Diabetes Mellitus Type 1 Presenting in the Setting of Diabetic Ketoacidosis and Acute SARS-CoV-2 Infection in Pregnancy.

Background/Objective: Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with a higher rate of maternofetal morbidity and mortality. Pregnancy itself is a ketosis-prone state and several unique mechanisms predispose to the development of insulin resistance, which can be further exacerbated by acute stressors such as infection. Thus, pregnant patients who additionally contract COVID-19 may be at an even higher risk of development of DKA. Case Report: A 32-year-old patient, with no prior history of impaired glucose tolerance, presented at 27 weeks of gestation with a 3-day history of shortness of breath, congestion, loss of taste and smell, polyuria, and polydipsia. Biochemical evaluation was consistent with DKA. Subsequently, she was diagnosed with acute SARS-CoV-2 infection. Treatment included intravenous hydration, electrolyte replacement, and insulin infusion. Postpartum phenotypic evaluation confirmed autoimmune diabetes (positive GAD-65 and zinc T8 antibodies) with residual ß-cell function. Six months postpartum, glycemic control remains at goal with basal- bolus insulin regimen. Discussion: This case describes the peculiar ability of SARS-CoV-2 infection to potentially rouse autoimmunity and how COVID-19 and DKA in pregnancy can be particularly challenging given the risk of significant maternal and fetal morbidity and mortality. Conclusion: Prompt diagnosis and evaluation of DKA in pregnancy as well as a higher level of suspicion is needed in the setting of SARS-CoV-2 infection. Additionally, this case depicts the need for closely monitoring the postpartum period for patients at risk of autoimmune disease, which may have been blunted in pregnancy.

Simulation to improve trainee knowledge and comfort in managing maternal cardiac arrest.

BACKGROUND: Maternal cardiac arrest is a rare outcome, and thus there are limited opportunities for specialists in obstetrics and gynecology to acquire the skills required to respond to it through routine clinical practice. OBJECTIVE: This study aimed to evaluate gaps in medical education in maternal cardiac arrest and whether a simulation-based training program improves resident knowledge and comfort in the diagnosis and treatment of maternal cardiac arrest. STUDY DESIGN: A 2-hour training for obstetrics and gynecology residents at an academic medical center was conducted, consisting of a didactic presentation, defibrillator skills station, and 2 high-fidelity simulations. Consenting residents completed a 21-item pretest followed by a 12-item posttest exploring knowledge of and exposure to maternal cardiac arrest. The McNemar and Wilcoxon signed-rank tests were used to compare pre- and posttest data. RESULTS: Of 21 residents, 15 (71.4%) had no previous education about maternal cardiac arrest, and 17 (81.0%) had never responded to a maternal code. Participants demonstrated increased knowledge about maternal cardiac arrest after the session, providing more correct answers on the reversible causes of pulseless electrical activity arrest (median 4 vs 7 correct responses; P<.01). After the training, more residents were able to identify the correct gestational age to perform a cesarean delivery during maternal cardiac arrest (19.0% vs 90.5%; P<.01) and the correct location for this procedure (52.4% vs 95.2%; P<.01). All residents reported that maternal cardiac arrest training was important and that they would benefit from additional sessions. Median composite comfort level in managing maternal cardiac arrest significantly increased after participation (pretest, 24.0 [interquartile range, 21.5-28.0]; posttest, 37.0 [interquartile range, 34.3-41.3]; P<.01). CONCLUSION: Residents report limited exposure to maternal cardiac arrest and desire more training. Simulation-based training about maternal cardiac arrest is needed during residency to ensure that graduates are prepared to respond to this high-acuity event.

Six versus twelve hours of single-balloon catheter placement with oxytocin administration for labor induction: a randomized controlled trial.

BACKGROUND: Induction of labor is common in the United States. Multiple previous studies have tried to outline a faster time to delivery to improve maternal and fetal outcomes. OBJECTIVE: This study aimed to evaluate whether women who undergo induction of labor with a single-balloon catheter and oxytocin have a shorter time to delivery with planned removal of the catheter at 6 vs 12 hours. STUDY DESIGN: In this randomized controlled trial, induction of labor was performed using a combination of single-balloon catheter and oxytocin. Term women, both nulliparous and multiparous, aged 18 to 50 years old with cephalic singletons were included if they were undergoing induction of labor with a Bishop score of <6 and cervical dilation of <2 cm. Women were randomized to planned removal of the single-balloon catheter at 6 hours vs 12 hours. The primary outcome was time from catheter insertion to delivery. We were powered to show a 4-hour time difference with a sample size of 89 women per group (n=178). Planned sensitivity analyses were performed to account for cesarean delivery in labor. RESULTS: From February 2019 to June 2020, 237 women were screened, 178 women were randomized, and 177 women were included in the final analysis (89 women in the 6-hour group and 88 women in the 12-hour group). Insertion to delivery time was significantly shorter in the 6-hour group (19.2 vs 24.3 hours; P=.04), and the proportion of women delivered by 24 hours was significantly greater in the 6-hour group (67.4% vs 47.4%; P<.01). There was no difference in the Bishop score at removal of the catheter or secondary maternal or neonatal outcomes. In a Cox proportional-hazards model censoring for cesarean delivery, the 6-hour group had a significantly shorter insertion to delivery time (hazard ratio, 0.67; P=.02). CONCLUSION: Induction of labor with a single-balloon catheter and oxytocin with planned removal of the catheter at 6 hours rather than 12 hours results in a shorter time from insertion to delivery without increasing the rate of cesarean delivery. Decreasing the length of time a single-balloon catheter is in place should be considered in clinical protocols.

Cephalic Elevation Device for Second-Stage Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: A cephalic elevation device is an inflatable device that elevates the fetal head. We sought to evaluate whether such a device reduces time to delivery after hysterotomy and lowers morbidity in cesarean deliveries during the second stage of labor. METHODS: We conducted a double-blind randomized controlled trial among nulliparous, term women aged 18-50 years with vertex singleton pregnancies. Women were eligible if they were to undergo cesarean delivery in the second stage of labor. All participating women had the cephalic elevation device inserted by the delivering provider and were randomly allocated to inflation or noninflation of the device. Inflation was performed in a blinded fashion. The primary outcome was time from hysterotomy to delivery. A sample size of 30 per group (N=60 participants) was planned to detect a 50% decrease in time to delivery after hysterotomy with cephalic elevation device inflation. RESULTS: From January 2018 through July 2019, 60 women who underwent cesarean delivery in the second stage were randomized. Analysis was by intention to treat. Women in the inflation group were older (33 vs 30.5 years), but the groups were otherwise similar. In both groups, most women had a low-transverse hysterotomy (93%). The median time from hysterotomy to delivery was significantly shorter in the inflation group (31 vs 54 seconds; P<.01). There was no significant difference in neonatal outcomes. CONCLUSION: Use of the cephalic elevation device during second-stage cesarean delivery led to a 23-second reduction time from hysterotomy to delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03342508. FUNDING SOURCE: The cephalic elevation devices used in this study were donated by Safe Obstetrics Systems.

Uterine evacuation in the setting of transabdominal cerclage.

OBJECTIVE: Patients with transabdominal cerclage in place present a management challenge in the setting of undesired pregnancy, pregnancy failure, or pre-viable pregnancy complications. Literature that guides safe surgical technique for uterine evacuation is sparse. This study sought to describe the management and safety profile of dilation and curettage (D&C) and dilation and evacuation (D&E) in patients with transabdominal cerclage. STUDY DESIGN: We used hospital billing records to identify patients with history of transabdominal cerclage placed between January 1998 and August 2019. We subsequently described the patient characteristics and surgical techniques of the procedures among those who underwent uterine evacuation. RESULTS: Of the 142 patients with an abdominal cerclage placed at our institution, fourteen had subsequent uterine aspiration for a total of 19 procedures over the study period. We describe fifteen D&C procedures in 11 patients between 5- and 12-weeks gestation, and four D&E procedures in three patients between 17- and 19-weeks gestation. Surgeons used osmotic dilators for cervical preparation and standard surgical techniques. There was one minor complication and no major complications. Three patients had procedures other than uterine evacuation. CONCLUSIONS: Dilation and curettage and D&E are reasonable potential methods of uterine evacuation in women with transabdominal cerclage. IMPLICATIONS STATEMENT: This chart review suggests D&C and D&E are reasonable management options in the setting of transabdominal cerclage. Current practice guidelines should reflect the utilization of these procedures as potentially less invasive means of uterine evacuation.

Hyponatremia Among Parturients Transferred to the Hospital After Prolonged Labor During an Attempted Home Birth.

BACKGROUND: Hypovolemic hyponatremia has not been widely reported in the obstetric literature. Anecdotally, we noticed severe hyponatremia in several of our patients who presented as home birth transfers, leading to a review of home birth cases and hyponatremia. Given the morbidity associated with hyponatremia, it is important to be aware of its potential occurrence. CASE: We present the cases of two patients transferred to our hospital with hyponatremia after prolonged labor. These women presented with altered mental status, somnolence, and decreased urine output. Both were admitted to the intensive care unit but made a full recovery. CONCLUSION: Hyponatremia is a serious potential complication of prolonged labor. We propose mechanisms for this condition and recommendations for surveillance and prevention.

A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery.

BACKGROUND: The obstetric comorbidity index summarizes the burden of maternal comorbidities into a single number and holds promise as a maternal risk-assessment tool. OBJECTIVE: The aim of this study was to assess the clinical performance of this comorbidity-based screening tool to accurately identify women on labor and delivery who are at risk of severe maternal morbidity on labor and delivery in real time. STUDY DESIGN: All patients with pregnancies ≥23 weeks gestation presenting to labor and delivery at a single tertiary-care center from February through July 2018 were included in the study. The patient's primary labor and delivery nurse assessed patient comorbidities and calculated the patient's obstetric comorbidity index. The score was recalculated at each 12-hour shift change. A multidisciplinary panel of clinicians determined whether patients experienced severe maternal morbidity based on the American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine consensus definition, blinded to the patient's obstetric comorbidity index score. We analyzed the association between the obstetric comorbidity index score and the occurrence of severe maternal morbidity. RESULTS: The study included 2828 women, of whom 1.73% experience severe maternal morbidity (n=49). The obstetric comorbidity index ranged from 0-15 for women in the study cohort, with a median obstetric comorbidity index of 1 (interquartile range, 0-3). The median obstetric comorbidity index score for women who experienced the severe maternal morbidity was 5 (interquartile range, 3-7) compared with a median of 1 (interquartile range, 0-3) for those without severe maternal morbidity (P<.01). The frequency of severe maternal morbidity increased from 0.41% for those with a score of 0 to 18.75% for those with a score ≥9. For every 1-point increase in the score, patients experienced a 1.55 increase in odds of severe maternal morbidity (95% confidence interval, 1.42-1.70). The c-statistic for the obstetric comorbidity index score was 0.83 (95% confidence interval, 0.76-0.89), which indicated strong discrimination. CONCLUSION: The obstetric comorbidity index can prospectively identify women at risk of severe maternal morbidity in a clinical setting. A particular strength of the obstetric comorbidity index is its ability to integrate multiple compounding comorbidities and highlight the cumulative risk that is associated with the patients' conditions. Routine clinical use of the obstetric comorbidity index has the potential to identify at-risk women whose condition warrants increased surveillance and targeted care to prevent adverse maternal outcomes.

Outcomes of Spontaneous Labor in Women Undergoing Trial of Labor after Cesarean as Compared with Nulliparous Women: A Retrospective Cohort Study.

OBJECTIVE: The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women. STUDY DESIGN: A 4-year retrospective cohort. We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator. RESULTS: Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p = 0.02) and uterine rupture (1.9 vs. 0.0%; p < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p = 0.51), maternal, or immediate neonatal complications. CONCLUSION: Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option.

The influence of noninvasive prenatal testing on gestational age at time of abortion for aneuploidy.

OBJECTIVE: The objective of this study is to compare the gestational age at termination for trisomy 13, 18, or 21 (aneuploidy) before and after the introduction of noninvasive prenatal testing (NIPT). METHODS: A retrospective cohort of women undergoing termination for aneuploidy at two academic institutions and one private clinic. We compared two time periods: before and after the introduction of NIPT (2006-2011 and 2012-2014, respectively). Maternal demographics and clinical characteristics were abstracted from the medical record. Nonparametric statistical methods were used to compare the two cohorts. RESULTS: Our cohort included 93 women: 41 prior to NIPT and 52 post-NIPT. Maternal age (38 post-NIPT vs 37 pre-NIPT; p = 0.17) did not differ between the time periods. Women in the post-NIPT were less likely to undergo diagnostic testing (82.7% vs 97.6%; p < 0.01) before proceeding to abortion after a positive screening result. In the post-NIPT period, there was a significant decrease in the gestational age at time of invasive testing (13.0 vs 15.7 weeks; p < 0.01) and women were more likely to undergo chorionic villous sampling (CVS) (59.6% vs 41.5%; p < 0.01). There was a significant decrease in the gestational age at termination (14.2 vs 17.2; p < 0.01). Women in the post-NIPT group were less likely to have terminations after 16 weeks (25.0% vs 61.0%; p < 0.01), 18 weeks (7.7% vs 39.0%; p < 0.01), or 20 weeks (3.9% vs 12.2%; p = 0.23). CONCLUSION: With the introduction of NIPT, the median gestational age at diagnosis and termination for women with Trisomy 13, 18, or 21 was 3 weeks earlier. Women were four times less likely to have a termination after 18 weeks and three times less likely to have a termination after 20 weeks. © 2017 John Wiley & Sons, Ltd.

Rhabdomyolysis After Hyperemesis Gravidarum.

BACKGROUND: Hyperemesis gravidarum may lead to hypovolemia and substantial electrolyte abnormalities, including hypokalemia. Hypokalemia, when profound, may result in rare consequences, such as rhabdomyolysis. CASE: A 20-year-old woman with hyperemesis gravidarum at 19 weeks of gestation presented with extreme leg weakness and was found to have hypokalemia and hypophosphatemia. Her course was complicated by rhabdomyolysis, which, after excluding other causes, was attributed to hypokalemia and severe dehydration. After aggressive electrolyte and hydration repletion, she experienced resolution of her symptoms. CONCLUSION: Pregnancies complicated by hyperemesis gravidarum represent potentially high-risk clinical scenarios for electrolyte abnormalities and subsequent complications, including rhabdomyolysis.