage was 16%, the rate of second trimester miscarriage was (4%) and 2 women (4%) elected to have pregnancy termination. A total of 36 pregnancies (72%) reached the third trimester. Of those, 3 (8%) ended prematurely at <32 weeks gestation, 5 (14%) delivered between 32 and 36 weeks and 28 (78%) delivered at term (>37 weeks). One newborn died of neonatal sepsis from E. coli infection and one died from cardiac malformation (trisomy-18). Seven patients (10%) had infertility problems: 3 from ovulatory causes of which 2 successfully conceived with IVF, one from endometriosis and low sperm count and 3 from probable cervical cause of which one conceived with IUI. One patient had a twin pregnancy following IVF and elected to have embryo reduction and subsequently delivered at 37 weeks. CONCLUSION: Based on our experience, the obstetrical results following VRT for early-stage cervical cancer are very encouraging. The majority of women can anticipate to conceive spontaneously and deliver near term.