Telehealth Utilization in High-Risk Pregnancies During COVID-19.

Purpose: To determine how telehealth has influenced outcomes in high-risk obstetrics patients during the Coronavirus disease 2019 (COVID-19) pandemic. Methods: A retrospective chart review was conducted to identify patterns in both telehealth and in-person clinic visits among patients of a Maternal Fetal Medicine (MFM) department from the onset of the COVID-19 pandemic from March 2020 until October 2021. For the descriptive analysis, p-values were calculated using Wilcoxon rank sum for continuous variables and chi-square or Fisher exact (where cell n < 5) for categorical variables. Variables of interest were then tested for their univariate association with telehealth utilization using logistic regression. Variables found to meet the criterion of p < 0.2 in the univariate case were introduced into a multivariable logistic model with a backward elimination for determining variable retention. We aimed to analyze whether telehealth visits significantly impacted pregnancy outcomes. Results: Four hundred nineteen high-risk patients visited the clinic via in-person and/or telehealth appointments during the study period: 320 patients without telehealth visits and 99 patients with telehealth visits. Care provided by telehealth visits was not found to be related to self-reported race (p = 0.81), maternal body mass index (p = 1.0), or maternal age (p = 0.53). Patients with private insurance were more likely to have telehealth visits than patients with public insurance (79.9% vs. 65.5%, p < 0.01). In univariate logistic analyses, patients with diagnoses of anxiety (p < 0.01), asthma (p = 0.03), and depression (p < 0.01), at the time care was established, were more likely to have telehealth visits. Those patients with telehealth visits did not have any statistical differences in mode of delivery (p = 0.2) or pregnancy outcomes (p = 0.12), including fetal demise, preterm delivery, or delivery at term as compared with patients with all in-office visits. In multivariable analysis, patient conditions of anxiety (p < 0.01), maternal obesity (p < 0.01), and twin pregnancy (p = 0.04) were associated with higher rates of telehealth visits. Conclusion: Patients with certain pregnancy complications elected to have more telehealth visits. Patients with private insurance were more likely to have telehealth visits than patients with public insurance. There are benefits for patients with certain pregnancy complications to incorporate telehealth visits in addition to regularly scheduled in-person clinic visits and may be suitable in a post-pandemic setting as well. Further research in this field is needed to better understand the impact of implementing telehealth in high-risk obstetrics patients.

Alignment of the Cervix with the Vagina in Uterine Retroversion: A Possible Risk Factor in Uterine Prolapse.

Multiple observational studies have found an association of uterine prolapse with uterine retroversion. Mechanisms proposed to explain this apparent association assume that the cervix of a retroverted uterus will usually insert at the apex of the vagina, with resultant alignment of the cervix with the vagina. The angle of the axis of the cervix with the axis of the vagina was measured by two readers on 323 sagittal pelvic MRI scans and sagittal reconstructions of pelvic CT scans performed for clinical purposes. One reader observed and recorded the anatomic relations of the uterus that differed by insertion site and version: 44 of 49 retroverted uteri (89.8%) inserted at the vaginal apex, and 13 of 274 anteverted uteri (4.7%) inserted at the vaginal apex. This difference was found to be statistically significant (p < 0.05) by the Chi square test. The urinary bladder, vaginal walls, and rectum were inferiorly related to anteriorly inserted anteverted uteri. Only the vaginal lumen and the rectum at a shallow oblique angle were inferiorly related to apically inserted retroverted uteri. Most retroverted uteri insert at the apex of the vagina. Apically inserted retroverted uteri appear to receive less support from adjacent structures than anteriorly inserted anteverted uteri.

A comparison of four systems for uterine septum diagnosis and indication for surgical correction.

INTRODUCTION: Existing guidelines do not settle on a specific length to indicate surgical incision of subseptations because of differences in the four published diagnostic methods: AFS-10 mm classification, 1988/2003, ESHRE-ESGE classification, 2013, ASRM criteria, 2016- and 5.9-mm length cut-off, 2017. With this review and data analysis we sought to identify the classification method with the most accurate association with early pregnancy loss, as to identify a subseptation length cut-off to indicate surgical correction. EVIDENCE ACQUISITION: We performed an exhaustive literature search of PubMed (MEDLINE), Embase, and Cochrane Library databases until April 20, 2020 (limited to articles published in English) of the terms "uterine septum," "arcuate uterus," "subseptation," "Müllerian anomalies," from 1980-2020. After identifying all the available classifications for uterine subseptations, we performed a secondary data analysis of our departmental database on uterine subseptations and compared the identified classification criteria. Measurement of the subseptation's length was obtained on 2-D and 3-D ultrasound in accordance with the different methods. The incidence of uterine subseptations according to each method's specifications was compared among the groups and the association with pregnancy loss was evaluated. EVIDENCE SYNTHESIS: The database comprised 125 women with uterine subseptations and all four diagnostic systems identified septate uteri within it. The 5.9-mm cut-off diagnosed 89 septate, and 36 normal uteri and was the most inclusive while the ASRM cut-off was the most restrictive one, diagnosing 92/125 as arcuate uteri, only 8/125 as septate, and 25 in the gray zone. The AFS-10 mm criteria diagnosed 92/125 as arcuate, and 33 (26.4%) as septate uteri. Subseptations were inconsistently diagnosed by the ESHRE-ESGE classification, as some subseptations longer than 10 mm would be classified as normal uteri. Five/24 women had had one previous early loss and 19/24 had recurrent pregnancy loss. The 5.9-mm system was the most sensitive, while the ASRM was the least sensitive in predicting pregnancy loss (71.2% vs. 9.5% of septate uteri). CONCLUSIONS: The proposed 5.9-mm cut-off was the most sensitive in diagnosing a septate uterus and in predicting an associated early pregnancy loss. Conversely, the AFS-10 mm and the ASRM were the most restrictive, potentially missing treatment for hazardous subseptations. This update highlights the major weaknesses in the current diagnosis of uterine subseptations and indication for surgical treatment. Standardization of clinical practice is essential for reproductive clinicians and efforts should be made to prevent even one further early pregnancy loss to uterine subseptations.

Impact of COVID-19 on maternal and neonatal outcomes: a systematic review and meta-analysis.

BACKGROUND: Previous outbreaks of severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV) have been associated with unfavourable pregnancy outcomes. SARS-CoV-2 belongs to the human coronavirus family, and since this infection shows a pandemic trend it will involve many pregnant women. AIMS: This systematic review and meta-analysis aimed to assess the impact of coronavirus disease 19 (COVID-19) on maternal and neonatal outcomes. SOURCES: PubMed, EMBASE, MedRxiv, Scholar, Scopus, and Web of Science databases were searched up to 8th May 2020. Articles focusing on pregnancy and perinatal outcomes of COVID-19 were eligible. Participants were pregnant women with COVID-19. CONTENT: The meta-analysis was conducted following the PRISMA and MOOSE reporting guidelines. Bias risk was assessed using the Joanna Briggs Institute (JBI) manual. The protocol was registered with PROSPERO (CRD42042020184752). Twenty-four articles, including 1100 pregnancies, were selected. The pooled prevalence of pneumonia was 89% (95%CI 70-100), while the prevalence of women admitted to the intensive care unit was 8% (95%CI 1-20). Three stillbirths and five maternal deaths were reported. A pooled prevalence of 85% (95%CI 72-94) was observed for caesarean deliveries. There were three neonatal deaths. The prevalence of COVID-19-related admission to the neonatal intensive care unit was 2% (95%CI 0-6). Nineteen out of 444 neonates were positive for SARS-CoV-2 RNA at birth. Elevated levels of IgM and IgG Serum antibodies were reported in one case, but negative swab. IMPLICATIONS: Although adverse outcomes such as ICU admission or patient death can occur, the clinical course of COVID-19 in most women is not severe, and the infection does not significantly influence the pregnancy. A high caesarean delivery rate is reported, but there is no clinical evidence supporting this mode of delivery. Indeed, in most cases the disease does not threaten the mother, and vertical transmission has not been clearly demonstrated. Therefore, COVID-19 should not be considered as an indication for elective caesarean section.

Restoration of Uterine Cavity Measurements after Surgical Correction.

Objective: We sought to define the uterine and uterine cavity dimensions of subseptate uteri before and after hysteroscopic surgical incision, and compare them to those obtained in normal uteri with 3-D ultrasound. Methods: Two cohorts of consecutive women with normal-appearing uterine cavity and women diagnosed with uterine subseptations, before and after undergoing hysteroscopic incision. 3-D ultrasound was used to measure the uterine cavity width, length, and area on a frozen coronal view of the uterus. Results: A total of 215 women were included: 89 in the normal, and 126 in the subseptate uterus, groups. Uterine length and height were similar in the pre-operative, post-operative subseptate uteri, and in the normal uteri, while the uterine width was significantly greater in the pre-operative (5.1 + 0.8 cm) than post-operative (4.7 + 0.8 cm) and normal uterus (4.6 + 0.7 cm; p < 0.001) groups. The pre-operative uterine cavity length (3.3 + 0.5 cm), width (3.2 + 0.7 cm), and area (4.4 + 1.2 cm2), were significantly greater than the post-operative ones (length 2.9 + 0.4 cm; width 2.6 + 0.6 cm; area 3.7 + 0.8 cm; overall p < 0.001), and became similar to the dimensions of the normal uterus. Of the patients who subsequently conceived, 2.6% miscarried in the corrected subseptation group and 28.8% miscarried in the normal uterus group. Conclusions: We defined the ultrasound dimensions of the uterine cavity in subseptate uteri and their change after surgical correction. Uterine cavity length, width, and area show very little variability in adult normal uteri, while they are increased in uteri with a subseptation greater than 5.9 mm in length, and regain normal measurements after surgical correction.

Vaginal Anatomy on MRI: New Information Obtained Using Distention.

OBJECTIVES: To demonstrate and confirm the presence of three anatomic zones of the vagina (a superficial sphincteric zone; a central wedge shaped transition zone; and a deep, expanded forniceal zone) using pelvic magnetic resonance imaging with contrast distention of the vagina. METHODS: A total of 107 consecutive female pelvic magnetic resonance imaging scans using vaginal contrast distention were retrospectively reviewed. The images were observed for the three-zone configuration. Anteroposterior and transverse diameter measurements were taken in the proximal, mid, and distal sphincteric, transition, and forniceal zones. Means and standard deviations were calculated at each site. Adjacent sites were compared using paired t tests. RESULTS: The three-zone configuration was observed in all of the cases but one. Statistically significant increases and decreases of mean anteroposterior diameters occurred at all levels expected by visual observation. CONCLUSIONS: The three-zone configuration of the distended vagina was confirmed by this study. The configuration of the vagina is more complex than has been reported previously. This configuration may facilitate parturition and may be useful in the design of intravaginal devices.

Relevance of Uterine Subseptations: What Length Should Warrant Hysteroscopic Resection?

OBJECTIVES: Existing recommendations warrant correction of uterine subseptations longer than 10 mm. We assessed whether a different subseptation length is indicated for intervention by evaluating the postoperative decrease in cavity width. METHODS: We conducted a prospective controlled cohort study at a university center. Healthy women and women with subseptations were evaluated with three-dimensional ultrasound before and after undergoing surgical resection of uterine subseptations by hysteroscopy. Measurement of the subseptum's length and width, and total cavity width, were obtained in both groups of women. We created a receiver operating characteristic curve using 7-mm cavity postoperative width change as the reference variable, and subseptation length as the outcome variable. Identifying a new subseptation length that warrants surgical intervention. RESULTS: Seventy-six women with subseptations and 77 with healthy uteri were included in the study. In the subseptate group, 50 had a subseptum less than 10 mm, and 26 were greater than 10 mm. Uterine and uterine cavity widths were significantly greater than in healthy women. The postoperative cavity width (28 ± 0.9 mm) was correlated with the preoperative subseptum length (R = 0.42; P = .016) and width (R = 0.54; P = .001) and was similar to healthy uteri. The receiver operator characteristic curve identified 5.9 mm (sensitivity = 100%, specificity = 41.4%) as a new threshold length of subseptation, which shows a postoperative cavity adjustment comparable to a subseptation greater than 10 mm. CONCLUSIONS: The relevance of subseptations shorter than 10 mm is currently undetermined and underestimated. Our data indicate a new subseptation cutoff length with postoperative remodeling and statistical relevance similar to longer subseptations. We propose a revision of the recommendations for surgical correction to include the objectively obtained subseptation length greater than or equal to 5.9 mm.