Insurance Disparities in Patient Outcomes and Healthcare Resource Utilization Following Neonatal Intraventricular Hemorrhage.

BACKGROUND: Within the field of pediatric neurosurgery, insurance status has been shown to be associated with surgical delay, longer time to referral, and longer hospitalization in epilepsy treatment, myelomeningocele repair, and spasticity surgery.1,2 The aim of this study was to investigate the association of insurance status with inpatient adverse events, length of stay, and costs for newborns diagnosed with intraventricular hemorrhage (IVH). METHODS: A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. Patients with a primary diagnosis of IVH were identified using ICD-10-CM diagnostic and procedural codes. Patients were categorized based on insurance status: Medicaid or Private Insurance (PI). Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as >75th percentile of LOS) and exorbitant cost (defined as >75th percentile of cost). RESULTS: Demographics differed significantly between groups, with the majority of newborns in the PI cohort being White (Medicaid: 35.8% vs PI: 60.3%, p<0.001) and the majority of Medicaid patients being in the 0-25th quartile of household income (Medicaid: 40.9% vs PI: 12.9%, p<0.001). While insurance status was not independently associated with increased odds of extended LOS or exorbitant cost, Medicaid patients had a greater mean LOS and total cost of admission than PI patients. CONCLUSIONS: Demographic characteristics, mean LOS, and mean total cost differed significantly between Medicaid and PI patients, indicating potential disparities based on insurance status. However, insurance status was not independently associated with increased healthcare utilization, necessitating further research in this area of study.

Clinical characteristics and outcomes of obstetric patients transferred directly to intensive care units.

BACKGROUND: Medical complications in peripartum patients are uncommon. Often, these patients are transferred to tertiary care centers, but their conditions and outcomes are not well understood. Our study examined peripartum patients transferred to an intensive care unit (ICU) at an academic quaternary center. METHODS: We reviewed charts of adult, non-trauma, interhospital transfer (IHT) peripartum patients sent to an academic quaternary ICU between January 2017 and December 2021. We conducted a descriptive analysis and used multivariable ordinal regression to examine associations of demographic and clinical factors with ICU length of stay (LOS) and hospital length of stay (HLOS). RESULTS: Of 1,794 IHT peripartum patients, 60 (3.2%) were directly transferred to an ICU. The average was 32 years, with a median Sequential Organ Failure Assessment (SOFA) score of 3 (1-4.25) and Acute Physiology and Chronic Health Evaluation (APACHE) II score of 8 (7-12). Respiratory failure was most common (32%), followed by postpartum hemorrhage (15%) and sepsis (14%). Intubation was required for 24 (41%), and 4 (7%) needed extracorporeal membrane oxygenation. Only 1 (1.7%) died, while 45 (76.3%) were discharged. Median ICU LOS and HLOS were 5 days (212) and 8 days (5-17). High SOFA score was linked to longer HLOS, as was APACHE II. CONCLUSIONS: Transfers of critically ill peripartum patients between hospitals were rare but involved severe medical conditions. Despite this, their outcomes were generally positive. Larger studies are needed to confirm our findings.

Reduced racial disparities among newborns with intraventricular hemorrhage.

INTRODUCTION: Intraventricular hemorrhage (IVH) can ensue permanent neurologic dysfunction, morbidity, and mortality. While previous reports have identified disparities based on patient gender or weight, no prior study has assessed how race may influence in neonatal or infantile IVH patients. The aim of this study was to investigate the impact of race on adverse event (AE) rates, length of stay (LOS), and total cost of admission among newborns with IVH. METHODS: Using the 2016-2019 National Inpatient Sample database, newborns diagnosed with IVH were identified using ICD-10-CM codes. Patients were stratified based on race. Patient characteristics and inpatient outcomes were assessed. Multivariate logistic regression analyses were used to identify the impact of race on extended LOS and exorbitant cost. RESULTS: Of 1435 patients, 650 were White (45.3%), 270 African American (AA) (18.8%), 300 Hispanic (20.9%), and 215 Other (15.0%). A higher percentage of AA and Other patients than Hispanic and White patients were < 28 days old (p = 0.008). Each of the cohorts had largely similar presenting comorbidities and symptoms, although AA patients did have significantly higher rates of NEC (p < 0.001). There were no observed differences in rates of AEs, rates of mortality, mean LOS, or mean total cost of admission. Similarly, on multivariate analysis, no race was identified as a significant independent predictor of extended LOS or exorbitant cost. CONCLUSIONS: Our study found that in newborns with IVH, race is not associated with proxies of poor healthcare outcomes like prolonged LOS or excessive cost. Further studies are needed to validate these findings.

Hemoglobin A1c as a Substitute for Oral Glucose Testing in Early Pregnancy Screening.

OBJECTIVE: Current recommendations for individuals with risk factors for gestational diabetes mellitus (GDM) call for screening in early pregnancy. However, there is currently no clear consensus on a specific screening modality. This study evaluates whether a hemoglobin A1c (HbA1c) screening in individuals with risk factors for gestational diabetes (GDM) could be used instead of an early 1-hour glucose challenge test (GCT). We hypothesized that the HbA1c could replace 1-hour GCT in early pregnancy evaluation STUDY DESIGN: This is a prospective observational trial at a single tertiary referral center of women with at least one risk factor for GDM who were screened at <16 weeks of gestation with both 1-hour GCT or HbA1c. Exclusion criteria include: previous diagnosis of diabetes mellitus, multiple gestation, miscarriage, or missing delivery information. The diagnosis of GDM was made by a 3-hour 100-g glucose tolerance test, using the Carpenter-Coustan criteria (at least two results >94, 179, 154, and 139 mg/dL for fasting, 1-, 2-, and 3-hour values, respectively), 1-hour GCT > 200 mg/dL, or HbA1c > 6.5%. RESULTS: A total of 758 patients met inclusion criteria. A total of 566 completed a 1-hour GCT and 729 had an HbA1c collected. The median gestational age at testing was 91/7 weeks (range: 40/7-156/7 weeks]. Twenty-one participants were diagnosed with GDM at <16 weeks' GA. The receiver operating characteristic (ROC) curves identified the optimal valves for a positive screen for an HbA1c > 5.6%. The HbA1c had a sensitivity of 84.2%, a specificity of 83.3%, and a false positive rate of 16.7% (p < 0.001). The area under the ROC curve for the HbA1c was 0.898. Gestational age of delivery was slightly earlier with individuals with an elevated HbA1c but no other changes in delivery or neonatal outcomes. Contingent screening improved specificity (97.7%) and decreased false positive rate to 4.4%. CONCLUSION: HbA1c may be a good assessment in early pregnancy for gestational diabetes. KEY POINTS: · HbA1c is a rational assessment in early pregnancy.. · An HbA1c > 5.6% is associated with gestational diabetes.. · Contingent screening limits the need for additional testing..

A pilot study: Application of paired ultrasound simulator training in obstetrics.

OBJECTIVE: Medical trainees in obstetrics must develop competency in fetal ultrasonography. To date, no studies have utilized ultrasound simulator training for basic fetal anatomy with paired didactic coursework. We hypothesize that ultrasound simulator training with paired didactics improves medical trainee competency in fetal ultrasonography. METHODS: A prospective observational study was performed at a tertiary care center during the 2021-2022 academic year. Medical trainees in obstetrics without prior simulator experience could participate. Participants completed ultrasound simulator training with standardized paired didactics and subsequent real-time patient scanning. All images were reviewed by the same physician for competency. Trainees completed 11-point Likert scale surveys at three time points: pre-simulator, post-simulator, and post-real-time patient scanning. Two-tailed student's t-tests with 95% confidence intervals were performed, and p-values <0.05 were considered significant. RESULTS: Of the 26 trainees that completed the training, 96% reported that simulation positively impacted their confidence and ability to perform real-time scanning of patients. Self-reported knowledge of fetal anatomy, ultrasound techniques, and application to clinical obstetrics all significantly increased after simulator training (p < 0.01). CONCLUSIONS: Paired ultrasound simulation with didactic instruction significantly improves medical trainees' knowledge of fetal anatomy and ability to perform fetal ultrasonography. Implementing an ultrasound simulation curriculum may become an essential tool for obstetric residency programs.

Third Trimester Ultrasound Stratifies Risk of Peripartum Complications in Pregnancies Complicated by Impaired Glucose Tolerance.

OBJECTIVE: The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain. RESULTS: A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar. CONCLUSION: Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications. KEY POINTS: · Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..

Prenatal diagnosis of a germline variant in TRAF7: Importance of accessibility to prenatal exome sequencing in cases of structural fetal anomalies.

Diagnosis of a pathogenic germline TRAF7 missense variant (c.1555 C > T, p.L519F) made on a prenatal basis by exome sequencing (ES) performed on chorionic villi. This case highlights the importance of both higher-level prenatal ultrasounds and the accessibility of ES in making genetic diagnoses in making pregnancy management decisions.

Sex-Selective Increase of IGF-2 Expression in the Hypoxic Guinea Pig Placenta of Growth-Restricted Fetuses.

Chronic hypoxia can cause fetal growth restriction (FGR) through placental dysfunction. Insulin-like growth factors (IGFs), such as IGF-2, play a major role in preservation of placental growth and function. We investigated the effects of chronic hypoxia and sex on protein expression of the IGF-2 pathway in placentas selected from asymmetric-FGR fetuses. Time-mated pregnant guinea pigs were assigned to normoxia (NMX, 21% O2) or hypoxia (HPX, 10.5% O2) during the last 14 days of pregnancy. Placentas were selected from male and female symmetrically grown NMX fetuses (fetal wt between 25th ile-75th ile) and HPX fetuses of asymmetric-FGR (fetal wt < 25th ile and brain:liver wt > 50th ile). Effects of HPX and sex on placenta protein expression of the IGF-2 signaling proteins (IGF-2, PI3K, AKT-P, total AKT, PCNA, a cell proliferation marker) were evaluated by immunoblotting. Effects of HPX and sex on morphometric parameters were analyzed using two-way ANOVA (p < 0.05). HPX reduced (p < 0.005) fetal wt by ~ 35% compared to NMX in both sexes. Expression of IGF-2 was lower (p = 0.029) in NMX female placentas compared to males. Despite lower NMX levels, HPX increased (p < 0.05) expression of IGF-2, AKT-P, relative AKT-P, and PCNA in female placentas only and had no effect on protein expression in male placentas. The female guinea pig placenta exhibits a greater sensitivity than males to HPX in upregulating expression of the IGF-2 axis. In addition, the sex difference in baseline IGF-2 expression suggests a greater capacity for females to increase IGF-2 in response to HPX as a placental adaptation in FGR.

In vivo Raman spectroscopy monitors cervical change during labor.

BACKGROUND: Biochemical cervical change during labor is not well understood, in part, because of a dearth of technologies capable of safely probing the pregnant cervix in vivo. The need for such a technology is 2-fold: (1) to gain a mechanistic understanding of the cervical ripening and dilation process and (2) to provide an objective method for evaluating the cervical state to guide clinical decision-making. Raman spectroscopy demonstrates the potential to meet this need, as it is a noninvasive optical technique that can sensitively detect alterations in tissue components, such as extracellular matrix proteins, lipids, nucleic acids, and blood, which have been previously established to change during the cervical remodeling process. OBJECTIVE: We sought to demonstrate that Raman spectroscopy can longitudinally monitor biochemical changes in the laboring cervix to identify spectral markers of impending parturition. STUDY DESIGN: Overall, 30 pregnant participants undergoing either spontaneous or induced labor were recruited. The Raman spectra were acquired in vivo at 4-hour intervals throughout labor until rupture of membranes using a Raman system with a fiber-optic probe. Linear mixed-effects models were used to determine significant (P<.05) changes in peak intensities or peak ratios as a function of time to delivery in the study population. A nonnegative least-squares biochemical model was used to extract the changing contributions of specific molecule classes over time. RESULTS: We detected multiple biochemical changes during labor, including (1) significant decreases in Raman spectral features associated with collagen and other extracellular matrix proteins (P=.0054) attributed to collagen dispersion, (2) an increase in spectral features associated with blood (P=.0372), and (3) an increase in features indicative of lipid-based molecules (P=.0273). The nonnegative least-squares model revealed a decrease in collagen contribution with time to delivery, an increase in blood contribution, and a change in lipid contribution. CONCLUSION: Our findings have demonstrated that in vivo Raman spectroscopy is sensitive to multiple biochemical remodeling changes in the cervix during labor. Furthermore, in vivo Raman spectroscopy may be a valuable noninvasive tool for objectively evaluating the cervix to potentially guide clinical management of labor.

An initiative to evaluate the safety of maternal bonding in patients with SARS-CoV-2 infection.

BACKGROUND: In the last two decades, the world faced three epidemics caused by novel coronaviruses, namely, SARS-CoV in 2002, MERS-CoV in 2012, and the ongoing SARS-CoV-2 that started in late 2019. Despite a growing understanding of SARS-CoV-2 virology, epidemiology, and clinical management strategies, other aspects, such as mode of delivery, vertical transmission, and maternal bonding, remain controversial. The question we faced upon the decision to separate the neonates of SARS-CoV-2 positive mother is whether we follow the principle of "do no harm"? METHODS: This is a quality improvement project that analyzed all cases of SARS-CoV-2 positive pregnancies that delivered at a major health care system from March 1, 2020 to June, 1 2020. The article was prepared following Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Data were prospectively collected and entered into the Research Electronic Data Capture (REDCap). Maternal bonding was defined by events such as rooming-in, skin to skin contact (STSC), and breastfeeding. Descriptive analysis was performed using the same software platform. INTERVENTION: We compared neonatal transmission rates between those neonates who experienced bonding versus those who were separated. RESULTS: A total of 1989 women were screened for SARS-CoV-2, from which 86 tested positive. Out of 31 analyzed pregnancies, five women (16%) were admitted to ICU and required mechanical ventilation. From the remaining 26 (84%), 17 (65%) opted for rooming-in, 12 (46%) for STSC, and 16 (61%) fed the infants with breastmilk (11 direct breastfeedings and five pumped the breast milk). All neonatal tests for SARS-CoV-2 returned negative. CONCLUSION: Our results have illustrated that maternal bonding appears safe in neonates born to mothers that are SARS-CoV-2 positive.

Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19.

INTRODUCTION: Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks. METHODS: We reviewed all the patients' charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format. RESULTS: During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO2 and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications. CONCLUSION: Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation.

Worm Sign: A possible first-trimester sonographic marker for intracranial haemorrhage resulting in significant cortical disruption.

Fetal intracranial haemorrhage (ICH) is a pathophysiological process involving haemorrhagic and hypoxic-ischaemic insults resulting in antenatal brain damage. Insults to the central nervous system are usually not detected until the second or third trimester. In this case presentation, we present a possible prenatal ultrasound marker, 'worm sign', representing cortical disruption secondary to suspected ICH at 13 weeks' gestation. According to current literature review, this is one of the first cases of ICH, diagnosed in the first-trimester and highlights the importance of early neurovascular and structural evaluation of the fetal brain at the time of first-trimester ultrasound screening.

Paraganglioma Presenting as Hypoxia and Syncope in Pregnancy: A Case Report.

Paragangliomas (PGLs) are rare tumors with an incidence of 0.007% in pregnant women. Patients with PGLs commonly present with hypertension and tachycardia. This case report describes the evaluation and management of a multiparous woman at 32 weeks of gestation with syncope, hypoxia, and tachycardia as unusual presenting symptoms of PGL. Her symptoms were attributable to paradoxical effects of circulating catecholamines on downregulated alpha-adrenergic receptors resulting in decreased systemic vascular resistance.

Peripartum Management in Myelodysplastic Syndrome Guided by Serial Thromboelastography: A Case Report.

Myelodysplastic syndrome with severe thrombocytopenia is a rare disease in women of child-bearing age. The challenging aspect in management of such a patient is maintaining optimal coagulation with minimum platelet transfusion during the peripartum period. Multiple transfusions can result in allo-sensitization which can affect lifesaving bone marrow transplantation in future. Thromboelastography is a useful tool to assess and guide appropriate transfusion requirements.

COVID-19 Barriers to Care for Pregnant Patients in Prolonged Isolation.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the agent responsible for coronavirus disease 2019 (COVID-19), continues to have a devastating impact on healthcare systems worldwide, and many questions remain unanswered. The effect of COVID-19 on the pregnant population is widely debated, and the unique risks in pregnancy have not yet been elucidated. What has been established, however, is the recommendation for healthcare workers to use personal protective equipment (PPE) for both contact and airborne precautions to prevent transmission of the pathogen-adding another barrier to care for vulnerable populations. We report a case of a young woman from Haiti during her first pregnancy, who was admitted to the antepartum service at 22 weeks of gestation with preterm premature rupture of membranes (PPROM) and remained admitted in isolation, though asymptomatic, for over six weeks due to persistent positive SARS-CoV-2 testing. Our case highlights the unique barriers to care that COVID-19 poses to antepartum patients, particularly in the setting of pregnant women with persistent positive testing.

Adaptation of labor and delivery to COVID-19.

As the novel coronavirus disease (COVID-19) escalates globally, and no end in sight, we describe an approach for adapting swiftly to the increasing number of COVID-19 parturients admitted into labor and delivery unit. The adaptability includes physical layout, triaging, quick testing, isolating confirmed parturients, access to designated intensive care units, facilitating emergent cesarean deliveries, and educating health care personnel. It is vital that other healthy parturi-ents and healthcare providers must be protected from COVID-19. It is encouraged that institutions exchange and dis-seminate information to succeed in the global fight against this dreaded pandemic.

Human papillomavirus vaccination completion rates among gynecological providers: an institutional retrospective review.

Objective: The primary aim of this study is to assess and characterize correlates of human papillomavirus (HPV) vaccine series completion among young adult women evaluated by gynecological (GYN) providers at a single institution and to measure changes over 4-y period. Methods: At a major academic center, the medical records of 845 women administered the HPV vaccine series by a GYN provider were retrospectively reviewed from 2006 to 2010 and 2014 to 2015. Patients were grouped based on the date of vaccine initiation into "earlier" (2006-2010) and "later" (2014-2015) cohorts. Patient demographics, dates of vaccine administration, and practice locations where vaccines were administered were collected. Patients who received all 3 vaccines within 6 months were deemed "complete". Patients seen by a provider but did not receive the vaccination were deemed "missed opportunities". The primary outcome was completion of HPV vaccination according to the ACIP guidelines. Results: The 845 patients were divided into earlier (n = 399) and later (n = 446) cohorts. There was no statistically significant difference in completion rates between the earlier-cohort compared to the later-cohort (35.2% vs. 30.9%, p = .20). Age at initiation were similar (p = .61), with the complete cohort having a significantly lower body mass index (BMI) than the incomplete cohort (p = .0015). There was a significant difference between the completion rates among race/ethnic groups (p = .036). African-American and Hispanic (18.9% and 20.0%, respectively, p = .04) patient-populations had the lowest completion rates and higher missed opportunities. Conclusion: Our study found an overall low completion rate in both earlier and later cohorts. Additionally, higher BMI and African-American and Hispanic race/ethnicity were associated with low vaccine completion.