Association between acceptance of routine pregnancy vaccinations and COVID-19 vaccine uptake in pregnant patients.

OBJECTIVE: COVID-19 vaccination is a key approach to reduce morbidity and mortality in pregnant patients and their newborns. Anti-vaccine sentiment has recently increased with unclear impact on pregnant patients. We examined the association between acceptance of tetanus-diphtheria-acellular pertussis (Tdap) and influenza vaccines, considered to be routine pregnancy vaccines, and COVID-19 vaccine acceptance. Secondarily, we identified other predictors of COVID-19 vaccine uptake and described pregnancy outcomes in patients who were and were not vaccinated during pregnancy. METHODS: A retrospective cohort study of all patients who delivered at a single site from December 2020 - March 2022. Demographic, pregnancy, neonatal, and vaccination data were abstracted from the electronic medical record, which imports vaccine history from the California Immunization Registry. The relationship between influenza and Tdap vaccine acceptance, other baseline characteristics, and COVID-19 vaccine uptake was assessed using univariable and multivariable regression analysis. RESULTS: Of the 7857 patients who delivered during the study period, 4410 (56.1%) accepted the COVID-19 vaccine. Of those who received the COVID-19 vaccine, 3363 (97.6%) and 3049 (88.5%) received influenza and Tdap vaccines, respectively. Patients were more likely to receive the COVID-19 vaccine if they had advanced maternal age, obesity, Asian race, and private insurance. After adjustment for baseline differences, COVID vaccine acceptance was associated with receipt of Tdap (aOR 2.10, 95% CI 1.90-2.33) and influenza vaccines (aOR 2.83, 95% CI 2.55-3.14). There were no differences in preterm birth, low birthweight, and NICU admission between patients who received and did not receive the COVID-19 vaccine. CONCLUSION: Patients were more likely to accept COVID-19 vaccination if they received Tdap or influenza vaccinations. Older age, obesity, Asian race, and private insurance were independent predictors of vaccine uptake. Disparities in COVID-19 vaccination uptake bear further exploration to guide efforts in equitable and widespread vaccine distribution.

Risk of Preterm Delivery in Very Advanced Maternal Age Parturients Utilizing In Vitro Fertilization.

OBJECTIVE: Among patients ≥45 years, the birth rate in the United States continues to increase. As fertility declines with age, this cohort often utilizes assisted reproductive technology, specifically in vitro fertilization (IVF). While both advancing maternal age and IVF are independently associated with adverse maternal outcomes, data regarding their additive effect are scant. This article aims to determine if patients who conceive via IVF are at increased risk for preterm birth (PTB) compared to patients with non-IVF pregnancies in a very advanced maternal age (vAMA) cohort (≥45 years). STUDY DESIGN: Retrospective cohort study of all pregnant patients ≥45 years old who delivered at a single institution (2014-2021). Those with incomplete delivery/neonatal records or multiples beyond twins were excluded. We compared individuals who conceived via IVF to those who conceived without IVF. The primary outcome was preterm delivery <37 weeks gestation. Secondary outcomes included other adverse perinatal outcomes. Using multivariable logistic regression, we adjusted for multiple gestation as well as confounders found to be significantly different in the univariable analysis and other known risk factors for PTB. RESULTS: In our study cohort of 420 vAMA patients, individuals who underwent IVF were more likely to be older, privately insured, nulliparous, and with a twin gestation. The PTB rate in vAMA patients who underwent IVF was 24.4 compared to 8.4% in patients who did not use IVF (p < 0.001). After adjusting for confounders, IVF was an independent risk factor for PTB <37 weeks in vAMA patients (adjusted odds ratio {aOR] = 4.3, 95% confidence interval [CI]: 1.7-10.4, p = 0.001). In vitro fertilization was also associated with a composite of adverse maternal outcomes (hypertensive disorder of pregnancy, postpartum hemorrhage, blood transfusion, and unplanned hysterectomy) (aOR 1.7, 95% CI [1.1-2.9], p = 0.03). CONCLUSION: In the vAMA population, conception via IVF is associated with an increased risk of PTB <37 weeks. KEY POINTS: · This study examines IVF as an independent risk factor for PTB in patients ≥45 years at delivery, which has not been specifically addressed in prior studies.. · In vAMA patients, use of IVF is associated with an increased risk of PTB <37 weeks. These patients also have higher rates of cesarean delivery. Neonates from IVF pregnancies are more likely to be very low birth weight or low birth weight.. · Bodies of research exist for both advanced maternal age and assisted reproductive technology, there is a paucity of data specifically in parturients of vAMA who conceive via IVF..

Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum.

Importance: Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective: To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants: This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures: ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures: The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results: From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance: In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.

Uterine necrosis during pregnancy following exploratory laparotomy.

Uterine necrosis is an infrequent event and is most commonly reported as a complication of interventions for postpartum haemorrhage management. Cases of uterine necrosis in pregnancy are rare. The mainstay of treatment for uterine necrosis is hysterectomy, and the data regarding conservative management are limited. A gravida 3, para 2 presented at 33 weeks gestation with ovarian torsion and underwent an exploratory laparotomy with ovarian cystectomy. The surgery was complicated by excess bleeding, which was controlled with the placement of sutures along the uterine body. She had multiple subsequent presentations for severe abdominal pain without clear aetiology. Four weeks after the initial surgery, she underwent caesarean delivery, at which time uterine necrosis was diagnosed. Her uterus was preserved. She received postoperative intravenous antibiotics and was closely observed. She continued to do well 10 months postpartum. In patients with uterine necrosis during pregnancy who are haemodynamically stable, conservative management may be an option.

Complement blockade with eculizumab for treatment of severe Coronavirus Disease 2019 in pregnancy: A case series.

PROBLEM: We evaluated eculizumab, a complement protein C5 inhibitor, for treatment of severe COVID-19 in pregnant and postpartum individuals. METHOD OF STUDY: Protocol ECU-COV-401 (clinicaltrials.gov NCT04355494) is an open label, multicenter, Expanded Access Program (EAP), evaluating eculizumab for treatment of severe COVID-19. Participants enrolled at our center from August 2020 to February 2021. Hospitalized patients were eligible if they had severe COVID-19 with bilateral pulmonary infiltrates and oxygen requirement. Eculizumab was administered on day 1 (1200 mg IV) with additional doses if still hospitalized (1200 mg IV on Days 4 and 8; 900 mg IV on Days 15 and 22; optional doses on Days 12 and 18). The primary outcome was survival at Day 15. Secondary outcomes included survival at Day 29, need for mechanical ventilation, and duration of hospital stay. We evaluated pharmacokinetic and pharmacodynamic data, safety, and adverse outcomes. RESULTS: Eight participants were enrolled at the Cedars-Sinai Medical Center, six during pregnancy (mean 30 ± 4.0 weeks) and two in the postpartum period. Baseline oxygen requirement ranged from 2 L/min nasal cannula to 12 L/min by non-rebreather mask. The median number of doses of eculizumab was 2 (range 1-3); the median time to hospital discharge was 5.5 days (range 3-12). All participants met the primary outcome of survival at Day 15, and all were alive and free of mechanical ventilation at Day 29. In three participants we demonstrated that free C5 and soluble C5b-9 levels decreased following treatment. There were no serious adverse maternal or neonatal events attributed to eculizumab at 3 months. CONCLUSION: We describe use of eculizumab to treat severe COVID-19 in a small series of pregnant and postpartum adults. A larger, controlled study in pregnancy is indicated.

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas.

OBJECTIVE: This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. STUDY DESIGN: This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. RESULTS: Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81). CONCLUSION: Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. KEY POINTS: · Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

Incorporating personal-device-based point-of-care ultrasound into obstetric care: a validation study.

BACKGROUND: Personal-device-based point-of-care-ultrasound (P-POCUS) probes plug directly into a cell phone or tablet to function as its display, creating the potential to increase access to obstetric ultrasonography in complex healthcare settings (COVID units, low resource settings); however, new technology must be proven to be reliable in the obstetric setting before integrating into practice. OBJECTIVE: To evaluate the intraclass correlation (reliability) of personal-device-based-point-of-care-ultrasound devices as compared with standard ultrasound machines in obstetrics. STUDY DESIGN: This was a prospective, observational study of patients between 19-39 weeks gestation in an urban, prenatal ultrasound diagnosis center. Each patient underwent assessment by an expert sonographer using standard ultrasound machines and personal-device-based-point-of-care-ultrasound devices to determine estimated fetal weight. The statistical reliability and agreement between the estimated fetal weights was assessed through intraclass correlation coefficients, Bland-Altman plots, and Pearson correlation coefficients. RESULTS: 100 paired sets of scans were performed from October 2020 to December 2020. For the estimated fetal weights, there was near-perfect agreement, with an intraclass correlation coefficient of 0.99 (P<.0001). Bland-Altman analysis showed an average difference of 53 grams, with 95% limit of agreement between -178 grams and 283 grams. Pearson correlation showed near-perfect correlation between the measurements (r=0.99, P<.0001). CONCLUSION: personal-device-based point-of-care-ultrasound devices are reliable tools for performing basic obstetrical ultrasound and have the potential to increase access to obstetrical ultrasound worldwide.

Monoclonal Antibodies Casirivimab and Imdevimab in Pregnancy for Coronavirus Disease 2019 (COVID-19).

BACKGROUND: For unvaccinated individuals with mild-to-moderate coronavirus disease 2019 (COVID-19), monoclonal antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) decrease the risk of severe disease and hospitalization. We describe the use of the monoclonal antibodies casirivimab and imdevimab for COVID-19 in pregnancy. CASE: Two unvaccinated pregnant individuals presented with moderate COVID-19, one in the second trimester and one in third trimester; both met criteria for outpatient management. To decrease the risk for severe disease, they were treated with casirivimab and imdevimab. Neither experienced an adverse drug reaction, and neither progressed to severe disease. CONCLUSION: Monoclonal antibodies such as casirivimab and imdevimab, approved under an emergency use authorization, should be considered in unvaccinated pregnant individuals with mild-to-moderate COVID-19 to decrease the risk of severe disease.

Subchorionic Hematomas and Adverse Pregnancy Outcomes among Twin Pregnancies.

OBJECTIVE: This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies. STUDY DESIGN: Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 60/7 to 136/7 weeks. Regression analysis was used to control for any differences in baseline characteristics. RESULTS: A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63-6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes. CONCLUSION: In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

Change in cervical length and spontaneous preterm birth in nulliparous women with a history of loop electrosurgical excision procedure.

BACKGROUND: Prior studies have shown an association between history of loop electrode procedures (LEEP) and spontaneous preterm delivery (SPTD) independent of mid-trimester cervical length. These studies suggest that there may be other factors beyond an individual cervical length, which contribute to identifying at-risk pregnancies. OBJECTIVE: The objective of this study is to determine the association between change in cervical length and SPTD in women with a history of LEEP. STUDY DESIGN: This is a retrospective cohort study of singleton nulliparous women with a history of LEEP who received serial cervical length measurements at a single institution between 2012 and 2016. Women with serial cervical lengths and available outcome data were included. The cervical length at different gestational ages and the rate of change in length were compared with the risk for SPTD <37 weeks using Student's t-test. RESULTS: One-hundred-thirty subjects met the inclusion criteria for the study. The mean cervical length (35.3 versus 39.8 mm, p = .042 at 16 weeks; 32.2 versus 37.8 mm, p < .01 at 20 weeks; 29.9 versus 35.6 mm, p = .027 at 24 weeks; 21.6 versus 33.4 mm, p < .01 at 28 weeks) was significantly different between women who had an SPTD <37 weeks compared to women who did not. The average rate of change in transvaginal cervical length between 16 to 28 weeks was significantly different between women who had an SPTD <37 weeks compared to women who did not (-1.4 versus 0.4 mm/week, p < .01). CONCLUSION: Women with a history of LEEP who had an SPTD <37 weeks had a shorter cervical length at 16, 20, 24, and 28 weeks' gestation and a higher rate of change in cervical length between 16 and 28 weeks than women without a history of SPTD. Our findings support the concept of the preterm birth syndrome as an evolving biophysical process rather than a distinct event, suggesting improved prediction in the setting of prior history of a LEEP with serial imaging.

Compassionate Use of Remdesivir in Pregnant Women With Severe Coronavirus Disease 2019.

BACKGROUND: Remdesivir is efficacious for severe coronavirus disease 2019 (COVID-19) in adults, but data in pregnant women are limited. We describe outcomes in the first 86 pregnant women with severe COVID-19 who were treated with remdesivir. METHODS: The reported data span 21 March to 16 June 2020 for hospitalized pregnant women with polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection and room air oxygen saturation ≤94% whose clinicians requested remdesivir through the compassionate use program. The intended remdesivir treatment course was 10 days (200 mg on day 1, followed by 100 mg for days 2-10, given intravenously). RESULTS: Nineteen of 86 women delivered before their first dose and were reclassified as immediate "postpartum" (median postpartum day 1 [range, 0-3]). At baseline, 40% of pregnant women (median gestational age, 28 weeks) required invasive ventilation, in contrast to 95% of postpartum women (median gestational age at delivery 30 weeks). By day 28 of follow-up, the level of oxygen requirement decreased in 96% and 89% of pregnant and postpartum women, respectively. Among pregnant women, 93% of those on mechanical ventilation were extubated, 93% recovered, and 90% were discharged. Among postpartum women, 89% were extubated, 89% recovered, and 84% were discharged. Remdesivir was well tolerated, with a low incidence of serious adverse events (AEs) (16%). Most AEs were related to pregnancy and underlying disease; most laboratory abnormalities were grade 1 or 2. There was 1 maternal death attributed to underlying disease and no neonatal deaths. CONCLUSIONS: Among 86 pregnant and postpartum women with severe COVID-19 who received compassionate-use remdesivir, recovery rates were high, with a low rate of serious AEs.

Establishing Better Evidence on Remote Monitoring for Postpartum Hypertension: A Silver Lining of the Coronavirus Pandemic.

The transformation of our health care system in response to coronavirus disease 2019 (COVID-19) provides a unique opportunity to examine the use of telehealth for postpartum care. The postpartum period can pose significant risks and challenges, particularly for women with hypertensive disorders of pregnancy. Remote blood pressure monitoring has proven feasible and acceptable among women and providers but has not been widely implemented or researched. Early studies have identified improved outcomes with use of telehealth, including increased compliance with care and decreased disparity in hypertension follow-up. Preliminary data make a compelling case for remote monitoring as a promising treatment strategy to manage postpartum hypertension. Remote monitoring technology should be incorporated as a standard component for the comprehensive management of postpartum hypertension during COVID-19. As a consequence of the pandemic, we now have an opportunity to research the impact of postpartum remote blood pressure monitoring on maternal outcome and disparities within these outcomes.

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

Background: In response to the coronavirus disease 2019 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with severe acute respiratory syndrome coronavirus 2. Beginning in March 2020, our hospital instituted labor, and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with coronavirus disease 2019, delivery management, and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes. Objective: The objective of this study was to determine whether labor and delivery unit policy modifications we made during the coronavirus disease 2019 pandemic were associated with differences in outcomes for mothers and newborns. Study Design: We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020, and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the preimplementation group, and those who delivered in March and April 2020 were designated as the postimplementation group. Maternal and neonatal outcomes between the pre- and postimplementation groups were compared. Differences between the 2 groups were then compared with the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the postimplementation group. Statistical analysis methods included Student's t-tests and Wilcoxon tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Results: Postpartum length of stay was significantly shorter after implementation of labor unit changes related to coronavirus disease 2019. A postpartum stay of 1 night after vaginal delivery occurred in 48.5% of patients in the postimplementation group compared with 24.9% of the preimplementation group (P<.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the postimplementation group compared with 11.8% in the preimplementation group (P<.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after 1 night in the postimplementation group compared with 24.9% in the preimplementation group (P<.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the postimplementation group compared with 12.5% in the preimplementation group (P<.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the 2 groups. Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from coronavirus disease 2019 indicate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of long-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.

Pituitary apoplexy associated with acute COVID-19 infection and pregnancy.

PURPOSE: We report a case of a pregnant female presenting with pituitary apoplexy and simultaneous SARS-CoV-2 infection with a focus on management decisions. CLINICAL HISTORY: A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery. CONCLUSION: Here we demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection.

Tocilizumab and Remdesivir in a Pregnant Patient With Coronavirus Disease 2019 (COVID-19).

BACKGROUND: There are limited data regarding treatment options for pregnant women with severe coronavirus disease 2019 (COVID-19). CASE: A 35-year-old primigravid patient at 22 weeks of gestation presented with 7 days of fever, cough, anosmia, and dyspnea. Nasopharyngeal swab was positive for the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and a chest X-ray demonstrated bilateral patchy infiltrates. Laboratory evaluation was notable for marked elevation of interleukin-6 and C-reactive protein concentrations. On hospital day 3, owing to increased dyspnea and oxygen requirement, the patient was treated with tocilizumab followed by 5 days of remdesivir. She responded well, recovered to room air, and was discharged home after a 9-day hospitalization. CONCLUSION: Tocilizumab and remdesivir may be effective for treatment of severe COVID-19 in pregnancy, but additional data are needed to guide risk-benefit considerations.

Cervical length, cervical dilation, and gestational age at cerclage placement and the risk of preterm birth in women undergoing ultrasound or exam indicated Shirodkar cerclage.

Background: Preterm birth is a major cause of neonatal morbidity and mortality in the USA. In many patients at risk for preterm birth, cervical length (CL) screening is used to guide decisions regarding cerclage placement. Quality evidence shows that cerclage prolongs pregnancy in high-risk women with a short CL in women with a history of preterm birth and in women with painless cervical dilation in the second trimester, though the degree of cervical shortening, dilation, or gestational age at cerclage placement are not consistently associated with the subsequent rate of preterm birth. Our objective was to determine if cervical length (CL), cervical dilation or gestational age (GA) at the time of cerclage placement are associated with preterm birth among women undergoing ultrasound-indicated or exam-indicated cerclage.Study design: This was a retrospective cohort study of all patients with a singleton pregnancy who underwent ultrasound-indicated or exam-indicated Shirodkar cerclage placement at a single maternal-fetal medicine practice in New York City between November 2005 and May 2017. All patients included in the study had previously undergone CL screening for an increased risk of preterm birth (for example, prior spontaneous preterm birth or mid-trimester loss, prior cervical excision). The cervical length or dilation and GA at the time of cerclage placement were collected, as were demographic and obstetric outcome data for the current pregnancy. The primary outcome was delivery <36 or ≥36 weeks. Planned subgroup analyses of the primary outcome were performed based on CL at the time of ultrasound-indicated cerclage (0-9 mm, 10-19 mm, ≥20 mm), cervical dilation at the time of physical exam-indicated cerclage (<2 cm vs. ≥2 cm), and gestational age at cerclage placement (<20 weeks vs. ≥20 weeks). Data were analyzed using the Student's t-test and chi-square test for trend.Results: There were 123 and 39 patients in the ultrasound- and exam-indicated cerclage groups, respectively. Twenty six (21.2%) patients in the ultrasound-indicated subgroup and 24 patients (61.5%) in the exam-indicated subgroup delivered <36 weeks. CL (16.4 versus 17.6 mm, p = .28) and GA (19.7 versus 20.0 weeks, p = .58) at the time of ultrasound-indicated cerclage placement were not significantly different in patients who delivered <36 and ≥36 weeks' gestation, respectively. Women with cervical dilation ≥2 cm prior to exam-indicated cerclage placement were significantly more likely to deliver <36 weeks when compared to women with cervical dilation <2 cm (77.8 versus 47.6%, p = .05); however, there were no significant differences in rates of preterm birth <28 and <32 weeks between these two groups (38.9 versus 23.8%, p = .31 and 50.0% versus 28.6%, p = .17, respectively).Conclusions: Cervical length and GA at the time of ultrasound-indicated Shirodkar cerclage placement do not appear to impact the likelihood of preterm birth <36 weeks, while cervical dilation ≥2 cm at the time of exam-indicated Shirodkar cerclage is associated with an increased rate of preterm birth <36 weeks, but not earlier gestational ages at delivery.

Induction of Labor versus Cesarean Delivery in Twin Pregnancies.

OBJECTIVE: This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD). STUDY DESIGN: This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks. RESULTS: A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66). CONCLUSION: Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of Gestation in Singleton Pregnancies.

OBJECTIVE: To assess the association of first-trimester subchorionic hematomas with pregnancy outcomes after 20 weeks of gestation in women with singleton pregnancies. METHODS: We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients underwent routine first-trimester ultrasound examinations. We compared rates of adverse pregnancy outcomes at more than 20 weeks of gestation in women with and without a subchorionic hematoma on the initial ultrasound examination, excluding women with pregnancy loss before 20 weeks of gestation. RESULTS: From January 2015 to December 2017, a total of 2,172 women met the inclusion criteria for the study, 389 (17.9%) of whom had a subchorionic hematoma (mean largest diameter 2.1±1.4 cm). Women with subchorionic hematomas had their first ultrasound examination at earlier gestational ages (8 5/7 vs 9 6/7 weeks, P<.001) and were more likely to have vaginal bleeding at the time of the ultrasound examination (31.9% vs 7.9%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was not associated with any pregnancy outcomes at more than 20 weeks of gestation, including gestational age at delivery, preterm birth, birth weight, birth weight less than the 10th percentile for gestational age, gestational hypertension, preeclampsia, placental abruption, intrauterine fetal death at more than 20 weeks of gestation, cesarean delivery, blood transfusion, and antepartum admissions. On regression analysis including subchorionic hematoma, vaginal bleeding, and gestational age at ultrasound examination, vaginal bleeding was independently associated with preterm birth at less than 37 weeks of gestation and birth weight less than the 10th percentile. Subchorionic hematoma was not independently associated with pregnancy outcomes. This study had 80% power to detect a 5% absolute difference in the frequency of preterm birth; that is, from 10% to 15%. CONCLUSION: In singleton pregnancies, a first-trimester subchorionic hematoma is not associated with adverse pregnancy outcomes at more than 20 weeks of gestation.