Vertical Transmission of SARS-CoV-2 in a Twin Pregnancy.

Description Transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in 2019 and rapidly evolved into the global coronavirus disease 2019 (COVID-19) pandemic. The emergence of a highly morbid disease has posed ongoing challenges in the diagnosis, management, and prevention of COVID-19. The uncertainty underlying medical decision making is further compounded by preexisting conditions, including pregnancy. Here, we report a twin pregnancy complicated by maternal COVID-19 and the vertical transmission of SARS-CoV-2. We hope that our experiences contribute to a better understanding of the disease in pregnancy and, ultimately, guide the development of effective treatment and prevention strategies.

Combination antiretroviral therapy with protease inhibitors in HIV-infected pregnancy.

OBJECTIVE: To evaluate the possible association between protease inhibitor (PI) and premature birth and low birth-weight in HIV-infected pregnancies. MATERIALS AND METHODS: Data were collected retrospectively for maternal and pregnancy characteristics, antiretroviral medication, lowest CD4 count and highest viral load during pregnancy, and pregnancy outcomes. χ(2) Analysis, Student's t-test, and multiple logistic regression analysis were performed. RESULTS: Data from 161 HIV-infected women who delivered singleton gestation were analyzed. Fifty-three received an antepartum regimen with PI, 84 received a regimen without PI, and six did not receive antepartum treatment. The mean estimated gestational age (EGA)± SD at delivery was 37.7 ± 3.2 weeks. The premature birth rate was 18.4%. No difference was detected between women receiving the antiretroviral regimen including PI and those on the regimen without PI or on no antepartum medication with regard to: EGA ± SD at delivery (37.7 ± 3.2 vs. 37.6 ± 3.1 weeks, respectively, P=0.87), rate of premature birth (14% vs. 20.6%, respectively, P=0.32) and low birth-weight (12.5% vs. 20.2%, respectively, P=0.25). In multiple logistic regression analysis, PI was not associated with premature birth or low birth-weight. CONCLUSION: Women receiving antiretroviral therapy with PI have a similar rate of premature birth and low birth-weight as women receiving antiretroviral therapy without PI or on no medication.

Residency Support During a Natural Disaster: Hurricane Ida.

Description Natural disasters can have extraordinary impacts on a community and its infrastructure. Disasters can weaken systems that provide crucial resources, such as shelter, food security, water and health care. Recently, southeast Louisiana sustained devastating damage from Hurricane Ida on the 16th anniversary of Hurricane Katrina. Our medical workforce faced challenges caring for patients in a facility without potable water and powered by a generator. With the support of corporate entities and our academic institution, however, these barriers were quickly overcome and thus highlights the importance of collective resilience in the face of a natural disaster.

Rapid HIV testing and obstetrical characteristics of women with unknown HIV serostatus at time of labor and delivery.

OBJECTIVE: To describe the obstetrical characteristics of women without prenatal care and/or undocumented human immunodeficiency virus (HIV) serostatus who presented for delivery and to assess the usefulness of rapid HIV screening in these women. MATERIALS AND METHODS: The study design was a retrospective analysis. Demographics, labor, delivery characteristics, and pregnancy outcomes of women without prenatal care and/or unknown HIV serostatus were reviewed. RESULTS: Three hundred fifty parturients met the inclusion criteria: 15.2% presented at complete cervical dilation, 48.6% with cervical dilation of at least 5 cm, and 43.1% with ruptured membranes. Twenty-two percent of parturients delivered within 1 hour of admission, 47.6% delivered within 4 hours of admission, and 5.5% delivered prior to arrival to the hospital. With the lengthy admission process and procurement of zidovudine from the pharmacy requiring at least 1 hour at best, 27.5% would not have the benefit of intrapartum zidovudine treatment. Single Use Diagnostic System HIV-1 rapid test was reactive and confirmed in 7 women (2.5%). CONCLUSION: Rapid HIV screening is a useful tool for guiding immediate obstetrical management and coordinated care for the neonate. In some circumstances, the full benefit of rapid HIV detection will not be realized due to advanced labor, ruptured members, or delivery prior to arrival.

Relationship among age, race, medical funding, and cervical cancer survival.

OBJECTIVE: To examine the impact of age, race, and medical funding on cervical cancer survival. MATERIALS AND METHODS: Study design was a retrospective chart review of cervical cancer patients. Charts were abstracted for demographic characteristics, Pap smear history, clinical presentation, treatment, and survival. Descriptive studies, Spearman correlation, and Cox's proportional hazards regression model were performed. RESULTS: One hundred-twenty-five cervical cancer patients were included. Mean age at diagnosis was 46.1 +/- 13.2 years, and median survival time from cervical cancer was 31 months; 11.2% of the study population was aged greater than 65 years; 63.4% were African American; and 44.6% had no medical funding. Diagnosis at age of at least 65 years was significantly correlated with suboptimal cervical cancer screening pattern (r = 0.36, p = .0003). Women aged at least 65 years old had a 3.39 time increased hazard of death compared to younger patients (p = .02; OR, 3.39; 95% CI, 1.20-9.56) after adjusting for advanced stage of disease and treatment modality. There was no significant association between medical funding or race on cervical cancer screening pattern, stage at diagnosis, or survival. CONCLUSION: Age at diagnosis (> or = 65 years), but not medical funding or race, was correlated with suboptimal cervical cancer screening pattern and poor survival.

An Obstetrics and Gynecology Residency Program's Approach to the COVID-19 Pandemic.

Background: The impact of COVID-19 on residency training nationwide has been substantial, and adapting to this unprecedented event has proven challenging for program directors throughout the United States. Here, the authors presented their initial experiences with restructuring an obstetrics and gynecology residency program during the pandemic. The authors outlined their strategies to maximize resident safety and address clinical care in outpatient and inpatient settings, resident education curriculum, resident wellness and consider the ethical dilemmas of health care providers during a pandemic. Conclusion: With perspectives from other residency programs, the authors hope this review will serve as an initial building block for developing an effective strategic response for programs to implement during a disaster.

Universal Testing of COVID-19 Infection on a New Orleans, LA Labor and Delivery Unit.

Background: The greater New Orleans area emerged as an early epicenter of the COVID-19 pandemic, with one of the highest infection and death rates per capita in the United States.1 The first case of COVID-19 in an obstetric patient at Tulane Lakeside Hospital occurred on March 22, 2020. Given increasing concern for asymptomatic carriers, the labor and delivery unit implemented universal testing of all patients and their support partners starting on April 1, 2020. Methods: A retrospective chart review of all obstetric encounters was performed to determine the incidence of COVID-19, characterize the natural history of COVID-19 and evaluate obstetric and neonatal outcomes. Results: Over a 5 week period of universal testing, there were 12/254 (4.72%) confirmed cases of COVID-19; 58% of COVID-positive patients were asymptomatic. The majority of the symptomatic COVID-19 patients had a mild course of the infection, similar to results from a previous study.2 As of completion of the study period, only 4 COVID-19-positive patients delivered; all of them had uncomplicated intra- and postpartum courses. There was no evidence of vertical transmission of COVID-19. Conclusion: These results confirm the asymptomatic carrier rate is high and support the case for universal testing in high prevalence cities. Ultimately, universal testing allows for a timely identification of disease, initiation of isolation and contact precautions and appropriate allocation of personal protective equipment (PPE).

Repeat Pregnancies Among US Women Living With HIV in the SMARTT Study: Temporal Changes in HIV Disease Status and Predictors of Preterm Birth.

BACKGROUND: Birth rates among women living with HIV (WLHIV) have increased recently, with many experiencing multiple pregnancies. Yet, viral suppression is often not sustained between pregnancies. In addition, protease inhibitors (PIs) have been associated with preterm birth, but associations between integrase strand transfer inhibitors (INSTIs) and preterm birth are less well characterized. METHODS: We studied WLHIV with ≥2 live-born infants enrolled into the Pediatric HIV/AIDS Cohort Study Surveillance Monitoring for Antiretroviral Treatment Toxicities (SMARTT) study between 2007 and 2018, comparing CD4 counts and viral loads (VLs) between 2 consecutive SMARTT pregnancies. We evaluated associations of covariates with CD4 and viral suppression and the association of PI/INSTI use during pregnancy with odds of preterm birth. RESULTS: There were 736 women who had ≥2 live-born children enrolled in SMARTT (1695 pregnancies). Median CD4 counts remained stable over repeat pregnancies. Although >80% of women achieved VL suppression during pregnancy, more than half had a detectable VL early in their subsequent pregnancy. In adjusted models including all singleton pregnancies, an increased odds of preterm birth was observed for women with first trimester PI initiation (adjusted odds ratio: 1.97; 95% confidence interval: 1.27 to 3.07) compared with those not receiving PIs during pregnancy and for first trimester INSTI initiation (adjusted odds ratio: 2.39; 95% confidence interval: 1.04 to 5.46) compared with those never using INSTIs during pregnancy. CONCLUSIONS: Most WLHIV achieved VL suppression by late pregnancy but many were viremic early in subsequent pregnancies. First trimester initiation of PIs or INSTIs was associated with a higher risk of preterm birth.

Postoperative infectious morbidities of cesarean delivery in human immunodeficiency virus-infected women.

OBJECTIVE: To compare the infectious complication rates from cesarean delivery of human immunodeficiency virus (HIV)-infected women and HIV-negative women. MATERIALS AND METHODS: A retrospective analysis was performed on data derived from HIV-infected women and HIV-negative women, who underwent cesarean delivery at two teaching hospitals. Main outcome measures were infectious postoperative morbidity. Descriptive, comparison analysis, and multiple logistic regression analysis were performed. RESULTS: One hundred and nineteen HIV-infected women and 264 HIV-negative women delivered by cesarean section and were compared. The HIV-negative women were more likely than the HIV-infected women to deliver by emergent cesarean section (78.0% versus 51.3%, resp., P < .05), to labor prior to delivery (69.4% versus 48.3%, resp., P < .01), and to have ruptured membranes prior to delivery (63.5% versus 34.8%, resp., P < .05). In bivariate analysis, HIV-infected and HIV-negative women had similar rates of post-operative infectious complications (16.8% versus 19.7%, resp., P > .05). In a multivariate stepwise logistic analysis, emergent cesarean delivery and chorioamnionitis but not HIV infection were associated with increased rate of post-operative endometritis (odds ratio (OR) 4.10, 95% confidence interval (95% CI) 1.41-11.91, P < .01, and OR 3.02, 95% CI 1.13-8.03, P < .05, resp.). CONCLUSION: In our facilities, emergent cesarean delivery and chorioamnionitis but not HIV infection were identified as risk factors for post-operative endometritis.

Cervical Pessary versus Expectant Management for the Prevention of Delivery Prior to 36 Weeks in Women with Placenta Previa: A Randomized Controlled Trial.

Objective This multicenter randomized controlled trial compared cervical pessary (CP) versus expectant management (EM) in women with placenta previa between 22.0 and 32.0 in prolonging gestation until ≥ 36.0 weeks' gestation. Study Design This study took place from November 2016 to June 2018. Women were randomized to receive either the Bioteque CP or EM. The pessary was removed at ≥ 36.0 weeks unless indicated. The primary outcome was gestational age (GA) at delivery, with secondary outcomes including need for transfusion, number and duration of antepartum admissions, type of delivery, and neonatal outcomes. A total of 140 patients were needed to show a 3-week prolongation of pregnancy in the pessary group; however, the trial was stopped early due to budgetary issues. Results Of the 33 eligible women, 17 were enrolled. Although not statistically significant, the mean GA at delivery in the CP group was greater than women in the EM group (36.5 ± 1.23 vs. 36.0 ± 2.0; p = 0.1673). The number and duration of antepartum admissions was greater in the EM group (2.7 ± 0.58 vs. 16.0 ± 22.76 days; p = 0.1264) as well. Conclusion Although the study was underpowered to determine the primary outcome, safety and feasibility of CP in pregnancies complicated with previa were demonstrated.

A multi-institutional effort for temporary training of residents displaced by disaster: lessons from Katrina.

OBJECTIVE: This study was undertaken to describe a comprehensive, collaborative temporary residency training curriculum after disaster. STUDY DESIGN: The Texas Southeast Alliance was created in response to the Katrina Disaster by regional obstetric/gynecology programs. Principles were devised to guide development of a temporary training curriculum. Learning opportunities were identified and pooled. Affected program directors were contacted who expressed interest in the curriculum which had been approved by institutional officials and appropriate regulatory bodies. RESULTS: In total, 41 different training opportunities were made available to the Tulane residents. Twenty-four residents completed 92 rotations in total. Residents met weekly with their program director. Free psychiatric consultative services were provided through resident counseling services. Housing was facilitated wherever possible. CONCLUSION: Consolidation of resources by the Texas Southeast Alliance provided temporary training experiences for Tulane obstetric and gynecology residents displaced by Hurricane Katrina. Effective training can be maintained after disaster by coordinating institutional efforts and establishing governing principles.

Eighty hour work reform: faculty and resident perceptions.

OBJECTIVE: The purpose of the study was to describe resident and faculty perceptions on the impact of the 80 hour work reform on residency training. STUDY DESIGN: Surveys were distributed to resident and faculty at a major university-based teaching institution. All responses were anonymous. Information abstracted from the survey included: demographic characteristics and resident and faculty perceptions on resident education, patient care, resident work environment, and quality of life after the institution of new regulations on resident duty hours. Descriptive and comparison analyses were performed. RESULTS: Ninety-four residents and 56 faculty members responded. Significant differences were detected in resident and faculty perceptions that work reform improved resident education (52.3% vs 20.8%, respectively, P < .01), and worsened quality of patient care (8.8% vs 45.3%, respectively, P < .01). Both residents (84.4%) and faculty (90.7%) agreed that work reform improved resident quality of life. CONCLUSION: Faculty and resident perceptions differed on the impact of the work reform on patient care and resident education but agreed that it improved resident quality of life.

Resolution of internal carotid dissection with middle cerebral artery occlusion in pregnancy.

Introduction. Cervical artery dissection (CAD) is a common cause of stroke in younger patients. While the incidence of stroke in pregnancy is increasing, CAD remains a rare cause of ischemic stroke in the pregnant population, with only 30 cases described in the literature, most in the postpartum period. Methods. The case of a pregnant patient at 18 weeks of gestation presenting with CAD and ischemic stroke following intercourse is discussed. Discussion. CAD results from an intimal tear in the carotid artery, allowing accumulation of blood in the vessel wall. Stroke results from embolization of thrombogenic material in the wall. Etiology includes minor trauma, connective tissue disorders, or anatomic variations of the carotid artery. Most patients present with headache and/or neck pain, while ischemic symptoms are seen in at least 50% of patients. In the pregnant population, imaging with MRI or MRA of the head and neck aids in diagnosis. Once the diagnosis is made, patients are treated with either anticoagulation or antiplatelet medications. The optimal treatment in both pregnant and nonpregnant patients has not been well-studied. Conclusion. CAD is an important diagnosis to consider in a pregnant patient with persistent headache, especially if neurological symptoms are present. Imaging should be quickly obtained so treatment can be initiated.

Significantly elevated serum lipase in pregnancy with nausea and vomiting: acute pancreatitis or hyperemesis gravidarum?

Hyperemesis gravidarum is a severe manifestation of nausea and vomiting of pregnancy and it is associated with weight loss and metabolic abnormalities. It is known that abnormal laboratory values, including mildly elevated serum lipase level, could be associated with hyperemesis gravidarum. However, in this case report details of two women with hyperemesis gravidarum but with significantly elevated serum lipase levels were discussed. These patients presented with severe nausea and vomiting but without abdominal pain. They were found to have severely elevated lipase levels over 1,000 units/liter. In the absence of other findings of pancreatitis, they were treated with conservative measures for hyperemesis gravidarum, with eventual resolution to normal lipase levels. Although significantly elevated lipase level in pregnant patients with nausea and vomiting is a concern for acute pancreatitis, these two cases of significantly elevated serum lipase without other clinical findings of pancreatitis led to this report that serum lipase could be quite elevated in hyperemesis gravidarum and that it might not be an accurate biochemical marker for acute pancreatitis. Imaging studies are thus necessary to establish the diagnosis of acute pancreatitis.

Recurrent posterior reversible encephalopathy syndrome potentially related to AIDS and end-stage renal disease: a case report and review of the literature.

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that is characterized by clinical features including headache, altered mental status, cortical blindness, seizures, and other focal neurological signs as well as subcortical edema without infarction on neuroimaging. Under the umbrella of hypertensive encephalopathy, PRES is defined by reversible cerebral edema due to dysfunction of the cerebrovascular blood-brain barrier unit. The pathophysiology of PRES is thought to result from abnormalities in the transmembrane flow of intravascular fluid and proteins caused by two phenomena: one, cerebral autoregulatory failure and two, loss of integrity of the blood-brain barrier. PRES is not a common disease in patients with human immunodeficiency virus (HIV) and AIDS with only three previously reported cases. Both the HIV and end-stage renal disease appear to further compromise the blood brain barrier. Although uncommon, PRES recurrence has been described. To the best of our knowledge, this is the first report demonstrating recurrent PRES in a HIV patient on hemodialysis for end-stage renal disease.

Acute HIV Infection in Pregnancy: The Case for Third Trimester Rescreening.

Combination testing with anti-HIV Elisa and Western blot is both sensitive and specific for diagnosis of established HIV-1 infection but could not detect acute HIV infection (AHI). AHI is a time of extremely high viral load, which may correlate to increased risk of horizontal or vertical transmission. Thus, early identification of AHI could allow for interventions to decrease transmission. However, recognition of AHI can be challenging as symptoms could be absent or nonspecific, therefore, AHI is often not detected, particularly in pregnancy. We present a case report of AHI in a pregnant woman who presented with headache and fever. She tested negative for HIV in the first trimester and at time of AHI at 26 3/7 weeks by anti-HIV Elisa, but was diagnosed with AHI based on an HIV RNA viral load of 434,000 copies/mL. This report presents a case for improved awareness of AHI in pregnancy, and the need for repeat HIV testing in late pregnancy, and highlighted that early detection of AHI might be possible with adding HIV RNA testing at time of standard anti-HIV Elisa screening test in pregnancy. Novel laboratory approaches including pooling of sera for HIV RNA could reduce the cost of HIV RNA testing.

Preterm birth after mature fetal lung indices: is there any neonatal morbidity?

OBJECTIVE: To determine the frequency of immediate morbidities in neonates with evidence of mature fetal lung indices who delivered before 37 weeks gestation. METHODS: A retrospective analysis was performed on pregnancies resulting in birth at < 37 weeks after mature fetal lung was documented by phosphatidylglycerol, lecithin/sphingomyelin ratio, or TDx-FLM studies. Pregnancies with multifetal gestations, maternal diabetes, or fetal anomalies were excluded. RESULTS: 179 patients were included. Eighty-one (45.3%) neonates did not sustain any morbidity, and 98 (54.7%) neonates sustained one or more morbidities. Compared to neonate without any morbidity, neonates experiencing morbidities were delivered at significantly younger gestation (35.7 ± 1.1 vs. 34.9 ± 1.5 weeks, respectively, p < 0.001) had lower birth- weight (2632.2 ± 475.5 vs. 2395.3 ± 496 g, respectively, p < 0.001), and required longer hospital stay (3.7 ± 2.8 vs. 6.9 ± 7.5 days, p < 0.001). A multivariate regression model was performed to control for the effect of birth-weight, steroid administration, and preterm premature rupture of membrane. An earlier gestational age at delivery was associated with a higher risk of neonatal morbidity. The risk of neonatal morbidity decreased by 40% (OR = 0.60, 95% CI = 0.41-0.88; p = 0.009) for each 1 week increase in gestational age. CONCLUSION: Even in the presence of documented fetal lung maturity, major morbidities--including respiratory distress - may still occur.

Pregnancy outcomes following placement of elective, urgent and emergent cerclage.

OBJECTIVE: To describe pregnancy outcomes following elective (history-indicated), urgent (ultrasound-indicated) or emergent (physical-exam indicated) cerclage placement. MATERIALS AND METHODS: Study design was retrospective chart review. Women with singleton gestation and cervical cerclage were categorised into: elective, urgent and emergent group. RESULTS: One hundred and thirty-three women were included; 89 in elective, 26 in urgent and 18 in emergent group. Difference was detected when elective and urgent groups were compared with emergent group for: gestation at delivery (35.9 +/- 5.1 vs. 34.2 +/- 5.9 vs. 29.3 +/- 7.2 weeks, respectively, P < 0.05), delivery beyond 36 weeks, (73.9%, 57.7%vs. 23.5%, respectively, P < 0.05), neonatal death (6.8%, 9.5%vs. 43.8%, respectively, P < 0.05) and Apgar score <7 at 5 min (9.1%, 11.5%vs. 47.1%, respectively, P < 0.05). Difference was also detected between elective vs. urgent and emergent groups for: preterm premature rupture of membranes (PPROM) (19.3%vs. 38.5%vs. 64.7%, respectively, P < 0.05) and chorioamnionitis (1.4%vs. 18.2%vs. 42.9%, respectively, P < 0.05). CONCLUSIONS: Emergent cerclage group had the poorest obstetric outcomes. The urgent cerclage group reached similar gestational age at delivery as the elective group but is more likely to have PPROM and chorioamnionitis.

Preeclampsia and eclampsia revisited.

Hypertensive disorders during pregnancy, which account for approximately 15% of pregnancy-related deaths, represent the second-leading cause of morbidity and mortality in the United States. New classifications recommended by the National Institutes of Health's Working Group on High Blood Pressure in Pregnancy have decreased the confusion often associated with these disorders. The cause of preeclampsia-eclampsia still remains elusive, but continued research has provided hope with regard to screening, improved diagnosis, and management. Risk factors that have recently gained attention include inherited thrombophilias, inherited metabolic disorders, and lipid disorders. Treatment and management of the hypertensive disorders of pregnancy have not changed substantially in the past 50 years. Prevention of preeclampsia-eclampsia has been unsuccessful, and recurrence risks remain high. Careful diagnosis, classification, and further investigation of the causes of hypertensive disorders in pregnancy are needed to achieve optimal management of affected women and their fetuses.

Placenta previa: does its type affect pregnancy outcome?

Our objective was to compare pregnancy outcomes associated with different types of placenta previa. This is a retrospective analysis of pregnancies complicated by placenta previa, from January 1990 to December 1997. Descriptive statistics and comparison analyses were performed. One hundred seventy-five singleton pregnancies beyond 24 weeks that were complicated by complete, partial, or marginal previa were included. Differences in pregnancy outcomes between complete, partial, and marginal previas were: onset of bleeding (29.9 +/- 4.5 versus 32.5 +/- 6.9 versus 32.7 +/- 5.0 weeks, respectively, p < 0.05), antepartum hospitalization (60.7% versus 38.1% versus 35.1%, respectively, p < 0.05), gestation at delivery (34.7 +/- 3.1 versus 37.4 +/- 2.6 versus 36.1 +/- 3.0 weeks, respectively, p < 0.05), birth weight (2498.3 +/- 746.8 versus 2978.8 +/- 568.3 versus 2813.4 +/- 728.4 g, respectively, p < 0.05), and hysterectomy at time of cesarean delivery (20.5% versus 0% versus 8.1%, respectively, p < 0.05). For all outcome parameters, the partial and marginal previa groups did not differ. Women with complete placenta previa, as diagnosed with modern ultrasound techniques, had poorer pregnancy outcome. They were more likely to deliver prematurely and were more likely to require a hysterectomy at the time of cesarean delivery.