COVID-19 Vaccine Hesitancy in an Underrepresented Minority Community.

To assess factors influencing acceptability of COVID-19 vaccine in a population of predominantly indigent, minority, pregnant and non-pregnant people of reproductive age. Cross-sectional survey using a modified Health Belief model administered between January 2021 and January 2022 at four hospitals in Brooklyn. Participants included English-speaking reproductive aged persons attending clinics at the participating sites. Descriptive and univariate data analyses were used for analysis. 283 eligible reproductive persons were approached of whom 272 completed the survey (96%). Three quarters said they would take the vaccine under certain circumstances ("as soon as it is ready" [28.6%], "when my doctor recommends it" [21.3%] or "when enough people have received it to know if it works" [25%]), while 25% said they would never take the vaccine. When comparing persons that would take it under certain circumstances to those that never would, the "never" group was significantly more likely to note that, "they would not trust any COVID vaccine" (71.4% vs. 28.5%; p ≤ 0.0001). This greater level of distrust extended to greater distrust of doctors, government, family, newspapers, and media. However, 36% said they would be influenced by their doctor's recommendation. Pregnant participants were significantly more likely to wait until their doctor recommended it (17.6% of pregnant persons compared to 3.7% of non-pregnant p < 0.0001). Despite mistrust and other discouraging factors, many persons, under appropriate circumstances (e.g., reassurance about vaccine safety) may be motivated to take the vaccine. Even those who claimed that they wouldn't take the vaccine under any circumstance may be influenced by their health care providers.

Removal of pregnancy categories and likelihood of prescribing: a randomized trial.

OBJECTIVES: To assess the degree to which removal of FDA' Pregnancy Categories (PC) of medications (A, B, C, and D) from labeling, affects the likelihood that providers will prescribe those medications. METHODS: Over a one-year period a convenience sample of providers was recruited into a randomized, survey-based, study. Two versions of the survey were randomly distributed; version 1 presented clinical vignettes, drug information, and PC, while version 2, presented the identical information without the PC. Respondents were asked to estimate their likelihood of prescribing the drug. A mixed linear model was constructed, with likelihood of prescription as the dependent variable, treated as interval-scaled. RESULTS: Out of 169 surveys given out, 162 (96%) were returned. Simple effects analysis showed that the presence of PC letter significantly affected the decision to prescribe category B (p<0.001) and C drugs (p=0.008) but not the A or D. Participants were significantly less likely to prescribe class B and C drugs when the letters were not available for review. These findings remained significant even when controlling for covariates (p=0.001). CONCLUSIONS: When a PC letter is absent on labeling, physicians were less likely to use category B and C drugs, the most common medications prescribed in pregnancy.

Cesarean Birth Morbidity among Women with SARS-CoV-2.

OBJECTIVE: The objective of this study was to compare maternal outcomes of women with and without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections who underwent cesarean births. STUDY DESIGN: This was a matched cohort study of pregnant women who had a cesarean birth between March 15, 2020, and May 20, 2020. Cases included women who tested positive for SARS-CoV-2. For every case, two patients who tested negative for SARS-CoV-2 were matched by maternal age, gestational age, body mass index, primary or repeat cesarean birth, and whether the procedure was scheduled or unscheduled. We compared rates of adverse postcesarean complications (intraoperative bladder or bowel injury, estimated blood loss more than or equal to 1,000 mL, hemoglobin drop more than 3 g/dL, hematocrit drop more than 10%, need for blood transfusion, need for hysterectomy, maternal intensive care unit admission, postoperative fever, and development of surgical site infection), with the primary outcome being a composite of those outcomes. We also assessed duration of postoperative stay. Fisher's exact tests were performed to compare the primary outcome between both groups. RESULTS: Between March and May 2020, 202 women who subsequently underwent cesarean birth were tested for SARS-CoV-2. Of those 202, 43 (21.3%) patients were positive. They were matched to 86 patients who tested negative. There was no significant difference in the rate of composite adverse surgical outcomes between the groups (SARS-CoV-2 infected 27.9%, SARS-CoV-2 uninfected 25.6%; p = 0.833). There was a higher rate of postoperative fevers (20.9 vs. 5.8%; p = 0.015), but that did not result in a longer length of stay (p = 0.302). CONCLUSION: Pregnant women with SARS-CoV-2 who underwent a cesarean birth did not have an increased risk of adverse surgical outcomes, other than fever, compared with pregnant women without SARS-CoV-2. KEY POINTS: · Women with SARS-CoV-2 had more postoperative fevers.. · Length of stay did not differ based on SARS-CoV-2 status.. · Composite postoperative outcome did not differ based on SARS-CoV-2 status..

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.

Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery.

BACKGROUND: It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. METHODS: Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. RESULTS: The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay. CONCLUSIONS: This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia.

Reducing Perinatal Health Disparities by Placing Equity at the Heart of Performance Improvement.

Multiple studies have demonstrated that low income and Black women in the United States are more likely to suffer from severe maternal morbidity and mortality during childbirth, even when accounting for the site of service. Structural racism, social determinants of health, and personally mediated racism are factors that may play a role. Assessing them is, therefore, critical in the attempt to deliver safe and equitable health care, which is a fundamental charge of performance-improvement committees. We argue that, for performance-improvement committees to fulfill their mandate, they must include equity as an organizing principle. A low rate of adverse outcomes in the overall population served by a hospital is not sufficient if, when stratified by race, a particular group is found to have rates above acceptable limits. In this piece we outline the process by which those charged with assuring optimal quality in departments of obstetrics and gynecology can include equity in their portfolio. This is a key step in moving beyond the recognition that disparities exist and toward a consideration of the specific ways in which inequity contributes to morbidity, and then to implementing steps to mitigate its effects.

Pregnancy outcomes among women with American College of Cardiology- American Heart Association defined hypertension.

OBJECTIVE: To compare the rate of adverse pregnancy outcomes of women with hypertension defined by the ACC-AHA guidelines, women with hypertension defined by ACOG guidelines, and normotensive women. METHODS: A historical cohort study of women with singleton, nonanomalous pregnancies who presented before 20 weeks for their first prenatal visit between 1 January 2014 and 31 January 2016 with (a) hypertension defined by ACC-AHA (systolic blood pressure 130 mmHg and/or diastolic blood pressure of 80 mmHg documented), (b) hypertension defined by ACOG (systolic blood pressure of 140 mmHg and/or diastolic blood pressure of 90 mmHg documented) and (c) women documented to be normotensive. Primary outcomes were preeclampsia and small for gestational age. Fisher's exact test was used to compare demographics and risk factors between the groups. Multivariable logistic regression analysis was used to predict the association of preeclampsia within the groups adjusting for additional risk factors. RESULTS: A total of 252 women were included. Of these, 92 (36.5%) had hypertension by ACC-AHA, 34 (13.5%) by ACOG and 126 (50%) were normotensive. Sixty percent of women with the ACOG definition developed preeclampsia compared to 45.1% of women with the ACC-AHA definition and 17.1% in the control group (p < .001). The rate of preeclampsia among women with hypertension by ACC-AHA criteria was not significantly different from the rate among women with hypertension by ACOG criteria (p = .288). Differences in small for gestational age among the groups were not significant (ACOG: 20%, ACC-AHA: 11.1%, normotensive: 9.8%, p = .423). CONCLUSION: Women with hypertension defined by ACC-AHA have a rate of developing preeclampsia that is similar to that of women with hypertension defined by ACOG.

A Novel Partogram for Stages 1 and 2 of Labor Based on Fetal Head Station Measured by Ultrasound: A Prospective Multicenter Cohort Study.

OBJECTIVE: This study was aimed to describe continuous labor curves, including second stage, based on fetal head station. STUDY DESIGN: We performed a prospective multicenter cohort study. The inclusion criteria were women with singleton uncomplicated cephalic term pregnancies in labor, who delivered vaginally. We used a device that combines ultrasound imaging with position-tracking technology to monitor the head station noninvasively throughout labor. We collected data on demographics, labor parameters, and delivery and neonatal outcomes. RESULTS: A total of 613 women delivered vaginally, 327 (53.3%) were nulliparous, while 286 (46.7%) were multiparous. Time to delivery (TTD) diminished progressively with descent of the fetal head. When the head is engaged, the labor curve of multiparous women demonstrated a more prominent downward shift in curve as compared with nulliparous women. When comparing multipara and nullipara at engagement level, the median TTD was 1 and 1.62 hours, respectively. In 95% of women with unengaged head during the second stage, TTD of nulliparous and multiparous women were less than 3.8 and 3 hours, respectively. CONCLUSION: While current labor curves end at full dilatation, the described curves were developed throughout stages 1 and 2 of labor. The TTD, according to the station curves, shows an acceleration of labor, once passed the engagement level, especially in multiparous women.

Confirmation Bias Affects Estimation of Blood Loss and Amniotic Fluid Volume: A Randomized Simulation-Based Trial.

OBJECTIVE: This study was aimed to determine if confirmation bias affects diagnoses in obstetrics, specifically estimation of blood loss and amniotic fluid volume. STUDY DESIGN: We performed a randomized simulation-based trial. Participants went through the following three consecutive scenarios: (1) the first involved estimating the volume of blood (actually a blood-like substance) in a container at the simulation model's perineum. The actual volume was either 500 or 1,500 mL. Participants were told it was blood seen after a vaginal delivery. One group was told that the "patient" was normotensive, the other was told that the "patient" was hypotensive. (2) The second scenario involved estimation of amniotic fluid from an ultrasound picture of four quadrants, with one group told that the patient was normotensive and the other group told that the patient had chronic hypertension. (3) The third scenario was a "negative image" of the first (i.e., if they had been randomized to the 500 mL/normotensive in scenario one, then they would be presented with the 1,500 mL/hypotensive). They also filled a survey including demographics and tolerance of ambiguity and confirmation bias scales. RESULTS: From April 2018 through May 2018, a convenience sample of 85 providers was recruited. Participants were more likely to overestimate blood loss when they were told that the patient was hypotensive (p = 0.024), in comparison to when they were told the patient had normal blood pressure. They were also less likely to estimate the amniotic fluid as normal when they were told that the patient was hypertensive (p = 0.032). CONCLUSION: Confirmation bias affects estimates of blood loss and amniotic fluid.

A Novel and Precise Profiling Tool to Predict Gestational Diabetes.

BACKGROUND: There is a trend in healthcare for developing models for predictions of disease to enable early intervention and improve outcome. INSTRUMENT: We present the use of artificial intelligence algorithms that were developed by Gynisus Ltd. using mathematical algorithms. EXPERIENCE: Data were retrospectively collected on pregnant women that delivered at a single institution. Hundreds of parameters were collected and found to have different importance and correlation with the likelihood to develop gestational diabetes mellitus (GDM). We highlight 3 of 29 specific parameters that were important in pregestation and in early pregnancy, which have not been previously correlated with GDM. CONCLUSION: This predictive tool identified parameters that are not currently being used as predictors in GDM, even before pregnancy. This tool opens the possibility of intervening on patients identified at risk for GDM and its complications. Future prospective studies are needed.

Prenatally diagnosed vasa previa: association with adverse obstetrical and neonatal outcomes.

BACKGROUND: Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus. OBJECTIVE: This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes. STUDY DESIGN: This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course. RESULTS: A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity. CONCLUSION: Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.

Correlation of Obesity with External Cephalic Version Success among Women with One Previous Cesarean Delivery.

Objective Our aim was to assess the correlation of body mass index (BMI) with the success rate of external cephalic version (ECV) among women with one prior cesarean delivery. Study Design A cross-sectional study of pregnant women with one previous cesarean delivery who underwent ECV. The relationship between BMI and success rate of ECV was assessed. Adverse outcomes were also compared between women with an ECV attempt, and women who had a repeat cesarean delivery. Data were extracted from the U.S. Natality Database from 2014 to 2017. Pearson's correlation coefficient was performed to assess the relationship between BMI and success rate of ECV. Results There were 2,329 women with prior cesarean delivery underwent an ECV attempt. The success rate of ECV among the entire cohort was 68.3%. There was no correlation between BMI and success rate of ECV ( r = 0.024, p = 0.239). Risks of adverse maternal and neonatal outcomes were similar between the ECV attempt group and the repeat cesarean delivery group. Conclusion There was no correlation of BMI with the rate of successful ECV among women with one prior cesarean delivery. Given the similar success rates of ECV and adverse outcomes, obese women with one prior cesarean delivery should be offered ECV.

The Relationship between Status at Presentation and Outcomes among Pregnant Women with COVID-19.

OBJECTIVE: This study was aimed to compare maternal and pregnancy outcomes of symptomatic and asymptomatic pregnant women with novel coronavirus disease 2019 (COVID-19). STUDY DESIGN: This is a retrospective cohort study of pregnant women with COVID-19. Pregnant women were divided into two groups based on status at admission, symptomatic or asymptomatic. All testing was done by nasopharyngeal swab using polymerase chain reaction (PCR) for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Initially, nasopharyngeal testing was performed only on women with a positive screen (symptoms or exposure) but subsequently, testing was universally performed on all women admitted to labor and delivery. Chi-square and Wilcoxon's rank-sum tests were used to compare outcomes between groups. RESULTS: Eighty-one patients were tested because of a positive screen (symptoms [n = 60] or exposure only [n = 21]) and 75 patients were universally tested (all asymptomatic). In total, there were 46 symptomatic women and 22 asymptomatic women (tested based on exposure only [n = 12] or as part of universal screening [n = 10]) with confirmed COVID-19. Of symptomatic women (n = 46), 27.3% had preterm delivery and 26.1% needed respiratory support while none of the asymptomatic women (n = 22) had preterm delivery or need of respiratory support (p = 0.007 and 0.01, respectively). CONCLUSION: Pregnant women who presented with COVID19-related symptoms and subsequently tested positive for COVID-19 have a higher rate of preterm delivery and need for respiratory support than asymptomatic pregnant women. It is important to be particularly rigorous in caring for COVID-19 infected pregnant women who present with symptoms. KEY POINTS: · Respiratory support is often needed for women who present with symptoms.. · Low rate of severe disease in women who present without symptoms.. · There were no neonatal infections on day 0 of life..

Caring for Pregnant Patients with COVID-19: Practical Tips Getting from Policy to Practice.

Novel coronavirus disease 2019 (COVID-19) is a pandemic with most American cases in New York. As an institution residing in a high-prevalence zip code, with over 8,000 births annually, we have cared for over 80 COVID-19-infected pregnant women, and have encountered many challenges in applying new national standards for care. In this article, we review how to change outpatient and inpatient practices, develop, and disseminate new hospital protocols, and we highlight the psychosocial challenges for pregnant patients and their providers. KEY POINTS: · Novel coronavirus disease 2019 (COVID-19) information rapidly changes.. · Multidisciplinary communication is key.. · This study addresses psychosocial challenges..

Antibiotic Prophylaxis Trials in Obstetrics: A Call for Pediatric Collaboration.

Surgical site infections are common complications of cesarean delivery. Many recent studies, including meta-analyses, have assessed the efficacy of antibiotic prophylaxis. Those articles have demonstrated that preincision antibiotic prophylaxis reduces the incidence of surgical site infections postcesarean, and that the use of adjunctive azithromycin further reduces infection after nonelective cesarean deliveries. However, long-term effects of fetal exposure to antibiotic prophylaxis-including asthma, obesity, and alterations in microbiota-have also been demonstrated. We suggest that while studies of optimal antibiotic regimens proceed, considerations of the potential risks to the neonate should be factored into discussions of benefits and burdens.

Improving Healthcare Responses to Obstetric Hemorrhage: Strategies to Mitigate Risk.

Obstetric hemorrhage, with its related complications, remains a significant and often preventable cause of maternal morbidity and mortality. The medical community has made strides in beginning to address the impact of obstetric hemorrhage as a cause of maternal morbidity and mortality with standardized bundles outlining key elements for hospitals to address in order to optimize hemorrhage prevention and management. Changes in definitions, an expansion of the spectrum of causes, variation in interventions and guidelines and lack of innovation are some of the issues that pose ongoing challenges for meaningful risk reduction. Opportunities to support risk reduction include helping to secure necessary resources, building team training and simulation programs, developing interventions targeted at minimizing cognitive biases, and facilitating patient and family support program development.

Association of uterine rupture with pregestational diabetes in women undergoing trial of labor after cesarean delivery.

Objective: To evaluate the association of pregestational diabetes with uterine rupture during a trial of labor with one prior cesarean delivery.Study design: A retrospective study of women undergoing a trial of labor after cesarean. The study group consisted of women with pregestational diabetes and the control group was women without pregestational diabetes. Primary outcome was a uterine rupture. Data were extracted from the USA. Natality Database from 2012 to 2016. Maternal and neonatal outcomes were analyzed. Multivariable logistic regression analysis was used to estimate risks of uterine rupture and maternal and neonatal outcomes.Results: There were 359,504 women undergoing labor after cesarean, with 3508 women with pregestational diabetes and 355,996 without. The prevalence of uterine rupture among women with pregestational diabetes undergoing labor after cesarean was 0.5%, while among women without pregestational diabetes, it was 0.2% (adjusted odds ratio [OR] 2.03 [95% CI 1.18-3.51]; p = .01). There was an increased risk of unplanned hysterectomy among pregnancies complicated by pregestational diabetes (adjusted OR 3.06 [95% CI 1.41-6.66]).Conclusion: Women undergoing a trial of labor, who have pregestational diabetes had a higher rate of uterine rupture than women without a history of pregestational diabetes.

Physician Burnout and Barriers to Care on Professional Applications.

We surveyed New York physicians to study their perceptions of reporting requirements related to their own mental health care on professional applications, including whether they were experiencing symptoms of burnout. Over half of the responding physicians reported experiencing symptoms of burnout and these physicians were at increased odds of perceiving a barrier to seeking mental health care if they had to report such care on professional applications and renewals for medical licensure, malpractice, and hospital privileges and credentialing compared to physicians not experiencing symptoms of burnout. As state medical boards, hospitals, and insurers seek information to help assess risks posed by physicians, it is essential to strike an appropriate balance between their duty to protect the public and the physician's right to confidentiality. This balance can be assessed based on the questions that are asked on various professional applications and how information gleaned through physician responses is used. Overly intrusive questions, though well intentioned to protect the public, may run counter to current interpretations of federal law and may inhibit care-seeking among physicians, which is critical to both patient safety and physician health.