Pulmonary Embolism in Pregnancy.

Pulmonary embolism during and after pregnancy remains a significant contributor to maternal morbidity and mortality. Symptoms that would be a clear indicator of a pulmonary embolus in the nonpregnant population can be masked by pregnancy and its routine pregnancy-related symptoms. To affect a reduction in this severe maternal mortality indicator, physicians need to maintain a high degree of suspicion coupled with expedient testing.

Severe Acute Respiratory Syndrome-Coronavirus-2 Antibody Status at the Time of Delivery and the Risk of Preeclampsia.

OBJECTIVE: Our objective was to evaluate the association between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) serologic status in immunologically naive patients and the risk of preeclampsia at the time of delivery. STUDY DESIGN: We conducted a retrospective cohort study of pregnant patients admitted to our institution from August 1 to September 30, 2020. We recorded maternal medical and obstetric characteristics and SARS-CoV-2 serologic status. Our primary outcome was the incidence of preeclampsia. Antibody testing was performed, and patients were classified into seropositive groups: immunoglobulin (Ig)G + , IgM + , or both IgG+ and IgM + . Bivariate and multivariable analyses were performed. RESULTS: We included 275 patients that were negative for SARS-CoV-2 antibodies, and 165 that were positive. Seropositivity was not associated with higher rates of preeclampsia (p = 0.183) or with preeclampsia with severe features (p = 0.916) even after adjusting for maternal age >35, BMI ≥ 30, nulliparity, and previous history of preeclampsia, and type of serologic status. Previous preeclampsia had the greatest association with the development of preeclampsia (odds ratio [OR] = 13.40; 95% confidence interval [CI]: 4.98-36.09; p < 0.05) and with preeclampsia with severe features (OR = 5.46; 95% CI: 1.65-18.02; p < 0.05). CONCLUSION: We found that in an obstetric population, there was no association between SARS-CoV-2 antibody status and the risk of preeclampsia. KEY POINTS: · Pregnant people with acute COVID-19 are at an increased risk of developing preeclampsia.. · Seroconversion during pregnancy was not associated with an increased risk of preeclampsia.. · Further study regarding the timing of infection and its association with preeclampsia is necessary..

Does greater morning sickness predict carrying a girl? Analysis of nausea and vomiting during pregnancy from retrospective report.

PURPOSE: The prevalence of severe nausea and vomiting during pregnancy (NVP) requiring hospitalization has been associated with female fetal sex. However, the question of whether fetal sex and less severe forms of NVP share that association has not been investigated. The objective of this study was to evaluate the relationship between fetal sex and the frequency of NVP. METHODS: We collected self-reported data from mothers via an international web-based survey on the Amazon Mechanical Turk (MTurk) platform about pregnancy and first trimester NVP history. We considered the covariables of maternal age, parity status, proneness to nausea, geographic cohort, and preconceived notions of a relationship between fetal sex and NVP. RESULTS: Two-thousand five hundred and forty-three mothers met the inclusion criteria, yielding data from 4320 pregnancies. Women gestating a female fetus reported higher frequencies of NVP (M = 6.35 on a 1-9 scale) than did women gestating males (M = 6.04, p = .007). This effect held true when all other variables were included in the regression. General proneness to nausea, maternal age, and parity were also significant independent predictors of NVP. CONCLUSIONS: Women that carried a female fetus, as opposed to a male fetus, reported significantly higher frequency of NVP during the first trimester of pregnancy. Further research should evaluate both the proximate and ultimate causes of this relationship.

Trauma in Pregnancy.

One of the most common causes of obstetric morbidity and mortality is trauma in pregnancy. Several maternal physiological changes during pregnancy have a significant impact on the mechanism, presentation, and management of trauma in this population. It is crucial for health providers dealing with trauma to know and understand these differences between pregnant and nonpregnant patients. The obstetric trauma patient requires a multidisciplinary approach, including obstetrics, maternal fetal medicine, anesthesiology, surgery, and intensive care teams. The aim of this article is to review the most updated information on trauma during pregnancy.

Severe COVID-19 during Pregnancy and Possible Vertical Transmission.

There are few cases of pregnant women with novel corona virus 2019 (COVID-19) in the literature, most of them with a mild illness course. There is limited evidence about in utero infection and early positive neonatal testing. A 41-year-old G3P2 with a history of previous cesarean deliveries and diabetes mellitus presented with a 4-day history of malaise, low-grade fever, and progressive shortness of breath. A nasopharyngeal swab was positive for COVID-19, COVID-19 serology was negative. The patient developed respiratory failure requiring mechanical ventilation on day 5 of disease onset. The patient underwent a cesarean delivery, and neonatal isolation was implemented immediately after birth, without delayed cord clamping or skin-to-skin contact. The neonatal nasopharyngeal swab, 16 hours after delivery, was positive for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) real-time polymerase chain reaction (RT-PCR), and immunoglobulin (Ig)-M and IgG for SARS-CoV-2 were negative. Maternal IgM and IgG were positive on postpartum day 4 (day 9 after symptom onset). We report a severe presentation of COVID-19 during pregnancy. To our knowledge, this is the earliest reported positive PCR in the neonate, raising the concern for vertical transmission. We suggest pregnant women should be considered as a high-risk group and minimize exposures for these reasons. KEY POINTS: · We report a severe presentation of COVID-19 in pregnancy requiring invasive ventilatory support.. · This is a case of positive RT-PCR in first day of life, suggesting possible vertical transmission.. · There were no detectable maternal antibodies for COVID-19 until after delivery..

Quality Improvement Initiative to Reduce Time from Regional Anesthesia Placement to Delivery for Cesarean Delivery.

OBJECTIVE: Our objective was to evaluate the impact of a quality improvement (QI) initiative on the regional anesthesia placement-to-infant delivery time during cesarean delivery (CD). STUDY DESIGN: We performed a quality improvement trial. Before June 18, 2018, the preoperative protocol was as follows: the anesthesiologist administered regional anesthesia in the operating room then the nurse placed the Foley's catheter, clipped pubic hair, precleaned the abdomen, and abdominal preparation. On June 18, 2018, the protocol changed and all the preoperative preparation (Foley's clip and preclean) were performed prior to the arrival in the operating room. The records of patients who underwent scheduled or nonemergency CD between May 1 and July 15, 2018, were reviewed. Our primary outcome was time between the placements of regional anesthesia to infant delivery at the time of CD. Bivariate and multivariable analyses were performed. RESULTS: A total of 194 patients were included, 124 before and 70 after the process change. The change in process leads to a significant reduction in anesthesia-to-delivery time, even after adjusting for number of prior CD and body mass index (BMI). Other times were also significantly impacted by the change. CONCLUSION: Our QI initiative significantly decreased the time from anesthesia placement to delivery of the fetus. Performing preoperative preparation activities, such as Foley's placement and shaving, after regional anesthesia for CD, increase the risk of fetal exposure to maternal hypotension. We evaluated the impact of a QI initiative on regional anesthesia placement to infant delivery time during CD.

The impact of low-dose versus high-dose antibiotic prophylaxis regimens on surgical site infection rates after cesarean delivery.

OBJECTIVE: The objective of this study was to determine if high-dose antibiotic prophylaxis with cefazolin decreases the risk of surgical site infection (SSI) after a cesarean delivery. METHODS: We performed a retrospective cohort study of women who underwent a cesarean section. Two preoperative antibiotic regimens were compared: low dose versus high dose. The primary outcome was SSI. A sample size of 343 patients per group was calculated for a 50% reduction in risk for SSI. RESULTS: Seven hundred and thirty women were included with an incidence of SSI of 5%. Women who received the high-dose antibiotic regimen had lower rates of risk factors for SSI. The only exception was skin incision closure with staples. The rate of SSI did not differ between the low-dose and high-dose groups, even after adjusting for confounding variables [aOR 1.78, 95% CI (0.82-3.9)]. CONCLUSIONS: Higher doses of antibiotic prophylaxis did not decrease the rates of SSI after cesarean delivery.

The Effect of Wearing White Coats on Patients' Appreciation of Physician Communication during Postpartum Rounds: A Randomized Controlled Trial.

OBJECTIVE: Wearing a white coat (WC) has been associated with risk of colonization and transmission of resistant pathogens. Also, studies have shown that physicians' attire in general affects patients' confidence in their physician and the patient-physician relationship. Our objective is to evaluate the hypothesis that not wearing a WC during physician postpartum rounds does not affect patient-physician communication scores. MATERIALS AND METHODS: This is an unblinded, randomized, parallel arms, controlled trial of postpartum women at a single university hospital. Women were randomly assigned to having their postpartum physicians' team wear a WC or not (no-WC) during rounds. Our primary outcome was "patient-physician communication" score. Univariable and multivariable analysis were used where appropriate. RESULTS: One hundred and seventy-eight patients were enrolled (87 in WC and 91 in no-WC groups). Note that 40.4% of patients did not remember whether the physicians wore a WC or not. There was no difference in the primary outcome (p = 0.64) even after adjusting for possible confounders. CONCLUSION: Not wearing a WC during postpartum rounds did not affect the patient-physician communication or patient satisfaction scores. In the setting of prior reports showing a risk of WC pathogen transmission between patients, our findings cannot support the routine wearing of WCs during postpartum rounds.

Incidence and Risk Factors for Hospital Readmission or Unexpected Visits in Women Undergoing Unscheduled Cesarean Delivery.

OBJECTIVE: Hospital readmissions are increasingly tracked and assessed for value-based compensation. Our objective was to determine the incidence and risk factors associated with post-cesarean delivery (CD) readmissions or unexpected visits, defined as unexpected office or emergency room visits. STUDY DESIGN: This is a secondary analysis of a multicenter randomized controlled trial of adjunctive azithromycin prophylaxis for CD performed in laboring patients with viable pregnancies. Patients were followed up to 6 weeks postpartum. Our primary outcome was a composite of hospital readmission or unexpected visit, defined as unscheduled clinic or emergency department visits. Data of hospital readmissions, unexpected visits, and their reasons were collected. Demographics, antepartum, intrapartum, and postpartum risk factors were evaluated in bivariate analyses and multivariable logistic regression modeling. RESULTS: A total of 1,019 women were randomized to azithromycin and 994 to placebo. The prevalence of readmission or unexpected visit was 10.2% (95% confidence interval [CI]: 8.9-11.6), with rates of 3.8% (95% CI: 3.0-4.7%) hospital readmissions, 6.9% (95% CI: 5.8-8.0%) emergency room visits, and 4.2% (95% CI: 3.4-5.2%) unexpected clinic visits. The most common causes were infectious disease and hypertensive disorder. Women with readmissions or unexpected visits were more likely to be obese and diabetic, as well as experience longer length of ruptured membranes, intrauterine pressure catheter placement, and postpartum fevers. On multivariable analysis, diabetes (adjusted odds ratio [aOR]: 1.6, 95% CI: 1.1-2.4), prolonged ruptured membranes (aOR: 1.9, 95% CI: 1.3-2.8), and postpartum fevers (aOR: 4.6, 95% CI: 3.0-7.0) were significantly positively associated with readmission or unscheduled visit, while azithromycin was a protective (aOR: 0.6, 95% CI: 0.5-0.9). CONCLUSION: Women who had postpartum fever were at especially high risk for readmission or unexpected visits. Diabetes, prolonged ruptured membranes, and postpartum fevers were significantly associated with the adverse outcome, and azithromycin was associated with lower rates of readmission and unexpected visits.

Robotic repair of uterine dehiscence.

BACKGROUND AND OBJECTIVES: During the past few decades, there has been a significant increase in the number of cesarean deliveries, and thus an increase in the number of complications. A common complication of multiple cesarean deliveries is symptomatic uterine scar dehiscence, for which there are no treatment guidelines available. We report a case of uterine scar dehiscence-the repair of it by robotic surgery-and review the literature on this defect. CASE: The patient was a 39-year-old woman, gravida 4 para 2022, complaining of persistent vaginal spotting for the prior 5 months with a history of a cesarean delivery 3 months before the onset of the symptoms. DISCUSSION: We report a case of a successful robotic repair of a symptomatic cesarean scar defect. CONCLUSION: We propose further studies that include more patients so this technique may become the standard for cesarean scar defect.

Support Systems and Limitations in Therapeutic Abortion Care by the Gynecologist-Obstetrician of Public Hospitals in Peru.

OBJECTIVE: To identify the barriers to provide to women and adequately train physicians on therapeutic abortions in public hospitals in Peru. METHODS: Descriptive cross-sectional survey-based study. We invited 400 obstetrics and gynecology specialists from 7 academic public hospitals in Lima and 8 from other regions of Peru. Expert judges validated the survey. RESULTS: We collected survey results from 160 participants that met the inclusion criteria. Of those, 63.7% stated that the hospital where they work does not offer abortion training. Most of the participants consider that the position of the Peruvian government regarding therapeutic abortion is indifferent or deficient. The major limitations to provide therapeutic abortions included Peruvian law (53.8%), hospital policies (18.8%), and lack of experts (10.6%). CONCLUSION: Most surveyed physicians supported therapeutic abortions and showed interest in improving their skills. However, not all hospitals offer training and education. The limited knowledge of the physicians regarding the law and institutional policies, as well as fear of ethical, legal, and religious repercussions, were the main barriers for providing abortions.

OBJETIVO: Identificar as barreiras para oferecer às mulheres e capacitar adequadamente os médicos sobre abortos terapêuticos nos hospitais públicos do Peru. MéTODOS: Estudo descritivo transversal baseado em inquérito. Convidamos 400 especialistas em obstetrícia e ginecologia de 7 hospitais públicos acadêmicos de Lima e 8 de outras regiões do Peru. Juízes especialistas validaram a pesquisa. RESULTADOS: Coletamos os resultados da pesquisa de 160 participantes que atenderam aos critérios de inclusão. Destes, 63,7% afirmaram que o hospital onde trabalham não oferece treinamento sobre aborto. A maioria dos participantes considera que a posição do governo peruano em relação ao aborto terapêutico é indiferente ou deficiente. As principais limitações para fornecer abortos terapêuticos incluem a lei peruana (53,8%), políticas hospitalares (18,8%) e falta de especialistas (10,6%). CONCLUSãO: A maioria dos médicos pesquisados apoiava o aborto terapêutico e demonstrava interesse em aprimorar suas habilidades. No entanto, nem todos os hospitais oferecem treinamento e educação. O conhecimento limitado dos médicos sobre a lei e as políticas institucionais, além do medo de repercussões éticas, legais e religiosas, foram as principais barreiras para a realização do aborto.

Murine Typhus Infection in Pregnancy: Case Series and Literature Review.

Murine typhus is a flea-borne disease of worldwide distribution with a recent reemergence in the United States of America. There are limited data about the presentation, treatment, and outcomes in the pregnant population. We report on two cases of murine typhus during pregnancy and review the literature to compile previously reported cases. A comprehensive search was performed via the PubMed database for published articles between 1990 and 2020. Seven articles met the criteria of symptomatic pregnant murine typhus infection. A total of 37 patients were identified. Patients frequently presented with a prolonged duration of fevers prior to presentation, headache, and elevated hepatic transaminases. The diagnosis was predominantly based on serology. Treatment varied. Overall, the pregnancy outcome was favorable. Murine typhus can mimic other pregnancy-related pathologies. More exclusive and large-scale studies are needed to learn more of murine typhus during pregnancy.

Lactation Leads to Modifications in Maternal Renin-Angiotensin System in Later Life.

The objective of this study was to evaluate whether the renin-angiotensin system (RAS) is associated with maternal cardioprotective phenotype observed in post-lactated mice later in life. Following the delivery, CD-1 female mice were randomized to one of the following groups: lactated (nursed pups for 3 weeks, n = 10) or non-lactated (pups were removed after birth, n = 10). The mice were sacrificed 6 months after the delivery, and tissues were collected. Protein levels of angiotensinogen, angiotensin type 1 and 2 receptors (AT1R, AT2R), angiotensin converting enzymes (ACE, ACE2), and MAS receptor were determined using Western blot. Results were analyzed using Student's t-test and Mann-Whitney test as appropriate (significance: P < 0.05). Angiotensinogen levels were significantly lower in the liver (P = 0.0002), and ACE was significantly decreased in the lungs (P = 0.04) and kidney (P = 0.001) from lactated mice as compared to non-lactated. The levels of AT2R in the kidney (P = 0.02) and visceral adipose tissue (VAT, P = 0.04), the ACE 2 in the VAT (P = 0.03) and heart (P = 0.04), and MAS receptor in VAT (P = 0.02) were significantly elevated in tissues from lactated mice. No other differences were found. Lactation led to the upregulation and downregulation of selected RAS components in lactated mice as compared to non-lactated group and may be a contributing factor to maternal cardioprotective phenotype later in life. Further studies are needed to dissect the mechanisms between lactation and the long-term maternal cardiometabolic benefits, which could lead to the therapies to prevent cardiovascular disease in women.

Elective Induction at 39 Weeks of Gestation and the Implications of a Large, Multicenter, Randomized Controlled Trial.

On August 8, 2018, Grobman et al published the findings from the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial, a large randomized controlled trial of elective induction of labor in nulliparous women at 39 weeks of gestation compared with expectant management. Conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, the trial found there was no difference between the two groups in the primary outcome, a composite of neonatal morbidity. Also, there was a reduction in rates of cesarean delivery and hypertensive disorders of pregnancy in the elective induction group. The topic of elective induction has been of interest to clinicians for decades, and research has yielded inconsistent results in the past. This trial offers the best evidence thus far to address this complex issue. Our objective is to briefly review the history and literature regarding elective induction of labor, discuss the recently published ARRIVE trial, and consider its implications on clinical practice and health policy.

Institutional Protocols for Vaginal Preparation With Antiseptic Solution and Surgical Site Infection Rate in Women Undergoing Cesarean Delivery During Labor.

OBJECTIVE: To evaluate the association of institutional protocols for vaginal preparation with antiseptic solution and the surgical site infection rate in women undergoing cesarean delivery during labor. METHODS: This is a secondary analysis of a multicenter randomized controlled trial of adjunctive azithromycin prophylaxis for cesarean delivery performed in laboring patients with viable pregnancies. The primary outcome for this analysis was the rate of superficial or deep surgical site infection within 6 weeks postpartum, as per Centers for Disease Control and Prevention criteria. Maternal secondary outcomes included a composite of endometritis, wound infection or other infections, postoperative maternal fever, length of hospital stay, and the rates of hospital readmission, unexpected office visits, and emergency department visits. RESULTS: A total of 523 women delivered in institutions with vaginal antisepsis policies before cesarean delivery and 1,490 delivered in institutions without such policies. There was no difference in superficial and deep surgical site infection rates between women with and without vaginal preparation (5.5% vs 4.1%; odds ratio [OR] 1.38, 95% CI 0.87-2.17), even after adjusting for possible confounders (adjusted OR 0.86, 95% CI 0.43-1.73). The lack of significant benefit was noted in all other maternal secondary outcomes. CONCLUSION: Institutional policies for vaginal preparation before cesarean delivery were not associated with lower rates of surgical site infection in women undergoing cesarean delivery during labor.

Protocolo de transfusión masiva en obstetricia

La hemorragia obstétrica es la causa más común de mortalidad materna en el mundo. Durante las últimas décadas, nuestro conocimiento de la fisiopatología y manejo del shock hemorrágico se ha incrementado de manera significativa. Una de las estrategias que más impacto ha tenido en la supervivencia de estas pacientes es la transfusión de productos sanguíneos. Debido a ello, es crucial contar con un protocolo de transfusión masiva en caso de hemorragia obstétrica masiva.

Obstetric hemorrhage is the most common cause of maternal mortality in the world. Our knowledge of hemorrhagic shock pathophysiology and management has significantly improved during the last decades. Blood transfusion has emerged as a strategy with great impact on patients' survival. Consequently, it is crucial to have a protocol of massive blood transfusion available for cases of massive obstetric hemorrhage.

Sífilis secundaria en un paciente viviendo con VIH / Secondary syphilis in a patient living with HIV

Se presenta el caso de un paciente varón de 31 años, con diagnóstico de infección por el virus de inmunodeficiencia humana (VIH) sin tratamiento antirretroviral, presentó lesiones ulcerativas en la región genital que luego progresaron por todo el cuerpo, se le diagnosticó sífilis secundaria. Fue tratado con penicilina benzatínica, con lo cual las lesiones desaparecieron. Se discute las pruebas diagnósticas realizadas y la terapéutica empleada. La coinfección por Treponema pallidum y por el VIH está presente en la población general y en especial en poblaciones de riesgo, como los hombres que tienen sexo con hombres y clientes de trabajadoras sexuales, esta situación puede afectar la presentación inicial así como el curso de la enfermedad.

We present a case of a 31-year-old male with HIV infection, not receiving antiretroviral therapy that presented an ulcerative lesion that began in the genital region and then progressed in all the body, with the diagnosis of secondary syphilis. He was treated with Benzatinic Penicillin and the lesions disappeared. We also discuss the available diagnostic tests and therapeutics regarding the case. Co-infection by Treponema pallidum and by HIV is present in the general population, especially in high-risk populations such as men who have sex with men and clients of sexual workers, and can affect the initial presentation and natural history of syphilis.