Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study.

BACKGROUND: Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum. OBJECTIVE: This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum. STUDY DESIGN: This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes. RESULTS: A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups. CONCLUSION: In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.

Infection and Sepsis Trends during United States' Delivery Hospitalizations from 2000 to 2020.

OBJECTIVE: This study aimed to evaluate trends, risk factors, and outcomes associated with infections and sepsis during delivery hospitalizations in the United States. STUDY DESIGN: The 2000-2020 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of patients aged 15 to 54 with and without infection and sepsis were identified. Common infection diagnoses during delivery hospitalizations analyzed included (i) pyelonephritis, (ii) pneumonia/influenza, (iii) endometritis, (iv) cholecystitis, (v) chorioamnionitis, and (vi) wound infection. Temporal trends in sepsis and infection during delivery hospitalizations were analyzed. The associations between sepsis and infection and common chronic health conditions including asthma, chronic hypertension, pregestational diabetes, and obesity were analyzed. The associations between clinical, demographic, and hospital characteristics, and infection and sepsis were determined with unadjusted and adjusted logistic regression models with unadjusted odds ratio (OR) and adjusted odds ratios with 95% confidence intervals as measures of association. RESULTS: An estimated 80,158,622 delivery hospitalizations were identified and included in the analysis, of which 2,766,947 (3.5%) had an infection diagnosis and 32,614 had a sepsis diagnosis (4.1 per 10,000). The most common infection diagnosis was chorioamnionitis (2.7% of deliveries) followed by endometritis (0.4%), and wound infections (0.3%). Infection and sepsis were more common in the setting of chronic health conditions. Evaluating trends in individual infection diagnoses, endometritis and wound infection decreased over the study period both for patients with and without chronic conditions, while risk for pyelonephritis and pneumonia/influenza increased. Sepsis increased over the study period for deliveries with and without chronic condition diagnoses. Risks for adverse outcomes including mortality, severe maternal morbidity, the critical care composite, and acute renal failure were all significantly increased in the presence of sepsis and infection. CONCLUSION: Endometritis and wound infections decreased over the study period while risk for sepsis increased. Infection and sepsis were associated with chronic health conditions and accounted for a significant proportion of adverse obstetric outcomes including severe maternal morbidity. KEY POINTS: · Sepsis increased over the study period for deliveries with and without chronic condition diagnoses.. · Endometritis and wound infection decreased over the study period.. · Infection and sepsis accounted for a significant proportion of adverse obstetric outcomes..

Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions.

OBJECTIVE: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis. METHODS: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure. RESULTS: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum. CONCLUSION: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Acquired Hemophilia A: A Rare, Acquired Coagulopathy in the Postpartum Setting.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity. Pregnancy-associated acquired hemophilia A (AHA) caused by autoantibodies against factor VIII can present with recurrent episodes of postpartum bleeding. Case 1 A 50-year-old G2P0112 presented with vaginal bleeding 22 days postcaesarean. She underwent dilation and curettage, hysterectomy, and interventional radiology (IR) embolization before AHA diagnosis. She was hospitalized for 32 days and received 23 units of blood product. She remains without relapse of AHA after 5 years. Case 2 A 48-year-old G3P1021 presented with vaginal bleeding 8 days postcaesarean. She underwent three surgeries and IR embolization before AHA diagnosis. She was hospitalized for 18 days and received 39 units of blood product. Prednisone and cyclophosphamide were continued after discharge. AHA is a rare cause of PPH. An isolated prolonged activated partial thromboplastin time (aPTT) should prompt further workup in postpartum patients with refractory bleeding. Rapid recognition of AHA can prevent significant morbidity related to hemorrhage, massive transfusion, and multiple surgeries.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths.

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly..

Cesarean Delivery Trends Among Patients at Low Risk for Cesarean Delivery in the US, 2000-2019.

Importance: Reducing rates of unnecessary cesarean deliveries is both a national and a global health objective. However, there are limited national US data on trends in indications for low-risk cesarean delivery. Objective: To determine temporal trends in and indications for cesarean delivery among patients at low risk for the procedure over a 20-year period. Design, Setting, and Participants: This cross-sectional study analyzed 2000 to 2019 delivery hospitalizations using the National Inpatient Sample. Births at low risk for cesarean delivery were identified using a definition from the Society for Maternal-Fetal Medicine and additional criteria. Temporal trends in cesarean birth were analyzed using joinpoint regression to estimate the average annual percentage change (AAPC) with 95% CIs. Data analysis was performed from August 2022 to January 2023. Exposure: This analysis evaluated cesarean birth trends in a population at low risk for this procedure over a 20-year period. Main Outcomes and Measures: In addition to overall cesarean birth risk, cesarean deliveries for nonreassuring fetal status and labor arrest were individually analyzed. Results: Of an estimated 76.7 million delivery hospitalizations, 21.5 million were excluded according to the Society for Maternal-Fetal Medicine definition, and 14.7 million were excluded according to additional criteria. Of the estimated 40 517 867 deliveries included, 12.1% (4 885 716 deliveries) were by cesarean delivery. Cesarean deliveries among patients at low risk for the procedure increased from 9.7% to 13.9% between 2000 and 2009, plateaued, and then decreased from 13.0% to 11.1% between 2012 and 2019. The AAPC for cesarean delivery was 6.4% (95% CI, 5.2% to 7.6%) from 2000 to 2005, 1.2% from 2005 to 2009 (95% CI, -1.2% to 3.7%), and -2.2% from 2009 to 2019 (95% CI, -2.7% to -1.8%). Cesarean delivery for nonreassuring fetal status increased from 3.4% of all deliveries in 2000 to 5.1% in 2019 (AAPC, 2.1%; 95% CI, 1.7% to 2.5%). Cesarean delivery for labor arrest increased from 3.6% in 2000 to a peak of 4.8% in 2009 before decreasing to 2.7% in 2019. Cesarean deliveries for labor arrest increased during the first half of the study (2000-2009) for the active phase (from 1.5% to 2.1%), latent phase (from 1.1% to 1.5%), and second stage (from 0.9% to 1.3%) and then decreased from 2010 to 2019, from 2.1% to 1.7% for the active phase, from 1.5% to 1.2% for the latent phase, and from 1.2% to 0.9% for the second stage. Conclusions and Relevance: Cesarean deliveries among patients at low risk for cesarean birth appeared to decrease over the latter years of the study period, with cesarean deliveries for labor arrest becoming less common.

Rate of Primary Cesarean Delivery by Language Preference among Nulliparas.

OBJECTIVE: Sociodemographic factors such as race/ethnicity and socioeconomic status affect primary cesarean delivery rates. Language is associated with disparate health care outcomes but has not been well studied in obstetrics. We examined the association between primary unscheduled cesarean delivery rate and preferred patient language. STUDY DESIGN: A retrospective cohort study was conducted at an urban medical center between January 2017 and January 2020. Nulliparous women with early or full-term gestation and having no obstetric or medical contraindication to vaginal delivery were included. We used multivariable linear and logistic regressions to evaluate language differences in cesarean delivery odds and indication for cesarean. RESULTS: Of the 1,314 eligible women, 76.8% of patients preferred English, 17.8% Spanish, and 5.4% other languages. Overall cesarean delivery rate was 27.6%. Controlling for age, race/ethnicity, body mass index, insurance, gravidity, pregnancy comorbidities, labor induction, and infant birth weight, Spanish- and other language-speaking women had significantly higher odds of undergoing cesarean compared with English-speaking women (adjusted odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.25, 2.46). Relative proportions of indications for cesarean did not differ by language group. Documented interpreter use was an effect modifier on the relationship between language preference and cesarean (OR with interpreter use: 2.89, 95% CI: 1.90, 4.39). CONCLUSION: Primary cesarean delivery rates were significantly higher among nulliparous women who prefer languages other than English. This difference may reflect lack of communication, provider bias or discrimination, or other factors, and should be further studied. Interpreter services should be routinely utilized and documented effectively. KEY POINTS: · Women who prefer languages other than English had higher odds of cesarean.. · Indication for cesarean did not differ by language.. · Interpreter use did not reduce risk for cesarean..

Incidence and characteristics of stillbirths before and during the Coronavirus 2019 pandemic.

OBJECTIVE: The aim of this study was to determine the incidence and characteristics of stillbirths during the initial wave of the Coronavirus 2019 (COVID-19) pandemic and whether or not this differed from the incidence and characteristics of stillbirths that occurred in the pre-pandemic period. STUDY DESIGN: This was a single-center retrospective cohort study of pregnant individuals who delivered stillbirths during two different time periods: March-September in 2017, 2018, and 2019 (pre-COVID-19 pandemic period) and March-September 2020 (COVID-19 pandemic period). RESULTS: No difference in the rate of stillbirths was found between the two time periods. The women who experienced a stillbirth during the pre-pandemic period attended on average more prenatal visits than women who experienced a stillbirth during the pandemic period (p < .05). During the pandemic period, a higher proportion of stillbirths were suspected to be due to poorly controlled hypertension (p = .04). CONCLUSIONS: The incidence of stillbirth during the pandemic period was similar to that during the pre-pandemic period; however, there were more stillbirths that occurred due to poorly controlled hypertension, a potentially preventable cause of stillbirth, during the pandemic period when compared to those of the pre-pandemic period. While the impact of the disease process of COVID-19 on stillbirth remains uncertain, the change in the provision of prenatal care during the pandemic period may have had unintended consequences with respect to the prevention and management of hypertension and the risk of potentially preventable stillbirths.

Novel Evidence-Based Labor Induction Algorithm Associated with Increased Vaginal Delivery within 24 Hours.

OBJECTIVE: This study aimed to assess whether concordance with our proposed labor induction algorithm is associated with an increased rate of vaginal delivery within 24 hours. STUDY DESIGN: We conducted a retrospective review of 287 induction of labors (IOLs) at a single urban, tertiary, academic medical center which took place before we created an evidence-based IOL algorithm. We then compared the IOL course to the algorithm to assess for concordance and outcomes. Patients age 18 years or over with a singleton, cephalic pregnancy of 366/7 to 420/7 weeks' gestation were included. Patients were excluded with a Bishop's score >6, contraindication to misoprostol or cervical Foley catheter, major fetal anomalies, or intrauterine fetal death. Patients with 100% concordance were compared with <100% concordant patients, and patients with ≥80% concordance were compared with <80% concordant patients. Adjusted hazard ratios (AHRs) were calculated for rate of vaginal delivery within 24 hours, our primary outcome. Competing risk's analysis was conducted for concordant versus nonconcordant groups, using vaginal delivery as the outcome of interest, with cesarean delivery (CD) as a competing event. RESULTS: Patients with 100% concordance were more likely to have a vaginal delivery within 24 hours, n = 66 of 77 or 85.7% versus n = 120 of 210 or 57.1% (p < 0.0001), with an AHR of 2.72 (1.98, 3.75, p < 0.0001) after adjusting for delivery indication and scheduled status. Patients with 100% concordance also had shorter time from first intervention to delivery (11.9 vs. 19.4 hours). Patients with ≥80% concordance had a lower rate of CD (11/96, 11.5%) compared with those with <80% concordance (43/191 = 22.5%; p = 0.0238). There were no differences in neonatal outcomes assessed. CONCLUSION: Our IOL algorithm may offer an opportunity to standardize care, improve the rate of vaginal delivery within 24 hours, shorten time to delivery, and reduce the CD rate for patients undergoing IOL. KEY POINTS: · Studies on IOL have focused on individual steps. A labor induction algorithm allows for standardization.. · Algorithm concordance is associated with decreased time to delivery.. · Algorithm concordance is associated with decreased CD rate..

The genomic landscape of low-grade serous ovarian/peritoneal carcinoma and its impact on clinical outcomes.

OBJECTIVE: Low-grade serous carcinoma (LGSOC) is a rare epithelial ovarian/peritoneal cancer characterized by younger age at diagnosis, relative chemoresistance, prolonged overall survival (OS), and mutations in the mitogen activated protein kinase (MAPK) pathway compared to high-grade serous carcinoma. We describe the genomic profile of LGSOC by next generation sequencing (NGS) and evaluated its potential relationship to clinical outcomes. METHODS: The study included 215 women with LGSOC with: 1) pathologically confirmed LGSOC, 2) availability of NGS data, and 3) adequate clinical data. Clinical subgroups were compared for progression-free survival (PFS) and OS. Multivariable Cox regression analysis was performed. RESULTS: Median age at diagnosis was 46.6 years. The majority had a stage III ovarian primary. One or more mutations were identified in 140 (65.1%) cases; 75 (34.9%) had none. The most common mutations were KRAS (n = 71; 33.0%), NRAS (n = 24; 11.2%), and BRAF (n = 18; 8.4%). Patients with MAPK-mutated tumors (n = 113) (52.6%) had a significantly longer OS compared to those with tumors lacking MAPK pathway mutations (n = 102) (47.4%) [median OS, 147.8 months (95% CI,119.0-176.6) versus 89.5 months (95% CI, 61.4-117.7) (p = 0.01)], respectively. Median OS for patients with MAPK-mutated tumors was also significantly better than for patients whose tumors had no mutations (n = 75) [median OS, 147.8 months (95% CI, 119.0-176.6) versus 78.0 months (95% CI, 57.6-98.3)], respectively (p = 0.001). Median OS for patients with non-MAPK-mutated tumors (n = 27) was 125.1 months (95% CI, 83.9-166.3). In multivariable analysis, having a MAPK mutation was associated with improved OS. CONCLUSIONS: Patients with MAPK-mutated tumors have a significantly improved OS compared to those without MAPK-mutated tumors.

Characteristics and Outcomes of Pregnant Women with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in New York City: A Matched Cohort Study.

OBJECTIVE: The aim of this study was to examine the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and preterm birth, cesarean birth, and composite severe maternal morbidity by studying women with and without SARS-CoV-2 infection at the time of delivery hospitalization from similar residential catchment areas in New York City. STUDY DESIGN: This was a retrospective cohort study of pregnant women with laboratory-confirmed or laboratory-denied SARS-CoV-2 on nasopharyngeal swab under universal testing policies at the time of admission who gave birth between March 13 and May 15, 2020, at two New York City medical centers. Demographic and clinical data were collected and follow-up was completed on May 30, 2020. Groups were compared for the primary outcome and preterm birth, in adjusted (for age, race/ethnicity, nulliparity, body mass index) and unadjusted analyses. RESULTS: Among this age-matched cohort, 164 women were positive and 247 were negative for SARS-CoV-2. Of the positive group, 52.4% were asymptomatic and 1.2% had critical coronavirus disease 2019 (COVID-19). The groups did not differ by race and ethnicity, body mass index, or acute or chronic comorbidities. Women with SARS-CoV-2 were more likely to be publicly insured. Preterm birth, cesarean birth, and severe maternal morbidity did not differ between groups. Babies born to women with SARS-CoV-2 were more likely to have complications of prematurity or low birth weight (7.7 vs. 2%, p = 0.01). CONCLUSION: Preterm and cesarean birth did not differ between women with and without SARS-CoV-2 across disease severity in adjusted and unadjusted analysis among this cohort during the pandemic peak in New York City.

Use of a cesarean delivery checklist in an African maternity ward to improve management and reduce length of hospital stay†.

OBJECTIVE: To create, implement, and evaluate the effectiveness of a cesarean delivery checklist on maternal and neonatal outcomes in a rural African hospital. METHODS: Based on input from local authorities, WHO's Safe Surgical Checklist was modified for cesarean delivery and adapted for use in low-resource settings. Retrospective chart review between April and August 2013 in Kibogora Hospital, Nyamasheke, Rwanda, included the first 100 women undergoing cesarean after checklist implementation and the last 100 women undergoing cesarean before implementation. Checklist utilization was determined and degree of completeness assessed. Outcomes were compared between patients for whom the checklist was utilized and patients for whom the checklist was not utilized, in both pre and post-implementation groups. RESULTS: Checklist utilization rate was 83.0% (83/100). Checklist utilization was associated with significant increases in documentation of estimated blood loss (91.6% [76/83] vs 0.9% [1/117], P<0.001) and antibiotic administration before incision (96.4% [80/83] vs 30.8% [36/117], P<0.001). It was also associated with decreased rates of hospitalization longer than the standard 4 days (19.3% [16/83] vs 70.1% [82/117], P<0.001). CONCLUSION: Implementation of a cesarean delivery checklist via a culturally specific and resource-specific strategy resulted in high utilization rates and improved performance in key best practices by healthcare providers.

From the trenches: inpatient management of coronavirus disease 2019 in pregnancy.

The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 has become a pandemic. It has quickly swept across the globe, leaving many clinicians to care for infected patients with limited information about the disease and best practices for care. Our goal is to share our experiences of caring for pregnant and postpartum women with novel coronavirus disease 2019 in New York, which is the coronavirus disease 2019 epicenter in the United States, and review current guidelines. We offer a guide, focusing on inpatient management, including testing policies, admission criteria, medical management, care for the decompensating patient, and practical tips for inpatient antepartum service management.

Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers.

OBJECTIVE: To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020. METHODS: We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020. RESULTS: Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%). CONCLUSION: During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.

The impact of menstrual hygiene management on adolescent health: The effect of Go! pads on rate of urinary tract infection in adolescent females in Kibogora, Rwanda.

OBJECTIVE: To determine the rates of urinary tract infection (UTI) in adolescent users of menstrual pads versus non-users in a rural area of Rwanda. METHODS: An interventional prospective cohort study was conducted at four secondary schools in the Western Province of Rwanda from May 12, 2017 to October 20, 2017. Inclusion criteria were female students aged 18-24 who were menstruating and volunteered to participate in the study. In total, 240 adolescent participants were assigned to two cohorts; 120 received menstrual pads for 6 months and the other 120 did not use pads. Baseline symptoms and urine cultures were obtained. Symptoms and methods of menstrual hygiene management were assessed and urine cultures were obtained every 2 months. The primary outcome was the presence of UTI diagnosed by positive urine culture. Secondary outcomes were symptoms of UTI, vulvovaginal symptoms, sexual activity, dyspareunia, and self-reported sexually transmitted infection. Generalized estimating equations with nesting were used to assess associations of pad use with study outcomes. RESULTS: A total of 209 participants completed the study. There was no difference in rates of positive urine culture. A decreased odds of vulvovaginal symptoms was found in self-reported "always" versus "never" pad users (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.43-0.96; P=0.031). CONCLUSIONS: Despite not finding any difference in rates of UTI, the present study showed a decreased rate of vulvovaginal symptoms in users of menstrual pads. Further research investigating rates of genital infections in this population is thus necessary.

Mate wareware: Understanding 'dementia' from a Maori perspective.

AIM: To investigate Maori (Indigenous people of Aotearoa New Zealand) understandings of dementia, its causes, and ways to manage a whanau (extended family) member with dementia. METHOD: We undertook kaupapa Maori research (Maori informed research) with 223 kaumatua (Maori elders) who participated in 17 focus groups across seven study regions throughout Aotearoa New Zealand and eight whanau from the Waikato region. We audio recorded all interviews, transcribed them and then coded and categorised the data into themes. RESULTS: Mate wareware (becoming forgetful and unwell) ('dementia') affects the wairua (spiritual dimension) of Maori. The findings elucidate Maori understandings of the causes of mate wareware, and the role of aroha (love, compassion) and manaakitanga (hospitality, kindness, generosity, support, caring) involved in caregiving for whanau living with mate wareware. Participants perceived cultural activities acted as protective factors that optimised a person's functioning within their whanau and community. CONCLUSION: Whanau are crucial for the care of a kaumatua with mate wareware, along with promoting healthy wairua for all. Whanau urgently need information to assist with their knowledge building and empowerment to meet the needs of a member affected by mate wareware. This requires collaborative healthcare practice and practitioners accessing the necessary matauranga Maori (Maori knowledge) to provide culturally appropriate and comprehensive care for whanau.

An overview of obstetric hemorrhage.

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality in the world. Disparities in the prevalence of obstetric hemorrhage and its related mortality both on a global scale and locally in the United States indicate that a significant proportion is preventable. In many parts of the world, including the United States, there has also been an unexplainable increase in rates of postpartum hemorrhage. Efforts should focus on implementing comprehensive hemorrhage toolkit/bundles, which research has shown may have the potential to reduce severe maternal morbidity from hemorrhage.

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial.

Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.