Glycated Albumin and Glycemia in Pregnancy and Postpartum: A Pilot Study.

OBJECTIVE: Percent glycated albumin (%GAlb) is a marker of glycemia over the past 2 to 3 weeks in nonpregnant individuals. Longitudinal changes in %GAlb extending throughout pregnancy and postpartum (PP) have not been described. We aimed to describe levels of %GAlb throughout pregnancy and PP and relationships with glycemia. STUDY DESIGN: Fifty women among those in the Study of Pregnancy Regulation of INsulin and Glucose cohort underwent 75-g oral glucose tolerance tests (OGTTs) at a mean of 13 weeks (V1) and 26 weeks (V2) of gestation and 11 weeks' PP. %GAlb was measured on frozen plasma samples. RESULTS: Total albumin decreased from V1 to V2 and increased PP to levels higher than at V1. %GAlb declined between V1 and V2 (ß = - 0.63% 95% CI [-0.8, -0.6] p < 0.001) and remained stable between V2 and PP (ß = - 0.04% [-0.3, 0.2] p = 0.78). Body mass index (BMI) was inversely related to %GAlb in pregnancy (V1: rho = - 0.5, p = 0.0001; V2 rho = - 0.4, p = 0.006), but not PP (rho = - 0.15, p = 0.31). The longitudinal changes in %GAlb persisted after adjusting for BMI. Neither glycemia measurements nor hemoglobin A1c were associated with %GAlb at any time point, and adjustments for BMI did not reveal additional associations. CONCLUSION: %GAlb decreases between early and late gestation and remains decreased PP, despite a PP increase in total albumin above early pregnancy values. Given the lack of correlation with OGTT values or A1c, %GAlb is unlikely to be useful in assessing glycemia in pregnant or PP women. KEY POINTS: · Changes in %GAlb extending to the postpartum period have not been described.. · %GAlb decreases in pregnancy and remains decreased postpartum, despite a postpartum increase in total albumin above early pregnancy values.. · Glycemia measurements nor A1c were associated with %GAlb at any time point, therefore, %GAlb is unlikely to be useful in assessing glycemia in pregnant or postpartum women..

Improving Postpartum Attendance among Women with Gestational Diabetes Using the Medical Home Model of Care.

OBJECTIVE: Poor attendance at the 6-week postpartum (PP) visit has been well reported. Attendance at this visit is crucial to identify women who have persistent diabetes mellitus (DM) following pregnancies affected by gestational DM (GDM). The medical home model has eliminated barriers to care in various other settings. This study sought to improve PP attendance among women with GDM by jointly scheduling PP visits and the 2-month well infant visits. STUDY DESIGN: All patients with a diagnosis of GDM who received care at a New York City-based publicly insured hospital clinic and delivered between October 2017 and June 2019 were eligible. Data were obtained via chart review. The primary outcome was attendance at the PP visit compared with previously published historical controls. Secondary outcomes were rates of PP glucose screening and well infant attendance. RESULTS: Of the 74 patients enrolled, 41.9% were Hispanic and 17.6% were Black, mean age was 31.6 years, and 58.1% delivered vaginally. Attendance at the 6-week PP visit was 68.9%, and attendance at the infant visit was 55.1%. PP glucose testing was ordered for 76.5% of attendees at the PP visit, and of those ordered, 43.6% of attendees completed testing. All patients had joint visits requested, though only 70.3% of visits were scheduled jointly. Among those who were jointly scheduled, 71.2% of women attended, 57.7% of infants attended, and 7.7% of pairs attended on the same day. The PP visit attendance rate was not significantly different than the prior attendance rate (p = 0.84). CONCLUSION: This study was unable to improve PP visit attendance among women with GDM by jointly scheduling the 6-week PP visit and the 2-month well-infant visit. Future research could be directed toward a shared space where both women and children can be seen to attempt to increase PP visit attendance and monitoring for women with GDM. KEY POINTS: · Attendance at the PP visit is poor, and without a visit, women with pregnancies affected by gestational diabetes remain unscreened for PP dysglycemia.. · Jointly scheduling women and their infants to eliminate barriers to care studied by this group, however, were unable to improve attendance.. · Innovative strategies are needed to improve PP attendance among women with pregnancies affected by GDM..

Impact of a Hybrid Model of Prenatal Care on the Diagnosis of Fetal Growth Restriction.

OBJECTIVE: Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and screening via fundal height or ultrasound is routinely performed. During the novel coronavirus disease 2019 (COVID-19) pandemic, we developed a hybrid model of prenatal care which decreased the frequency of in-person visits and incorporated telemedicine visits. We sought to determine if prenatal FGR diagnoses decreased with this hybrid model compared with routine prenatal care. STUDY DESIGN: This was a retrospective cohort study of singleton nonanomalous neonates with birth weights <10th percentile at term. The "routine care" group was consisted of those who born between April and July 2019 with in-person prenatal care, and the "hybrid care" group was consisted of those who born between April and July 2020 with both in-person and telemedicine prenatal cares at a collaborative academic practice. The primary outcome was the rate of diagnosis of small for gestational age (SGA) as defined as infant birth weight <10th percentile without a prenatal diagnosis of FGR. The secondary outcome was timing of diagnosis of FGR. RESULTS: Overall, 1,345 and 1,296 women gave birth in the routine and hybrid groups, respectively. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7,727 in the hybrid period; 3,265 telemedicine visits occurred during the hybrid period. The total number of prenatal patients remained relatively stable at 3,993 and 3,753 between periods. Third trimester ultrasounds decreased from 2,929 to 2,014 between periods. Birth weights <10 percentile occurred in 115 (8.6%) births during the routine period and 79 (6.1%) births during the hybrid period. Of 115, 44 (38.3%) cases were prenatally diagnosed with FGR in the routine versus 28 of 79 (35.4%) in the hybrid group (p = 0.76). Median gestational age at diagnosis did not vary between groups (36 vs. 37 weeks, p = 0.44). CONCLUSION: A hybrid prenatal care model did not alter the detection of FGR. Future efforts should further explore the benefits of incorporating telemedicine into prenatal care. KEY POINTS: · Telemedicine visits can provide comprehensive prenatal care.. · FGR was diagnosed equally with hybrid versus routine prenatal care.. · FGR diagnosis was not delayed with hybrid care..

Congenital thrombotic thrombocytopenic purpura (TTP) with placental abruption despite maternal improvement: a case report.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a rare but serious complication in pregnancy that places the mother and fetus at high risk for morbidity and mortality. This case illustrates novel pregnancy complications associated with this rare medical condition. CASE PRESENTATION: A 31-year-old G3P0020 at 28 weeks and 1 day was admitted with severe thrombocytopenia and was ultimately diagnosed with TTP. With therapeutic plasma exchange (TPE), maternal status improved. At 28 weeks 6 days, however, non-reassuring fetal testing prompted cesarean delivery with placental abruption noted intraoperatively. Pathology examination confirmed placental abruption and also revealed multiple placental infarcts. CONCLUSION: While medical management of TTP can significantly improve the health of the mother, this case highlights the potential role of TTP in abruption and other placental pathology and thus, the need for close fetal surveillance throughout an affected pregnancy.

Crashing eclamptic patient and a resulting peri-mortem C-section.

BACKGROUND: Cardiac arrest in pregnancy is high acuity, low occurrence event. It involves the coordination of multiple teams to take care of ultimately two patients. This is further compounded by physiology that is frequently unfamiliar to the providers taking care of the patient. CASE REPORT: This case report will detail sudden onset eclampsia in a patient whose condition deteriorated rapidly into cardiac arrest. It will delve into the complexities of managing this complex disease process and how the multi-disciplinary team quickly integrated to manage both the mother and the baby. Why should the emergency physician be aware of this?: Cardiac arrest in pregnancy is an incredibly difficult situation due to both the physiological differences in the pregnant woman and the emotional factors on the treating providers (1). Due to its rarity, the pregnant cardiac arrest situation should be frequently reviewed to ensure appropriate care when the time arrives. The per-mortem c-section for a woman in cardiac arrest is a critical resuscitation technique that must be understood by providers who take care of critically ill patients ranging from emergency medicine to obstetrics and gynecology (Ob/Gyn) clinicians.

In Search of Accurate Fetal Heart Rate Monitoring Mobile Applications.

Background: Regulation of medical applications (apps) has not been rigorous. Concern for inaccurate medical apps with potential health consequences has increased. Objective: To identify mobile apps for fetal heart rate monitoring (FHM) and to evaluate their accuracy through a case report. Methods: A list of FHM apps was found in the Apple iTunes stores using a comprehensive list of search terms. After excluding apps irrelevant to this study, all unique apps were then downloaded and evaluated for necessary purchase of an accessory item, presence of disclaimer regarding medical advice, and accuracy of medical content. Those apps that did not require additional purchases were tested for ability to detect heart rates. Results: A total of 30 unique FHM apps were generated. Of these apps, 1 app required an in-app purchase to use and 7 apps required purchase of an accessory device and thus were not further evaluated. Of the 22 remaining apps, all (100%) of the applications were unable to detect the fetal heart rate. Further data collection revealed additional issues, including duplicates, lack of medical disclaimers regarding medical use of the app, and false information in the app content. Conclusion: Identification of FHM apps that do not require additional purchases revealed that all apps were inaccurate. In addition, some apps did not provide a disclaimer and/or contained false information. Healthcare providers should understand the problems with these FHM apps and educate their patients on the inaccuracies and potential dangers of the use of these applications.

Epoprostenol Exposure During Pregnancy.

Institutional policies restricting pregnant providers from caring for patients receiving inhaled epoprostenol exist across the nation based on little to no data to substantiate this practice. Over the last 2 decades, the use of inhaled pulmonary vasodilators has expanded in patients with cardiac and respiratory disease providing more evidence for the safety of these medications in obstetrical patients. We propose a thoughtful consideration and review of the literature to remove this restriction to reduce the need to reveal early pregnancy status to employers, to alleviate undue stress for pregnant caregivers who are exposed to patients receiving epoprostenol, and to ensure safe, equal employment, and learning opportunities for pregnant providers.

Anesthesia for cesarean delivery in a patient with congenitally corrected transposition of the great arteries: A case report.

Congenitally corrected transposition of the great arteries (CCTGA) is a rare form of congenital heart disease often associated with other cardiac defects. The adaptations and physiologic changes in pregnancy can present maternal challenges and complications; multidisciplinary care allows for the safest management of pregnancy and delivery in these patients. We present a case of the anesthetic management of cesarean delivery in a woman with CCTGA with her pregnancy complicated by recurrent volume overload, pulmonary hypertension, and dysrhythmias.

Carbohydrate Intake and Oral Glucose Tolerance Test Results in the Postpartum Period.

CONTEXT: The American Diabetes Association (ADA) recommends a 3-day preparatory diet prior to a diagnostic oral glucose tolerance test (OGTT), a test often recommended in postpartum individuals with a history of gestational diabetes (GDM). OBJECTIVE: Evaluate the relationship between carbohydrate intake and OGTT glucose in 2 cohorts of postpartum individuals. METHODS: We performed analyses of postpartum individuals from 2 prospective studies with recent GDM (Balance after Baby Intervention, BABI, n = 177) or risk factors for GDM (Study of Pregnancy Regulation of INsulin and Glucose, SPRING, n = 104) .We measured carbohydrate intake using 24-hour dietary recalls (SPRING) or Food Frequency Questionnaire (BABI) and performed 2-hour 75-g OGTTs. The main outcome measure was 120-minute post-OGTT glucose. RESULTS: There was no relationship between carbohydrate intake and 120-minute post-OGTT glucose level in either study population (SPRING: ß = 0.03, [-5.5, 5.5] mg/dL, P = .99; BABI: ß = -3.1, [-9.5, 3.4] mg/dL, P = .35). Adding breastfeeding status to the model did not change results (SPRING ß = -0.14, [-5.7, 5.5] mg/dL, P = .95; BABI ß = -3.9, [-10.4, 2.7] mg/dL, P = .25). There was, however, an inverse relationship between glycemic index and 120-minute post OGTT glucose (BABI: ß = -1.1, [-2.2, -0.03] mg/dL, P = .04). CONCLUSION: Carbohydrate intake is not associated with post-OGTT glucose levels among postpartum individuals. Dietary preparation prior to the OGTT may not be necessary in this population.

Trends in gestational age at delivery for intrahepatic cholestasis of pregnancy and adoption of society guidelines.

BACKGROUND: Intrahepatic cholestasis of pregnancy is associated with a significant risk of stillbirth, which contributes to variation in clinical management. Recent Society for Maternal-Fetal Medicine guidance recommends delivery at 36 weeks of gestation for patients with serum bile acid levels of >100 µmol/L, consideration for delivery between 36 and 39 weeks of gestation stratified by bile acid level, and against preterm delivery for those with clinical features of cholestasis without bile acid elevation. OBJECTIVE: This study aimed to investigate institutional practices before the publication of the new delivery timing recommendations to establish the maternal and neonatal effects of late preterm, early-term, and term deliveries in the setting of cholestasis. STUDY DESIGN: This study examined maternal and neonatal outcomes of 441 patients affected by cholestasis delivering 484 neonates in a 4-hospital system over a 30-month period. Logistic and linear regression analyses were performed to assess neonatal outcomes concerning peak serum bile acid levels at various gestational ages controlling for maternal comorbidities, multiple pregnancies, and neonatal birthweight. RESULTS: With the clinical flexibility afforded by the new guidelines, pregnancy prolongation to term may have been achieved in 91 patients (21%), and 286 patients (74%) with bile acid elevation could have delivered at a later gestational age. Preterm deliveries of patients with bile acid levels of >10 µmol/L were associated with higher rates of neonatal intensive care unit admission and adverse neonatal outcomes than early-term deliveries. CONCLUSION: Study data suggested an opportunity for education and practice change to reflect current Society for Maternal-Fetal Medicine guidelines in efforts to reduce potential neonatal morbidities associated with late preterm deliveries among pregnancies affected by cholestasis.

Acceptability of virtual prenatal care: thinking beyond the pandemic.

OBJECTIVE: Obstetrical providers have had to rapidly rethink how to provide comprehensive prenatal care during the SARS-CoV-2 pandemic. At our institution, we implemented a risk-stratified approach to incorporating telemedicine into our prenatal care. The objective of this study was to determine acceptability of virtual prenatal care and preferences for future pregnancies among our patient population. STUDY DESIGN: We sought feedback from a convenience sample of patients regarding the acceptability of virtual prenatal care and desires for future pregnancies. RESULTS: We found that virtual prenatal care is acceptable to patients, and the majority would like to incorporate it into future post-pandemic pregnancy care, although preferences differ by race. CONCLUSION: Virtual prenatal care should continue to be employed in post-pandemic obstetric practice. Obstetrical providers must determine how to incorporate this practice in a risk-stratified and equitable fashion.

Risk factors for positive postpartum depression screen in women with private health insurance and access to care.

Objective: To determine risk factors for a positive postpartum depression screen among women with private health insurance and 24/7 access to care.Study design: Retrospective cohort study of all patients delivered by a single MFM practice from April 2015 to September 2016. All patients had private health insurance and 24/7 access to care. All patients were scheduled to undergo the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit and a positive screen was defined as a score of 10 or higher, or a score greater than zero on question 10 (thoughts of selfharm). Using logistic regression, risk factors for postpartum depression were compared between women with and without a positive screen.Results: Of the 1237 patients delivered, 1113 (90%) were screened with the EPDS. 81 patients (7.3, 95%CI 5.9-9.0%) of those tested had a positive screen. On regression analysis, risk factors associated with a positive screen were nulliparity (aOR 1.8, 95%CI 1.1, 2.9), cesarean delivery (aOR 1.7, 95%CI 1.1, 2.8), non-White race (aOR 2.0, 95%CI 1.1, 3.5), and a history of depression or anxiety (aOR 4.6, 95%CI 2.6, 8.1). Among the 100 women with a history of depression or anxiety, selective serotonin reuptake inhibitor (SSRI) use in the postpartum period was not associated with a reduced risk of a positive screen (25.5% in those taking an SSRI versus 18.4% of those not taking an SSRI, p = .39).Conclusions: Among women with private health insurance and access to care, the incidence of a positive screen for postpartum depression is approximately 7%. The use of an SSRI did not eliminate this risk. All women should be screened for postpartum depression.

The association between maternal race and adverse outcomes in twin pregnancies with similar healthcare access.

OBJECTIVE: To compare twin pregnancy outcomes between white and nonwhite women with similar access to health care. METHODS: Retrospective cohort study of all twin pregnancies delivered by a single maternal-fetal medicine practice from 2005-2016. All patients had private health insurance and equal access to physician care. Outcomes were compared between white and nonwhite women using logistic regression to adjust for differences at baseline. RESULTS: Of the 858 women included, 730 (85.1%) were white and 128 (14.9%) were nonwhite. Univariate analysis demonstrated that nonwhite women had higher rates of preterm birth <32 weeks (12.5 versus 6.7%, p = .022), cesarean delivery (78.1% versus 61.4% of all women, p < .001 and 43.5% versus 16.1% of women who attempted labor, p < .001), preeclampsia (22.4% versus 14.5%, p = .029) and gestational diabetes (23.2% versus 7.3%, p < .001). On adjusted analysis, nonwhite race remained significantly associated with cesarean delivery in women who attempted labor (aOR 2.27, 95% CI: 1.09, 4.71) and gestational diabetes (aOR 2.61, 95% CI: 1.53, 4.45). CONCLUSIONS: Nonwhite women with twin pregnancies have an increased risk of adverse outcomes that cannot be explained by access to care. Although improving access to care is an important goal for health care systems, our data suggest that this alone will not eliminate all disparities in health care outcomes between women of different races.