Severe Maternal Morbidity and Neonatal Mortality After COVID-19 Infection: Case Report.

BACKGROUND: Maternal coagulopathy and adverse fetal effects are both possible results of COVID-19 infection during pregnancy. This case demonstrates the potentially fatal outcomes when both occur simultaneously. CASE PRESENTATION: A 39-year-old multiparous woman at 31 weeks gestation presented with mild COVID-19 symptoms and decreased fetal movement. Evaluation included a biophysical profile with 2/8 scoring and fetal heart rate tracing that developed a terminal bradycardia. She underwent an emergent cesarean delivery that was complicated by disseminated intravascular coagulation (fibrinogen < 60mg/dL, platelets 34, international normalized ratio [INR] 2.1) and maternal hemorrhage requiring massive transfusion. The neonate ultimately required prolonged resuscitation with Apgar scores of 0/0/0 at 1, 5, and 10 minutes and passed away on day 6 of life. CONCLUSIONS: Even in the absence of severe symptoms, maternal COVID-19 infection during pregnancy can cause a maternal systemic and placental reaction that can lead to serious maternal morbidity, as well as fetal or neonatal morbidity and mortality.

Racial and Ethnic Disparities in Maternal and Neonatal Outcomes among Women with Chronic Hypertension.

OBJECTIVE: The objective of this study was to compare maternal and neonatal outcomes in women with chronic hypertension by maternal race and ethnicity. METHODS: A retrospective cohort study of women with chronic hypertension was performed from the Consortium on Safe Labor (2002-2008). Maternal self-reported race and ethnicity were analyzed as non-Hispanic White, non-Hispanic Black, and Hispanic. Maternal outcomes included cesarean birth, postpartum hemorrhage, blood transfusion, placental abruption, eclampsia, maternal intensive care unit admission, and death. Neonatal outcomes included preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA), 5-minute Apgar <7, respiratory distress syndrome, hypoxic-ischemic encephalopathy, intraventricular hemorrhage, neonatal intensive care unit admission, sepsis, and death. Univariable and multivariable analyses were performed to examine the association between maternal race and ethnicity and perinatal outcomes. RESULTS: A total of 2,729 women were included. In unadjusted analysis, non-Hispanic White women had higher rates of placental abruption and Hispanic women had higher rates of placental abruption and eclampsia. In multivariable analysis, non-Hispanic Black continued to have higher odds of placental abruption (adjusted odds ratio 4.16, 95% confidence interval 1.29-18.70), but the rest of the maternal outcomes did not differ between the groups. When comparing neonatal outcomes, PTB, SGA, and LBW were more frequent in, 5-minute Apgar <7 non-Hispanic Black and Hispanic women compared with non-Hispanic White women. In addition, 5-minute Apgar <7 and neonatal sepsis were more frequent in non-Hispanic Black neonates and neonatal death was more frequent in Hispanic neonates compared with non-Hispanic White women. In multivariable regression, neonates of non-Hispanic Black women had higher odds of PTB, SGA, LBW, 5-minute Apgar < 7, and sepsis compared with non-Hispanic White women. Similarly, neonates of Hispanic women had higher odds of SGA, LBW, and death. CONCLUSION: Significant racial and ethnic disparities were identified mainly in neonatal outcomes of women with chronic hypertension. KEY POINTS: · Non-Hispanic Black women with chronic hypertension had higher rates of placental abruption.. · Neonates of non-Hispanic Black women with chronic hypertension had higher odds of PTB, SGA, and LBW.. · Neonates of Hispanic women with chronic hypertension had higher odds of SGA, LBW, and neonatal death..

Challenges of Genomic Testing for Hereditary Breast and Ovarian Cancers.

Completion of genetic testing is increasingly important for the complex care of patients with suspected hereditary breast and ovarian cancers (HBOC) and their at-risk family members. Identification of individuals with pathogenic variants has implications for targeted treatment recommendations, risk reduction strategies, increased surveillance recommendations, as well as the genetic testing of family members, known as cascade testing or screening. Due to advances in technology and decreasing costs, what was once single-gene genetic testing has evolved into large-scale multi-gene panel genomic testing. As germline genomic testing for HBOC becomes more and more available, it is important to identify the challenges that are associated with its use. In this manuscript, we review the current issues faced by germline genomic testing for HBOC which include effectively managing the marked increases in genetic referrals, interpreting the vast amount of information yielded by newer testing methods such as next generation sequencing (NGS), recognizing the need for better cascade screening strategies, potential exacerbation of health disparities and improving support for patients navigating the emotional impact related to positive, negative and indeterminate testing results.

Bicornuate Bicollis Uterus with Obstruction of the Lower Uterine Segment and Cervical Prolapse Complicating Pregnancy.

Congenital Mullerian duct anomalies are conditions involving the female genital tract. Cases of complex Mullerian duct anomalies with involvement of the renal system are rare. Occasionally, these cases can be associated with obstetrical complications. Cervical prolapse infrequently complicates pregnancy, and an association between uterine malformations and cervical prolapse has not been cited in the literature. We describe the case of a primigravid patient at 38 weeks of gestation noted to have cervical prolapse during evaluation for preeclampsia and labor induction. Obstetrical ultrasound at presentation to the labor and delivery suite revealed a high suspicion for a bicornuate uterus. The patient was delivered by cesarean section due to obstruction of the lower uterine segment of the gravid uterus. Further evaluation post-partum revealed a bicornuate bicolis uterus and renal agenesis. Pregnancies in patients with bicornuate bicollis uterus can be complicated by obstruction of the gravid uterus, resulting in cervical prolapse and necessitating cesarean section.

An acellular biologic scaffold treatment for volumetric muscle loss: results of a 13-patient cohort study.

Volumetric muscle loss (VML) is a severe and debilitating clinical problem. Current standard of care includes physical therapy or orthotics, which do not correct underlying strength deficits, and surgical tendon transfers or muscle transfers, which involve donor site morbidity and fall short of restoring function. The results of a 13-patient cohort study are described herein and involve a regenerative medicine approach for VML treatment. Acellular bioscaffolds composed of mammalian extracellular matrix (ECM) were implanted and combined with aggressive and early physical therapy following treatment. Immunolabeling of ultrasound-guided biopsies, and magnetic resonance imaging and computed tomography imaging were performed to analyse the presence of stem/progenitor cells and formation of new skeletal muscle. Force production, range-of-motion and functional task performance were analysed by physical therapists. Electrodiagnostic evaluation was used to analyse presence of innervated skeletal muscle. This study is registered with ClinicalTrials.gov, numbers NCT01292876. In vivo remodelling of ECM bioscaffolds was associated with mobilisation of perivascular stem cells; formation of new, vascularised, innervated islands of skeletal muscle within the implantation site; increased force production; and improved functional task performance when compared with pre-operative performance. Compared with pre-operative performance, by 6 months after ECM implantation, patients showed an average improvement of 37.3% (P<0.05) in strength and 27.1% improvement in range-of-motion tasks (P<0.05). Implantation of acellular bioscaffolds derived from ECM can improve strength and function, and promotes site-appropriate remodelling of VML defects. These findings provide early evidence of bioscaffolding as a viable treatment of VML.

Altered lower extremity movement variability in female soccer players during side-step cutting after anterior cruciate ligament reconstruction.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction (ACLR) is common after an ACL tear and is thought to restore functional stability to the knee. A recent investigation demonstrated that individuals who have undergone ACLR exhibited increased lower extremity coupling variability during gait, suggestive of altered dynamic stability. However, little is known about whether they exhibit alterations in lower extremity variability during dynamic sport-specific tasks. PURPOSE: To determine if female soccer players who have had an ACLR demonstrate differences in lower extremity coupling variability as compared with athletes with no history of knee injury during a side-step cutting maneuver. STUDY DESIGN: Controlled laboratory study. METHODS: Ten female soccer players who had undergone ACLR served as the experimental group, and 10 female soccer players with no history of knee ligament injury composed the control group (CON). Three-dimensional kinematics and ground-reaction forces were collected while each participant performed a side-step cutting maneuver. Based on known ACL loading patterns, 7 lower extremity intralimb couplings were created. With use of a vector-coding technique, the coordination variability was calculated for each coupling. Independent t tests were used to determine group differences in variability for each coupling (P ≤ .05). RESULTS: Individuals who had undergone ACLR exhibited increased lower extremity variability during side-step cutting as compared with control subjects in the following couplings: hip rotation/knee abduction-adduction (27.2° ± 11.5° [ACLR] vs 19.7° ± 6.8° [CON]; P = .04), hip flexion-extension/knee abduction-adduction (26.0° ± 13.3° [ACLR] vs 18.6° ± 5.3° [CON]; P = .05), knee abduction-adduction/knee flexion-extension (13.5° ± 5.7° [ACLR] vs 7.3° ± 2.7° [CON]; P < .01), and knee abduction-adduction/knee rotation (26.4° ± 10.8° [ACLR] vs 19.3° ± 4.5° [CON]; P = .03). In addition, there was a trend toward increased variability in the hip rotation/ankle inversion-eversion coupling (22.9° ± 9.3° [ACLR] vs 18.0° ± 6.7° [CON]; P = .09) and knee abduction-adduction/ankle inversion-eversion coupling (25.9° ± 10.0° [ACLR] vs 20.2° ± 9.7° [CON]; P = .10). CONCLUSION: Female soccer players who have undergone ACLR and returned to sports participation exhibit altered lower extremity coupling variability during side-step cutting. CLINICAL RELEVANCE: While individuals who have had an ACLR exhibit mechanical knee stability before returning to sports, the observed increased movement variability during side-step cutting is likely reflective of altered neuromuscular control and may contribute to the known increased risk for ACL reinjury and knee osteoarthritis after return to sports participation. Improving the understanding of altered lower extremity coupling variability after ACLR will aid in the development of more effective rehabilitation programs.

Targeted rehabilitation after extracellular matrix scaffold transplantation for the treatment of volumetric muscle loss.

Rehabilitation therapy is an important aspect of recovery after volumetric muscle loss. However, the traditional rehabilitation approach involves a period of rest and passive loading followed by gradual active loading. Extracellular matrix is a naturally occurring material consisting of structural proteins that provide mechanical strength, structural support, and functional molecules with diverse bioactive properties. There is evidence to suggest that the addition of aggressive regenerative rehabilitation protocols immediately after surgical implantation of an extracellular matrix scaffold to an area of volumetric muscle loss has significant benefits for extracellular matrix remodeling. Rehabilitation exercises likely provide the needed mechanical signals to encourage cell migration and site-specific differentiation in the temporal framework required for constructive remodeling. Herein, the authors review the literature and present an example of an aggressive rehabilitation program implemented immediately after extracellular matrix transplantation into a severely injured quadriceps muscle.

Improvements in hip muscle performance result in increased use of the hip extensors and abductors during a landing task.

BACKGROUND: Impaired hip muscle performance has been implicated as a contributing factor to the increased risk of anterior cruciate ligament (ACL) injury in women. PURPOSE: To determine the influence of a hip-focused training program on lower extremity biomechanics during a drop-jump task. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty-one recreationally active women (18-25 years of age) participated in a 4-week training program consisting of hip-focused plyometric and balance perturbation exercises (3 times/wk, 30 min/session). Maximum isometric strength of the hip extensors, hip abductors, and knee extensors was assessed, along with lower extremity biomechanics during a drop-jump task. All assessments were performed within 5 days of initiation and completion of the training program. RESULTS: After training, subjects demonstrated significantly greater maximum isometric strength of the hip extensors (2.87 ± 0.7 vs 3.11 ± 0.7 N·m/kg; P < .01) and hip abductors (2.08 ± 0.7 vs 2.23 ± 0.07 N·m/kg; P = .004). No significant difference in knee extensor strength was observed. After training, subjects landed with significantly greater peak knee flexion (94.0° ± 8.5° vs 98.0° ± 10.1°; P < .001) and hip flexion (83.4° ± 7.6° vs 89.9° ± 8.8°; P = .008) and a lower knee/hip extensor moment ratio (1.33 ± 0.6 vs 0.99 ± 0.3; P = .001). In addition, subjects demonstrated significantly lower peak knee abduction angles (6.8° ± 3.3° vs 5.6° ± 3.1°; P = .04) and average knee adductor moments (0.06 ± 0.1 vs -0.02 ± 0.1 N·m/kg; P < .001). CONCLUSION: Changes in lower extremity biomechanics consistent with decreased risk for ACL injury were observed after participation in a hip-focused training program. CLINICAL RELEVANCE: The study results suggest that ACL injury prevention programs targeting hip muscle performance may be important in mitigating biomechanical risk factors associated with ACL injury in women.

Abnormal frontal plane knee mechanics during sidestep cutting in female soccer athletes after anterior cruciate ligament reconstruction and return to sport.

BACKGROUND: Athletes who have undergone anterior cruciate ligament reconstruction (ACLR) have a high risk of reinjury upon the return to sports participation. While the mechanisms behind this increased risk of reinjury are unknown, it has been suggested that altered knee biomechanics during sports-specific activities may be a contributing factor. Purpose/ HYPOTHESIS: To compare frontal plane knee joint angles and moments during a sidestep cutting maneuver in female soccer athletes who have undergone ACLR with those in athletes with no history of knee injury. It was hypothesized that athletes with a history of ACLR would exhibit increased knee abduction angles and knee adductor moments compared with those with no history of injury. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve female soccer players with a history of ACLR served as the experimental group, and 12 female soccer players with no history of knee injury constituted the control group. Three-dimensional kinematics and ground-reaction forces were collected while each participant performed a sidestep cutting maneuver. Variables of interest included the knee abduction angle and knee adductor moment during the early deceleration phase of the cutting maneuver. Independent-samples t tests were used to evaluate differences between groups (P ≤ .05). RESULTS: Participants in the ACLR group exhibited increased average knee abduction angles (ACLR: 3.8° vs control: 1.8°; P = .03) and peak knee adductor moments (ACLR: 1.33 N·m/kg vs control: 0.80 N·m/kg; P = .004) compared with the control group. CONCLUSION: Female soccer players who have undergone ACLR and returned to sports participation exhibited increased knee abduction angles and knee adductor moments during the early deceleration phase of cutting compared with their healthy counterparts with no history of knee injury. CLINICAL RELEVANCE: Even though athletes are able to return to sport after ACLR, they are at an increased risk for reinjury. It may be the case that the increased frontal plane knee angles and moments exhibited by these athletes after ACLR could be contributing to this risk for reinjury. Therefore, it is important that rehabilitation programs after ACLR include the restoration of frontal plane knee mechanics.

Influence of relative hip and knee extensor muscle strength on landing biomechanics.

PURPOSE: This study aimed to determine whether the tendency of women to exhibit higher knee extensor moments relative to hip extensor moments during the deceleration phase of landing can be explained by the relative strength of the knee and hip extensors. METHODS: Forty recreationally active individuals participated in this study (20 men and 20 women). The maximum isometric strength of the knee extensors and hip extensors was assessed using a load cell and custom testing setup. Lower extremity kinematics and kinetics were collected during a double-leg drop-jump task. RESULTS: When compared with men, women demonstrated a significantly higher knee-hip extensor moment ratio during the deceleration phase of landing (1.42 ± 0.6 vs 1.12 ± 0.3, P < 0.001). In addition, the knee-hip extensor isometric strength ratio was significantly higher in women compared with men (1.01 ± 0.2 vs 0.89 ± 0.2, P < 0.001). The Pearson partial correlation (controlling for sex) revealed a significant positive association between the knee-hip extensor isometric strength ratio and the knee-hip extensor moment ratio (r = 0.41, P = 0.005). CONCLUSION: The tendency of women to exhibit higher knee extensor moments relative to hip extensor moments may be explained, in part, by the relative strength of the hip and knee extensors.