RESUMO
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.
Assuntos
Anti-Inflamatórios não Esteroides , Aspirina , Doenças Inflamatórias Intestinais , Pré-Eclâmpsia , Humanos , Feminino , Gravidez , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Adulto , Estudos Retrospectivos , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Pré-Eclâmpsia/prevenção & controle , Pré-Eclâmpsia/epidemiologia , Doenças Inflamatórias Intestinais/tratamento farmacológico , Complicações na Gravidez/tratamento farmacológico , Complicações na Gravidez/epidemiologia , Fatores de RiscoRESUMO
OBJECTIVE: Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes including intrauterine fetal demise, spontaneous preterm labor, and meconium-stained amniotic fluid. Studies have yet to determine if patients with a history of pregnancy complicated by cholestasis had an association with more severe adverse outcomes in a subsequent pregnancy complicated by cholestasis. STUDY DESIGN: Retrospective cohort study of multiparous, singleton, nonanomalous live gestations complicated by cholestasis at Elmhurst Hospital Center from 2005 to 2019. We compared rates of adverse outcomes in multiparous pregnancies complicated by cholestasis with versus without prior cholestasis. Our primary outcome was rates of spontaneous preterm labor. Our secondary outcomes included rates of iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing. Chi-square and multivariate regression tests were used to determine the strength of association. In all analyses, a p-value less than 0.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. Mount Sinai Icahn School of Medicine Institutional Review Board approval was obtained for this project. RESULTS: Of the 795 multiparous pregnancies complicated by cholestasis, 618 (77.7%) had no prior history of cholestasis and 177 (23.3%) had prior history of cholestasis. Multiparous pregnancies with history of cholestasis had higher rates of prior preterm birth, earlier gestational age at diagnosis and delivery, and were more likely to receive ursodeoxycholic acid therapy. Pregnancies with history of cholestasis were not associated with spontaneous preterm labor in subsequent pregnancies with cholestasis, but history of cholestasis was associated with iatrogenic preterm birth and neonatal intensive care unit (NICU) admission. After adjusting for confounders, the association with iatrogenic preterm birth and NICU admission were no longer statistically significant. There was no significant association between history of cholestasis and other adverse obstetric outcomes. CONCLUSION: Findings suggests that history of prior cholestasis is not associated with worsening outcomes in subsequent pregnancies complicated by cholestasis. KEY POINTS: · Prior cholestasis may not alter risk in subsequent pregnancies.. · Unclear relationship between cholestasis and hepatobiliary disease.. · Studies needed to develop cholestasis screening protocol..
RESUMO
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..
RESUMO
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..
Assuntos
Anti-Infecciosos Locais , Clorexidina/análogos & derivados , Endometrite , Gravidez , Feminino , Humanos , Endometrite/prevenção & controle , Cuidados Pré-Operatórios , Infecção da Ferida Cirúrgica/prevenção & controle , Povidona-IodoRESUMO
OBJECTIVE: Dichorionic twins have increased risk of preterm birth and hypertensive disorders of pregnancy. Grand multiparity may be associated with adverse perinatal outcomes in singleton pregnancies, although the effect of increasing parity in twins is unclear. This study aimed to elucidate whether grand multiparity leads to adverse outcomes in dichorionic twins compared with multiparity and nulliparity. STUDY DESIGN: This was a retrospective review of dichorionic twins at a single institution between January 2008 and December 2019 comparing pregnancy outcomes among grand multiparity, multiparity, and nulliparity. Primary outcome was preterm birth less than 37 weeks. Multivariable regression controlled for differing demographics, prior preterm birth, use of reproductive technologies, and hypertensive disorders of pregnancy. Chi square and Fisher's exact were used for categorical variables and Kruskal-Wallis was used for continuous variables. RESULTS: A total of 843 (60.3%) pregnancies were nulliparous, 499 (35.7%) multiparous, and 57(4.1%) grand multiparous. Univariate analysis indicated that multiparous women had lower incidence of preterm birth less than 37, 34, and 32 weeks (57 vs. 51%, p = 0.04; 19.2 vs. 14.0%, p = 0.02; 9.6 vs. 5.6%, p = 0.01) and that grand multiparous women had lower incidence of preterm birth less than 34 weeks (19.2 vs. 5.3%, p = 0.008) compared with nulliparous women. Multivariable regression confirmed multiparous women had lower odds of preterm birth less than 34 and 32 weeks compared with nulliparous women (<34 wk: odds ratio [OR] = 0.69, 95% confidence interval [CI] = 0.49-0.97, p = 0.03; <32 wk: OR = 0.48, 95% CI = 0.29-0.79, p = 0.004) and that multiparous women (OR = 0.57, 95% CI = 0.42-0.77, p = 0.0002) and grand multiparous women (OR = 0.23, 95% CI = 0.08-0.68, p = 0.0074) had lower incidence of hypertensive disorders of pregnancy when compared with nulliparous women. CONCLUSION: Grand multiparity is not associated with adverse perinatal outcomes compared with nulliparity or multiparity in dichorionic twins. Increasing parity may protect against incidence of preterm birth and hypertensive disorders of pregnancy even among grand multiparous women. KEY POINTS: · Incidence of preterm birth may decrease with increasing parity in twins.. · Hypertensive disorders of pregnancy may decrease with increasing parity in twins.. · Grand multiparity is not associated with adverse perinatal outcomes in twins..
RESUMO
OBJECTIVE: Evidence is inconsistent regarding grand multiparity and its association with adverse obstetric outcomes. Few large American cohorts of grand multiparas have been studied. We assessed if increasing parity among grand multiparas is associated with increased odds of adverse perinatal outcomes. STUDY DESIGN: Multicenter retrospective cohort of patients with parity ≥ 5 who delivered a singleton gestation in New York City from 2011 to 2019. Outcomes included postpartum hemorrhage, preterm delivery, hypertensive disorders of pregnancy, shoulder dystocia, birth weight > 4,000 and <2,500 g, and neonatal intensive care unit (NICU) admission. Parity was analyzed continuously, and multivariate analysis determined if increasing parity and other obstetric variables were associated with each adverse outcome. RESULTS: There were 2,496 patients who met inclusion criteria. Increasing parity among grand multiparas was not associated with any of the prespecified adverse outcomes. Odds of postpartum hemorrhage increased with history (adjusted odds ratio [aOR]: 2.65, 95% confidence interval [1.83, 3.84]) and current cesarean delivery (aOR: 4.59 [3.40, 6.18]). Preterm delivery was associated with history (aOR: 12.36 [8.70-17.58]) and non-White race (aOR: 1.90 [1.27, 2.84]). Odds of shoulder dystocia increased with history (aOR: 5.89 [3.22, 10.79]) and birth weight > 4,000 g (aOR: 9.94 [6.32, 15.65]). Birth weight > 4,000 g was associated with maternal obesity (aOR: 2.92 [2.22, 3.84]). Birth weight < 2,500 g was associated with advanced maternal age (aOR: 1.69 [1.15, 2.48]), chronic hypertension (aOR: 2.45 [1.32, 4.53]), and non-White race (aOR: 2.47 [1.66, 3.68]). Odds of hypertensive disorders of pregnancy increased with advanced maternal age (aOR: 1.79 [1.25, 2.56]), history (aOR: 10.09 [6.77-15.04]), and non-White race (aOR: 2.79 [1.95, 4.00]). NICU admission was associated with advanced maternal age (aOR: 1.47 [1.06, 2.02]) and non-White race (aOR: 2.57 [1.84, 3.58]). CONCLUSION: Among grand multiparous patients, the risk factor for adverse maternal, obstetric, and neonatal outcomes appears to be occurrence of those adverse events in a prior pregnancy and not increasing parity itself. KEY POINTS: · Increasing parity is not associated with adverse obstetric outcomes among grand multiparas.. · Prior adverse pregnancy outcome is a risk factor for the outcome among grand multiparas.. · Advanced maternal age is associated with adverse obstetric outcomes among grand multiparas..
RESUMO
BACKGROUND: Intrahepatic cholestasis of pregnancy is associated with adverse pregnancy outcomes, including sudden fetal cardiac arrhythmias, resulting in stillbirth. This association has been correlated with the total bile acid levels, which are a marker for disease severity. Studies are yet to determine if intrahepatic cholestasis of pregnancy severity is also associated with increased rates of other adverse neonatal outcomes. OBJECTIVE: This study aimed to determine whether pregnancies complicated by intrahepatic cholestasis of pregnancy show a bile acid severity-based relationship with other adverse obstetrical outcomes beyond stillbirth alone. STUDY DESIGN: This was a retrospective cohort study of singleton, nonanomalous gestations complicated by intrahepatic cholestasis of pregnancy at the Elmhurst Hospital Center from 2005 to 2019. Severity was defined by the peak total bile acid levels (µmol/L): mild (10-19), low moderate (20-39), high moderate (40-99), and severe (>100). We examined the rates of spontaneous preterm labor, fetal growth restriction, preterm prelabor rupture of membranes, iatrogenic preterm birth, meconium-stained amniotic fluid, cesarean delivery for nonreassuring fetal heart tracing, umbilical artery pH, neonatal intensive care unit admission, and neonatal birthweight. The chi-square, Fisher exact, Student t, Mann-Whitney, and multivariate regression tests were used to determine the association of intrahepatic cholestasis of pregnancy severity and adverse neonatal outcomes. In all analyses, mild severity was used as the base comparator. A P value of <.05 and 95% confidence interval not crossing 1.00 indicated statistical significance. RESULTS: Of the 1202 pregnancies complicated by intrahepatic cholestasis of pregnancy, 306 (25.5%) were mild, 449 were low moderate (37.4%), 327 were high moderate (27.2%), and 120 were severe (10.0%). After adjusting for confounders, progressive intrahepatic cholestasis of pregnancy severity was associated with an increased risk of spontaneous preterm labor (low moderate adjusted odds ratio, 1.60; 95% confidence interval, 0.76-3.38; high moderate adjusted odds ratio, 3.49; 95% confidence interval, 1.69-7.22; severe adjusted odds ratio, 6.58; 95% confidence interval, 2.97-14.55), iatrogenic preterm birth (low moderate adjusted odds ratio, 1.54; 95% confidence interval, 0.95-2.52; high moderate adjusted odds ratio, 3.11; 95% confidence interval, 1.91-5.06; severe adjusted odds ratio, 4.94; 95% confidence interval, 2.81-8.71), and meconium-stained amniotic fluid (low moderate adjusted odds ratio, 1.33; 95% confidence interval, 0.75-2.36; high moderate adjusted odds ratio, 2.63; 95% confidence interval, 1.48-4.65; severe adjusted odds ratio, 3.91; 95% confidence interval, 1.98-7.69). There was no significant association between intrahepatic cholestasis of pregnancy severity and other adverse outcomes. CONCLUSION: The findings suggest that intrahepatic cholestasis of pregnancy disease severity is associated with an increased risk of spontaneous preterm labor, iatrogenic preterm birth, and meconium-stained amniotic fluid. These findings provide valuable insight toward patient anticipatory counseling.
Assuntos
Colestase Intra-Hepática , Complicações na Gravidez , Nascimento Prematuro , Ácidos e Sais Biliares , Colestase Intra-Hepática/epidemiologia , Feminino , Humanos , Doença Iatrogênica , Recém-Nascido , Gravidez , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , Natimorto/epidemiologiaRESUMO
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..
Assuntos
Nascimento Prematuro , Síndrome do Desconforto Respiratório do Recém-Nascido , Taquipneia Transitória do Recém-Nascido , Corticosteroides/uso terapêutico , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Morbidade , Gravidez , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , Cuidado Pré-Natal/métodos , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Síndrome do Desconforto Respiratório do Recém-Nascido/prevenção & controle , Taquipneia , Taquipneia Transitória do Recém-Nascido/epidemiologiaRESUMO
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..
Assuntos
COVID-19 , Pandemias , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Cidade de Nova Iorque , Readmissão do Paciente , Período Pós-Parto , Gravidez , Estudos Retrospectivos , SARS-CoV-2 , Centros de Atenção TerciáriaRESUMO
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.
Assuntos
COVID-19 , Complicações Infecciosas na Gravidez , Nascimento Prematuro , COVID-19/epidemiologia , Estudos de Coortes , Feminino , Humanos , Recém-Nascido , Cidade de Nova Iorque/epidemiologia , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Resultado da Gravidez/epidemiologia , Gestantes , Nascimento Prematuro/epidemiologia , Estudos Retrospectivos , SARS-CoV-2RESUMO
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..
Assuntos
COVID-19 , Complicações Infecciosas na Gravidez , Adulto , Anticorpos Antivirais , Formação de Anticorpos , Teste para COVID-19 , Feminino , Humanos , Imunoglobulina G , Lactente , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , SARS-CoV-2RESUMO
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.
Assuntos
COVID-19/complicações , Complicações Infecciosas na Gravidez , SARS-CoV-2 , Adulto , COVID-19/mortalidade , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva , Tempo de Internação , Pessoa de Meia-Idade , Morbidade , Gravidez , Resultado da Gravidez , Gestantes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: Increasing placental thickness is associated with adverse outcomes including earlier gestational age at delivery, lower birthweight, and lower umbilical artery pH. We aim to determine whether mid-trimester placenta previa thickness is associated with persistence of previa at time of delivery. STUDY DESIGN: Single-center retrospective cohort study of singleton gestations with previa diagnosed at 18-24 weeks delivering between 2015 and 2019. The thickest portion of the placenta was measured in a longitudinal plane on transabdominal imaging to determine placental thickness. We defined three cohorts: 1) thick placenta (>1 standard deviation above the mean), 2) thin placenta (>1 standard deviation below the mean), and 3) average placenta (within 1 standard deviation above or below the mean). Primary outcome was previa persistence at time of delivery. Secondary outcomes included postpartum hemorrhage, cesarean delivery, placenta accreta spectrum, and maternal morbidity composite (use of Bakri balloon, B-lynch, or O'Leary, peripartum hysterectomy, blood transfusion, ICU admission, or death). In all analyses, average thickness was used as the base comparator. RESULTS: Of 239 pregnancies with mid-trimester previa there were 34 thin, 166 average, and 39 thick placentas. Patients with thick placenta were older, more likely to have prior cesarean delivery, fibroid uterus, and delivery at an earlier gestational age. After adjusting for confounders, thick placenta was associated with persistent previa (aOR 6.85 [3.13-15.00]) and cesarean delivery (aOR 2.76 [1.26-6.08]). CONCLUSION: At diagnosis of mid-trimester previa, thick placenta is associated with persistence at time of delivery and delivery by cesarean section. This suggests placental thickness may assist with risk stratification and coordination of care.
Assuntos
Placenta Acreta , Placenta Prévia , Gravidez , Humanos , Feminino , Cesárea/efeitos adversos , Estudos Retrospectivos , Placenta , Ultrassonografia , Placenta Acreta/etiologiaRESUMO
OBJECTIVE: Given the call to reduce rates of non-medically indicated cesarean deliveries (CDs) by encouraging trials of labor after cesarean (TOLAC), this study looks at social characteristics of patients choosing a TOLAC versus a scheduled repeat cesarean delivery (SRCD) to determine disparities regarding delivery method choice. METHODS: This was a retrospective cohort study of patients with a history of one CD between April 29, 2015-April 29, 2020. Patients were divided based on type of delivery chosen at admission. Chi-squared tests examined proportional differences between groups and logistic regression models examined odd ratios of choosing TOLAC versus SRCD according to socially dependent categories including race/ethnicity, health insurance, pre-pregnancy body mass index, and Social Vulnerability Index (SVI). RESULTS: 1,983 patients were included. Multivariable logistic regression models revealed that patients with a high SVI (reference: low/medium SVI) (AOR 2.0, CI: 1.5, 2.5), self-identified as Black/ African American (AOR: 2.4, CI: 1.6, 3.6) or Hispanic/Latina (AOR: 2.0, CI: 1.4, 2.8) (reference: White), had public insurance (reference: private insurance) (AOR: 3.7, CI: 2.8, 5.0), and who had an obese BMI (reference: non-obese BMI) were more likely to opt for a TOLAC rather than SRCD. CONCLUSION: These findings demonstrate differences in delivery method preferences. Specifically, more disadvantaged patients are more likely to choose TOLAC, suggesting that social and economic factors may play a role in delivery preferences. These findings have implications for improving individualized counselling and engaging in shared decision-making around mode of delivery.
RESUMO
OBJECTIVE: Obesity and maternal age are increasing among pregnant patients. The understood effect of body mass index (BMI), advanced maternal age (AMA), and second stage of labor on obstetric anal sphincter injury (OASIS) at delivery is varied. The objective of this study was to assess whether incorporating BMI, second stage of labor length, and AMA into a model for predicting OASIS among forceps-assisted vaginal deliveries (FAVD) had a higher predictivity value compared to models without these additions. METHOD: This was an IRB-approved retrospective cohort study of singleton gestations who underwent a FAVD between 2017 and 2021. The primary outcome was prediction of OASIS via established models versus models including the addition of new predictive factors. RESULTS: A total of 979 patients met inclusionary criteria and were included in the final analysis. 20.4% of patients had an OASIS laceration, 11.3% of neonates had NICU admissions, 23.7% had a composite all neonatal outcome, and 8% had a composite subgaleal/cephalohematoma outcome. Comparisons of known factors that predict OASIS (nulliparity, race, episiotomy status) to known factors with additional predictors (BMI, AMA, and length of second stage in labor) were explored. After comparing each model's AUC to one another (a total of 3 comparisons made), there was no statistically significant difference between the models (all P > 0.62). CONCLUSION: Including BMI, AMA, and second stage of labor length does not improve the predictivity of OASIS in patients with successful FAVD. These factors should not impact a provider's decision to perform a FAVD when solely considering increased odds of OASIS.
RESUMO
INTRODUCTION: Transvaginal cervical length (TVCL) surveillance post-transvaginal cerclage placement is not universally performed, despite the correlated risk of short TVCL with spontaneous preterm birth (sPTB). This study evaluated if patients with a TVCL <2.5 cm after cerclage placement had higher odds of sPTB than those with a TVCL ≥2.5 cm after cerclage placement. METHODS: This retrospective cohort study included patients with a singleton, non-anomalous gestation with a transvaginal cerclage who had TVCL surveillance post-cerclage placement. The primary outcome was the odds of sPTB among patients with TVCL <2.5 cm vs TVCL ≥2.5 cm after cerclage placement. Transvaginal cerclage placement indications included history indicated, physical exam indicated, and ultrasound indicated. Outcomes were assessed using univariate and multivariate analysis while adjusting for progesterone use, TVCL before cerclage placement, and cerclage indication. RESULTS: The analysis included 210 patients, and the sPTB rate was 46.7%. Those with sPTB underwent cerclage placement at later gestational ages, had higher rates of exam-indicated cerclage, and were more likely to be prescribed vaginal progesterone. Patients with a TVCL of <2.5 cm after cerclage placement did not have significantly increased odds of sPTB (OR: 2.8, 95% CI: 0.9-8.7, p=0.07); however, patients with a TVCL <2.0 cm had significantly increased odds of sPTB (OR: 6.3, 95% CI: 2.2-18.8, p<0.001). CONCLUSION: In patients with transvaginal cerclage, there does not appear to be increased odds of sPTB with TVCL <2.5 cm after cerclage placement; however, there does appear to be an increased odds of sPTB in patients with a TVCL of <2.0 cm after cerclage placement.
RESUMO
BACKGROUND: Cell-free fetal DNA (cffDNA) screening is routinely performed in pregnancy. Abnormal fetal fraction has been associated with adverse pregnancy outcomes, including hypertensive disorders of pregnancy, which are associated with severe maternal and neonatal morbidity and mortality. OBJECTIVE: This study examined whether abnormal fetal fraction, defined in this study as fetal fraction either <6 or >15 on the basis of restricted-cubic-spline-plot within our study population, was associated with HDP in a retrospective sample, as well as whether fetal fraction improves the prediction of hypertensive disorders of pregnancy (HDP). We hypothesized that abnormal fetal fraction would be associated with HDP and that adding fetal fraction to a model would significantly improve its strength to predict HDP. STUDY DESIGN: This was a retrospective cohort study of 729 patients delivering singleton, non-anomalous pregnancies with conclusive cffDNA screening. The primary outcome was HDP. Logistic regression models tested associations between fetal fraction and HDP. We evaluated the impact of including fetal fraction on the prediction of hypertensive disorders of pregnancy (HDP) by comparing the area under the receiver operating characteristic (ROC) curve (AUC) between predictive models with and without fetal fraction. RESULTS: Among the study sample, there was an HDP rate of 11.5 %. Abnormal fetal fraction was defined as <6 % percentile and >15 %, HDP incidence was significantly higher in patients with fetal fraction <6 % compared to patients with fetal fraction in normal range (fetal fraction 6-15 %) (19.5 % vs 10.7 %, p = 0.006 on post hoc comparison). Model 1 had one predictor (fetal fraction) with an AUC of 0.59, Model 2 had three predictors (BMI, nulliparity, history of HDP) with an AUC of 0.71, and Model 3 had four predictors (BMI, nulliparity, history of HDP, and fetal fraction) with an AUC of 0.73. Models 2 and 3 were not significantly different (p = 0.18). CONCLUSIONS: More patients who developed HDP had low fetal fraction and fewer patients who developed HDP had high fetal fraction compared to those patients who did not develop HDP. Based on results from multivariable regression models, we cannot conclude that fetal fraction improves HDP prediction. However, developing standardized values for abnormal fetal fraction may be clinically useful.
RESUMO
Tragically, preeclampsia is a leading cause of pregnancy-related complications and is linked to a heightened risk for morbid and fatal cardiovascular disease (CVD) outcomes. Although the mechanism connecting preeclampsia to CVD risk has yet to be fully elucidated, evidence suggests distinct pathways of early and late preeclampsia with shared CV risk factors but with profound differences in perinatal and postpartum risk to the mother and infant. In early preeclampsia, <34 weeks of gestation, systemic vascular dysfunction contributes to near-term subclinical myocardial damage. Hypertrophy and diastolic abnormalities persist postpartum and contribute to early onset heart failure (HF). This HF risk remains elevated decades later and contributes to premature death. Black women are at the highest risk of preeclampsia and HF. These findings support closer monitoring of women postpartum, especially for those with early and severe preeclampsia to control chronic hypertension and reduce the potentially preventable sequelae of heightened CVD and HF risk.
RESUMO
Gestational alloimmune liver disease is a rare complication associated with reactive maternal immunoglobulins resulting in neonatal liver pathology. The mainstay treatment for prevention in future pregnancies is intravenous immunoglobulins. Although relatively well tolerated, adverse reactions may occur. In this report, we highlight a case of intravenous immunoglobulin induced pancytopenia diagnosed by exclusion after thorough work-up. The patient was counseled on options and an informed decision was made to proceed with re-trial of intravenous immunoglobulin without systemic prednisone. This resulted in the delivery of a healthy neonate. We propose that future adverse reactions to intravenous immunoglobulin in pregnancy may warrant the trial of a new medication lot and use of systemic steroids only if subsequently indicated.
RESUMO
OBJECTIVE: Neonatal opioid withdrawal syndrome (NOWS) can occur in newborns exposed to opioids in pregnancy. Opioids delay gastric emptying and inhibit gastric motility in adults, but little is known about their effect in the fetus. We sought to assess gastric area ratio (GAR) in opioid-exposed fetuses. STUDY DESIGN: Retrospective cohort study including opioid-exposed maternal-neonatal dyads between 2007-2017. Primary outcome: severe NOWS (three consecutive Finnegan scores ≥8 or three scores totaling ≥24 within 96 h of life). GAR: (gastric area)/(transverse abdominal area) × 100. Data analysis was by descriptive, parametric, and non-parametric tests. RESULTS: Forty-nine maternal-neonatal dyads were included, 67% (n = 33) with severe NOWS. GAR <95th percentile for gestational age was seen in 80% of neonates (n = 39). However, GAR was not different between groups (p = .90) and did not predict severe NOWS. CONCLUSION: Fetal GAR was <95th percentile in 80% of opioid-exposed neonates. However, fetal GAR may not predict NOWS treatment.