Frequency and Clinical Implications of Referrals to Heart Failure Among Patients with Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare but significant cause of new-onset heart failure (HF) during the peri- and post-partum periods. Advances in GDMT for HF with reduced ventricular function have led to substantial improvements in survival and quality of life, yet few studies examine the longitudinal care received by patients with PPCM. The aim of this research is to address this gap by retrospectively characterizing patients with PPCM across a multihospital health system and investigating the frequency of cardiology and HF specialty referrals. Understanding whether surveillance and medical management differ among patients referred to HF will help to underscore the importance of referring patients with PPCM to HF specialists for optimal care.

Low-Dose Aspirin Use Does Not Increase Disease Activity in Pregnant Patients with Inflammatory Bowel Disease.

BACKGROUND: The adverse effects of non-steroidal anti-inflammatory (NSAID) drugs on the gastrointestinal system are well recognized, but the effect of NSAID use on disease activity patients with inflammatory bowel disease (IBD) remains unresolved. Low-dose aspirin (LDA) is recommended for all pregnant patients with risk factors for developing preeclampsia, including autoimmune conditions. As recognition of risk factors for preeclampsia improves, the preventative use of LDA is likely to increase. AIMS: To investigate if LDA use for prevention of preeclampsia increases the risk of disease activity in pregnant women with IBD. METHODS: Single-center retrospective cohort study of pregnant patients with IBD who delivered from 2012 to 2020, comparing those with and without LDA use. Primary outcome was odds of clinical IBD activity in patients in remission at time of conception. Secondary outcomes were rate of elevated inflammatory biomarkers, defined as C-reactive protein > 5 ug/mL or fecal calprotectin > 250 ug/g, and rate of preeclampsia. Univariate analyses tested for associations. RESULTS: Patients taking LDA were older (p = 0.003) and more likely to have chronic hypertension (p = 0.002), to have undergone in vitro fertilization (p < 0.001), and to be on biologics (p = 0.03). Among patients in remission at conception, there was no difference in clinical disease activity or biomarker elevation during pregnancy based on LDA use (OR 1.27, 95% CI [0.55-2.94], p = 0.6). Rates of preeclampsia were similar between groups. CONCLUSION: LDA use for preeclampsia prevention did not increase the incidence of disease activity in pregnant patients with IBD.

Examining provider practice-level disparities in delivery outcomes among patients with a history of Cesarean Delivery.

BACKGROUND: Choosing whether to pursue a trial of labor after cesarean (TOLAC) or scheduled repeat cesarean delivery (SRCD) requires prenatal assessment of risks and benefits. Providers and patients play a central role in this process. However, the influence of provider-associated characteristics on delivery methods remains unclear. We hypothesized that different provider practice groups have different obstetric outcomes in patients with one prior cesarean delivery (CD). METHODS: This was a retrospective cohort study of deliveries between April 29, 2015 - April 29, 2020. Subjects were divided into three cohorts: SRCD, successful VBAC, and unsuccessful VBAC (patients who chose TOLAC but had a CD). Disparities were reviewed between five different obstetric provider practice groups, determined from a breakdown of different providers delivering at the study site during the study period. Proportional differences were examined using Chi-squared tests and logistic regression models. RESULTS: 1,439 deliveries were included in the study. There were significant proportional disparities between patients in the different groups. Specifically, patients from Group D were significantly more likely to undergo successful VBAC, while patients seeing a provider from Group A were more likely to deliver by SRCD. In our multivariate analysis of successful versus unsuccessful VBAC, patients from Group D had greater odds ratios of successful VBAC compared to Group A. Patients delivered by Group E had a significantly lower odds ratio of successful VBAC. CONCLUSION: This study suggests an association between provider practice groups and delivery outcomes among patients with one prior CD. These data contribute to a growing body of literature around patient choice in pregnancy and the interplay of patients and providers. These findings help to guide future investigations to improve outcomes among patients with a history of CD.

Use of Respiratory and Contact Precautions to Decrease the Spread of SARS-CoV-2 Infection Was Not Associated with a Decrease in Endometritis-Intra-Amniotic Infection.

OBJECTIVE: To decrease the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the Mount Sinai Hospital's obstetric service, additional contact and respiratory precautions for patients and staff were implemented. Patients were allowed only one support person, SARS-CoV-2 tested on admission, and required to mask during hospitalization. Staff were required to wear masks and eye shields, gloves for all patient care, and gowns for care with SARS-CoV-2-infected patients. This study determined if the risk of endometritis/intra-amniotic infection (IAI) changed under the new pandemic precautions. STUDY DESIGN: A single-center, historical cohort study via electronic medical record review compared singleton deliveries among patients who labored during the "pandemic period" (from March 1 through May 31, 2020) with those who labored during the "prepandemic period" (March 1 through May 31, 2019) to determine if the risk of endometritis/IAI differed. The analysis was done using logistic regression with inverse probability of treatment weighting (IPTW) to adjust for possible differences in obstetric practice and patient population between the two periods. RESULTS: Four percent (53/1,318) of patients in the pandemic period and 5.1% (82/1,596) of patients in the prepandemic period were diagnosed with endometritis/IAI (p = 0.15). Compared with patients who delivered in the prepandemic period, those who delivered during the pandemic period had a higher body mass index at delivery (median: 28.36 [interquartile range, IQR: 25.70, 32.07] vs. 28.00 [IQR: 25.23, 31.50], p = 0.01) and experienced fewer digital exams (median: 4 [range: 1, 10] vs. 4 (range: 1, 19], p = 0.004), a practice not included in the SARS-CoV-2 prevention strategy. In multivariable logistic regression with IPTW adjusting for risk factors for endometritis/IAI, period of delivery was not associated with endometritis/IAI (odds ratio = 0.76, 95% confidence interval [0.52, 1.11], p = 0.15). CONCLUSION: The use of respiratory and contact precautions to limit the spread of SARS-CoV-2 was not associated with risk of endometritis/IAI. KEY POINTS: · Pandemic infection control precautions were not associated with a decrease in endometritis/IAIs.. · The early months of the pandemic were associated with the performance of fewer digital cervical exams.. · The early months of the pandemic were associated with a higher BMI at delivery..

Preoperative Application of Chlorhexidine to Reduce Infection with Cesarean Delivery after Labor (PRACTICAL): A Randomized Clinical Trial.

OBJECTIVE: To evaluate whether use of both preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub is effective in reducing surgical site infections (SSIs) in patients undergoing cesarean delivery after labor. STUDY DESIGN: This is a single-center, randomized clinical trial in which patients were randomized 1:1 to receive 2% chlorhexidine gluconate cloth applied to the abdomen in addition to the application of 4% chlorhexidine gluconate vaginal scrub versus standard of care. The primary outcome was rate of SSIs, including endometritis, by 6 weeks postdelivery. The secondary outcomes were other wound complications (erythema at the operative site, skin separation, drainage, fever, hematoma, seroma) by 6 weeks postdelivery, hospital readmission for wound complications, and day of discharge after cesarean delivery. RESULTS: A total of 319 patients between September 2018 and February 2021 met eligibility criteria: 160 were randomized to the chlorhexidine gluconate abdominal cloth and vaginal scrub group and 159 were randomized to the standard of care group. The groups did not have significant differences in maternal demographic characteristics. Of the 302 (95%) individuals included in primary analysis, there was no statistically significant difference in SSI and endometritis rate by 6 weeks postdelivery (6.6% in chlorhexidine vs. 5.3% standard of care, p = 0.65). Secondary outcomes were also similar among the two groups. CONCLUSION: The combination of preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub does not appear to reduce the risk of SSI with cesarean delivery after trial of labor when compared with standard of care. KEY POINTS: · Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease SSI in cesarean after labor.. · Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease other wound complications in cesarean after labor.. · There was no difference in discharge day, 2-week or 6-week SSI rates..

Multidisciplinary management of a pregnancy complicated by Glanzmann thrombasthenia: A case report.

BACKGROUND: Glanzmann thrombasthenia (GT) is a rare, autosomal recessive disorder of platelet glycoprotein IIb-IIIa receptors. Pregnant patients with GT are at increased risk of maternal and fetal bleeding. There is a paucity of literature on the peripartum management of patients. CASE DESCRIPTION: We present the antepartum through the postpartum course of a patient with GT who was managed by a multidisciplinary approach that included communication across maternal-fetal medicine, hematology, transfusion medicine, and anesthesiology services. In addition to routine prepartum obstetric imaging and hematologic laboratory studies, we proactively monitored the patient for anti-platelet antibodies every 4-6 weeks to gauge the risk for neonatal alloimmune thrombocytopenia. Furthermore, we prioritized uterotonics, tranexamic acid, and transfusion of HLA-matched platelets to manage bleeding for mother and fetus intrapartum through the postpartum periods. CONCLUSION: To date, there are limited guidelines for managing bleeding or preventing alloimmunization during pregnancy in patients with GT. Here, we present a complex case with aggressive management of bleeding prophylactically for the mother while serially monitoring both mother and fetus for peripartum bleeding risks and events. Moreover, future studies warrant continued evaluation of these approaches to mitigate increased bleeding risks in subsequent pregnancies.

Intra-Sonographer Correlation Between Transabdominal and Transvaginal Cervical Length Measurements and Associated Patient Demographics.

OBJECTIVES: To assess transvaginal (TV) and transabdominal (TA) cervical length (CL) measurements' variability and patient factors associated with TA CL accuracy. We hypothesized that patient factors would affect the accuracy of TA CL. METHODS: This was a prospective cohort study. During anatomy ultrasound, TA and TV CL measurements were obtained, distance from placental edge to internal cervical os assessed, and demographic questionnaires completed. Patients between 18 to 22 weeks and 6 days were included and those <18 year old or with a twin gestation were excluded. TA CL >0.5 cm different from TV length was considered inaccurate. RESULTS: A total of 530 patients were included. Exactly 18.7% had a prior cesarean, 9.8% a preterm birth, and 2.2% a cervical procedure. Mean age and BMI were 31.1 years and 27.8 kg/m2 . Median number of living children was one. Median TA and TV CL were 3.42 and 3.53 cm. Exactly 36% (95% CI: 32-40%) of TA CL measurements were inaccurate. CL of 3.4 cm corresponded to a mean difference of zero between TA and TV CL. TA ultrasound had a sensitivity of 25% and a specificity of 98.5% to detect TV CL <2.5 cm. On multivariable analyses, Hispanic ethnicity was associated with inaccurate TA measurement (OR 0.48, 95% CI: 0.24-0.96, P = .04). CONCLUSIONS: On average, TA CL underestimates TV CL when TV CL >3.40 cm and overestimates TV CL when TV CL <3.40 cm. Additional co-variates did not impact accuracy. TA ultrasound has low sensitivity to predict short cervix. Relying solely on TA CL to identify those who need intervention may miss diagnoses. It may be reasonable to develop protocols in which TV CL is used for TA CL <3.4 cm.

Pregnancy during a Pandemic: A Cohort Study Comparing Adverse Outcomes during and before the COVID-19 Pandemic.

OBJECTIVE: This study was aimed to evaluate how the novel coronavirus disease 2019 (COVID-19) pandemic may have negatively impacted birth outcomes in patients who tested negative for the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus. STUDY DESIGN: We conducted a retrospective cohort study using electronic health records of pregnant women admitted to a tertiary medical center in New York City, an epicenter of the pandemic. Women with a singleton gestation admitted for delivery from March 27 to May 31, 2019, and March 27 to May 31, 2020, were included. Women less than 18 years of age, those with a positive SARS-CoV-2 polymerize chain reaction (PCR) test on admission, fetal anomaly, or multiple gestation were excluded. Adverse pregnancy outcomes were compared between groups. Univariable and multivariable logistic regression analyses were used to assess outcomes. The primary outcome was preterm birth. RESULTS: Women who delivered during the 2020 study interval had a significantly higher rate of hypertensive disorders of pregnancy (gestational hypertension [GHTN] or preeclampsia; odds ratio [OR] = 1.40, 95% confidence interval [CI]: 1.05-1.85; p = 0.02), postpartum hemorrhage (PPH; OR = 1.77, 95% CI: 1.14-2.73; p = 0.01), and preterm birth (OR = 1.49, 95% CI: 1.10-2.02; p = 0.01). Gestational age at delivery was significantly lower in the 2020 cohort compared with the 2019 cohort (39.3 versus 39.4 weeks, p = 0.03). After adjusting for confounding variables, multivariate analysis confirmed a persistent increase in hypertensive disorders of pregnancy (OR = 1.56, 95% CI: 1.10-2.20, p = 0.01), PPH (OR = 1.74, 95% CI: 1.06-2.86, p = 0.03), and preterm birth (OR = 1.72, 95% CI: 1.20-2.47, p = 0.003) in patients who delivered in 2020 compared with the same period in 2019. Specifically, medically indicated preterm births increased during the pandemic (OR = 3.17, 95% CI: 1.77-5.67, p < 0.0001). CONCLUSION: Those who delivered during the COVID-19 pandemic study interval were more likely to experience hypertensive disorders of pregnancy, medically indicated preterm birth, and PPH even in the absence of SARS-CoV2 infection. KEY POINTS: · Stressful life events can lead to adverse pregnancy outcomes.. · Even patients negative for COVID-19 experienced GHTN, preeclampsia, PPH and preterm birth during the pandemic.. · Pandemic-related stress may adversely affect perinatal outcomes..

COVID-19 pandemic-related change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery hospitalization: a differences-in-differences analysis.

OBJECTIVE: Exclusive breastmilk feeding during the delivery hospitalization, a Joint Commission indicator of perinatal care quality, is associated with longer-term breastfeeding success. Marked racial and ethnic disparities in breastfeeding exclusivity and duration existed prior to COVID-19. The pandemic, accompanied by uncertainty regarding intrapartum and postpartum safety practices, may have influenced disparities in infant feeding practices. Our objective was to examine whether the first wave of the COVID-19 pandemic in New York City was associated with a change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery stay. METHODS: We conducted a cross-sectional study of electronic medical records from 14,964 births in two New York City hospitals. We conducted a difference-in-differences (DID) analysis to compare Black-white, Latina-white, and Asian-white disparities in exclusive breastmilk feeding in a pandemic cohort (April 1-July 31, 2020, n=3122 deliveries) to disparities in a pre-pandemic cohort (January 1, 2019-February 28, 2020, n=11,842). We defined exclusive breastmilk feeding as receipt of only breastmilk during delivery hospitalization, regardless of route of administration. We ascertained severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status from reverse transcription-polymerase chain reaction tests from nasopharyngeal swab at admission. For each DID model (e.g. Black-white disparity), we used covariate-adjusted log binomial regression models to estimate racial and ethnic risk differences, pandemic versus pre-pandemic cohort risk differences, and an interaction term representing the DID estimator. RESULTS: Exclusive breastmilk feeding increased from pre-pandemic to pandemic among white (40.8% to 46.6%, p<0.001) and Asian (27.9% to 35.8%, p=0.004) women, but not Black (22.6% to 25.3%, p=0.275) or Latina (20.1% to 21.4%, p=0.515) women overall. There was an increase in the Latina-white exclusive breastmilk feeding disparity associated with the pandemic (DID estimator=6.3 fewer cases per 100 births (95% CI=-10.8, -1.9)). We found decreased breastmilk feeding specifically among SARS-CoV-2 positive Latina women (20.1% pre-pandemic vs. 9.1% pandemic p=0.013), and no change in Black-white or Asian-white disparities. CONCLUSIONS: We observed a pandemic-related increase in the Latina-white disparity in exclusive breastmilk feeding, urging hospital policies and programs to increase equity in breastmilk feeding and perinatal care quality during and beyond this health emergency.

The Impact of the COVID-19 Pandemic on Postpartum Readmission Rates at a Single Tertiary Care Center in New York City.

OBJECTIVE: The aim of this study was to mitigate transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and decrease exposure to the hospital setting, Mount Sinai Hospital implemented new protocols, including early postpartum discharge. Early discharge would allow for more single-bedded rooms, limiting exposure to other patients and their support persons. During the pandemic, patients were discharged to home on postpartum day 1 or 2 after vaginal or cesarean delivery, respectively, instead of day 2 or 3, unless longer hospitalization was needed for medical indications. We aim to determine if the readmission rate was increased in the setting of earlier discharge during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Historical cohort study comparing the readmission rate in SARS-CoV-2 negative women who presented to Mount Sinai Hospital for delivery admission from March to May 2019 versus March to May 2020. The primary outcome was readmission rate within 6 weeks of discharge day. Maternal and neonatal characteristics and outcomes were compared between groups using t-tests or Wilcoxon's rank-sum test for continuous measures and chi-squared or Fisher's exact tests for categorical measures, as appropriate. Primary and secondary outcomes were assessed using linear and logistic univariable and multivariable regression. RESULTS: Patients in the 2020 cohort (n = 1,078) were significantly less likely to have public/state insurance (p = 0.02), more likely to have pregestational diabetes (p = 0.02), gestational diabetes (p = 0.04), gestational hypertension (p < 0.01), and an operative vaginal or cesarean delivery (vs. spontaneous vaginal delivery, p = 0.01) compared with 2019 cohort patients (n = 1,910). Patients in the 2020 cohort were significantly more likely to have an earlier postpartum day of discharge and a shorter median length of stay compared with 2019 cohort patients (both p < 0.01). Despite differences in length of stay, the rate of readmission was similar between the two groups (p = 0.45). CONCLUSION: During the COVID-19 pandemic, there was no difference in readmission rate despite shorter hospital stays. KEY POINTS: · Maternal length of stay during COVID-19 was shorter.. · Earlier maternal discharge occurred during COVID-19.. · Shorter maternal postpartum stay did not increase readmission rate..

Antenatal Corticosteroids Decrease the Risk of Composite Neonatal Respiratory Morbidity in Planned Early Term Cesarean Deliveries.

OBJECTIVE: While administration of antenatal corticosteroids prior to term elective cesarean deliveries has been shown in international randomized controlled trials to decrease the rates of respiratory distress syndrome and transient tachypnea of the newborn, this is not a standard practice in the United States. We aim to determine if the administration of antenatal corticosteroids for fetal lung maturation within 1 week of scheduled early term cesarean delivery resulted in decreased composite respiratory morbidity. STUDY DESIGN: Historical cohort study including women who underwent scheduled early term cesarean delivery of a singleton, non-anomalous neonate at Mount Sinai Hospital between May 2015 and August 2019, comparing those who completed a course of antenatal corticosteroids within 1 week of delivery to those who did not. The primary outcome was composite respiratory morbidity defined as respiratory distress syndrome, transient tachypnea of the newborn, and neonatal intensive care unit admission for respiratory morbidity. Maternal and neonatal characteristics were compared between groups using t-tests or Wilcoxon-Rank Sum tests for continuous measures and Chi-square or Fisher's exact tests for categorical measures, as appropriate. The outcomes were assessed using logistic regression. RESULTS: History of preterm birth was significantly higher in those who received antenatal corticosteroids compared with those who did not (24.0 vs. 10.9%, p = 0.01). Neonates who were not exposed to antenatal corticosteroids were more likely to experience the composite respiratory morbidity compared with those who were exposed (RR 4.1, 95% CI 1.2-13.7; p = 0.02). Between 37 and 38 weeks, neonates who did not receive steroids were at increased risk of composite respiratory morbidity (RR 11.7, 95% CI 1.5-89.0, p < 0.01), however, there was no difference for those born between 38 and 39 weeks. CONCLUSION: Betamethasone course administered prior to planned early term cesarean delivery was associated with a statistically significant reduction in the neonatal composite respiratory morbidity compared with routine management. KEY POINTS: · Steroids administered prior to scheduled cesarean lead to decreased neonatal respiratory morbidity.. · Steroid administration was not associated with increased adverse neonatal outcomes.. · Steroid administration was most beneficial between 37 and 38 weeks..

Characteristics and Outcomes of Pregnant Women with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in New York City: A Matched Cohort Study.

OBJECTIVE: The aim of this study was to examine the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and preterm birth, cesarean birth, and composite severe maternal morbidity by studying women with and without SARS-CoV-2 infection at the time of delivery hospitalization from similar residential catchment areas in New York City. STUDY DESIGN: This was a retrospective cohort study of pregnant women with laboratory-confirmed or laboratory-denied SARS-CoV-2 on nasopharyngeal swab under universal testing policies at the time of admission who gave birth between March 13 and May 15, 2020, at two New York City medical centers. Demographic and clinical data were collected and follow-up was completed on May 30, 2020. Groups were compared for the primary outcome and preterm birth, in adjusted (for age, race/ethnicity, nulliparity, body mass index) and unadjusted analyses. RESULTS: Among this age-matched cohort, 164 women were positive and 247 were negative for SARS-CoV-2. Of the positive group, 52.4% were asymptomatic and 1.2% had critical coronavirus disease 2019 (COVID-19). The groups did not differ by race and ethnicity, body mass index, or acute or chronic comorbidities. Women with SARS-CoV-2 were more likely to be publicly insured. Preterm birth, cesarean birth, and severe maternal morbidity did not differ between groups. Babies born to women with SARS-CoV-2 were more likely to have complications of prematurity or low birth weight (7.7 vs. 2%, p = 0.01). CONCLUSION: Preterm and cesarean birth did not differ between women with and without SARS-CoV-2 across disease severity in adjusted and unadjusted analysis among this cohort during the pandemic peak in New York City.

SARS-CoV-2 Antibody Response among Women Infected during Pregnancy.

OBJECTIVES: Novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus has been declared a pandemic by the World Health Organization as of March 11, 2020. Pregnant women naturally have a reduced immune system due to immunological changes and decreased lung capacity due to respiratory adaptations, making them more susceptible to coronavirus complications. Within the Mount Sinai Health system, more than 15,000 deliveries are performed annually. We began to care for pregnant women with known COVID-19 infections in late March of 2020. In early April 2020, a policy was implemented to perform universal COVID-19 testing for all women planning to deliver within the Mount Sinai Health system. We examined the antibody response of postpartum women who delivered at Mount Sinai Hospital with a SARS-CoV-2 infection between the study intervals during March 15, 2020, through April 30, 2020. STUDY DESIGN: This was a prospective observational study examining the immune response of pregnant women who delivered at Mount Sinai Hospital with a polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection. Women with a SARS-CoV-2 infection were contacted via phone to discuss participation in the study. Patients who consented were scheduled for a phlebotomy visit to assess their antibody titer levels to COVID-19. The COVID-19 enzyme-linked immunosorbent assay (ELISA) immunoglobulin (Ig)-G antibody test was used to evaluate the patients' antibody titers. The assay detects IgG antibodies for the detection of IgG seroconversion in patients following a known recent SARS-CoV-2 infection. RESULTS: A total of 120 patients were identified with a documented SARS-CoV-2 infection who delivered within the prespecified time frame. Of those patients, 25 women agreed to participate and were included. Of them, 64.00% were Caucasian with a mean age of 35 years. The mean body mass index (BMI) was 30 kg/m2 and the majority of patients had commercial insurance (88.00%). The majority of women were asymptomatic for COVID-19 at the time of admission (80.00%) and the average gestational age of delivery and diagnosis of COVID-19 was 39 weeks' gestation. The later the gestational age at the time of diagnosis, the lower the antibody titer response. When examining the interval from diagnosis to antibody titer analysis, patients with the highest titers (2,880) tended to have a shorter interval between their COVID-19 diagnosis and the time at which the titer level was drawn. Patients with symptoms on admission had similar antibody titer levels when compared with women who were asymptomatic. CONCLUSION: The antibody response among women infected with COVID-19 during pregnancy appears to be greater when the patients are diagnosed at an earlier gestational age. KEY POINTS: · COVID-19 antibody status appears to be greater when diagnosed at an earlier gestational age.. · Asymptomatic and symptomatic pregnant women had similar antibody responses.. · Patients with the highest titers tended to have a shorter interval between their COVID-19 diagnoses..

Pregnant women with severe or critical coronavirus disease 2019 have increased composite morbidity compared with nonpregnant matched controls.

BACKGROUND: In March 2020, as community spread of severe acute respiratory syndrome coronavirus 2 became increasingly prevalent, pregnant women seemed to be equally susceptible to developing coronavirus disease 2019. Although the disease course usually appears mild, severe and critical cases of coronavirus disease 2019 seem to lead to substantial morbidity, including intensive care unit admission with prolonged hospital stay, intubation, mechanical ventilation, and even death. Although there are recent reports regarding the impact of coronavirus disease 2019 on pregnancy, there is a lack of information regarding the severity of coronavirus disease 2019 in pregnant vs nonpregnant women. OBJECTIVE: We aimed to describe the outcomes of severe and critical cases of coronavirus disease 2019 in pregnant vs nonpregnant, reproductive-aged women. STUDY DESIGN: This is a multicenter, retrospective, case-control study of women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection hospitalized with severe or critical coronavirus disease 2019 in 4 academic medical centers in New York City and 1 in Philadelphia between March 12, 2020, and May 5, 2020. The cases consisted of pregnant women admitted specifically for severe or critical coronavirus disease 2019 and not for obstetrical indications. The controls consisted of reproductive-aged, nonpregnant women admitted for severe or critical coronavirus disease 2019. The primary outcome was a composite morbidity that includes the following: death, a need for intubation, extracorporeal membrane oxygenation, noninvasive positive pressure ventilation, or a need for high-flow nasal cannula O2 supplementation. The secondary outcomes included intensive care unit admission, length of stay, a need for discharge to long-term acute care facilities, and discharge with a home O2 requirement. RESULTS: A total of 38 pregnant women with severe acute respiratory syndrome coronavirus 2 polymerase chain reaction-confirmed infections were admitted to 5 institutions specifically for coronavirus disease 2019, 29 (76.3%) meeting the criteria for severe disease status and 9 (23.7%) meeting the criteria for critical disease status. The mean age and body mass index were markedly higher in the nonpregnant control group. The nonpregnant cohort also had an increased frequency of preexisting medical comorbidities, including diabetes, hypertension, and coronary artery disease. The pregnant women were more likely to experience the primary outcome when compared with the nonpregnant control group (34.2% vs 14.9%; P=.03; adjusted odds ratio, 4.6; 95% confidence interval, 1.2-18.2). The pregnant patients experienced higher rates of intensive care unit admission (39.5% vs 17.0%; P<.01; adjusted odds ratio, 5.2; 95% confidence interval, 1.5-17.5). Among the pregnant women who underwent delivery, 72.7% occurred through cesarean delivery and the mean gestational age at delivery was 33.8±5.5 weeks in patients with severe disease status and 35±3.5 weeks in patients with critical coronavirus disease 2019 status. CONCLUSION: Pregnant women with severe and critical coronavirus disease 2019 are at an increased risk for certain morbidities when compared with nonpregnant controls. Despite the higher comorbidities of diabetes and hypertension in the nonpregnant controls, the pregnant cases were at an increased risk for composite morbidity, intubation, mechanical ventilation, and intensive care unit admission. These findings suggest that pregnancy may be associated with a worse outcome in women with severe and critical cases of coronavirus disease 2019. Our study suggests that similar to other viral infections such as severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, pregnant women may be at risk for greater morbidity and disease severity.

Study To Reduce Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized clinical trial of chlorhexidine.

BACKGROUND: Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora. OBJECTIVE: To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo. STUDY DESIGN: In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery. RESULTS: From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis. CONCLUSION: Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.

The role of microorganisms on biotransformation of brewers' spent grain.

Brewers' spent grain (BSG) is the most abundant by-product of brewing. Due to its microbiological instability and high perishability, fresh BSG is currently disposed of as low-cost cattle feed. However, BSG is an appealing source of nutrients to obtain products with high added value through microbial-based transformation. As such, BSG could become a potential source of income for the brewery itself. While recent studies have covered the relevance of BSG chemical composition in detail, this review aims to underline the importance of microorganisms from the stabilization/contamination of fresh BSG to its biotechnological exploitation. Indeed, the evaluation of BSG-associated microorganisms, which include yeast, fungi, and bacteria, can allow their safe use and the best methods for their exploitation. This bibliographical examination is particularly focused on the role of microorganisms in BSG exploitation to (1) produce enzymes and metabolites of industrial interest, (2) supplement human and animal diets, and (3) improve soil fertility. Emerging safety issues in the use of BSG as a food and feed additive is also considered, particularly considering the presence of mycotoxins.Key points• Microorganisms are used to enhance brewers' spent grain nutritional value.• Knowledge of brewers' spent grain microbiota allows the reduction of health risks. Graphical abstract.

A Survey of Labor and Delivery Practices in New York City during the COVID-19 Pandemic.

Recently, a novel coronavirus, precisely severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), that causes the disease novel coronavirus disease 2019 (COVID-19) has been declared a worldwide pandemic. Over a million cases have been confirmed in the United States. As of May 5, 2020, New York State has had over 300,000 cases and 24,000 deaths with more than half of the cases and deaths occurring in New York City (NYC). Little is known, however, of how this virus impacts pregnancy. Given this lack of data and the risk for severe disease in this relatively immunocompromised population, further understanding of the obstetrical management of COVID-19, as well as hospital level preparation for its control, is crucial. Guidance has come from expert opinion, professional societies and public health agencies, but to date, there is no report on how obstetrical practices have adapted these recommendations to their local situations. We therefore developed an internet-based survey to elucidate the practices put into place to guide the care of obstetrical patients during the COVID-19 pandemic. We surveyed obstetrical leaders in four academic medical centers in NYC who were implementing and testing protocols at the height of the pandemic. We found that all sites made changes to their practices, and that there appeared to be agreement with screening and testing for COVID-19, as well as labor and delivery protocols, for SARS-CoV-2-positive patients. We found less consensus with respect to inpatient antepartum fetal surveillance. We hope that this experience is useful to other centers as they formulate their plans to face this pandemic. KEY POINTS: · Practices changed to accommodate public health needs.. · Most practices are screened for novel COVID-19 on admission.. · Fetal testing in COVID-19 patients varied..

A randomized trial of Foley Bulb for Labor Induction in Premature Rupture of Membranes in Nulliparas (FLIP).

BACKGROUND: In premature rupture of membranes (PROM), the risk of chorioamnionitis increases with increasing duration of membrane rupture. Decreasing the time from PROM to delivery is associated with lower rates of maternal infection. The American College of Obstetricians and Gynecologists suggests that all women with PROM who do not have a contraindication to vaginal delivery have their labor induced instead of being managed expectantly. Although the use of oxytocin for labor induction has been demonstrated to decrease the time to delivery compared with expectant management, no studies have evaluated the effectiveness of cervical ripening with a Foley bulb to additionally decrease the time to delivery. OBJECTIVE: To determine whether simultaneous use of an intracervical Foley bulb and oxytocin decreases time from induction start to delivery in nulliparous patients with PROM compared with the use of oxytocin alone. STUDY DESIGN: A randomized trial was conducted from August 2014 to February 2016 that compared the use of concurrent Foley bulb/oxytocin vs oxytocin alone in nulliparous patients ≥34 weeks' gestational undergoing labor induction for PROM. Our primary outcome was time from induction to delivery. Secondary outcomes were mode of delivery, tachysystole, chorioamnionitis, postpartum hemorrhage, Apgar scores, and admission to the neonatal intensive care unit. RESULTS: A total of 128 women were randomized. Baseline characteristics were similar between groups. We found no difference in induction-to-delivery time between women induced with concurrent Foley bulb/oxytocin vs oxytocin alone (median time 13.0 hours [interquartile 10.7, 16.1] compared with 10.8 hours [interquartile range 7.8, 16.6], respectively, P = .09). There were no significant differences in mode of delivery, rates of postpartum hemorrhage, chorioamnionitis, or epidural use. Both groups had similar rates of tachysystole as well as total oxytocin dose. There were no differences in neonatal birth weight, Apgar scores, cord gases, or admissions to the neonatal intensive care unit. CONCLUSION: This is the first randomized trial to compare concurrent Foley bulb/oxytocin vs oxytocin alone in nulliparous patients undergoing induction of labor for PROM. We found no difference in time from induction to delivery in patients induced with concurrent Foley bulb/oxytocin vs oxytocin alone. In nulliparous patients with PROM, this study suggests that addition of a Foley bulb to oxytocin does not decrease the time from induction start to delivery.

A randomized trial of Foley balloon induction of labor trial in nulliparas (FIAT-N).

BACKGROUND: With an increasing rate of induction of labor, it is important to choose induction methods that are safe and efficient in achieving a vaginal delivery. The optimal method for inducing nulliparous women with an unfavorable cervix is not known. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and Foley balloon vs sequential use of Foley balloon followed by oxytocin decreases the time to delivery in nulliparous women. STUDY DESIGN: We conducted a randomized controlled trial of nulliparous women presenting for induction at a single institution from December 2013 through March 2015. After decision for induction was made by their primary provider, women with gestational age ≥24 weeks with a nonanomalous, singleton fetus in vertex presentation with intact membranes were offered participation. Exclusion criteria included history of uterine surgery, unexplained vaginal bleeding, latex allergy, or contraindication to vaginal delivery. Participants were randomized to either simultaneous (oxytocin and Foley balloon) or sequential (oxytocin after expulsion of Foley balloon) induction group. The primary outcome was time from induction to delivery. Secondary outcomes included mode of delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, and composite neonatal outcome. Maternal and neonatal outcomes were collected via chart review. Analyses were done on an intention-to-treat basis. RESULTS: A total of 166 patients were enrolled; 82 in the simultaneous and 84 in the sequential group. There were no differences in baseline characteristics in the 2 groups. Patients who received simultaneous oxytocin with insertion of a Foley balloon delivered significantly earlier (15.92 vs 18.87 hours, P = .004) than those in the sequential group. There was no difference in rate of cesarean delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, or composite neonatal outcome. CONCLUSION: Simultaneous use of oxytocin and Foley balloon for induction of labor results in a significantly shorter interval to delivery in nulliparas.