Impact of cesarean delivery due to maternal choice on perinatal outcome in term nulliparous patients with a singleton fetus in a vertex presentation.

OBJECTIVE: The objectives of our study were to: (1) evaluate the prevalence of cesarean delivery due to maternal request among nulliparous, term, singleton, vertex (NTSV) patients; (2) identify the clinical profile, if any, of these patients; and (3) compare the perinatal outcomes between NTSV patients who requested a cesarean delivery versus patients who did not request cesarean delivery. STUDY DESIGN: This was a retrospective case control study performed at a single institution between November 2018 and July 2019. All NTSV patients who had a cesarean delivery due to maternal choice were identified and compared to the next two NTSV patients in labor who delivered vaginally or by medically indicated cesarean delivery following a cesarean delivery by maternal choice. The primary outcome was composite neonatal morbidity. Secondary outcomes were individual components of composite neonatal and maternal morbidity. RESULTS: Of 1138 NTSV patients, 61 (5.4%) patients opted for cesarean delivery by maternal choice. There were significant differences in the demographic/clinical profile between cases and controls including BMI (35.3 kg/m2 vs. 32.7 kg/m2, p < .01), birthweight (3552 gr vs. 3333 gr, p < .001) and documented mental illness (41.0% vs. 22.1% respectively, p < .01). There was no significant difference in composite neonatal morbidity between cases and controls (6.6% vs. 5.7%, adjusted odds ratio [aOR] 0.96, 95% CI 0.25-3.61). The risk for postpartum hemorrhage requiring blood transfusion was higher (but not statistically significant) in the study group (5.0% vs. 0.0%, aOR 6.43, 95% CI: 0.65-63.24). Patients who chose cesarean delivery during the intrapartum period had a higher (but not statistically significant) composite neonatal morbidity (14.3% vs. 5.7%, aOR 2.24, 95% CI 0.52-9.78) and composite maternal morbidity (28.6% vs.11.8%, aOR 2.90, 95% CI 0.92-9.16) and significantly higher transfusion rate (aOR 16.93, 95% CI 1.53-187.74). CONCLUSION: Cesarean delivery by maternal choice in NTSV patients is not associated with improved neonatal outcomes; in contrast, it is associated with increased composite maternal morbidity and increased transfusion rate.

Coronavirus disease 2019 infection and placental histopathology in women delivering at term.

BACKGROUND: There is a paucity of data describing the effects of coronavirus disease 2019 on placental pathology, especially in asymptomatic patients. Although the pathophysiology of coronavirus disease 2019 is not completely understood, there is emerging evidence that it causes a severe systemic inflammatory response and results in a hypercoagulable state with widespread microthrombi. We hypothesized that it is plausible that a similar disease process may occur in the fetal-maternal unit. OBJECTIVE: This study aimed to determine whether coronavirus disease 2019 in term patients admitted to labor and delivery, including women without coronavirus disease 2019 symptomatology, is associated with increased placental injury compared with a cohort of coronavirus disease 2019-negative controls. STUDY DESIGN: This was a retrospective cohort study performed at NYU Winthrop Hospital between March 31, 2020, and June 17, 2020. During the study period, all women admitted to labor and delivery were routinely tested for severe acute respiratory syndrome coronavirus 2 regardless of symptomatology. The placental histopathologic findings of patients with coronavirus disease 2019 (n=77) who delivered a singleton gestation at term were compared with a control group of term patients without coronavirus disease 2019 (n=56). Controls were excluded if they had obstetrical or medical complications including fetal growth restriction, oligohydramnios, hypertension, diabetes, coagulopathy, or thrombophilia. Multivariable logistic regression models were performed for variables that were significant (P<.05) in univariable analyses. A subgroup analysis was also performed comparing asymptomatic coronavirus disease 2019 cases with negative controls. RESULTS: In univariable analyses, coronavirus disease 2019 cases were more likely to have evidence of fetal vascular malperfusion, that is, presence of avascular villi and mural fibrin deposition (32.5% [25/77] vs 3.6% [2/56], P<.0001) and villitis of unknown etiology (20.8% [16/77] vs 7.1% [4/56], P=.030). These findings persisted in a subgroup analysis of asymptomatic coronavirus disease 2019 cases compared with coronavirus disease 2019-negative controls. In a multivariable model adjusting for maternal age, race and ethnicity, mode of delivery, preeclampsia, fetal growth restriction, and oligohydramnios, the frequency of fetal vascular malperfusion abnormalities remained significantly higher in the coronavirus disease 2019 group (odds ratio, 12.63; 95% confidence interval, 2.40-66.40). Although the frequency of villitis of unknown etiology was more than double in coronavirus disease 2019 cases compared with controls, this did not reach statistical significance in a similar multivariable model (odds ratio, 2.11; 95% confidence interval, 0.50-8.97). All neonates of mothers with coronavirus disease 2019 tested negative for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction. CONCLUSION: Despite the fact that all neonates born to mothers with coronavirus disease 2019 were negative for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction, we found that coronavirus disease 2019 in term patients admitted to labor and delivery is associated with increased rates of placental histopathologic abnormalities, particularly fetal vascular malperfusion and villitis of unknown etiology. These findings seem to occur even among asymptomatic term patients.

Identification of factors associated with delayed treatment of obstetric hypertensive emergencies.

BACKGROUND: Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, confirmed 15 minutes apart. The American College of Obstetricians and Gynecologists recommends that acute-onset, severe hypertension be treated with first line-therapy (intravenous labetalol, intravenous hydralazine or oral nifedipine) within 60 minutes to reduce risk of maternal morbidity and death. OBJECTIVE: Our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN: A retrospective cohort study was performed that compared women who were treated appropriately within 60 minutes vs those with delay in first-line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension, or preeclampsia using International Classification of Diseases-10 codes and obstetric antihypertensive usage in a pharmacy database at 1 academic institution from January 2017 through June 2018. Of these, 267 women (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within 2 days of delivery; the results from 213 women were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon rank-sum, and sample t-tests were used to compare the 2 groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed; C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at P<.05. RESULTS: Of the 213 women, 110 (51.6%) had delayed treatment vs 103 (48.4%) who were treated within 60 minutes. Patients who had delayed treatment were 3.2 times more likely to have an initial blood pressure in the nonsevere range vs those who had timely treatment (odds ratio, 3.24; 95% confidence interval, 1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms; patients without preeclampsia symptoms were 2.7 times more likely to have delayed treatment (odds ratio, 2.68; 95% confidence interval, 1.50-4.80). Patients with hypertensive emergencies that occurred overnight between 10 pm and 6 am were 2.7 times more likely to have delayed treatment vs those emergencies that occurred between 6 am and 10 pm (odds ratio, 2.72; 95% confidence interval, 1.27-5.83). Delayed treatment also had an association with race, with white patients being 1.8 times more likely to have delayed treatment (odds ratio, 1.79; 95% confidence interval, 1.04-3.08). Patients who were treated at <60 minutes had a lower gestational age at presentation vs those with delayed treatment (34.6±5 vs 36.6±4 weeks, respectively; P<.001). For every 1-week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (odds ratio, 1.11; 95% confidence interval, 1.04-1.19). Another factor that was associated with delay of treatment was having a complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (odds ratio, 2.17; 95% confidence interval, 1.07-4.41). CONCLUSION: Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation overnight, white race, having complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to a delay in the treatment of obstetric hypertensive emergency. Quality improvement initiatives that target these barriers should be instituted to improve timely treatment.

Patient safety in clinical research articles.

Patient safety has remained one of the most important priorities over the past decade, particularly in hospital settings. Implementation of patient safety measures has focused not only on reducing medication and surgical errors but also on the development of a culture of safety, including enhanced communication among all healthcare stakeholders. Academic medicine may further contribute to the culture of safety if all relevant clinical article submissions address patient safety. In order to improve communication between the authors of clinical research articles and practicing physicians, we propose that each clinical research article may be accompanied by a clear statement from the authors regarding practice implications and patient safety.

A novel approach to teaching placement of a B-lynch suture: description of technique and validation of teaching model.

INTRODUCTION: Postpartum hemorrhage is a major cause of maternal morbidity and mortality throughout the world and uterine atony is the leading cause of postpartum hemorrhage. The B-Lynch brace suture is a fertility-sparing approach to treating intractable uterine atony at the time of cesarean delivery. However, many obstetricians lack confidence to perform this procedure, which they may not have performed during residency. In order to train all residents to perform the B-Lynch brace suture, we developed a realistic model by using a flank steak to imitate a gravid uterus. METHODS: A convenience sample of obstetrics-gynecology faculty and residents at different levels of training at a single large hospital participated in this pilot project. Each physician reported self-perceived understanding of and confidence in performing the B-Lynch procedure before and immediately after practicing the technique using the flank-steak model, via a Likert-type survey (scale 1  =  low, 5  =  high). A Wilcoxon matched-pairs signed rank test was used to compare the before and after responses. RESULTS: Thirty-four participants completed the flank-steak model training and pretraining/posttraining surveys. The median score (range) for self-perceived understanding was 4 (2-5) and increased to 5 (4-5) (P < .01) after exposure to the training model. The confidence scores rose from 3 (1-5) to 5 (4-5) (P < .01) after training. CONCLUSION: The flank-steak model for teaching the B-Lynch suture significantly improved resident and faculty self-perceived understanding of and confidence in performing this procedure, which is otherwise rarely practiced in residency.

Live three-dimensional echocardiography of the human fetus.

The purpose of this study was to investigate the feasibility of using a new three-dimensional ultrasound system to perform fetal echocardiographic examination in real time. The device consisted of a Philips Sonos 7500 (Andover, MA) ultrasound system and a 4 MHz, 4X matrix transducer. The study was approved by the Institutional Review Board and was performed with the informed consent of the mother. The study population consisted of 12 singleton fetuses with gestational ages of 16-37 weeks. Of these, ten fetuses had normal cardiac anatomy, one had complete atrioventricular septal defect, and the other a thickened tricuspid valve. The system allowed comprehensive visualization of fetal cardiac anatomy and color Doppler flow unattainable by two-dimensional approaches. This preliminary investigation suggests that live three-dimensional fetal echocardiography could be a significant tool for prenatal diagnosis and assessment of congenital heart disease in the human fetus.

Arnold-Chiari malformation in a pregnant woman.

BACKGROUND: The Arnold-Chiari malformation type I is characterized by the prolapse of the cerebellar tonsils below the foramen magnum. There is a lack of literature on the management of a pregnancy in a woman affected by an Arnold-Chiari malformation. CASE: A young primipara with severe headaches underwent an elective primary cesarean delivery under general anesthesia successfully. Five years earlier, she had undergone neurosurgical resection for filum terminale syndrome shortly after her first pregnancy (term vaginal delivery) and decompression of a type I Arnold-Chiari malformation 4 months later. CONCLUSION: Careful selection of anesthetic technique for the delivery of a woman with an Arnold-Chiari malformation is of paramount importance.