Is Obesity a Risk Factor for Disorders of Amniotic Fluid?

OBJECTIVES: Prior studies show conflicting evidence as to whether obesity in the absence of other medical or pregnancy-related conditions contributes to amniotic fluid disorders. The purpose of this study is to determine the association between late-pregnancy obesity with oligohydramnios (amniotic fluid index [AFI] ≤5 cm or maximum vertical pocket [MVP] <2 cm) and/or polyhydramnios (AFI ≥24 cm or MVP ≥8 cm). METHODS: This is a retrospective cohort study of 961 women with singleton gestations who had one or more obstetrical ultrasounds at a single institution at 36 0/7 weeks gestation or beyond between August 1, 2015, and May 1, 2020. Patients were included if they had valid pregnancy dating and a documented AFI and/or MVP. Patients were categorized based on body mass index or BMI (eg, normal, overweight, Class I Obesity, Class II Obesity, or Class III Obesity). RESULTS: A total of 6.2% of patients met criteria for oligohydramnios based on AFI, MVP or both (n = 60). There was no significant association between oligohydramnios and increasing BMI, regardless of obesity class (P = .21). In terms of polyhydramnios, 5.6% of patients met criteria based on AFI, MVP, or both (n = 54). Similarly, there was also no significant association between polyhydramnios and increasing BMI, regardless of obesity class (P = .66). CONCLUSIONS: Elevated maternal BMI was not significantly associated with disorders of amniotic fluid, regardless of the severity of obesity.

Is enhanced, structured prenatal counseling in third trimester associated with postpartum contraceptive uptake?

INTRODUCTION: Contraception is key for maternal well-being in the postpartum period. This study aims to evaluate the impact of prenatal counseling on postpartum contraception uptake. METHODS: This cohort study assessed pregnant patients who received their prenatal care at our outpatient obstetrics clinic in 2021-2022. The intervention group received counseling at their 28- and 36-week prenatal visits with a language-congruent paper handout and a review of methods by the provider. The non-intervention group was seen in the outpatient clinic prior to implementation. Intervention patients were surveyed on postpartum days 1-3 to evaluate recollection of counseling and intent to start contraception. Data on uptake and type of contraception chosen was collected for both groups at 6- and 12-weeks postpartum. Our primary outcome was uptake of any type of contraception at the 6-week postpartum visit. RESULTS: A total of 126 patients over two five-month intervals (64 intervention and 62 non-intervention) were included in analysis. Baseline patient characteristics were similar between the groups, including predominance of public insurance. Groups differed by race/ethnicity, with higher rates of Hispanic patients in the intervention group. Patients in the intervention group had higher contraception uptake within six weeks of delivery (OR 2.61, p = 0.0287). Forty-three patients in the intervention group desired postpartum contraception (including permanent methods, such as tubal ligation), although only 21 (48.8 %) received their desired method. There were no differences in method chosen between the non-intervention and intervention groups (p = 0.15). CONCLUSIONS: Structured prenatal counseling regarding contraceptive options can improve the timely initiation of contraception.

COVID-19 Vaccine Acceptance in Pregnancy.

OBJECTIVE: The purpose of the study is to evaluate the acceptance rate of the coronavirus disease 2019 (COVID-19) vaccine among pregnant women at our institution prior to recommendations by national organizations (American College of Obstetricians and Gynecologists/The Society for Maternal-Fetal Medicine) in July 2021 and to determine whether factors including health disparities are associated with acceptance. STUDY DESIGN: This is an Institutional Review Board exempt descriptive study. Anonymous surveys were administered from February 2021 to May 2021 to pregnant patients at Mount Sinai South Nassau's affiliated Maternal Fetal Medicine office. The survey was completed by 701 pregnant women. Descriptive statistics were calculated for the overall sample, as well as separately by group (acceptance versus declining/undecided about getting the COVID-19 vaccine). The two groups were compared using the chi-square test or Fisher's exact test and the two-sample t-test. Analysis was compared between two groups (patients who accepted the COVID-19 vaccine and people who declined/undecided about the vaccine). A result was considered statistically significant at the p < 0.05 level of significance. RESULTS: Of the 701 pregnant women who completed the survey, 96 patients accepted the vaccine. More pregnant women who were older accepted the COVID-19 vaccine compared with those who were younger (p = 0.0343). Pregnant women willing to get the flu vaccine and/or the Tdap vaccine in pregnancy were more likely to obtain the COVID-19 vaccine (p < 0.05). Pregnant patients who had household members willing to receive the COVID-19 vaccine sought to obtain the vaccine for themselves (p < 0.0001). Interestingly, pregnant women who had an underlying respiratory illness in the pregnancy were less likely to accept the COVID-19 vaccine than those who had either other or no medical problems (p < 0.05). CONCLUSION: There is a low rate of COVID-19 vaccine acceptance among pregnant women (13.69%). Efforts should be made to encourage the vaccine in this vulnerable population to protect them from the health risks of the COVID-19 virus. KEY POINTS: · COVID-19 vaccine acceptance rates in our population were 13.6%.. · Accepting Tdap and influenza vaccines increased the likelihood of accepting the COVID vaccine.. · Pregnant patients with respiratory illnesses were more likely to decline the COVID vaccine..

Psychological measures of patient's decision-making for prenatal genetic testing.

OBJECTIVE: To use a questionnaire to determine the levels of maternal decision-related distress, clarity of the pros and cons, and certainty when considering prenatal genetic diagnostic testing; and to assess the relationship between these constructs and patient characteristics. METHOD: Cross-sectional study. Voluntary, anonymous questionnaires distributed 2017-2019 to women referred for invasive prenatal genetic testing. Excluded: English or Spanish illiterate. Maternal characteristics were collected. Questions evaluated distress, decisional certainty, and decisional clarity on a 5-point Likert scale (range: 0 = low/uncertain/unclear to 4 = high/certain/clear). Analysis: non-parametric Kruskal-Wallis, correlation statistics, and ANOVA. RESULTS: Forty-four female patients completed it. Most were married, white, Catholic, and multiparous. 58% had already made a testing decision. Patients expressed low distress levels (mean 1.18 ± 0.80) and expressed high decisional certainty (mean 3.28 ± 0.76) and clarity (mean 3.30 ± 0.99). Decisional certainty and clarity were positively correlated (r = 0.47, p < .01), whereas distress was negatively correlated with decisional certainty (r = -0.8136, p < .0005) and decisional clarity (r = -0.49, p = .007). No significant differences by religion or parity. Greater distress (p < .05) and less decisional clarity (p = .07) occurred between those still debating testing vs those who had decided. CONCLUSIONS: Higher maternal distress scores were associated with lower decisional certainty and decisional clarity in women considering prenatal genetic testing.

Testing of Patients and Support Persons for Coronavirus Disease 2019 (COVID-19) Infection Before Scheduled Deliveries.

OBJECTIVE: To evaluate the rate of coronavirus disease 2019 (COVID-19) infection with the use of universal testing in our obstetric population presenting for scheduled deliveries, as well as the concordance or discordance rate among their support persons during the initial 2-week period of testing. Additionally, we assessed the utility of a screening tool in predicting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing results in our cohort. METHODS: This was an observational study in which all women who were scheduled for a planned delivery within the Mount Sinai Health system from April 4 to April 15, 2020, were contacted and provided with an appointment for themselves as well as their support persons to undergo COVID-19 testing 1 day before their scheduled delivery. Both the patients and the support persons were administered a standardized screen specific for COVID-19 infection by telephone interview. Those support persons who screened positive were not permitted to attend the birth. All patients and screen-negative support persons underwent SARS-CoV-2 testing. RESULTS: During the study period, 155 patients and 146 support persons underwent SARS-CoV-2 testing. The prevalence of asymptomatic COVID-19 infection was 15.5% (CI 9.8-21.2%) and 9.6% (CI 4.8-14.4%) among patients and support persons, respectively. The rate of discordance among tested pairs was 7.5%. Among patients with COVID-19 infection, 58% of their support persons also had infection; in patients without infection, fewer than 3.0% of their support persons had infection. CONCLUSION: We found that more than 15% of asymptomatic maternity patients tested positive for SARS-CoV-2 infection despite having screened negative with the use of a telephone screening tool. Additionally, 58% of their asymptomatic, screen-negative support persons also tested positive for SARS-CoV-2 infection. Alternatively, testing of the support persons of women who had tested negative for COVID-19 infection had a low yield for positive results. This has important implications for obstetric and newborn care practices as well as for health care professionals.

Should women with gestational diabetes be screened at delivery hospitalization for type 2 diabetes?

BACKGROUND: Less than one-half of women with gestational diabetes mellitus are screened for type 2 diabetes postpartum. Other approaches to postpartum screening need to be evaluated, including the role of screening during the delivery hospitalization. OBJECTIVE: To assess the performance of an oral glucose tolerance test administered during the delivery hospitalization compared with the oral glucose tolerance test administered at a 4- to 12-week postpartum visit. STUDY DESIGN: We conducted a combined analysis of patient-level data from 4 centers (6 clinical sites) assessing the utility of an immediate postpartum 75-g oral glucose tolerance test during the delivery hospitalization (PP1) for the diagnosis of type 2 diabetes compared with a routine 4- to 12-week postpartum oral glucose tolerance test (PP2). Eligible women underwent a 75-g oral glucose tolerance test at both PP1 and PP2. Sensitivity, specificity, and negative and positive predictive values of the PP1 test were estimated for diagnosis of type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance. RESULTS: In total, 319 women completed a PP1 screening, with 152 (47.6%) lost to follow-up for the PP2 oral glucose tolerance test. None of the women with a normal PP1 oral glucose tolerance test (n=73) later tested as having type 2 diabetes at PP2. Overall, 12.6% of subjects (n=21) had a change from normal to impaired fasting glucose/impaired glucose tolerance or a change from impaired fasting glucose/impaired glucose tolerance to type 2 diabetes. The PP1 oral glucose tolerance test had 50% sensitivity (11.8-88.2), 95.7% specificity (91.3-98.2%) with a 98.1% (94.5-99.6%) negative predictive value and a 30% (95% confidence interval, 6.7-65.3) positive predictive value for type 2 diabetes vs normal/impaired fasting glucose/impaired glucose tolerance result. The negative predictive value of having type 2 diabetes at PP2 compared with a normal oral glucose tolerance test (excluding impaired fasting glucose/impaired glucose tolerance) at PP1 was 100% (95% confidence interval, 93.5-100) with a specificity of 96.5% (95% confidence interval, 87.9-99.6). CONCLUSION: A normal oral glucose tolerance test during the delivery hospitalization appears to exclude postpartum type 2 diabetes mellitus. However, the results of the immediate postpartum oral glucose tolerance test were mixed when including impaired fasting glucose or impaired glucose tolerance. As a majority of women do not return for postpartum diabetic screening, an oral glucose tolerance test during the delivery hospitalization may be of use in certain circumstances in which postpartum follow-up is challenging and resources could be focused on women with an abnormal screening immediately after the delivery hospitalization.

First-trimester maternal serum alpha fetoprotein is associated with ischemic placental disease.

BACKGROUND: While elevated second-trimester maternal serum alpha fetoprotein has been associated with adverse pregnancy outcomes, the utility of first-trimester maternal serum alpha fetoprotein in predicting these outcomes is limited. Some laboratories have been including maternal serum alpha fetoprotein as part of the first-trimester analyte screening for aneuploidy and preeclampsia, offering its potential utility in predicting pregnancy outcomes. OBJECTIVE: Our primary objective was to determine the association between elevated first-trimester maternal serum alpha fetoprotein and preeclampsia as well as ischemic placental disease (a composite of preeclampsia, fetal growth restriction, and/or placental abruption). Secondary outcomes included early-onset preeclampsia requiring delivery at <34 weeks gestation, fetal growth restriction, placental abruption, preterm delivery, fetal demise, and spontaneous abortion. STUDY DESIGN: An institutional review board-approved multisite retrospective cohort study was performed including all patients with first-trimester maternal serum alpha fetoprotein as part of routine first-trimester aneuploidy screening from April 2015 through January 2017. Pregnancies with multiple gestations, known structural or chromosomal abnormalities, known malignancy, and incomplete delivery records were excluded. Delivery records were reviewed for baseline characteristics and adverse pregnancy outcomes. The optimal cutoff point for first-trimester maternal serum alpha fetoprotein to predict these outcomes was assessed, and an elevated maternal serum alpha fetoprotein was considered >2.0 multiple of the median. A Fisher exact test and odds ratios were used to determine the association between elevated first-trimester maternal serum alpha fetoprotein and adverse pregnancy outcomes. Spearman correlation coefficient assessed the relationship between first- and second-trimester maternal serum alpha fetoprotein. RESULTS: Of 1478 patients with first-trimester maternal serum alpha fetoprotein, 1280 had complete records available for review (86.6%). There was no association demonstrated between elevated first-trimester maternal serum alpha fetoprotein (>2.0 multiple of the median) and the primary outcome, overall preeclampsia (5.8% vs 4.6%, odds ratio, 1.29, 95% confidence interval, 0.58-2.91). However, there was an increased incidence of ischemic placental disease, 15.8% vs 7.7% (odds ratio, 2.26, 95% confidence interval, 1.33-3.87) in those with an elevated alpha fetoprotein. Also, elevated first-trimester maternal serum alpha fetoprotein was associated with a higher incidence of fetal growth restriction (7.5% vs 2.3%, odds ratio, 3.40, 95% confidence interval, 1.56-7.42) and preterm birth (18.3% vs 10.3%, odds ratio, 1.95, 95% confidence interval, 1.18-3.21). Also, a positive correlation between first- and second-trimester maternal serum alpha fetoprotein was demonstrated (rho = 0.46, P < .0001). CONCLUSION: Elevated first-trimester maternal serum alpha fetoprotein is associated with ischemic placental disease, fetal growth restriction, and preterm birth. This suggests that elevated maternal serum alpha fetoprotein may help to identify high risk pregnancies as early as the first trimester of pregnancy. Future studies are necessary to determine whether the addition of first-trimester maternal serum alpha fetoprotein to existing algorithms can improve the early detection of ischemic placental disease.

Software-guided insulin dosing improves intrapartum glycemic management in women with diabetes mellitus.

BACKGROUND: During labor, maintenance of maternal euglycemia is critical to decrease the risk of neonatal hypoglycemia and associated morbidities. When continuous intravenous insulin infusion is needed, standardized insulin dosing charts have been used for titration of insulin to maintain glucose in target range. The GlucoStabilizer software program (Indiana University Health Inc, Indianapolis, IN) is a software-guided insulin dosing system that calculates the dose of intravenous insulin that is needed based on metabolic parameters, target glucose concentration, and an individual's response to insulin. Although this tool has been validated and shown to reduce both hypoglycemia and errors in critical care settings, the utility of this software has not been examined in obstetrics. OBJECTIVE: The purpose of this study was to determine whether the use of intravenous insulin dosing software in women with pregestational or gestational diabetes mellitus that requires intrapartum insulin infusion can improve the rate of glucose concentration in target range (70-100 mg/dL; 3.9-5.5 mmol/L) at the time delivery. STUDY DESIGN: We performed a retrospective cohort study comparing laboring patients with diabetes mellitus that required insulin infusion who were dosed by standard insulin dosing chart vs the GlucoStabilizer software program from January 2012 to December 2017. The GlucoStabilizer software program, which was implemented in May 2016, replaced the standard intravenous insulin dosing chart. Inclusion criteria were women with pregestational or gestational diabetes mellitus who were treated with an intravenous insulin infusion intrapartum for at least 2 hours. Maternal characteristics, glucose values in labor, and neonatal outcomes were extracted from delivery and neonatal records. The primary outcome was the percentage of women who achieved the target glucose range (defined as a blood glucose between 70-100 mg/dL; 3.9-5.5 mmol/L) before delivery. Parametric and nonparametric statistics were used to compare both groups; a probability value of <.05 was considered statistically significant. RESULTS: We identified 22 patients who were dosed by a standard insulin dosing chart and 11 patients who were dosed by the GlucoStabilizer software program during intrapartum management. The GlucoStabilizer software program was superior in achieving glucose values in target range at delivery (81.8% vs 9.1%; P<.001) compared with standard insulin dosing without increasing maternal hypoglycemia (0% vs 4.3%; P=.99). Patients whose insulin dosing was managed by the GlucoStabilizer software program also had lower mean capillary blood glucose values compared with the standard insulin infusion (102.9±5.9 mg/dL [5.7±0.33 mmol/L] vs 121.7±5.9 mg/dL [6.8±0.33 mmol/L]; P=.02). Before the initiation of the infusion, both groups demonstrated mean capillary blood glucose values outside of target range (122.6±8.8 mg/dL [6.7±0.49 mmol/L] for the GlucoStabilizer software program vs 131.9±10.1 mg/dL [7.3±0.56 mmol/L] for standard insulin treatment group; P=not significant). There were no significant differences in baseline maternal characteristics between the groups or neonatal outcomes. CONCLUSION: This study is the first to demonstrate that the use of software-guided intravenous insulin dosing in obstetrics can improve intrapartum glycemic management without increasing hypoglycemia in women with both pregestational and gestational diabetes mellitus that is treated with an insulin infusion.

Revisiting ectopic pregnancy: a pictorial essay.

Ectopic pregnancies occur in approximately 1.4% of all pregnancies and account for 15% of pregnancy-related deaths. Considering the high degree of mortality, recognizing an ectopic pregnancy is important. Signs and symptoms of an ectopic pregnancy are nonspecific and include pain, vaginal bleeding, and an adnexal mass. Therefore, imaging can play a critical role in diagnosis. There are different types of ectopic pregnancies, which are tubal, cornual, cesarean scar, cervical, heterotopic, abdominal, and ovarian. Initial imaging evaluation of pregnant patients with pelvic symptoms is by ultrasonography, transabdominal, transvaginal or both. We review the sonographic appearance of different types of ectopic pregnancies that will aid in accurate and prompt diagnosis.

Anticoagulation for stroke prevention in elderly patients with atrial fibrillation, including those with falls and/or early-stage dementia: a single-center, retrospective, observational study.

BACKGROUND: Anticoagulation for stroke prevention is underused in elderly patients with nonvalvular atrial fibrillation (AF). Those with falls and/or early dementia may be at particular risk for stroke and hemorrhage. OBJECTIVE: The aim of this study was to determine the prescribing patterns, risks, and benefits of anticoagulation with warfarin or acetylsalicylic acid (ASA) in elderly patients with AF at risk for stroke and hemorrhage, including those with falls and/or dementia. METHODS: In this single-center, retrospective, observational study, data from patients aged > or =65 years with chronic nonvalvular AF treated at an urban academic geriatrics practice over a 1-year period were included. Eligible patients were receiving noninvasive management of AF with warfarin or ASA. Data were assessed to determine the prevalences of stroke, hemorrhage, falls, and the possible effects of anticoagulation with dementia. Outcomes events at 12 months, including time-in-therapeutic range (TTR), stroke, hemorrhage, and death, were determined. The stroke risk in each patient was estimated using the CHADS(2) (congestive heart failure, hypertension, age > or =75 years, diabetes, history of stroke or transient ischemic attack) score, and the risk for hemorrhage was estimated using the Outpatient Bleeding Risk Index. RESULTS: A total of 112 patients (mean age, 82 years) were identified; 106 were included in the present analysis (80 women, 26 men); 6 were not receiving antithrombotic therapy and thus were excluded from the analysis. Warfarin was prescribed in 85% (90 patients); ASA, 15% (16). International normalized ratio testing was done frequently, with a median interval of 13.7 days between tests (92% within 28 days). No association was found between an improved TTR and the number of tests per unit of time or the number of patients per clinician. The distributions of both the CHADS(2) and Outpatient Bleeding Risk Index scores were not significantly different between the warfarin and ASA groups. The proportions of patients treated with warfarin were not significantly different between the groups with a high risk for hemorrhage and the groups at lower risk. At 12 months in the 90 patients initially treated with warfarin, the rate of stroke was 2% (2 patients); major hemorrhage, 6% (5); and death, 20% (18). Mortality was greater in patients with falls (45% [5/11]) and/or dementia (47% [8/17]) compared with those without either falls or dementia (12% [8/65]). CONCLUSIONS: In this well-monitored geriatric population with chronic AF, including patients with falls and/or dementia, a high percentage were prescribed warfarin (85%), with low rates of stroke, hemorrhage, and death at 12 months despite a low TTR. Patients with falls and/or dementia had a high mortality rate (approximately 45%).

Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.

OBJECTIVE: To evaluate the efficacy of a pictogram-based health literacy intervention to decrease liquid medication administration errors by caregivers of young children. DESIGN: Randomized controlled trial. SETTING: Urban public hospital pediatric emergency department. PARTICIPANTS: Parents and caregivers (N = 245) of children aged 30 days to 8 years who were prescribed liquid medications (daily dose or "as needed"). INTERVENTION: Medication counseling using plain language, pictogram-based medication instruction sheets. Control subjects received standard medication counseling. OUTCOME MEASURES: Medication knowledge and practice, dosing accuracy, and adherence. RESULTS: Of 245 randomized caregivers, 227 underwent follow-up assessments (intervention group, 113; control group, 114). Of these, 99 were prescribed a daily dose medication, and 158 were prescribed medication taken as needed. Intervention caregivers had fewer errors in observed dosing accuracy (>20% deviation from prescribed dose) compared with caregivers who received routine counseling (daily dose: 5.4% vs 47.8%; absolute risk reduction [ARR], 42.4% [95% confidence interval, 24.0%-57.0%]; number needed to treat [NNT], 2 [2-4]; as needed: 15.6% vs 40.0%; ARR, 24.4% (8.7%-38.8%); NNT, 4 [3-12]). Of intervention caregivers, 9.3% were nonadherent (ie, did not give within 20% of the total prescribed doses) compared with 38.0% of controls (ARR, 28.7% [11.4%-43.7%]; NNT, 3 [2-9]). Improvements were also seen for knowledge of appropriate preparation for both medication types, as well as knowledge of frequency for those prescribed daily dose medications. CONCLUSION: A plain language, pictogram-based intervention used as part of medication counseling resulted in decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00537433.