Exercise testing unmasks exaggerated blood pressure independent of fibrinolytic response in Black but not White postmenopausal females.

Exercise testing unmasks more exaggerated systolic blood pressure responses (SBP) in Black compared with White male adults. Such responses, if translatable to females, may detect racial disparities particularly relevant during menopause. Given the endothelial involvement in BP regulation and as a source of fibrinolytic markers, it follows that fibrinolytic and BP response to exercise could be linked. Thus, we examined BP and fibrinolytic responses to exercise testing in Black and White postmenopausal females. Postmenopausal females (Black = 40; White = 41; 51-70 yr) performed maximal treadmill exercise. BP and blood draws were conducted before and immediately after exercise. Plasma samples, using minimal stasis, were analyzed for tissue plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-1) activity and antigen, respectively. Resting SBP and fibrinolytic potential were similar between races. Black females exhibited greater increases in SBP during exercise [change (d)=75, 95% CI: 64-86 mmHg, P < 0.001] than White females (d = 60, 95% CI: 48-71 mmHg, P < 0.001). Black compared with White females had smaller changes in tPA (d = 3.27, 95% CI: 2.28-4.27 IU/mL, P < 0.001 vs. d = 5.55, 95% CI: 4.58-6.53, P < 0.001) and PAI-1 (d = -2.89, 95% CI: -4.39 to -1.40 IU/mL, P < 0.001 vs. d = -5.08, 95% CI: -6.59 to -3.61, P < 0.001) activities after exercise. SBP exercise-induced changes were not associated with tPA (r = -0.10, P = 0.42) or PAI-1 (r = 0.13, P = 0.30), without any influence of race (P > 0.05). Our findings show that maximal exercise unmasks risk factors for cardiovascular disease in Black postmenopausal females.NEW & NOTEWORTHY Exaggerated SBP responses to exercise testing are more frequent in Black than in White male adults. Such responses, if translatable to females, may detect early racial disparities arriving during menopause. Because the endothelium regulates BP and fibrinolytic responses, these could be linked during exercise. At peak exercise, Black but not White postmenopausal females had more exaggerated SPB responses regardless of reduced fibrinolytic potential. Maximal exercise unmasked risk factors for cardiovascular disease in Black postmenopausal females.

Obstetric Anesthetic Management for Parturients with Hereditary Angioedema: A Case Report and Suggested Protocol.

Hereditary angioedema (HAE) is a disease manifested by repeated episodes of localized submucosal or subcutaneous edematous episodes, potentially triggered by emotional stress, mechanical trauma, or intake of estrogens. We present our experience managing two parturients with HAE. Multidisciplinary care is essential for planning and executing the specialized care of these patients, and management included extensive planning among obstetric, anesthesiology, and allergy and immunology teams. Pregnancy has been shown to have a variable effect on triggering HAE episodes. First-line treatment includes C1 esterase inhibitor concentrate, which can also be used for prophylaxis in high-risk patients. Neuraxial analgesia is recommended to avoid general anesthesia and was established early in both individuals. Vaginal delivery was well tolerated without need for emergent treatment for angioedema symptoms.

Diabesity and Pregnancy: How Do We Get Our Patients Moving?

Obesity and diabetes are 2 commonly encountered complications in pregnancy that adversely affect pregnancy outcomes, maternal health, and the health of the offspring, both short-term and long-term. It is well established that physical activity provides numerous health benefits, both during and outside of pregnancy. By participating in physical activity, many of the negative consequences of both obesity and diabetes may be mitigated. Physical activity guidelines recommend that all adults, including pregnant women, perform at least 150 minutes of moderate-intensity exercise weekly in order to obtain health benefits. More physical activity may be needed to achieve weight management goals.

Multiple Gestations and Hypertensive Disorders of Pregnancy: What Do We Know?

PURPOSE OF REVIEW: The occurrence of hypertensive disorders of pregnancy (HDP) including gestational hypertension, chronic hypertension, preeclampsia, and eclampsia is proportional to the number of fetuses: singletons 6.5%, twins 12.7%, and triplets 20.0%. Literature on HDP in multifetal gestation is sparse compared with singletons. We aim to summarize the current evidence on HDP, specifically in twins. RECENT FINDINGS: HDP occurs more frequently, at an earlier gestational age, and can present more severely and atypically in twin pregnancies. HDP in twins carries a higher risk of maternal/fetal morbidity and mortality including renal failure, stroke, cardiac arrest, pulmonary edema, placental abruption, cesarean delivery, fetal growth restriction, and iatrogenic preterm delivery. Low-dose aspirin (60-150 mg) should be initiated in all multifetal pregnancies to reduce the risk of preeclampsia. To improve outcomes and reduce inherent risks associated with multiple gestations, twins should be managed as high-risk pregnancies, and different from singletons.

The Elite Athlete and Strenuous Exercise in Pregnancy.

Highly trained women continue to exercise during pregnancy, but there is little information available to guide them, and their health care providers, in how to maximize performance without jeopardizing the maternal-fetal unit. Available evidence focusing on average women who perform regular vigorous exercise suggests that this activity is helpful in preventing several maladies of pregnancy, with little to no evidence of harm. However, some studies have shown that there may be a limit to how intense an elite performer should exercise during pregnancy. Health care providers should monitor these women athletes carefully, to build trust and understanding.

Iatrogenic Uterine Diverticulum in Pregnancy After Robotic-assisted Myomectomy.

Uterine diverticula are rare outpouchings of the uterus associated with abnormal uterine bleeding, pelvic pain, dysmenorrhea, and adverse obstetric events. At the time of cesarean delivery at 36 5/7 weeks' gestation during the patient's first pregnancy and 36 6/7 weeks during the second pregnancy, a fundal iatrogenic uterine diverticulum at the site of a prior robotic-assisted myomectomy was noted. The outpouching communicated with the endometrial cavity and was extremely attenuated, palpably 2 to 3 mm thick. Further research is needed to determine the incidence of iatrogenic uterine diverticulum after robotic myomectomy and whether these malformations increase the risk of adverse obstetric outcomes.

Hospitalization in pregnancy due to human respiratory syncytial virus associated disease.

Background: Despite pregnancy being a state of physiologic immune alteration, it has not previously been described as a risk factor for hospitalization due to human respiratory syncytial virus (RSV). Case: This retrospective case series describes two cases of hospitalization due to RSV associated illness in pregnancy. Conclusion: It remains to be determined if the current RSV surge is more dangerous to pregnant patients than those in seasons past. These cases support the importance of maintaining RSV on the differential for respiratory illness in pregnancy.

Strenuous exercise during pregnancy: is there a limit?

OBJECTIVE: The purpose of this study was to evaluate fetal responses to strenuous exercise in physically active and inactive women. STUDY DESIGN: Forty-five healthy women (15 who were nonexercisers, 15 who were regularly active, 15 who were highly active) underwent a peak treadmill test at 28 weeks' gestation to 32 weeks 6 days' gestation. Fetal well-being (umbilical artery Doppler indices, fetal heart tracing/rate, biophysical profile [BPP]) was evaluated before and after exercise. Uterine artery Doppler scans were also obtained. RESULTS: Umbilical and uterine artery Doppler indices were similar among activity groups and did not change with exercise (P > .05). BPP and fetal heart tracings were reassuring in all groups. However, subgroup analyses showed transient fetal heart rate decelerations after exercise and elevated umbilical and uterine artery Doppler indices in 5 highly active women. After this, BPP and fetal heart tracings were reassuring. CONCLUSION: Overall fetal well-being is reassuring after short-duration, strenuous exercise in both active and inactive pregnant women. A subset of highly active women experienced transient fetal heart rate decelerations and Doppler changes immediately after exercise. Athletes may push beyond a threshold intensity at which fetal well-being may be compromised. However, potential impact on neonatal outcomes is unknown.

Intraabdominal pressure as a marker for physiologic and pathologic processes in pregnancy.

Increased intraabdominal pressure (IAP) can result in compression of the abdominal-pelvic venous system leading to signs and symptoms of end organ dysfunction. It has been hypothesized as a pathophysiologic process of preeclampsia. We aim to evaluate the role of IAP in normotensive vs preeclamptic, and singleton vs twin pregnancies. We hypothesized that IAP would be higher in preeclamptics and twins.Women undergoing scheduled cesarean delivery were enrolled in four groups: Singletons- Preeclamptic and Normotensive, Twins- Preeclamptic and Normotensive. Elevated IAP was seen in singleton pregnancies with preeclampsia, representing a pathologic process; and in all twin pregnancies, suggesting a physiologic process.

Characterization of knee dysfunction and related risk factors during pregnancy.

BACKGROUND: Knee pain can be a common complaint during pregnancy; however, the severity of symptoms and their associated risk factors have not been described. QUESTIONS/PURPOSES: The aim of this study was to characterize knee-related dysfunction and describe risk factors in a general obstetric population. PATIENTS AND METHODS: Patients in obstetric clinics completed the International Knee Documentation Committee (IKDC) questionnaire to assess their knee function, as well as the Pregnancy Physical Activity Questionnaire (PPAQ), a validated tool to assess physical activity. Age, weeks gestation, height, weight, and history of knee problems prior to pregnancy were analyzed to identify independent associations with IKDC score and determine predictors of knee dysfunction. RESULTS: 310 patients were included in this study, of which 68, 111 and 131 were in their first, second and trimesters, respectively. Mean age of the total study group was 30.3 ± 5.5 years. Knee function decreased with each trimester, from a mean IKDC score of 88.9 ± 13.0 in the first trimester, 84.5 ± 16.8 in the second, and 82.0 ± 20.0 in the third, with corresponding decreases in activity levels of 258.5 ± 141.7, 254.0 ± 141.5, and 246.1 ± 156.6 MET-h/wk. Of the total study group, 26.1% had IKDC scores <75, including 13.2%, 25.2%, and 33.6% in the first, second and third trimesters. Risk factors for knee dysfunction included high activity levels of PPAQ ≥ 500 MET-h/wk (OR 2.8), history of knee problems (OR 2.7), age <25 years (OR 2.6), and BMI ≥ 30 kg/m2 (OR 1.9). CONCLUSION: In our cohort, 26.1% of pregnant women reported severe knee dysfunction, and this was associated with high levels of activity, younger age, greater BMI, and history of knee problems. These findings may have implications for women who wish to maintain training and fitness during pregnancy. Future studies are recommended to assess the need for intervention, as well as to identify optimal methods to prevent and address symptoms in this population. LEVEL OF EVIDENCE: IV, Case Series.

Vaginal breech delivery in very low birth weight (VLBW) neonates: experience of a single center.

AIMS: To compare the short-term maternal and neonatal outcomes of very low birth weight (VLBW) breech singletons by mode of delivery. METHODS: All breech fetuses born from 24-0/7 to 26-6/7 weeks' gestation at our institution between 2000 and 2008 were eligible for the study. Abstracted medical record data included maternal demographics, delivery data, and neonatal outcomes. RESULTS: There were 26 vaginal and 39 cesarean deliveries. Maternal age did not differ between groups; gestational age was greater in the cesarean group by five days. Short-term neonatal outcomes did not differ between groups. Of the 39 cesarean deliveries, 27 involved classical uterine incisions. Estimated blood loss (732 mL vs. 362 mL) and postpartum infection rate (26% vs. 4%) were greater with cesarean delivery. CONCLUSION: Neonatal outcome is not improved in VLBW infants born by cesarean section. Given the morbidity of classical cesarean sections, vaginal delivery of the breech VLBW infant may be safely considered.

Acute Pancreatitis in a Pregnant Patient With Coronavirus Disease 2019 (COVID-19).

BACKGROUND: Pregnant women with coronavirus disease 2019 (COVID-19) infection are at risk for a variety of COVID-19 complications. CASE: We report a case of acute pancreatitis in a pregnant patient hospitalized for COVID-19 pneumonia. Comprehensive evaluation ruled out other etiologies of acute pancreatitis. Preterm labor developed at 33 5/7 weeks of gestation, and the patient delivered a liveborn male neonate; neonatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening was negative. The patient improved significantly postpartum and was discharged home on postpartum day 3. CONCLUSION: Coronavirus disease 2019 may present in pregnancy with a myriad of clinical symptoms other than respiratory. Acute pancreatitis represents an infrequent complication of primary COVID-19 infection.

Timing of delivery with coronavirus disease 2019 pneumonia requiring intensive care unit admission.

Approximately 4% of pregnant patients with coronavirus disease 2019 require intensive care unit admission. Given the practical implications of advanced ventilatory and circulatory support techniques, urgent or emergent delivery for nonreassuring fetal status frequently presents a logistical impossibility. This article proposes a protocol for obstetrical management of patients in these situations, emphasizing coordinated preparation among obstetrical, anesthesiology, and intensivist teams for planned preterm delivery at gestational ages when neonatal outcomes are likely to be favorable.

Management of Complicated Monochorionic Twin Gestations: An Evidence-Based Protocol.

IMPORTANCE: Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. OBJECTIVE: The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. EVIDENCE ACQUISITION: Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. RESULTS: This article summarizes management for each specific type of MC complication in a structured and clear manner. CONCLUSIONS: Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery.

Effects of Overweight and Obesity in Pregnancy on Health of the Offspring.

Overweight and obesity in pregnancy confer a wide range of risks on mother, fetus, and offspring throughout their lives. In addition to compounding many common pregnancy complications, including both iatrogenic preterm delivery and cesarean delivery, obesity is associated with multiple fetal anomalies, metabolic sequelae including diabetes and obesity, allergy and asthma, attention-deficit disorder, and likely many other challenges for the offspring. As targeted interventions are being developed, encouraging solid nutrition and exercise in women of childbearing age may stave off risks and mitigate obesity in the next generation.

Hospitalization Duration Following Uncomplicated Cesarean Delivery: Predictors, Facility Variation, and Outcomes.

Objectives This study was designed to: (1) characterize stay duration following cesarean delivery, (2) ascertain whether facility variation exists, and (3) determine whether shorter stays are associated with rates of readmission or costs. Study Design The 2017 Nationwide Readmissions Database was used to identify uncomplicated cesarean deliveries. Hierarchical logistic regression was used to assess for facility variation in percentage of patients discharged within 2 days. Similar models were used to assess for associations between probability of readmission within 30 days and facility-level rates of discharge within 2 days. Results In total, 456,312 patients from 1,535 hospitals were included. The median facility discharged 46.8% of patients within 2 days, with the 25th percentile of hospitals 23.7% and the 75th percentile 71.2%. In adjusted regression, there was significant facility heterogeneity ( p < 0.0001). The overall readmission rate was 1.7%, and proportion of patients discharged within 2 days of cesarean delivery was not associated with readmission probability (adjusted relative risk: 1.02, confidence interval: 0.90-1.16), but was associated with lower inpatient costs (adjusted incremental cost: $111, confidence interval: -181 to -41). Conclusion Unexplained facility variation in percentage of patients discharged within 2 days of cesarean delivery was not associated with differences in readmissions. Key Points We find significant facility-level variation in outcomes following uncomplicated cesarean delivery in the United States.High rates of early (postoperative day 2) discharge was not associated with differences in readmission rates in adjusted analyses but was associated with lower inpatient costs.

Fetal and maternal responses to yoga in the third trimester.

Objective: The primary purpose of this study was to examine maternal and fetal responses to a typical, moderate-intensity yoga session in healthy pregnant women during the third trimester using continuous monitoring.Methods: This prospective observational study in low-risk, pregnant women used the Monica AN24 Abdominal ECG wireless maternal-fetal monitor to measure fetal heart rate, maternal heart rate, and uterine activity during a prenatal yoga session. Sessions included 4 time periods: (1) 20-minute rest, (2) 50 minutes standard prenatal yoga, (3) 10-minute meditation, (4) 20-minute recovery. Data were continuously recorded throughout the entire session, stored at 0.25-second intervals, and then averaged over 5-minute intervals. To evaluate changes over time, overall means for the four time periods (rest, yoga, meditation, recovery) were compared using one-way ANOVA with repeated measures. Post-hoc pairwise comparisons (Tukey's) were used to probe significant differences between the four time points. Statistical significance was reached at p < .05.Results: Twenty participants were enrolled; 19 completed the yoga session. Mean gestational age was 35 weeks and 6 days (range of 32-0/7 to 38-6/7) with an average participant age of 32 ± 2.7 years. Maternal heart rates significantly increased during the yoga period (102 ± 11 bpm) compared to rest (90 ± 10), meditation (85 ± 12), and recovery (88 ± 10) (p < .01). The maximum maternal heart rate reached during the yoga session was 125 ± 13 bpm. While fetal heart rates fluctuated slightly over the course of the yoga session, there were no significant fetal heart rate decelerations to suggest deleterious fetal effects. There were no statistically significant differences among resting (138 ± 14 bpm), yoga (137 ± 11 bpm), meditation (139 ± 7 bpm), or recovery (135 ± 22 bpm) fetal heart rates (p = .814). Uterine activity was significantly greater during the yoga period compared with the other time points (p < .001).Conclusion: Yoga can be recommended for low-risk women during pregnancy as no adverse fetal or maternal heart rate changes were observed during a typical prenatal yoga session.

SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review.

The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), has been associated with worse outcomes in several patient populations, including the elderly and those with chronic comorbidities. Data from previous pandemics and seasonal influenza suggest that pregnant women may be at increased risk for infection-associated morbidity and mortality. Physiologic changes in normal pregnancy and metabolic and vascular changes in high-risk pregnancies may affect the pathogenesis or exacerbate the clinical presentation of COVID-19. Specifically, SARS-CoV-2 enters the cell via the angiotensin-converting enzyme 2 (ACE2) receptor, which is upregulated in normal pregnancy. Upregulation of ACE2 mediates conversion of angiotensin II (vasoconstrictor) to angiotensin-(1-7) (vasodilator) and contributes to relatively low blood pressures, despite upregulation of other components of the renin-angiotensin-aldosterone system. As a result of higher ACE2 expression, pregnant women may be at elevated risk for complications from SARS-CoV-2 infection. Upon binding to ACE2, SARS-CoV-2 causes its downregulation, thus lowering angiotensin-(1-7) levels, which can mimic/worsen the vasoconstriction, inflammation, and pro-coagulopathic effects that occur in preeclampsia. Indeed, early reports suggest that, among other adverse outcomes, preeclampsia may be more common in pregnant women with COVID-19. Medical therapy, during pregnancy and breastfeeding, relies on medications with proven safety, but safety data are often missing for medications in the early stages of clinical trials. We summarize guidelines for medical/obstetric care and outline future directions for optimization of treatment and preventive strategies for pregnant patients with COVID-19 with the understanding that relevant data are limited and rapidly changing.