Comprehensive appraisal of pregnancy and neonatal outcomes in singleton pregnancies conceived via in vitro fertilization in the USA (2016-2021).

OBJECTIVES: We set out to compare adverse pregnancy and neonatal outcomes in singleton gestations conceived via in vitro fertilization (IVF) to those conceived spontaneously. METHODS: Retrospective, population-based cohort using the CDC Natality Live Birth database (2016-2021). All singleton births were stratified into two groups: those conceived via IVF, and those conceived spontaneously. The incidence of several adverse pregnancy and neonatal outcomes was compared between the two groups using Pearson's chi-square test with Bonferroni adjustments. Multivariate logistic regression was used to adjust outcomes for potential confounders. RESULTS: Singleton live births conceived by IVF comprised 0.86 % of the cohort (179,987 of 20,930,668). Baseline characteristics varied significantly between the groups. After adjusting for confounding variables, pregnancies conceived via IVF were associated with an increased risk of several adverse pregnancy and neonatal outcomes compared to those conceived spontaneously. The maternal adverse outcomes with the highest risk in IVF pregnancies included maternal transfusion, unplanned hysterectomy, and maternal intensive care unit admission. Increased rates of hypertensive disorder of pregnancy, preterm birth (delivery <37 weeks of gestation), and cesarean delivery were also noted. The highest risk neonatal adverse outcomes associated with IVF included immediate and prolonged ventilation, neonatal seizures, and neonatal intensive care unit admissions, among others. CONCLUSIONS: Based on this large contemporary United States cohort, the risk of several adverse pregnancy and neonatal outcomes is increased in singleton pregnancies conceived via IVF compared to those conceived spontaneously. Obstetricians should be conscious of these associations while caring for and counseling pregnancies conceived via IVF.

Risk of Severe Maternal Morbidity Associated with Maternal Comorbidity Burden and Social Vulnerability.

OBJECTIVE: We evaluated the associations of the obstetric comorbidity index (OB-CMI) and social vulnerability index (SVI) with severe maternal morbidity (SMM). STUDY DESIGN: Multicenter retrospective cohort study of all patients who delivered (gestational age > 20 weeks) within a university health system from January 1, 2019, to December 31, 2021. OB-CMI scores were assigned to patients using clinical documentation and diagnosis codes. SVI scores, released by the Centers for Disease Control and Prevention (CDC), were assigned to patients based on census tracts. The primary outcome was SMM, based on the 21 CDC indicators. Mixed-effects logistic regression was used to model the odds of SMM as a function of OB-CMI and SVI while adjusting for maternal race and ethnicity, insurance type, preferred language, and parity. RESULTS: In total, 73,518 deliveries were analyzed. The prevalence of SMM was 4% (n = 2,923). An association between OB-CMI and SMM was observed (p < 0.001), where OB-CMI score categories of 1, 2, 3, and ≥4 were associated with higher odds of SMM compared with an OB-CMI score category of 0. In the adjusted model, there was evidence of an interaction between OB-CMI and maternal race and ethnicity (p = 0.01). After adjusting for potential confounders, including SVI, non-Hispanic Black patients had the highest odds of SMM among patients with an OB-CMI score category of 1 and ≥4 compared with non-Hispanic White patients with an OB-CMI score of 0 (adjusted odds ratio [aOR] 2.76, 95% confidence interval [CI] 2.08-3.66 and aOR 10.07, 95% CI 8.42-12.03, respectively). The association between SVI and SMM was not significant on adjusted analysis. CONCLUSION: OB-CMI was significantly associated with SMM, with higher score categories associated with higher odds of SMM. A significant interaction between OB-CMI and maternal race and ethnicity was identified, revealing racial disparities in the odds of SMM within each higher OB-CMI score category. SVI was not associated with SMM after adjusting for confounders. KEY POINTS: · OB-CMI was significantly associated with SMM.. · Racial disparities were seen within each OB-CMI score group.. · SVI was not associated with SMM on adjusted analysis..

The impact of fresh versus frozen-thawed embryos on maternal serum analyte levels in IVF singleton and twin pregnancies.

PURPOSE: To determine whether embryo cryopreservation is associated with a difference in maternal serum analyte levels in singleton and twin pregnancies conceived via in vitro fertilization (IVF). METHODS: This was a retrospective cohort study of singleton and twin pregnancies conceived via IVF from a university health system from 01/2014 to 09/2019. Patients with available first and second trimester serum analyte data were included and analyzed separately. Multiple of the median (MoM) values for free ß-human chorionic gonadotropin (ß-hCG), pregnancy-associated plasma protein A, alpha-fetoprotein (AFP), Inhibin A, and unconjugated estriol (uE3) were compared between two groups: pregnancies conceived after the transfer of fresh embryos versus pregnancies conceived after the transfer of frozen-thawed embryos. Multiple linear regression of log MoM values with F test was performed to adjust for potential confounders. RESULTS: For singletons, fresh embryos were associated with a lower median first trimester free ß-hCG (1.00 MoM vs. 1.14 MoM; parameter estimate [PE] 0.90, 95% CI 0.82-0.99, p = .03) compared to frozen-thawed embryos. Fresh embryos were also associated with a lower median second trimester uE3 (0.93 MoM vs. 1.05 MoM; PE 0.88, CI 0.83-0.95, p = .0004) and AFP (1.02 MoM vs. 1.19 MoM; PE 0.91, CI 0.84-0.99, p = .02) compared to frozen-thawed embryos in singletons. There were no significant differences between median first and second trimester serum analytes in twin pregnancies compared between the two groups. CONCLUSION: Singleton pregnancies derived from fresh embryos had lower first (free ß-hCG) and second (uE3 and AFP) trimester analytes compared to frozen-thawed embryos. Twin pregnancies demonstrated no difference between the groups.

Socioeconomic and clinical factors associated with excessive gestational weight gain.

PURPOSE: Excessive gestational weight gain (EGWG) is associated with adverse maternal and offspring outcomes but efforts to identify women at high risk for EGWG have been limited. The objective of this study is to identify socioeconomic and clinical factors associated with EGWG. METHODS: This retrospective cohort included pregnant patients who delivered live, term, singleton newborns between January 2018 and February 2020 at seven hospitals within a large health system in New York. Patients were stratified by pre-pregnancy body mass index and then classified based on whether they exceeded the Institute of Medicine guidelines for gestational weight gain (GWG) and whether they gained more than 50 pounds in pregnancy. RESULTS: A total of 44,872 subjects were included for analysis: 48% had EGWG and 17% had GWG exceeding 50 pounds. Patients with EGWG were more likely to be Black race, English speakers, overweight or obese pre-pregnancy, and have a mood disorder diagnosis. Patients who were underweight, multiparous, and those with gestational diabetes were less likely to have EGWG. CONCLUSION: Sociodemographic and clinical findings associated with GWG > 50 pounds were similar but only overweight and not obese patients were at increased risk. Patients at risk for EGWG may benefit from early nutrition counseling and education on lifestyle changes.

Vacuum-Induced Hemorrhage Control versus Uterine Balloon Tamponade for Postpartum Hemorrhage.

OBJECTIVE: To compare maternal outcomes of uterine balloon tamponade (UBT) versus an intrauterine vacuum-induced hemorrhage control device (VHD) for the management of primary postpartum hemorrhage (PPH). METHODS: Retrospective cohort of all patients with PPH due to uterine atony treated with an intrauterine device within a university health system from January 2019 to June 2021. The primary outcome of massive transfusion, defined as PPH requiring transfusion of ≥4 units of packed red blood cells (PRBC), was compared between 2 groups: UBT (n = 78) versus VHD (n = 36). Statistical analysis included the use of chi-squared and Wilcoxon rank sum tests with statistical significance set at P < 0.05. RESULTS: Baseline characteristics were similar between the 2 groups. The proportion of patients who received ≥4 units of PRBC was significantly lower in the VHD group compared to the UBT group (2.8% vs. 20.5%, P = <0.01). The proportion of patients who were transfused ≥2 units of PRBC and median estimated blood loss (EBL) were also both significantly lower in the VHD group compared to the UBT group (36.1% vs. 57.7%, P = < 0.01, and 1 500 mL vs. 1 875 mL, P = 0.02, respectively). Rates of other secondary outcomes were similar between the 2 groups. CONCLUSION: Our data suggest that the use of intrauterine VHD in the management of PPH is associated with a lower number of massive transfusions and EBL compared to UBT. Randomized controlled trials are needed before drawing definitive conclusions on which device is more effective in this setting.

Time interval to delivery in asymptomatic twin pregnancies with a short cervix at 23-28 weeks' gestation.

OBJECTIVES: To evaluate the risk and timing of spontaneous preterm birth (PTB) in asymptomatic twin pregnancies with a short cervical length (CL≤25 mm) at 23-28 weeks of gestation. METHODS: Multicenter retrospective cohort study of asymptomatic twin pregnancies with a short CL between 23 and 28 weeks' gestation within a university health system from 1/2012 to 12/2019. Cases were divided into 4 groups based on CL measurement (≤10 mm, 11-15 mm, 16-20 mm, and 21-25 mm). The primary outcome was time interval from presentation to delivery. Secondary outcomes included delivery within one and two weeks of presentation, and delivery prior to 32, 34, and 37 weeks, respectively. RESULTS: 104 patients were included. The time interval from presentation to delivery was significantly different among the four groups (p<0.001), with the CL≤10 mm group having the shortest time interval to delivery. Regardless of the CL measurement, spontaneous PTB within one and two weeks was extremely uncommon and occurred in only one patient within the study cohort (1/104, 1.0%). The risk of spontaneous PTB was highest in the shortest CL group (CL ≤ 10 mm; 53.8% PTB<32 weeks, 61.5% PTB<34 weeks, 92.3% PTB<37 weeks). CONCLUSIONS: Asymptomatic twin pregnancies with a CL ≤ 10 mm had the shortest time interval to delivery and thus represent a specifically high risk group for sPTB. Although all patients were at high risk of sPTB, only one delivered within 1 or 2 weeks of presentation.

Hypertensive disorders of pregnancy and severe acute respiratory syndrome coronavirus-2 infection.

OBJECTIVES: We aimed to determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is associated with an increased risk of hypertensive disorders of pregnancy (HDP). METHODS: A multicenter retrospective cohort study of all pregnant patients who had SARS-CoV-2 testing and delivered in a large health system between March 2020 and March 2021. Cases were stratified into two groups: patients who tested positive for SARS-CoV-2 during pregnancy vs. patients who tested negative. The primary outcome of HDP, defined as a composite of gestational hypertension, preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP Syndrome), and eclampsia by standard criteria, was compared between the two groups. Statistical analysis included multivariable logistic regression to adjust for potential confounders such as maternal demographics and comorbidities. Patient ZIP codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey. RESULTS: Of the 22,438 patients included, 1,653 (7.4%) tested positive for SARS-CoV-2 infection. Baseline demographics such as age, body mass index, race, ethnicity, insurance type, neighborhood-built environmental and socioeconomic status, nulliparity, and pregestational diabetes differed significantly between the two groups. SARS-CoV- 2 infection in pregnancy was not associated with an increased risk of HDP compared to those without infection (14.9 vs. 14.8%; aOR 1.06 95% CI 0.90-1.24). CONCLUSIONS: In this large cohort that included a universally-tested population with several socioeconomic indicators, SARS-CoV-2 infection in pregnancy was not associated with an increased risk of HDP.

Risk factors associated with third- and fourth-degree perineal lacerations in singleton vaginal deliveries: a comprehensive United States population analysis 2016-2020.

OBJECTIVES: Perineal lacerations are a common complication of vaginal birth, affecting approximately 85 % of patients. Third-and fourth-degree perineal lacerations (3/4PL) remain a significant cause of physical and emotional distress. We aimed to perform an extensive assessment of potential risk factors for 3/4PL based on a comprehensive and current US population database. METHODS: Retrospective population-based cohort analysis based on the US Centers for Disease Control and Prevention Natality Live Birth online database between 2016-2020. Baseline characteristics were compared between women with 3/4PL and without 3/4PL by using Pearson's Chi-squared test with statistical significance set at p<0.05. Bonferroni correction was used to account for multiple comparisons. Multivariable logistic regression was performed to evaluate the association between a variety of potential risk factors and the risk of 3/4P. RESULTS: Asians/Pacific Islanders had the highest risk of 3/4PL (2.6 %, aOR 1.74). Gestational hypertension and preeclampsia were associated with increased risk of 3/4PL (aOR 1.28 and 1.34, respectively), as were both pre-gestational and gestational diabetes (aOR 1.28 and 1.46, respectively). Chorioamnionitis was associated almost double the risk (aOR 1.86). Birth weight was a major risk factor (aOR 7.42 for greater than 4,000 g), as was nulliparity (aOR 9.89). CONCLUSIONS: We identified several maternal, fetal, and pregnancy conditions that are associated with an increased risk for 3/4PL. As expected, nulliparity and increased birth weight were associated with the highest risk. Moreover, pregestational and gestational diabetes, hypertensive disorders of pregnancy, Asian/Pacific Islander race, and chorioamnionitis were identified as novel risk factors.

Sociodemographic Factors Associated With Gonorrhea and Chlamydia Infection in Pregnancy.

BACKGROUND: We explored the impact of maternal sociodemographic parameters on the prevalence of chlamydial and gonorrheal infection in pregnancy in a large United States population of live births. METHODS: Retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database (2016-2019). We compared pregnancies complicated by maternal infection with either gonorrhea or chlamydia to those without gonorrheal or chlamydial infection, separately. Both analyses included assessment of multiple maternal sociodemographic factors, which were compared between the 2 groups. Multivariable logistic regression was performed to evaluate the association of these factors with gonorrheal or chlamydial infection in pregnancy. RESULTS: Of the 15,341,868 included live births, 45,639 (0.30%) were from patients who had gonorrheal infection, and 282,065 (1.84%) were from patients who had chlamydial infection during pregnancy. Concurrent infection with chlamydia and gonorrhea was associated with the highest risk of gonorrhea and chalmydia in pregnancy (adjusted odds ratio, 26.28; 95% confidence interval, 25.74-26.83, and adjusted odds ratio, 26.03; 95% confidence interval, 25.50-26.58, respectively). Young maternal age, low educational attainment, non-Hispanic Black race/ethnicity, concurrent infection with syphilis, and tobacco use were also associated with a substantial increase in the risk of gonorrheal and chlamydial infection in pregnancy. CONCLUSIONS: Several sociodemographic factors including young maternal age, low educational attainment, Medicaid insurance, and non-Hispanic Black race/ethnicity, are associated with a marked increase in the risk for gonorrheal and chlamydial infection in current US pregnancies. These data may be used to better screen, educate, and treat pregnancies of vulnerable populations at risk for such infections.

Antenatal corticosteroids and neonatal outcomes in preterm birth in the United States.

OBJECTIVES: To determine the impact of antenatal corticosteroids (ACS) on neonatal outcomes in a large United States population of preterm births. METHODS: Retrospective cohort study utilizing the United States Natality Live Birth database from the Centers for Disease Control and Prevention (2016-2017). Women with singleton preterm births were eligible for inclusion. Out-of-hospital births, fetal anomalies, and cases where ACS exposure was unknown were excluded. Neonates from reported live births were divided into two groups based on whether the mother received ACS before delivery or not. The incidence of several reported neonatal outcomes were compared between the two groups at each gestational week. Subsequently, comparisons between three gestational age groups (23 0/7 to 27 6/7, 28 0/7 to 33 6/7, and 34 to 36 6/7 weeks) were performed. Statistical analysis included use of Chi-squared test and multivariate logistic regression. RESULTS: Of the 588,077 live births included, 121,151 (20.6%) had been exposed to ACS. ACS use was associated with a significantly decreased odds of neonatal mortality and 5-min Apgar score <7, but an increased rate of several neonatal outcomes such as surfactant replacement therapy, prolonged ventilation, antibiotics for suspected neonatal sepsis, and neonatal intensive care unit (NICU) admissions. CONCLUSIONS: ACS administration prior to preterm birth is associated with a decrease in neonatal mortality and low Apgar scores, and increased odds of several adverse neonatal outcomes.

Adverse perinatal outcomes of chlamydia infections: an ongoing challenge.

OBJECTIVES: Chlamydia trachomatis is one of the most common sexually transmitted diseases in the world, but there are limited data on its impact on perinatal outcomes. Our objective was to investigate the association between chlamydia infections and adverse perinatal outcomes. METHODS: This is a retrospective analysis of the United States Centers for Disease Control and Prevention natality live birth database for the years 2016-2019. The rates of adverse perinatal outcomes were compared between patients with a chlamydia infection during pregnancy and patients without such infection, using Pearson's chi-square test with the Bonferroni adjustment. A multivariate logistic regression was then used to adjust outcomes for potential confounders. RESULTS: Chlamydia infections were associated with small, but statistically significant, increased odds of preterm birth (<37 weeks), early preterm birth (<32 weeks), low birthweight (<2,500 g), congenital anomalies, low 5-min Apgar score (<7), neonatal intensive care unit admission, immediate neonatal ventilation, prolonged (>6 h) neonatal ventilation, and neonatal antibiotic treatment for suspected sepsis. CONCLUSIONS: Chlamydia infections during pregnancy are associated with adverse perinatal outcomes. These results call for increased education regarding the potential risks of pregnancies with a chlamydia infection, as well as for increased antenatal surveillance and post-natal pediatric assessment in these pregnancies.

The impact of preimplantation genetic testing for aneuploidy on prenatal screening.

OBJECTIVES: To determine whether preimplantation genetic testing for aneuploidy (PGT-A) is associated with a reduced risk of abnormal conventional prenatal screening results in singleton pregnancies conceived using in vitro fertilization (IVF). METHODS: This was a retrospective cohort study of singleton IVF pregnancies conceived from a single tertiary care center between January 2014 and September 2019. Exclusion criteria included mosaic embryo transfers, vanishing twin pregnancies, and cycles with missing outcome data. Two cases of prenatally diagnosed aneuploidy that resulted in early voluntary terminations were also excluded. The primary outcome of abnormal first or second-trimester combined screening results was compared between two groups: pregnancy conceived after transfer of a euploid embryo by PGT-A vs. transfer of an untested embryo. Multivariable backwards-stepwise logistic regression with Firth method was used to adjust for potential confounders. RESULTS: Of the 419 pregnancies included, 208 (49.6%) were conceived after transfer of a euploid embryo by PGT-A, and 211 (50.4%) were conceived after transfer of an untested embryo. PGT-A was not associated with a lower likelihood of abnormal first-trimester (adjusted OR 1.64, 95% CI 0.82-3.39) or second-trimester screening results (adjusted OR 0.96, 95% CI 0.56-1.64). The incidences of cell-free DNA testing, fetal sonographic abnormalities, genetic counseling, and invasive prenatal diagnostic testing were similar between the two groups. CONCLUSIONS: Our data suggest that PGT-A is not associated with a change in the likelihood of abnormal prenatal screening results or utilization of invasive prenatal diagnostic testing. Counseling this patient population regarding the importance of prenatal screening and prenatal diagnostic testing, where appropriate, remains essential.

The Risk of Readmission after Early Postpartum Discharge during the COVID-19 Pandemic.

OBJECTIVE: To determine whether early postpartum discharge during the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in the odds of maternal postpartum readmissions. STUDY DESIGN: This is a retrospective analysis of uncomplicated postpartum low-risk women in seven obstetrical units within a large New York health system. We compared the rate of postpartum readmissions within 6 weeks of delivery between two groups: low-risk women who had early postpartum discharge as part of our protocol during the COVID-19 pandemic (April 1-June 15, 2020) and similar low-risk patients with routine postpartum discharge from the same study centers 1 year prior. Statistical analysis included the use of Wilcoxon's rank-sum and chi-squared tests, Nelson-Aalen cumulative hazard curves, and multivariate logistic regression. RESULTS: Of the 8,206 patients included, 4,038 (49.2%) were patients who had early postpartum discharge during the COVID-19 pandemic and 4,168 (50.8%) were patients with routine postpartum discharge prior to the COVID-19 pandemic. The rates of postpartum readmissions after vaginal delivery (1.0 vs. 0.9%; adjusted odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.39-1.45) and cesarean delivery (1.5 vs. 1.9%; adjusted OR: 0.65, 95% CI: 0.29-1.45) were similar between the two groups. Demographic risk factors for postpartum readmission included Medicaid insurance and obesity. CONCLUSION: Early postpartum discharge during the COVID-19 pandemic was associated with no change in the odds of maternal postpartum readmissions after low-risk vaginal or cesarean deliveries. Early postpartum discharge for low-risk patients to shorten hospital length of stay should be considered in the face of public health crises. KEY POINTS: · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after vaginal delivery.. · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after cesarean delivery.. · Early postpartum discharge for low-risk patients should be considered during a public health crisis..

Maternal and neonatal outcomes in pregnancies conceived after preimplantation genetic testing.

OBJECTIVE: To determine whether preimplantation genetic testing (PGT) is associated with an increase in adverse maternal or neonatal outcomes in singleton and twin live births conceived via in vitro fertilization (IVF). METHOD: Retrospective cohort of live births resulting from IVF within a university health system between January 2014 and August 2019. Adverse maternal outcomes (e.g., hypertensive disorders of pregnancy, abnormal placentation, and preterm birth), and adverse neonatal outcomes were compared in singleton and twin pregnancies conceived after transfer of one or two PGT-screened euploid embryos versus untested embryos in separate analyses. Multivariate backwards-stepwise logistic regression was used to adjust for potential confounders. RESULTS: Of 1160 live births, 539 (46.5%) resulted from PGT-screened embryos, 1015 (87.5%) were singletons, and 145 (12.5%) were twins. After adjusting for potential confounders, there were no significant differences between the two groups with respect to hypertensive disorders of pregnancy, fetal growth restriction, preterm birth, and adverse neonatal outcomes in both analyses, as well as abnormal placentation for singletons. CONCLUSION: Our data suggest that IVF with PGT is not associated with an increased risk of adverse maternal or neonatal outcomes compared to IVF without PGT. Further research utilizing larger cohorts are needed before drawing definitive conclusions.

Preterm birth among women with and without severe acute respiratory syndrome coronavirus 2 infection.

INTRODUCTION: Studies directly comparing preterm birth rates in women with and without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. Our objective was to determine whether preterm birth was affected by SARS-CoV-2 infection within a large integrated health system in New York with a universal testing protocol. MATERIAL AND METHODS: This retrospective cohort study evaluated data from seven hospitals in New York City and Long Island between March 2020 and June 2021, incorporating both the first and second waves of the coronavirus disease 2019 (COVID-19) pandemic in the USA. All patients with live singleton gestations who had SARS-CoV-2 polymerase chain reaction (PCR) testing at delivery were included. Deliveries before 20 weeks of gestation were excluded. The rate of preterm birth (before 37 weeks) was compared between patients with positive and negative SARS-CoV-2 test results. This analysis was performed separately for resolved prenatal infections and infections at delivery, with the latter group subdivided by symptom status. Multiple logistic regression analysis was used to examine the association between SARS-CoV-2 infection and preterm birth, adjusting for maternal age, race-ethnicity, parity, history of preterm birth, body mass index, marital status, insurance type, medical co-morbidities, month of delivery, and wave of pandemic. RESULTS: A total of 31 550 patients were included and 2473 (7.8%) had laboratory-confirmed infection. Patients with symptomatic COVID-19 at delivery were more likely to deliver preterm (19.0%; adjusted odds ratio 2.76, 95% CI 1.92-3.88) compared with women with asymptomatic infection (8.8%) or without infection (7.1%). Among preterm births associated with symptomatic infection, 72.5% were medically indicated compared with 44.1% among women without infection (p < 0.001). Risk of preterm birth in patients with resolved prenatal infection was unchanged when compared with women without infection. Among women with infection at delivery, preterm birth occurred more frequently during the second wave compared with the first wave (13.6% vs. 8.7%, respectively; p < 0.006). However, this was not significant on multiple regression analysis after adjusting for other explanatory variables. CONCLUSIONS: Pregnant women with symptomatic COVID-19 are more than twice as likely to have a preterm delivery than patients without infection. Asymptomatic infection and resolved prenatal infection are not associated with increased risk.

Chorioamnionitis after premature rupture of membranes in nulliparas undergoing labor induction: prostaglandin E2 vs. oxytocin.

OBJECTIVES: To assess the risk of chorioamnionitis in nulliparous, term, singleton, vertex (NTSV) pregnancies with premature rupture of membranes (PROM) and an unfavorable cervix undergoing labor induction with either prostaglandin E2 (PGE2) or oxytocin only. METHODS: Retrospective cohort of NTSV pregnancies presenting with PROM who underwent labor induction with either PGE2 (n=94) or oxytocin (n=181) between October 2015 and March 2019. The primary outcome of chorioamnionitis was compared between the two groups. Statistical analysis included Chi-squared and Wilcoxon rank-sum tests, as well as logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR (aHR). RESULTS: Baseline characteristics were similar between the two groups. Cervical ripening with PGE2 was associated with an increased rate of chorioamnionitis (18.1 vs. 6.1%; aOR 4.14, p=0.001), increased neonatal intensive care unit admissions (20.2 vs. 9.9%; aOR 2.4, p=0.02), longer time interval from PROM to delivery (24.4 vs. 17.9 h; aHR 0.56, p=<0.0001), and lower incidence of meconium (7.4 vs. 14.4%; aOR 0.26, p=0.01), compared to the oxytocin group. CONCLUSIONS: Based on our data, the use of oxytocin appears both superior and safer compared to PGE2 in NTSV pregnancies with PROM undergoing labor induction.

Ethical challenges in management of critically ill pregnant patients with coronavirus disease 2019 (COVID-19).

Despite the overwhelming number of coronavirus disease 2019 (COVID-19) cases worldwide, data regarding the optimal clinical guidance in pregnant patients is not uniform or well established. As a result, clinical decisions to optimize maternal and fetal benefit, particularly in patients with critical COVID-19 in the early preterm period, continue to be a challenge for obstetricians. There is often uncertainty in clinical judgment about fetal monitoring, timing of delivery, and mode of delivery because of the challenge in balancing maternal and fetal interests in reducing morbidity and mortality. The obstetrician and critical care team should empower pregnant patients or their surrogate decision maker to make informed decisions in response to the team's clinical evaluation. A clinically grounded ethical framework, based on the concepts of the moral management of medical uncertainty, beneficence-based obligations, and preventive ethics, should guide the decision-making process.

Virtual obstetrics and gynecology fellowship interviews during the coronavirus disease 2019 (COVID-19) pandemic: a survey study.

BACKGROUND: Due to the coronavirus disease 2019 (COVID-19) pandemic, all Obstetrics and Gynecology fellowship interviews were held virtually for the 2020 fellowship match cycle. The aim of this study was to describe our initial experience with virtual Obstetrics and Gynecology fellowship interviews and evaluate its effectiveness in assessing candidates. METHODS: This was a cross-sectional survey study that included all interviewing attending physicians and fellows from five Obstetrics and Gynecology subspecialties at a single academic institution following the 2020-2021 fellowship interview season. The survey consisted of 19 questions aimed to evaluate each subspecialty's virtual interview process, including its feasibility and performance in evaluating applicants. The primary outcome was the subjective utility of virtual interviews. Secondary outcomes included a comparison of responses from fellows and attending physicians. RESULTS: Thirty-six attendings and fellows completed the survey (36/53, 68% response rate). Interviewers felt applicants were able to convey themselves adequately during the virtual interview (92%) and the majority (70%) agreed that virtual interviews should be offered in future years. Attending physicians were more likely than fellows to state that the virtual interview process adequately assessed the candidates (Likert Scale Mean: 4.4 vs. 3.8, respectively, p = 0.02). Respondents highlighted decreased cost, time saved, and increased flexibility as benefits to the virtual interview process. CONCLUSION: The use of virtual interviews provides a favorable method for conducting fellowship interviews and should be considered for use in future application cycles. Most respondents were satisfied with the virtual interview process and found they were an effective tool for evaluating applicants.

Early postpartum discharge during the COVID-19 pandemic.

Objectives To report our experience with early postpartum discharge to decrease hospital length of stay among low-risk puerperium patients in a large obstetrical service during the COVID-19 pandemic in New York. Methods Retrospective analysis of all uncomplicated postpartum women in seven obstetrical units within a large health system between December 8th, 2019 and June 20th, 2020. Women were stratified into two groups based on date of delivery in relation to the start of the COVID-19 pandemic in New York (Mid-March 2020); those delivering before or during the COVID-19 pandemic. We compared hospital length of stay, defined as time interval from delivery to discharge in hours, between the two groups and correlated it with the number of COVID-19 admissions to our hospitals. Statistical analysis included use of Wilcoxon rank sum test and Chi-squared test with significance defined as p-value<0.05. Results Of the 11,770 patients included, 5,893 (50.1%) delivered prior to and 5,877 (49.9%) delivered during the COVID-19 pandemic. We detected substantial shortening in postpartum hospital length of stay after vaginal delivery (34 vs. 48 h, p≤0.0001) and cesarean delivery (51 vs. 74 h, p≤0.0001) during the COVID-19 pandemic. Conclusions We report successful implementation of early postpartum discharge for low-risk patients resulting in a significantly shorter hospital stay during the COVID-19 pandemic in New York. The impact of this strategy on resource utilization, patient satisfaction and adverse outcomes requires further study.

Clinical Implications of SARS-CoV-2 Infection in the Viable Preterm Period.

OBJECTIVE: This study aimed to determine the rate of preterm birth (PTB) during hospitalization among women diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between 23 and 37 weeks of gestation and whether this rate differs by gestational age at diagnosis of infection. STUDY DESIGN: Retrospective, cross-sectional study of all women diagnosed with SARS-CoV-2 infection between 23 and 37 weeks of gestation within a large integrated health system from March 13 to April 24, 2020. Cases with severe fetal structural malformations detected prior to infection were excluded. Women were stratified into two groups based on gestational age at diagnosis: early preterm (230/7 to 336/7 weeks) versus late preterm (34 to 366/7 weeks). We compared the rate of PTB during hospitalization with infection between the two groups. Statistical analysis included use of Wilcoxon rank sum and Fisher exact tests, as well as a multivariable logistic regression. Statistical significance was defined as a p-value <0.05. RESULTS: Of the 65 patients included, 36 (53.7%) were diagnosed in the early preterm period and 29 (46.3%) were diagnosed in the late preterm period. Baseline demographics were similar between groups. The rate of PTB during hospitalization with infection was significantly lower among women diagnosed in the early preterm period compared with late preterm (7/36 [19.4%] vs. 18/29 [62%], p-value = 0.001). Of the 25 patients who delivered during hospitalization with infection, the majority were indicated deliveries (64%, 16/25). There were no deliveries <33 weeks of gestation for worsening coronavirus disease 2019 and severity of disease did not alter the likelihood of delivery during hospitalization with SARS-CoV-2 infection (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.24-1.59). Increased maternal age was associated with a lower likelihood of delivery during hospitalization with SARS-CoV-2 infection (aOR: 0.77; 95% CI: 0.58-0.96), while later gestational age at diagnosis of infection was associated with a higher likelihood of delivery during hospitalization (aOR: 2.9; 95% CI: 1.67-8.09). CONCLUSION: The likelihood of PTB during hospitalization with SARS-CoV-2 infection is significantly lower among women diagnosed in the early preterm period compared with late preterm. Most women with SARS-CoV-2 infection in the early preterm period recovered and were discharged home. The majority of PTB were indicated and not due to spontaneous preterm labor. KEY POINTS: · Preterm delivery is less likely among women diagnosed in the early preterm compared with late preterm.. · Most women infected in the early preterm period recovered and were discharged home undelivered.. · The majority of preterm birth were indicated and not due to spontaneous preterm labor..