Comparative analysis of ultrasonographic fetal lung texture in twin and singleton fetuses.

OBJECTIVES: Increased fetal lung heterogeneity has been associated with term fetal lungs in singleton gestations. The objective of this study was to determine if fetal lung heterogeneity index (HI) differs between twin and singleton fetuses in the late second and third trimesters. METHODS: Prospective cohort study of women with singleton and twin gestations with medically-indicated ultrasound examinations at 24 weeks of gestation onward. Grayscale transverse fetal lung images were obtained at the level of the four-chamber heart. A region of interest was selected in each fetal lung image. Fetal lung HI was determined with MATLAB software using a dithering technique with ultrasound image pixels transformed into a binary map form from which a dynamic range value was determined. HI averages and standard deviations were generated for twin and singleton fetuses from 24 weeks gestation onward. Two sample t-tests were used to compare the mean HI at each gestational week between singleton and twin fetuses. RESULTS: In total, 388 singleton and 478 twin images were analyzed. From 35 through 38 weeks of gestation a statistically significant divergence in mean HI was observed with higher means in singleton compared to twin fetuses. At 24 weeks of gestation there was a significantly higher HI in twin fetuses compared to singletons. No differences in fetal lung HI were observed between 25 and 34 weeks gestational age. CONCLUSIONS: Differences in fetal lung HI were observed when comparing twin and singleton fetuses. Further investigation is required to determine the potential clinical significance of these findings.

Environmental Justice Index and adverse pregnancy outcomes.

BACKGROUND: The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood. OBJECTIVE: This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors. STUDY DESIGN: This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language. RESULTS: A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people. CONCLUSION: Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.

Presence and Size of Placental Lakes on 20-Week Fetal Anatomy Ultrasound and Obstetrical Outcomes.

Our objective was to determine if placental lake presence or size is associated with adverse pregnancy outcomes. This was a retrospective cohort of patients who had fetal anatomy ultrasounds at 18-22 weeks and delivered between 2018 and 2022. Placental lakes were classified as small (>2.0 to 3.9 cm) or large (≥4 cm). Multiple gestations, placenta previas, and placenta accretas were excluded. Outcomes included low birthweight, cesarean delivery, primary cesarean for non-reassuring fetal heart tracing, fetal growth restriction, preterm birth, and severe preeclampsia. A total of 1052 patients were included; 294 had placental lakes (204 small, 90 large). No differences in pregnancy outcomes were observed.

Novel characterization of CASK variant c.1963 A>G (p.Asn655Asp) through whole-exome sequencing in a monochorionic diamniotic twin fetus with significant brain anomalies: A case report.

Whole-exome sequencing is an evolving technology in perinatal diagnosis which allows identification of genetic etiologies that would otherwise go undetermined. In this case report, a 38-year-old Hispanic woman, G5P3013, with a monochorionic diamniotic twin gestation with one fetus displaying significant cranial abnormalities on prenatal ultrasound and magnetic resonance imaging (MRI) of the brain is presented. Fetal anomalies included bilateral ventriculomegaly, absent cavum septum pellucidum, and absent corpus callosum. Diagnostic amniocentesis with chromosome analysis, chromosomal microarray, alpha-fetoprotein, cytomegalovirus, toxoplasmosis, and parvovirus had normal results. Whole-exome sequencing for the anomalous fetus detected a de novo mosaic variant of uncertain significance (VUS) in the calcium/calmodulin dependent serine protein kinase (CASK) gene: c.1963 A > G (p.Asn655Asp). This variant was absent in the normal twin fetus, the mother, and the father. Pathogenic CASK gene mutations are associated with three syndromes: FG syndrome 4, intellectual developmental disorder and microcephaly with pontine and cerebellar hypoplasia (MICPCH), and intellectual developmental disorder with or without nystagmus. Whole-exome sequencing identified a potential etiology for the anomalies detected. The variant likely arose de novo and was the potential cause of the identified cranial abnormalities in one fetus of this monochorionic diamniotic twin gestation. Whole-exome sequencing may provide additional diagnostic utility when standard diagnostic testing is noncontributory.

Socioeconomic and clinical factors associated with excessive gestational weight gain.

PURPOSE: Excessive gestational weight gain (EGWG) is associated with adverse maternal and offspring outcomes but efforts to identify women at high risk for EGWG have been limited. The objective of this study is to identify socioeconomic and clinical factors associated with EGWG. METHODS: This retrospective cohort included pregnant patients who delivered live, term, singleton newborns between January 2018 and February 2020 at seven hospitals within a large health system in New York. Patients were stratified by pre-pregnancy body mass index and then classified based on whether they exceeded the Institute of Medicine guidelines for gestational weight gain (GWG) and whether they gained more than 50 pounds in pregnancy. RESULTS: A total of 44,872 subjects were included for analysis: 48% had EGWG and 17% had GWG exceeding 50 pounds. Patients with EGWG were more likely to be Black race, English speakers, overweight or obese pre-pregnancy, and have a mood disorder diagnosis. Patients who were underweight, multiparous, and those with gestational diabetes were less likely to have EGWG. CONCLUSION: Sociodemographic and clinical findings associated with GWG > 50 pounds were similar but only overweight and not obese patients were at increased risk. Patients at risk for EGWG may benefit from early nutrition counseling and education on lifestyle changes.

Severity of excessive gestational weight gain and risk of severe maternal morbidity.

BACKGROUND: Both obesity and excessive gestational weight gain are associated with severe maternal morbidity, but there is limited literature evaluating whether the risk of severe maternal morbidity is further increased by the degree or severity of excessive gestational weight gain. OBJECTIVE: This study aimed to determine whether pregnant patients with excessive gestational weight gain who gained more than 50 lb were at increased risk of severe maternal morbidity compared with those who only moderately exceeded recommended gestational weight gain guidelines. A secondary objective was to determine whether patients who gained 10 lb more than the recommended upper limit of total weight gain for a given prepregnancy body mass index group were at increased risk of severe maternal morbidity compared with those who exceeded that upper limit by a lesser amount. STUDY DESIGN: This was a retrospective cohort study of all patients with live, term, singleton deliveries with excessive gestational weight gain from 7 hospitals within a large health system in New York between January 2019 and February 2020. Excessive gestational weight gain was defined as exceeding the recommended upper limit of total weight gain for a given prepregnancy body mass index category using the National Academy of Medicine gestational weight gain guidelines: >40 lb for a body mass index of <18.5 kg/m2, >35 lb for a body mass index of 18.5 to 24.9 kg/m2, >25 lb for a body mass index of 25.0 to 29.9 kg/m2, and >20 lb for a body mass index of ³30.0 kg/m2. Patient height and weight data were self-reported at the time of delivery hospitalization and retrieved from the electronic medical record system. Patients were classified into 2 excessive gestational weight gain groups: moderate (≤50 lb) or severe (>50 lb). Patients with missing body mass index or gestational weight gain were excluded. The primary exposure was severe excessive gestational weight gain. The primary outcome was severe maternal morbidity, defined using the Centers for Disease Control and Prevention criteria. Logistic regression was used to model the likelihood of severe maternal morbidity, adjusting for race and ethnicity, nulliparity, advanced maternal age, gestational diabetes mellitus, and maternal mood disorder. For the secondary analysis, severe maternal morbidity rates were compared between patients who exceeded their body mass index-specific upper limit of total weight gain by ≥10 lb and those who exceeded it by <10 lb. RESULTS: A total of 11,506 patients were included for analysis, and 1965 patients (17.1%) had severe excessive gestational weight gain. The overall rate of severe maternal morbidity was 3.3%. Severe maternal morbidity occurred in 85 of 1965 patients (4.3%) with severe excessive gestational weight gain and 292 of 9541 patients (3.1%) with moderate excessive gestational weight gain. On regression analysis, after adjustment for covariate factors, patients with a severe excessive gestational weight gain were 39% more likely to experience severe maternal morbidity than those with moderate excessive gestational weight gain (adjusted odds ratio, 1.39; 95% confidence interval, 1.08-1.79). Patients with excessive gestational weight gain of ≥10 lb above the recommended body mass index-specific upper limit for gestational weight gain were 32% more likely (adjusted odds ratio, 1.32; 95% confidence interval, 1.07-1.62) to experience severe maternal morbidity than patients who exceeded that upper limit by <10 lb. CONCLUSION: Patients with live, term, singleton pregnancies who gain more than 50 lb are at increased risk of severe maternal morbidity compared with those who only moderately exceed gestational weight gain guidelines. Similarly, patients who gain ≥10 lb above the recommended body mass index-specific upper limit for gestational weight gain are at increased risk. Further study is warranted to determine the most effective interventions to manage gestational weight gain and mitigate maternal risk.

Risk of Severe Maternal Morbidity Associated with Maternal Comorbidity Burden and Social Vulnerability.

OBJECTIVE: We evaluated the associations of the obstetric comorbidity index (OB-CMI) and social vulnerability index (SVI) with severe maternal morbidity (SMM). STUDY DESIGN: Multicenter retrospective cohort study of all patients who delivered (gestational age > 20 weeks) within a university health system from January 1, 2019, to December 31, 2021. OB-CMI scores were assigned to patients using clinical documentation and diagnosis codes. SVI scores, released by the Centers for Disease Control and Prevention (CDC), were assigned to patients based on census tracts. The primary outcome was SMM, based on the 21 CDC indicators. Mixed-effects logistic regression was used to model the odds of SMM as a function of OB-CMI and SVI while adjusting for maternal race and ethnicity, insurance type, preferred language, and parity. RESULTS: In total, 73,518 deliveries were analyzed. The prevalence of SMM was 4% (n = 2,923). An association between OB-CMI and SMM was observed (p < 0.001), where OB-CMI score categories of 1, 2, 3, and ≥4 were associated with higher odds of SMM compared with an OB-CMI score category of 0. In the adjusted model, there was evidence of an interaction between OB-CMI and maternal race and ethnicity (p = 0.01). After adjusting for potential confounders, including SVI, non-Hispanic Black patients had the highest odds of SMM among patients with an OB-CMI score category of 1 and ≥4 compared with non-Hispanic White patients with an OB-CMI score of 0 (adjusted odds ratio [aOR] 2.76, 95% confidence interval [CI] 2.08-3.66 and aOR 10.07, 95% CI 8.42-12.03, respectively). The association between SVI and SMM was not significant on adjusted analysis. CONCLUSION: OB-CMI was significantly associated with SMM, with higher score categories associated with higher odds of SMM. A significant interaction between OB-CMI and maternal race and ethnicity was identified, revealing racial disparities in the odds of SMM within each higher OB-CMI score category. SVI was not associated with SMM after adjusting for confounders. KEY POINTS: · OB-CMI was significantly associated with SMM.. · Racial disparities were seen within each OB-CMI score group.. · SVI was not associated with SMM on adjusted analysis..

Importance of the Third Trimester Complete Blood Count: A Case Report on Aplastic Anemia in Pregnancy.

Aplastic anemia (AA) poses a significant threat to maternal and fetal health throughout the perinatal period. Diagnosis is based on complete blood count (CBC) and bone marrow biopsy with treatment varying based on severity of disease. This report highlights a case of AA incidentally identified by the third trimester CBC drawn in the outpatient office. Patient was referred for inpatient management to mobilize a multidisciplinary team of healthcare professionals including obstetricians, hematologists, and anesthesiologists to optimize maternal and fetal outcome. The patient received blood and platelet transfusions prior to delivering a healthy liveborn infant by cesarean section. This case highlights the importance for routine third trimester CBC screening to identify potential complications and decrease maternal and fetal morbidity and mortality.

Fetal hypertrophic cardiomyopathy with elevated middle cerebral artery peak systolic velocity (MCA PSV): A potentially grim association.

An elevated middle cerebral artery peak systolic velocity (MCA PSV) in the setting of nondiabetic hypertrophic cardiomyopathy may portend an especially poor prognosis.

The effect of colorization on the fetal lung heterogeneity index.

No previous studies have quantitatively assessed the effect of color tones on ultrasound texture analysis techniques. Our objective was to compare heterogeneity index (HI) between fetal lung images captured in grayscale and those same images after conversion to Ice and Sepia. Fetal lung images were obtained during medically indicated ultrasound examinations. We observed that HI is affected by the application of color tones to ultrasound images of the fetal lung. Therefore, for each type of biological tissue and color tone, determination of distinct HI nomograms and cut off points is recommended.

Placental calcifications after coronavirus disease 2019 in first trimester of pregnancy: ultrasound and pathology findings.

The effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on placental tissue is unclear. We present a case of symptomatic first trimester SARS-CoV-2 infection in which longitudinal ultrasound images demonstrated diffuse areas of echogenic foci. Her 39-week delivery, following an elective induction of labor, was uncomplicated, and placental pathol-ogy evaluation noted extensive calcifications. Such findings are sometimes seen in late and post-term pregnancies and those complicated by smoking, hypertensive disorders, diabetes, and viral infections. In this case, no other potential etiology was identified. Thus, we conclude that placental calcifications may be associated with SAR-CoV-2 infection in early pregnancy.

Acceptance of coronavirus disease 2019 vaccination among postpartum women during delivery hospitalization.

OBJECTIVE: The immediate postpartum period, during delivery hospitalization, represents a unique opportunity to offer coronavirus disease 2019 (COVID-19) vaccination to those who did not previously receive it. In this study, we evaluated patient characteristics associated with acceptance of vaccination in this group. METHODS: This retrospective cohort study evaluated all unvaccinated patients who were offered postpartum COVID-19 vaccination during delivery hospitalization between May 2021 and September 2021 at seven hospitals within a large integrated health system in New York. During the study period, each hospitalized, unvaccinated obstetrical patient was offered the vaccine prior to discharge. Patients with positive SARS-CoV-2 PCR testing during hospitalization were excluded. Medical records were reviewed to obtain sociodemographic characteristics and to confirm administration of COVID-19 vaccination. Multiple logistic regression was performed to model the probability of receiving postpartum vaccination. RESULTS: A total of 8,281 unvaccinated postpartum patients were included for analysis and 412 (5%) received a COVID-19 vaccine before hospital discharge. Patients who received the vaccine were more likely to be older, have private insurance, decline to answer questions about religious affiliation, and deliver in the final two months of the study period. Likelihood of receiving postpartum vaccination was not affected by race-ethnicity, preferred language, marital status, parity, body mass index, or neighborhood socioeconomic conditions. Patients who declined vaccination were more likely to have positive SARS-CoV-2 antibody testing at delivery compared to those who received vaccination (49 vs. 29%; p < .001). CONCLUSION: Only 5% of unvaccinated postpartum patients received a COVID-19 vaccine before hospital discharge. It is concerning that patients with public health insurance were less likely to receive vaccination. This may be due to variation in vaccine counseling or other unmeasured factors. Despite the low acceptance rate in our study population, COVID-19 vaccination should be offered in a variety of clinical settings to maximize opportunities for administration.

Breast Milk and Breastfeeding of Infants Born to SARS-CoV-2 Positive Mothers: A Prospective Observational Cohort Study.

OBJECTIVE: There are limited published data on the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus from mothers to newborns through breastfeeding or from breast milk. The World Health Organization released guidelines encouraging mothers with suspected or confirmed COVID-19 to breastfeed as the benefits of breastfeeding outweighs the possible risk of transmission. The objective of this study was to determine if SARS-CoV-2 was present in the breast milk of lactating mothers who had a positive SARS-CoV-2 nasopharyngeal swab test prior to delivery, and the clinical outcomes for their newborns. STUDY DESIGN: This was a single-center, observational, prospective cohort study. Maternal-newborn dyads that delivered at New York University Langone Hospital Brooklyn with confirmed maternal SARS-CoV-2 positive screen test at the time of admission were recruited for the study. Breast milk samples were collected during postpartum hospitalization and tested for the presence of SARS-CoV-2 genes N1 and N2 by two-step reverse transcription polymerase chain reaction. Additionally, the clinical characteristics of the maternal newborn dyad, results of nasopharyngeal SARS-CoV-2 testing, and neonatal follow-up data were collected. RESULTS: A total of 19 mothers were included in the study and their infants who were all fed breast milk. Breast milk samples from 18 mothers tested negative for SARS-CoV-2, and 1 was positive for SARS-CoV-2 RNA. The infant who ingested the breast milk that tested positive had a negative nasopharyngeal test for SARS-CoV-2, and had a benign clinical course. There was no evidence of significant clinical infection during the hospital stay or from outpatient neonatal follow-up data for all the infants included in this study. CONCLUSION: In a small cohort of SARS-CoV-2 positive lactating mothers giving birth at our institution, most of their breast milk samples (95%) contained no detectable virus, and there was no evidence of COVID-19 infection in their breast milk-fed neonates. KEY POINTS: · Breast milk may rarely contain detectable SARS-CoV-2 RNA and was not detected in asymptomatic mothers.. · Breast milk with detectable SARS-CoV-2 RNA from a symptomatic mother had no clinical significance for her infant.. · Breast feeding with appropriate infection control instructions appears to be safe in mother with COVID infection..