Cord blood troponin I levels: biomarker evidence of fetal cardiac injury in intrahepatic cholestasis of pregnancy.

BACKGROUND: Intrahepatic cholestasis of pregnancy has been linked to sudden stillbirth. The suddenness of the stillbirths in these cases have led clinicians to suspect that the pathogenesis of stillbirth in women with intrahepatic cholestasis of pregnancy is not related to asphyxia but rather to an undefined etiology. One leading hypothesis relates certain bile acid metabolites to myocardial injury. OBJECTIVE: The purpose of this study was to determine whether cord blood troponin I levels are increased in fetuses born to mothers with a diagnosis of intrahepatic cholestasis of pregnancy. STUDY DESIGN: A prospective, case-control study was performed at a single institution between 2017 to 2019 in which 87 pregnant patients with a diagnosis of intrahepatic cholestasis of pregnancy (total bile acids ≥10 µmol/L) were enrolled as cases and 122 randomly selected pregnant patients (asymptomatic with intrapartum total bile acids <10 µmol/L) were enrolled as controls. Cord blood troponin I levels were measured at delivery in both groups using a commercially available chemiluminescent immunoassay. Values ≤0.04 ng/mL were considered negative. Values >0.04 ng/mL were considered positive. The primary outcome was the presence of elevated troponin levels in both cases and controls as a surrogate marker for cardiac status. Our secondary outcomes included neonatal intensive care unit stay, low Apgar scores, neonatal acidosis, and hypoxia indicated by cord blood pH and base excess levels at the time of birth. Chi square and t tests were performed to compare social and obstetrical variables. A P value of <.05 was considered significant. A stratification by total bile acids range of <40 µmol/L, 40 to 100 µmol/L, and >100 µmol/L was performed to assess the relationship between the different severities of intrahepatic cholestasis of pregnancy (by risk of fetal demise with those with total bile acids of >100 µmol/L considered at greatest risk) and the likelihood of a positive troponin I result. Finally, a logistic regression analysis was performed to determine if levels of ≥10 µmol/L were associated with elevated troponin levels. RESULTS: The mean gestational age at delivery was 38.96±1.47 and 37.71±1.59 weeks of gestation in the controls and cases respectively (P<.001). The mean total bile acids values were 5.2±1.28 ng/mL and 43.2±40.62 ng/mL in the controls and cases respectively (P<.001). Cord blood troponin I was positive in 15 of 122 (12.30%) controls and in 20 of 87 (22.99%) cases. (P<.001). When further stratified by total bile acids levels of <40, 40 to 100, and >100 µmol/L, we found a positive correlation between higher total bile acids levels and a positive troponin I test (P=.002). When controlling for gestational age at delivery, maternal age, and body mass index, higher total bile acids levels were associated with a positive troponin I level (adjusted odds ratio, 1.015; 95% confidence interval, 1.004-1.026). CONCLUSION: Elevated troponin I was more likely to be found in patients with intrahepatic cholestasis of pregnancy than in those without intrahepatic cholestasis of pregnancy. When stratified by total bile acids levels, a positive troponin I level was more likely to be found with higher levels of total bile acids. In addition, as total bile acids levels increased, they were more likely to be associated with a positive troponin I level. Although there were no stillbirths in our cohort, our findings suggest a potential relationship between cardiac injury and high levels of total bile acids demonstrated by the presence of elevated troponin I levels in cord blood at the time of birth.

One-step vs 2-step gestational diabetes mellitus screening and pregnancy outcomes: an updated systematic review and meta-analysis.

OBJECTIVE: This was a systematic review and meta-analysis comparing maternal and neonatal outcomes of patients screened with the 1-step or 2-step screening method for gestational diabetes mellitus. DATA SOURCES: PubMed, Scopus, Cochrane, ClinicalTrials.gov, and LILACS were searched from inception up to September 2022. STUDY ELIGIBILITY CRITERIA: Only randomized controlled trials were included. Studies that had overlapping populations were excluded (International Prospective Register of Systematic Review registration number: CRD42022358903). METHODS: Risk ratios were computed with 95% confidence intervals by 2 authors. Unpublished data were requested. Large for gestational age was the primary outcome. RESULTS: The search yielded 394 citations. Moreover, 7 randomized controlled trials met the inclusion criteria. A total of 54,650 participants were screened for gestational diabetes mellitus by either the 1-step screening method (n=27,163) or the 2-step screening method (n=27,487). For large for gestational age, there was no significant difference found between the groups (risk ratio, 0.99; 95% confidence interval, 0.93-1.05; I2=0%). Newborns of patients who underwent 1-step screening had higher rates of neonatal hypoglycemia (risk ratio, 1.24; 95% confidence interval, 1.14-1.34; I2=0%) and neonatal intensive care unit admissions (risk ratio, 1.13; 95% confidence interval, 1.04-1.21; I2=0%) than newborns of patients who underwent 2-step screening. Patients in the 1-step screening method group were more likely to be diagnosed with gestational diabetes mellitus (risk ratio, 1.73; 95% confidence interval, 1.44-2.09; I2=80%) than patients in the 2-step screening method group. In addition, among trials that tested all patients before randomization and excluded patients with pregestational diabetes mellitus, newborns were more likely to have macrosomia (risk ratio, 1.27; 95% confidence interval, 1.21-1.34; I2=0%). Overall risk of bias assessment was of low concern. CONCLUSION: Large for gestational age did not differ between patients screened using the 1-step screening method and those screened using the 2-step screening method. However, patients randomized to the 1-step screening method had higher rates of neonatal hypoglycemia and neonatal intensive care unit admission and maternal gestational diabetes mellitus diagnosis than the patients randomized to the 2-step screening method.

Antenatal steroids and neonatal outcomes in late preterm births with pregestational diabetes.

OBJECTIVE: To evaluate if antenatal steroid use was associated with a lower rate of respiratory complications in neonates born late preterm to patients with pregestational diabetes mellitus (PGDM). METHODS: This was a retrospective cohort study of live, singleton, non-anomalous, late preterm births complicated by PGDM using data from the Centers for Disease Control and National Vital Statistics System from 2017 to 2021. The primary (assisted ventilation use >6 h) and secondary neonatal outcomes (immediate assisted ventilation, Apgar score, neonatal intensive care unit [NICU] admission, and surfactant use) were compared between births that received steroids and those that did not. Multivariable analyses were performed to adjust for differences in demographic and clinical characteristics. RESULTS: There were 24 323 late preterm births with PGDM, of which 4613 received antenatal steroids and 19 710 did not receive steroids. After adjusting for the differences among the two groups, the need for assisted neonatal ventilation for more than 6 h (adjusted odds ratio [aOR] 1.69, 95% confidence interval [CI] 1.53-1.86), immediate assisted neonatal ventilation (aOR 1.67, 95% CI 1.55-1.80), NICU admission (aOR 1.95, 95% CI 1.81-2.10), and surfactant use (aOR 1.68, 95% CI 1.40-2.02) were higher in the births that received steroids compared with those that did not. These findings did not differ when examining outcomes at each gestational week of delivery between 34 weeks 0 days and 36 weeks 6 days. CONCLUSIONS: Antenatal steroid use in late preterm births complicated with PGDM was associated with worse immediate respiratory neonatal outcomes. Our findings support current recommendations against the use of steroids in the late preterm period in pregnancies with PGDM.

Changes in Rates of Hypertensive Disorders of Pregnancy Among Nulliparous Patients After the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial.

The ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial demonstrated lower rates of hypertensive disorders of pregnancy (HDP) among low-risk nulliparous patients undergoing labor induction at 39 weeks of gestation. We conducted a population-based cohort study in which we evaluated the association between the routinization of 39-week induction and the rate of HDP by comparing rates before and after the ARRIVE trial publication, using the National Vital Statistics System. Logistic regression models were used to project what the HDP rate would have been based on trends seen pre-ARRIVE. Despite an overall increase in the rate of HDP from pre-ARRIVE to post-ARRIVE (4.9% pre vs 6.3% post, adjusted odds ratio [aOR] 1.26, 95% CI 1.24-1.27), the HDP rate was significantly lower in the post-ARRIVE group among patients undergoing induction at 39 weeks of gestation (14.7% pre vs 14.1% post, aOR 0.91, 95% CI 0.90-0.93), decreasing by 12.0% per year (P<.001). The rate of HDP among all other delivering patients was higher in the post-ARRIVE group (4.1% pre vs 5.5% post, aOR1.32, 95% CI 1.30-1.34). Our findings may suggest that, as the overall HDP rate rises, the relative advantage of 39-week induction will rise similarly.

Connecting the dots: Carrier screening and the Genetic Information Nondiscrimination Act in the United States.

OBJECTIVE: To highlight the possibility of genetic discrimination in the United States with respect to carrier screening under limitations of the Genetic Information Nondiscrimination Act (GINA) and to encourage providers to educate patients about this possibility during pretest counseling. METHODS: Review of current professional guidelines and practice resources regarding the necessary components of pretest counseling for carrier screening in the context of GINA's limitations and the potential impact of carrier screening results on life, long-term care and disability insurance. RESULTS: Current practice resources advise that patients in the United States should be informed that their employer or health insurance company generally cannot use their genetic information during the underwriting process. However, these resources do not elaborate on GINA's limitations or explain why there may be adverse consequences to patients regarding these limitations. Studies have demonstrated significant gaps in provider knowledge of GINA, especially for those without formal genetic training. CONCLUSION: Enhanced education and provision of GINA educational resources for providers and patients will help ensure that patients have the opportunity to prioritize their insurance needs prior to undergoing carrier screening.

HELLP syndrome at <23 weeks' gestation: a systematic literature review.

OBJECTIVE: We performed a systematic review to evaluate the clinical presentation and maternal and fetal outcomes in pregnancies with early-onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. DATA SOURCES: PubMed, Ovid MEDLINE, Scopus, CINAHL, Cochrane Library, and ClinicalTrials.gov were queried from inception through January 1, 2023 with the following terms: "HELLP syndrome," "HELLP," "hemolysis, elevated liver enzymes, low platelets," "hemolysis, elevated liver enzymes, low platelets syndrome," "pre-viable," "peri-viable," "previable," "periviable," "first trimester," "second trimester," "before 23 weeks," "<23 weeks," "<23 week gestation," and "before 23 weeks gestation." We also included an additional case from our institution. STUDY ELIGIBILITY CRITERIA: Abstracts, unpublished studies, and review articles were excluded, yielding 46 studies that met our inclusion criteria. METHODS: Two reviewers (N.S.I. and M.H.M.) performed the study selection and subsequent data extraction independently, after which the results were reviewed together. PRISMA guidelines were followed, and our study was registered at PROSPERO (CRD42021292692). RESULTS: A total of 55 patients had 58 pregnancies complicated by early-onset HELLP syndrome, including 3 with recurrent HELLP. The most common presenting signs/symptoms were abdominal pain (35/45; 78%), hypertension (32/49; 65%), nausea/vomiting (16/45; 36%), headache (13/45; 29%), and edema (8/45; 18%). Lactate dehydrogenase ≥600 IU/L was observed in 21 of 31 (68%) cases, whereas liver enzyme abnormalities and thrombocytopenia were reported in 48 of 51 (94%) and 50 of 54 (93%) cases, respectively. Maternal complications were encountered in 25 of 56 (45%) cases. The most common complications were hepatic (13/56; 23%), central nervous system-related (11/56; 20%), and respiratory (11/56; 20%). In 36 of 57 (63%) cases, pregnancy was terminated. Of the 21 continued pregnancies, early fetal death (at <20 weeks' gestation) was reported in 10 (48%), stillbirth in 6 (28%), and neonatal demise in 2 (10%). Living neonates were reported in 3 of 21 (14%) cases, all delivered at 23 weeks. The perinatal mortality rate was 73% (8/11). One case (2%) reported maternal death. Antiphospholipid syndrome was diagnosed in 14 of 29 (48%) cases. CONCLUSION: Early-onset HELLP syndrome presents with symptoms similar to those observed in later gestation. Maternal complications are life-threatening, with the most common complications being hepatic, central nervous system-related, and respiratory. Fetal outcomes are poor.

Rates of Influenza and Tdap Vaccination in Teaching and Private Obstetrical Practices, and the Influence of Vaccine Hesitancy.

OBJECTIVES: We evaluated differences in vaccination rates of patients of teaching and private practices, and explored the rate of vaccine hesitancy in pregnant women. METHODS: This was a cross-sectional study of a convenience sample of recently delivered women. Women completed a survey, which included a question about whether they received the influenza and/or Tdap vaccine, and a vaccine hesitancy scale for both influenza and Tdap vaccines. We also reviewed prenatal records to confirm vaccine administration and collected demographic data. Patients who received care on the teaching service (care by residents supervised by faculty) were compared with those who received care from 26 private practitioners in nine groups. The primary outcome was rate of vaccination. Fisher's exact test was performed to compare groups. RESULTS: Of the 231 women approached, 208 (90.0%) agreed to participate. Of the 208 participants, 70 (33.7%) had prenatal care with a teaching practice, and 138 (66.3%) with a private practice. Patients of teaching practices had a higher influenza and Tdap vaccination rate compared with patients of private practices (Influenza: 70% versus 54.3%, p = 0.036; Tdap: 77.1% versus 58.4%, p = 0.009). Among the entire cohort, 55.3% had some degree of vaccine hesitancy. This did not differ between teaching and private practices (54.3% versus 55.8%, p = 0.883). CONCLUSIONS: In spite of similar prevalence of vaccine hesitancy, pregnant women cared for in teaching practices had higher vaccination rates than those cared for in private practices.

Early screening for gestational diabetes mellitus: a meta-analysis of randomized controlled trials.

OBJECTIVE: Current evidence is conflicting on whether early screening and treatment for gestational diabetes mellitus improve pregnancy outcomes. Thus, this systematic review and meta-analysis of randomized controlled trials aimed to assess the rate of adverse pregnancy outcomes among participants with early screening and treatment for gestational diabetes mellitus vs those with routine care. DATA SOURCES: A systematic review of the literature was conducted using MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, ScienceDirect, the Cochrane Library at the Central Register of Controlled Trials, and SciELO from inception to November 2021. STUDY ELIGIBILITY CRITERIA: Studies were eligible for inclusion if they described randomized controlled trials comparing early screening with routine care for gestational diabetes mellitus to assess the effects of early screening and treatment on pregnancy outcomes. METHODS: All randomized controlled trials comparing early vs standard screening of gestational diabetes mellitus assessing the effect of early screening (defined as a screening at <20 weeks of gestation) vs routine screening (defined as a screening at ≥20 weeks of gestation) on pregnancy outcomes were included. The primary outcome was defined as large for gestational age, as defined by the trial. The secondary maternal and neonatal outcomes were also evaluated. Subgroup analyses were performed on the basis of screening strategy and methods. RESULTS: After exclusion, 8 randomized clinical trials (1920 participants) of early screening and treatment vs standard care were included. There were a total of 746 participants with early gestational diabetes mellitus. The risk of large for gestational age at birth did not differ between early screening and treatment for gestational diabetes mellitus and routine care among all included trials (8.1 vs 9.0%; relative risk, 0.94; 95% confidence interval, 0.73-1.22). Trials with a protocol of universal screening of participants at their first prenatal visit (>80% screened with HbA1c) and receiving early treatment if the screening test returned positive had a lower risk of large for gestational age (2.3 vs 9.1%; relative risk, 0.29; 95% confidence interval, 0.09-0.90) than those who had routine screening and care. CONCLUSION: Overall, early screening and treatment of gestational diabetes mellitus did not reduce the risk of large for gestational age at birth. However, trials that screened all participants at their first visit and treated early, most for an HbA1c of 5.7% to 6.4%, had a reduced risk of large for gestational age at birth compared with routine care, suggesting a possible benefit of screening all pregnant patients. However, future well-designed trials are needed to confirm these findings.

Change in prevalence of chronic hypertension in pregnancy after the updated ACC/AHA hypertension guidelines.

The objective of this population-based retrospective study was to determine the effect of the updated hypertension definition by the American College of Cardiology (ACC) and the American Heart Association (AHA) on the prevalence of chronic hypertension (CHTN) diagnosis in pregnancy. The pre-ACC/AHA group (N = 14,505,399) consisted of births between 2013 and 2016 and the post-ACC/AHA group (N = 7,269,010) consisted of births between 2018 and 2019. After adjusting for differences between groups, CHTN diagnosis was more common in the post-ACC/AHA group (p < 0.001). In conclusion, the prevalence of CHTN diagnosis in pregnancy increased after the new ACC/AHA guidelines publication.

The ability of a low value on an early GCT to identify women not needing repeat testing in the second trimester.

OBJECTIVE: To evaluate the predictive value of a low early glucose challenge test (GCT) in ruling out a subsequent diagnosis of gestational diabetes in the second trimester. METHODS: This was a retrospective cohort study of women at a single clinic who had a normal early GCT between 2016 and 2020. Patients who did not have repeat screening in the late second trimester were excluded. Demographic data were extracted from the record. The primary outcome was a normal GCT or glucose tolerance test in the late second trimester. Logistic regression and receiver operator curves (ROC) were performed to assess the ability of the early GCT value to predict subsequent normal glucose screening. RESULTS: Of the 532 pregnant persons with normal early GCT, 62 (11.7%) were subsequently diagnosed with gestational diabetes in the second trimester. None of the patients (N = 56), who had a GCT value less than 80 mg/dL were diagnosed with gestational diabetes in the second trimester. The prediction of subsequent normal screening using the early GCT on a ROC plot produced an area under the curve (AUC) of 0.67, 95% CI (0.60-0.74). Adding age, prior history of gestational diabetes and family history of diabetes mellitus to the prediction, only improved the AUC to 0.75, 95% CI (0.66, 0.82). CONCLUSION: Early GCT value was a fair predictor for normal second trimester glucose testing for gestational diabetes. However, high-risk patients with an early GCT value of less than 80 mg/dL may be able to forego repeat second trimester screening.

Pre- and postpregnancy platelet counts: evaluating accuracy of gestational thrombocytopenia and immune thrombocytopenia purpura diagnoses.

BACKGROUND: Given the overlapping clinical indicators and lack of diagnostic testing, misdiagnosis of immune thrombocytopenic purpura and gestational thrombocytopenia in pregnancy may be common. Current recommendations suggest utilizing platelet nadir during pregnancy to guide diagnosis. OBJECTIVE: This study aimed to assess the accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses using pre- and postpregnancy platelet counts. STUDY DESIGN: This was a retrospective cohort study of patients diagnosed with gestational thrombocytopenia and immune thrombocytopenic purpura from January 2017 to December 2019. Platelet counts were extracted from charts and evaluated at several time periods, namely prepregnancy (within 5 years), during pregnancy, and postpartum (>6 weeks to 5 years). A diagnosis of gestational thrombocytopenia was considered inaccurate if platelet counts were <150,000/µL pre- or postpregnancy with no other apparent causes or if the platelet nadir dropped below 100,000/µL during pregnancy. A diagnosis of immune thrombocytopenic purpura was deemed inaccurate if pre- or postpregnancy platelet counts were >150,000/µL. The primary outcome was accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses in patients. Secondary outcomes included mean platelet counts during pregnancy and difference in mean platelet counts for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia. Outcomes were summarized with descriptive statistics and compared using Student t tests. RESULTS: A total of 116 patients met the inclusion criteria of which 111 (96%) and 5 (4%) had gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses, respectively. Platelet counts outside of pregnancy were available for 91 (82%) of the patients, and 66 (57%) had prepregnancy platelet counts available. Of the 91 patients, the diagnosis was considered accurate in 61 (67%) and 5 (100%) patients with gestational thrombocytopenia and immune thrombocytopenic purpura, respectively. Conversely, 30 of 35 (86%) patients with immune thrombocytopenic purpura were found to be inaccurately diagnosed with gestational thrombocytopenia after application of platelet thresholds. Among these 30 patients, 10 had a prepregnancy platelet count <150,000/µL, 12 had a postpartum platelet count <150,000/µL, 3 had a platelet count nadir <100,000/µL during pregnancy, and 7 met more than 1 criterion. Pre- and postpregnancy platelet counts and platelet count nadir differed significantly for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia (P<.001). CONCLUSION: When pre- and postpregnancy platelet counts were checked, one-third of cases of gestational thrombocytopenia met the criteria for immune thrombocytopenic purpura and were thus incorrectly diagnosed during pregnancy. Prepregnancy platelet counts, available for most patients, should be considered when diagnosing gestational thrombocytopenia vs immune thrombocytopenic purpura.

Changes in obstetrical practices and pregnancy outcomes following the ARRIVE trial.

BACKGROUND: The ARRIVE trial demonstrated the benefit of induction of labor at 39 weeks gestation. Obstetrics departments across the United States faced the challenge of adapting clinical practice in light of these data while managing logistical constraints. OBJECTIVE: To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication. STUDY DESIGN: This was a population-based retrospective cohort study of low-risk, nulliparous women who initiated prenatal care by 12 weeks gestation with singleton, nonanomalous pregnancies delivering at ≥39 weeks. Data were obtained from the US Natality database. The pre-ARRIVE group were women who delivered between January 1, 2015 and December 31, 2017. The post-ARRIVE group consisted of women who delivered between January 1, 2019 and December 31, 2019. Births that occurred in 2018 were excluded. Practice outcomes were rates of induction of labor, timing of delivery, and cesarean delivery rate. Adverse maternal outcomes were blood transfusion and admission to medical intensive care unit. Adverse neonatal outcomes were need for assisted ventilation (immediate and >6 hours), 5-minute APGAR score <3, neonatal intensive care unit admission, seizures, and surfactant use. Univariate and multivariate analyses were performed. Trends were tested across the time period represented by the pre-ARRIVE group using Cochran-Armitage trend test. RESULTS: There were 1,966,870 births in the pre-ARRIVE group and 609,322 in the post-ARRIVE group. The groups differed in age, race, body mass index, marital status, infertility treatment, and smoking history (P<.001). After adjusting for these differences, the post-ARRIVE group was more likely to undergo induction (36.1% vs 30.2%; adjusted odds ratio, 1.36 [1.36-1.37]) and deliver by 39+6 weeks of pregnancy (42.8% vs 39.9%; adjusted odds ratio, 1.14 [1.14-1.15]). The post-ARRIVE group had a significantly lower rate of cesarean delivery than the pre-ARRIVE group (27.3 % vs 27.9%; adjusted odds ratio, 0.94 [0.93-0.94]). Patients in the post-ARRIVE group were more likely to receive a blood transfusion (0.4% vs 0.3%; adjusted odds ratio, 1.43 [1.36-1.50]) and be admitted to medical intensive care unit (0.09% vs 0.08%; adjusted odds ratio, 1.20 [1.09-1.33]). Neonates in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs 2.8%; adjusted odds ratio, 1.28 [1.26-1.30]) and >6 hours (0.6% vs 0.5%; adjusted odds ratio, 1.36 [1.31-1.41]). The neonates in the post-ARRIVE group were more likely to have low 5-minute APGAR scores (0.4% vs 0.3%; adjusted odds ratio, 0.91 [0.86-0.95]). Neonatal intensive care unit admission did not differ between the 2 groups (4.9% vs 4.9%; adjusted odds ratio, 1.01 [0.99-1.03]). There were no differences in neonatal seizures (0.04% vs 0.04%; adjusted odds ratio, 0.97 [0.84-1.13]), and surfactant use (0.08% vs 0.07%; adjusted odds ratio, 1.05 [0.94-1.17]) between the 2 groups. CONCLUSION: There were more inductions of labor, more deliveries at 39 weeks' gestation, and fewer cesarean deliveries in the year after the ARRIVE trial publication. The small but statistically significant increase in some adverse maternal and neonatal outcomes should be explored to determine if they are related with concurrent changes in obstetrical practices.

COVID-related "lockdowns" and birth rates in New York.

OBJECTIVE: Recent analyses have suggested that the number of births in the United States may decrease substantially in the wake of the COVID-19 pandemic.1 Some of this decline may be attributable to economic disruptions that are often linked to lowered birth rates.1 However to the best of our knowledge, empirical data to validate these projections and to look more specifically at the consequences of "lockdowns," have not yet been published. The objective of our study was to compare the birth rates in New York City and Long Island hospitals during the 9 months after the lockdown, to the birth rates during the same time frames in previous years. STUDY DESIGN: This was a multicenter, retrospective study of live births from hospitals in the New York City Maternal-Fetal Medicine Research Consortium, an ongoing collaboration at several hospitals in New York City and Long Island. This consortium captures approximately one-third of the births in New York City (eg, of the 117,013 births recorded in 2017, 42,680 [36.6%] were from this consortium). To evaluate whether the lockdown in New York City (the first in the United States) between March 2020 and June 2020 resulted in a change in the number of births after the lockdown, we calculated the total live births 9 months after the lockdown (between December 2020 and February 2021) and compared the number with the total in the same 3 months during the previous 4 years. Fourteen hospitals with a total of greater than 55,000 annualized live births were included. Time series regression was performed to test the birth trends and to determine whether any change was a part of an ongoing trend. RESULTS: Figure 1 shows the total live births in the different time frames. There were 12,099 live births that occurred between December 2020 and February 2021. This is 2994 (19.8%) less live births than the previous year. In addition, the average number of live births in the 4 years before the study period was 15,101 births. This decrease was seen in all the hospitals included in the cohort. The hospitals located within New York City (N=10) had a larger drop in birth rate in the last 2 years (-1947, 18.9%) than in the hospitals located in Long Island (N=4) (-581, 13.4%). Figure 2 represents the total live births by individual hospitals in the different time frames. Among the entire cohort, the largest drop in birth rate in the previous years was only 4.9%. In addition, there was no significant trend in the number of births in the previous years (P=.586). Furthermore, no significant trend was identified in the hospitals located in New York City or Long Island (P=.831 and P=.178, respectively). Hospitals with large numbers of Medicaid-funded births showed the same trend as hospitals with smaller numbers of such births. CONCLUSION: Nine months after the lockdown was implemented, we observed a nearly 20% decrease in live births than the previous year. Although these data demonstrate a decline that is even greater than previously projected by analysts,1 there are several issues that should be considered. Firstly, the relationship between lockdowns and preterm birth is unclear, because we did not evaluate the birth outcomes, and thus, we cannot comment on preterm birth. However, most data do not suggest a major effect in the direction of more preterm births.2-4 We are unable to comment on the outmigration of pregnant women to other hospitals, the 3 accredited free-standing birth centers in New York City, or other geographic areas. However, the estimates on the outmigration data were less than the decrease we found. Using anonymized smartphone location data of approximately 140,000 New York City residents, a company specializing in geospatial analysis found that approximately 5% of New York City residents left New York City between March and May, with the majority moving to surrounding locations in the Northeast and to South Florida.5 The steeper decrease in live births in hospitals located in New York City than in those located in Long Island may be related to the population density and the recommended social distancing practices. The population density is higher in New York City than in Long Island (27,000 people per square mile vs 2360 people per square mile). Thus, the lockdown may have had a reduced effect on the number of live births in areas with a lower population density. In addition, most of the New York City residents outmigrated to surrounding locations including Long Island, which may have diminished the decrease in live births. Our data clearly demonstrate that there were significant changes in the number of births in the 9 months after the nation's first lockdown. Although we cannot definitively determine the contributions of migration, family choice, or other factors to those changes, these preliminary findings should provide direction to future studies. That work should consider zip codes, parities, and other factors that might exaggerate or mitigate the trends we report here.

Predictors of readmission for postpartum preeclampsia.

Objective: To develop a predictive model for re-admission for postpartum preeclampsia (PPEC).Methods: A case-control study; cases were patients re-admitted for PPEC; controls were not re-admitted. Mixed linear modelling was used to develop a predictive model on the training set, then validated on the validation set.Results: Two-hundred-sixty-nine patients were readmitted, and matched to 538 controls. A risk calculator was developed and yielded a sensitivity and specificity for readmission of 80.9% and 53.5%, respectively.Conclusion: A predictive model using age, race, discharge blood pressures, and preeclampsia was able to predict re-admission for PPEC with a high level of sensitivity.

Health Care Workers' Attitudes Toward Patients With COVID-19.

BACKGROUND: Early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, before the routine availability and/or use of personal protective equipment, health care workers were understandably concerned. Our aim was to explore health care workers' attitudes toward patients infected with SARS-CoV-2 at the time of the nation's first surge in 2 highly affected hospitals in New York. METHODS: We performed a cross-sectional, self-administered survey study of health care workers. The survey consisted of 17 multiple-choice questions including demographic information, ethics, and willingness to care for patients with SARS-CoV-2 infection. Subgroup analyses were performed using the Fisher exact test. RESULTS: Of 340 health care workers approached, 338 (99.4%) consented to the survey; 163 (48.7%) were registered nurses and 160 (48.3%) lived with children. While 326 (97.3%) workers were concerned about putting their family/coworkers at risk of infection after caring for a patient with SARS-CoV-2, only 30 (8.9%) were unwilling to treat a patient with SARS-CoV-2 infection. Registered nurses were more likely than other health care workers to think it was ethical to refuse care for SARS-CoV-2-infected patients, worried more often about contracting infection, and felt that SARS-CoV-2 added to their stress level (P = .009, P = .018, P < .001, respectively). A similar contrast was seen when comparing workers who live with children with those who did not. CONCLUSIONS: Levels of stress and concern were extremely high. In spite of that, the overwhelming majority of workers were willing to treat patients with SARS-CoV-2 infection. Registered nurses and health care workers who live with children were more likely to think it is ethical to refuse care for SARS-CoV-2-infected patients.