The Importance of Fetal Station in the First Stage of Labor.

OBJECTIVE: This study aimed to examine the relationship of fetal station in the first stage of labor to labor curves and cesarean delivery rates among women presenting in spontaneous labor. STUDY DESIGN: Labor curves for patients with nonanomalous singletons who presented in spontaneous labor to our hospital's Obstetric Triage Unit with intact membranes from January 1, 2012, to August 31, 2016 were reviewed. Cervical exams and time of exam were obtained for each patient from presentation to triage until delivery. Station for each presentation and cervical dilation was estimated using a random effects model and the slope of cervical station change was calculated to estimate the change in dilation by hour. Perinatal outcomes, including cesarean delivery rates, were examined according to fetal station at initial presentation. Factors known to affect labor curves-epidural analgesia, infant birthweight, maternal habitus, and parity-were also examined. RESULTS: There were 8,123 patients presented in spontaneous labor with intact membranes. For patients presenting at 6-cm dilation, the rate of change of labor was significantly different when identified to have a station greater than 0 (+1 and more caudad) when compared with those with -1 and more cephalad station (both p < 0.001). This relationship persisted when analyzed according to epidural analgesia, birthweight, maternal habitus, and parity. The frequency of cesarean delivery was significantly higher for women presenting in spontaneous labor with negative fetal station (p < 0.05). When stratified across all dilation (3-9 cm), this trend remained significant (p < 0.001). CONCLUSION: In the first stage of labor, advanced fetal station was significantly associated with differing rates of labor progression, and positive fetal station was significantly less likely to result in cesarean delivery. Physical examination, including station, remains a critical element in labor management. KEY POINTS: · Fetal station is important in labor management.. · Fetal station at initial exam is related to time to delivery.. · Positive fetal station at initial exam is less likely to result in cesarean delivery..

Hepatitis C and obstetrical morbidity in a substance use disorder clinic: a role for telemedicine?

BACKGROUND: Hepatitis C infection often co-occurs with substance use disorders in pregnancy. Accessing hepatitis C treatment is challenging because of loss to follow-up in the postpartum period, attributable to social and financial barriers to care. Telemedicine has been explored as a means of increasing routine postpartum care, but the potential impact on retention in and completion of care for postpartum hepatitis C has not been assessed. OBJECTIVE: This study aimed to evaluate the impact of hepatitis C on obstetrical morbidity in a substance use disorder-specific prenatal clinic, and the effect of Infectious Disease telemedicine consultation on subsequent treatment delivery. STUDY DESIGN: We performed a retrospective cohort study of all patients in our substance use disorder prenatal clinic from June 2018 to February 2023. Telemedicine consults for hepatitis C diagnoses began in March 2020 and included electronic chart review by Infectious Disease when patients were unable to be seen. Our primary outcome was composite obstetrical morbidity (preterm birth, preeclampsia, fetal growth restriction, fetal anomaly, abruption, postpartum hemorrhage, or chorioamnionitis) compared between patients with and without active hepatitis C. We additionally evaluated rates of completed referral and initiation of hepatitis C treatment before and after implementation of telemedicine consult. RESULTS: A total of 224 patients were included. Of the 222 patients who underwent screening, 71 (32%) were positive for active hepatitis C. Compared with patients without hepatitis C, a higher proportion of patients with hepatitis C were White (80% vs 58%; P=.02), had a history of amphetamine use (61% vs 32%; P<.01), injection drug use (72% vs 38%; P<.01), or overdose (56% vs 29%; P<.01), and were on methadone (37% vs 18%; P<.01). There was no difference in the primary outcome of composite obstetrical morbidity. The rate of hepatitis C diagnosis was not statistically significantly different between the pre- and posttelemedicine cohorts (N=29 [41%], N=42 [27%]), and demographics of hepatitis C virus-positive patients were similar, with most being unemployed, single, and publicly insured. A lower proportion of patients in the posttelemedicine group reported heroin use compared with the pretelemedicine cohort (62% vs 90%; P=.013). After implementation of telemedicine, patients were more likely to attend the visit (19% vs 44%; P=.03), and positive patients were much more likely to receive treatment (14% vs 57%; P<.01); 100% of visits in the posttelemedicine group occurred via telemedicine. There were 7 patients who were prescribed treatment by their obstetrician after chart review by Infectious Disease. CONCLUSION: Patients with and without hepatitis C had similar maternal and neonatal outcomes, with multiple indicators of social and financial vulnerability. Telemedicine Infectious Disease consult was associated with increased follow-up and hepatitis C treatment, and obstetricians were able to directly prescribe. Because patients with substance use disorders and hepatitis C may have increased barriers to care, telemedicine may represent an opportunity for intervention.

An evidence-based definition of anemia for singleton, uncomplicated pregnancies.

BACKGROUND: The definition for anemia in pregnancy is outdated, derived from Scandinavian studies in the 1970's to 1980's. To identity women at risk of blood transfusion, a common cause of Severe Maternal Morbidity, a standard definition of anemia in pregnancy in a modern, healthy United States cohort is needed. OBJECTIVE: To define anemia in pregnancy in a United States population including a large county vs. private hospital population using uncomplicated patients. MATERIALS AND METHODS: Inclusion criteria were healthy women with the first prenatal visit before 20 weeks. Exclusion criteria included preterm birth, preeclampsia, hypertension, diabetes, short interval pregnancy (<18 months), multiple gestation, abruption, and fetal demise. All women had iron fortification (Ferrous sulfate 325 mg daily) recommended. The presentation to care and pre-delivery hematocrits were obtained, and the percentiles determined. A total of 2000 patients were included, 1000 from the public county hospital and 1000 from the private hospital. Each cohort had 250 patients in each 2011, 2013, 2015, and 2018. The cohorts were compared for differences in the fifth percentile for each antepartum epoch. Student's t-test and chi-squared statistical tests were used for analysis, p-value of ≤0.05 was considered significant. RESULTS: In the public and private populations, 777 and 785 women presented in the first trimester while 223 and 215 presented in the second. The women at the private hospital were more likely to be older, Caucasian race, nulliparous, and present earlier to care. The fifth percentile was compared between the women in the private and public hospitals and were clinically indistinguishable. When combining the cohorts, the fifth percentile for hemoglobin/hematocrit was 11 g/dL/32.8% in the first trimester, 10.3 g/dL/30.6% in the second trimester, and 10.0 g/dL/30.2% pre-delivery. CONCLUSIONS: Fifth percentile determinations were made from a combined cohort of normal, uncomplicated pregnancies to define anemia in pregnancy. Comparison of two different cohorts confirms that the same definition for anemia is appropriate regardless of demographics or patient mix.

Natural history of postpartum hematocrit recovery in an urban, safety-net population.

BACKGROUND: Postpartum anemia is common after delivery, and postpartum blood transfusion is the leading indicator of severe maternal morbidity in the United States. Although hematologic changes during the antepartum period are well understood, little is known about postpartum hematologic changes. Therefore, we investigated the hematologic changes in the postpartum period in a large, contemporary cohort. OBJECTIVE: This study aimed to characterize hematologic recovery in the postpartum period and evaluate the effect of demographics, medical conditions, and pregnancy characteristics on the recovery. STUDY DESIGN: In a contemporary cohort of deliveries in 2019 at a single institution, the hematocrit of postpartum women before hospital discharge was compared with the hematocrit of women at the postpartum follow-up. Our population was composed of a predominantly Hispanic population at an urban, safety-net hospital. All women received a complete blood count on postpartum day 1 and a spun hematocrit at their postpartum follow-up visit in our hospital system. All women were scheduled for a routine postpartum visit 2 to 3 weeks after delivery. All deliveries of a live-born infant with available postpartum hematocrit before hospital discharge and at postpartum follow-up were included. Demographics and pregnancy characteristics, along with medical conditions, were evaluated. To evaluate an uncomplicated cohort, those with multiple gestation, preeclampsia with severe features, chronic hypertension, and diabetes mellitus were excluded in the secondary analysis. Statistical analysis included chi-square, paired Student t test, Student t test for independent groups, and analysis of variance. RESULTS: Of 12,456 deliveries, 9003 met the inclusion criteria. The average number of days from discharge to follow-up was 21.73±10.39 days. The average hematocrit levels were 30.77±3.61 before discharge and 38.70±3.61 at postpartum follow-up. From discharge to postpartum follow-up, the hematocrit levels increased by an average of 7.93±3.24. In the cohort without complications, the average increase in hematocrit levels was 8.19±3.09. The rise in hematocrit levels was significantly lower for those with chronic hypertension (6.9±3.6), diabetes mellitus (7.3±3.3), and preeclampsia with severe features (6.9±3.7). The severity of anemia influenced the rise in hematocrit levels in the postpartum period. In women with postpartum anemia (hematocrit<30%), the rise in hematocrit levels was 9.49±2.97 in the uncomplicated cohort. Postpartum hemorrhage did not influence the rise in postpartum hematocrit levels; women receiving blood transfusion had a greater rise in hematocrit levels (9.01±3.29). CONCLUSION: Our study establishes the natural course of hematologic recovery in the postpartum period, and we found that women with asymptomatic postpartum anemia may have a hematocrit level of 37% to 39% at their postpartum follow-up approximately 3 weeks after hospital discharge. Women with preexisting and obstetrical complications experienced less hematologic recovery and adapted more slowly to postpartum physiological changes.

Effectiveness of Chlamydia trachomatis expedited partner therapy in pregnancy.

BACKGROUND: Expedited partner therapy for Chlamydia trachomatis has had mixed efficacy in different populations, but limited data exist on the efficacy of the therapy in a pregnant population. OBJECTIVE: This study aimed to evaluate the real-world effectiveness of establishing a prenatal expedited partner therapy program in eradicating chlamydia before delivery and to examine the maternal and neonatal outcomes between women who received expedited partner therapy for chlamydia and women who received standard partner referral testing and treatment during pregnancy. STUDY DESIGN: An expedited partner therapy program was implemented on August 21, 2019, at a public hospital in a county with high chlamydia prevalence. Pregnant women were provided with single-dose packets of azithromycin to treat partners following a diagnosis of chlamydia infection. We prospectively observed pregnant women treated in the expedited partner therapy program who delivered at our institution in the same year and compared the outcomes with a historic cohort from the previous year that had traditional partner referral testing and treatment. We excluded women with concurrent gonorrhea, HIV, syphilis, or current intimate partner violence. The primary outcome was chlamydia reinfection or no-cure rates at repeat testing in 4 to 6 weeks following treatment or at the 36-week prenatal care screening. Secondary outcomes included obstetrical, maternal, and neonatal outcomes, including premature rupture of membranes, chorioamnionitis, endometritis, neonatal intensive care unit admission, neonatal sepsis, pneumonia, and conjunctivitis. RESULTS: The rate of chlamydia infection was 3.6% over a 2-year period in our delivered population. In the year following the implementation of the expedited partner therapy, compared with 419 women (mean±standard deviation, 23.4±5.5 years) who were diagnosed with chlamydia infection in the previous year, 471 women (mean±standard deviation age, 23.8±5.3 years) who delivered at our institution were diagnosed with chlamydia infection. There was no difference in race, parity, prenatal care attendance, or concomitant sexually transmitted infections. Compared with the pre-expedited partner therapy group, the rate of reinfection in the post-expedited partner therapy group was not statistically different (60/471 [13%] vs 61/419 [15%]; odds ratio, 0.86 [95% confidence interval 0.58-1.26]). In a per-protocol analysis, 72 women (17%) in the pre-expedited partner therapy group and 389 women (83%) in post-expedited partner therapy group received expedited partner therapy; reinfection was not statistically different between groups (P=.47). There was no difference in secondary outcomes, although a trend toward improved rates of endometritis was noted in the post-expedited partner therapy group (odds ratio, 0.13; 95% confidence interval, 0.02-1.02). CONCLUSION: The implementation of a prenatal expedited partner therapy program did not affect the rate of chlamydia reinfection before delivery. Treatment of chlamydia in an inner-city population has multiple factors that lead to successful treatment. Future efforts to reduce sexually transmitted infection and chlamydia reinfection rates in an at-risk population should include exploring patient education and safe sex practices beyond expedited partner therapy alone during pregnancy.

Pregnancy Outcomes Among Women With and Without Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Importance: Published data suggest that there are increased hospitalizations, placental abnormalities, and rare neonatal transmission among pregnant women with coronavirus disease 2019 (COVID-19). Objectives: To evaluate adverse outcomes associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and to describe clinical management, disease progression, hospital admission, placental abnormalities, and neonatal outcomes. Design, Setting, and Participants: This observational cohort study of maternal and neonatal outcomes among delivered women with and without SARS-CoV-2 during pregnancy was conducted from March 18 through August 22, 2020, at Parkland Health and Hospital System (Dallas, Texas), a high-volume prenatal clinic system and public maternity hospital with widespread access to SARS-CoV-2 testing in outpatient, emergency department, and inpatient settings. Women were included if they were tested for SARS-CoV-2 during pregnancy and delivered. For placental analysis, the pathologist was blinded to illness severity. Exposures: SARS-CoV-2 infection during pregnancy. Main Outcomes and Measures: The primary outcome was a composite of preterm birth, preeclampsia with severe features, or cesarean delivery for abnormal fetal heart rate among women delivered after 20 weeks of gestation. Maternal illness severity, neonatal infection, and placental abnormalities were described. Results: From March 18 through August 22, 2020, 3374 pregnant women (mean [SD] age, 27.6 [6] years) tested for SARS-CoV-2 were delivered, including 252 who tested positive for SARS-CoV-2 and 3122 who tested negative. The cohort included 2520 Hispanic (75%), 619 Black (18%), and 125 White (4%) women. There were no differences in age, parity, body mass index, or diabetes among women with or without SARS-CoV-2. SARS-CoV-2 positivity was more common among Hispanic women (230 [91%] positive vs 2290 [73%] negative; difference, 17.9%; 95% CI, 12.3%-23.5%; P < .001). There was no difference in the composite primary outcome (52 women [21%] vs 684 women [23%]; relative risk, 0.94; 95% CI, 0.73-1.21; P = .64). Early neonatal SARS-CoV-2 infection occurred in 6 of 188 tested infants (3%), primarily born to asymptomatic or mildly symptomatic women. There were no placental pathologic differences by illness severity. Maternal illness at initial presentation was asymptomatic or mild in 239 women (95%), and 6 of those women (3%) developed severe or critical illness. Fourteen women (6%) were hospitalized for the indication of COVID-19. Conclusions and Relevance: In a large, single-institution cohort study, SARS-CoV-2 infection during pregnancy was not associated with adverse pregnancy outcomes. Neonatal infection may be as high as 3% and may occur predominantly among asymptomatic or mildly symptomatic women. Placental abnormalities were not associated with disease severity, and hospitalization frequency was similar to rates among nonpregnant women.

Syphilis Immunoassay Signal Strength Correlates with Active Infection in Pregnant Women.

OBJECTIVE: This study aimed to evaluate the association of ARCHITECT chemiluminescent immunoassay (CIA) signal strength (signal-to-cutoff [S/CO] ratio), with maternal syphilis stage, rapid plasma reagin (RPR) reactivity, and congenital syphilis. STUDY DESIGN: A prospective observational study of reverse syphilis screening was conducted. Pregnant women were screened with CIA. Reactive CIA was reflexed to RPR; particle agglutination test (Treponema pallidum particle agglutination [TPPA]) was performed for CIA+/RPR- results. Clinical staging with history and physical was performed, and disease stage was determined. Prior treatment was confirmed. We compared S/CO ratio and neonatal outcomes among the following groups: Group 1: CIA+/RPR+/TPPA+ or CIA+/RPR-/TPPA+ with active syphilis; Group 2: CIA+/RPR-/TPPA+ or CIA+/serofast RPR/TPPA+, previously treated; Group 3: CIA+/RPR-/TPPA+, no history of treatment or active disease; Group 4: CIA+/RPR-/TPPA-, false-positive CIA. RESULTS: A total of 144 women delivered with reactive CIA: 38 (26%) in Group 1, 69 (48%) in Group 2, 20 (14%) in Group 3, and 17 (12%) in Group 4. Mean (±standard deviation) S/CO ratio was 18.3 ± 5.4, 12.1 ± 5.3, 9.1 ± 4.6, and 1.9 ± 0.8, respectively (p < 0.001). Neonates with overt congenital syphilis occurred exclusively in Group 1. CONCLUSION: Women with active syphilis based on treatment history, clinical staging, and laboratory indices have higher CIA S/CO ratio and are more likely to deliver neonates with overt evidence of congenital syphilis.

Microangiopathic Hemolytic Anemia Due to Malignancy in Pregnancy.

BACKGROUND: Microangiopathic disorders during pregnancy remain a diagnostic challenge because these conditions often imitate more common obstetric diseases. CASE: A 31-year-old multigravid woman delivered at term with a postpartum course complicated by laboratory indices consistent with hemolysis, elevated liver enzymes, and low platelet count syndrome. After clinical recovery, she was readmitted 2 weeks after delivery with presumptive pyelonephritis. Persistent hemolysis and worsening thrombocytopenia suggested a diagnosis of thrombotic microangiopathy, which did not respond to plasma exchange. Directed bone biopsy revealed metastatic signet ring cell adenocarcinoma. CONCLUSION: Microangiopathic hemolytic anemia is rarely the initial clinical manifestation of malignancy. Given the similar features of several common obstetric complications, additional diagnostic measures may be necessary to refine the diagnosis in cases unresponsive to standard obstetric management.