Efficacy of continuous monitoring of maternal temperature during labor using wireless axillary sensors.

Neonatal early onset sepsis (EOS) occurs in 0.5-0.8/1000 live births and is a major cause of morbidity and mortality. Its presenting signs in newborns are non-specific, so risk assessment before birth is essential. Maternal fever during labor is the strongest predictor of EOS, but the current standard is for infrequent manual determinations of temperature. We aimed to determine whether continuous measurement of temperature during labor is feasible, accurate, and more effective than manual measurements for detecting fever. Women were recruited on admission in labor at > 35 weeks gestational age, with < 6 cm cervical dilation. Sensors were affixed in the axilla, which transmitted every 4 minutes by Bluetooth to a dedicated tablet. Conventional temperature measurements were taken every 3-6 hours per routine. Of 336 subjects recruited, 155 had both > 4 hours of continuous data and > 2 manual temperature measurements and were included for analysis. Continuous recordings were feasible and correlated well with manual measurements independent of mean temperature. Of 15 episodes of fever > 38 °C detected by both methods, 13 were detected earlier by continuous (9 of those more than 1 hour earlier). Manual measurements missed 32 fevers > 38 °C and 13 fevers > 38.5 °C that were identified by continuous. Continuous measurement of maternal temperature for the duration of labor is practical and accurate. It may be more sensitive for identifying infants at risk for EOS than the current practice, enabling earlier and more effective targeted treatment of affected infants.

Preterm birth among women with and without severe acute respiratory syndrome coronavirus 2 infection.

INTRODUCTION: Studies directly comparing preterm birth rates in women with and without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. Our objective was to determine whether preterm birth was affected by SARS-CoV-2 infection within a large integrated health system in New York with a universal testing protocol. MATERIAL AND METHODS: This retrospective cohort study evaluated data from seven hospitals in New York City and Long Island between March 2020 and June 2021, incorporating both the first and second waves of the coronavirus disease 2019 (COVID-19) pandemic in the USA. All patients with live singleton gestations who had SARS-CoV-2 polymerase chain reaction (PCR) testing at delivery were included. Deliveries before 20 weeks of gestation were excluded. The rate of preterm birth (before 37 weeks) was compared between patients with positive and negative SARS-CoV-2 test results. This analysis was performed separately for resolved prenatal infections and infections at delivery, with the latter group subdivided by symptom status. Multiple logistic regression analysis was used to examine the association between SARS-CoV-2 infection and preterm birth, adjusting for maternal age, race-ethnicity, parity, history of preterm birth, body mass index, marital status, insurance type, medical co-morbidities, month of delivery, and wave of pandemic. RESULTS: A total of 31 550 patients were included and 2473 (7.8%) had laboratory-confirmed infection. Patients with symptomatic COVID-19 at delivery were more likely to deliver preterm (19.0%; adjusted odds ratio 2.76, 95% CI 1.92-3.88) compared with women with asymptomatic infection (8.8%) or without infection (7.1%). Among preterm births associated with symptomatic infection, 72.5% were medically indicated compared with 44.1% among women without infection (p < 0.001). Risk of preterm birth in patients with resolved prenatal infection was unchanged when compared with women without infection. Among women with infection at delivery, preterm birth occurred more frequently during the second wave compared with the first wave (13.6% vs. 8.7%, respectively; p < 0.006). However, this was not significant on multiple regression analysis after adjusting for other explanatory variables. CONCLUSIONS: Pregnant women with symptomatic COVID-19 are more than twice as likely to have a preterm delivery than patients without infection. Asymptomatic infection and resolved prenatal infection are not associated with increased risk.

Point-of-care lung ultrasound patterns in late third-trimester gravidas with and without preeclampsia.

BACKGROUND: Transthoracic point-of-care ultrasonography of the lungs has become a standard technique in critical care medicine for the evaluation of patients with respiratory signs or symptoms but has not been well studied in pregnancy. OBJECTIVE: To compare lung ultrasound patterns in third-trimester gravidas with and without preeclampsia and assess interobserver agreement between 3 obstetrical providers and a physician expert in critical care lung ultrasound. STUDY DESIGN: This is a prospective observational study of 262 women with singleton pregnancies between 32 0/7 and 41 6/7 weeks' gestation. Lung ultrasound examinations were performed and interpreted by a team of obstetrical care providers and then interpreted by an expert in point-of-care lung ultrasound. The number of B-lines in each of the 4 lung fields, indicating the accumulation of fluid in the interstitial space and the alveoli, was evaluated. The primary outcome was a positive study for pulmonary interstitial edema, defined as an ultrasound study with 3 or more B-lines in 2 or more bilateral lung fields. The secondary outcome was a lung ultrasound study with 1 or 2 B-lines in 1 or more lung fields or 3 B-lines in 1 lung field. Interobserver agreement in lung ultrasound interpretation between obstetrical care providers and an expert in critical care point-of-care ultrasonography of the lung was assessed. RESULTS: Among healthy gravidas, no subject had a lung ultrasound examination positive for pulmonary interstitial edema. Notably, 2 patients with preeclampsia had positive lung ultrasound studies, and both had respiratory symptoms or signs of pulmonary edema. One or 2 B-lines or 3 B-lines in 1 lung field were identified in 11.4% of healthy gravidas and 18.6% of patients with preeclampsia. There was no difference in lung ultrasound patterns between healthy gravidas and those with preeclampsia. The obstetrical care providers and the lung ultrasound expert had a high proportion of agreement regarding the interpretation of negative lung ultrasound examinations. The 2 patients with clinical signs of pulmonary edema were judged to have positive studies by both the obstetrical team and the expert; however, the obstetrical team classified more studies as positive. CONCLUSION: Lung ultrasound patterns in women with preeclampsia without respiratory symptoms or clinical signs of pulmonary edema are similar to the lung ultrasound patterns of healthy gravidas. Point-of-care lung ultrasound can be used to evaluate third-trimester gravidas with preeclampsia and respiratory complaints or signs concerning for pulmonary edema. Formal training is important before the widespread adoption of point-of-care lung ultrasound by obstetrical healthcare providers.

Adherence and acceptability of telehealth appointments for high-risk obstetrical patients during the coronavirus disease 2019 pandemic.

Background: Telehealth has been successfully implemented for the delivery of obstetrical care. However, little is known regarding the attitudes and acceptability of patients and providers in high-risk obstetrics and whether the implementation of a telehealth model improves access to care in nonrural settings. Objective: This study aimed to describe patient and provider attitudes toward telehealth for the delivery of high-risk obstetrical care in a large healthcare system with both urban and suburban settings and to determine whether the implementation of a telehealth model improves patient adherence to scheduled appointments in this patient population. Study Design: Two self-administered surveys were designed. The first survey was sent to all high-risk obstetrical patients who received a telehealth visit between March 1, 2020, and May 30, 2020. The second survey was designed for providers who participated in these visits. We also compared the attended, cancelled, and no-show visit rates before (March 1 to May 30, 2019) and after (March 1 to May 30, 2020) the telehealth implementation and telehealth vs in-person visits in 2020. We reviewed scheduled high-risk prenatal care appointments, diabetes mellitus education sessions, and genetic counseling and Maternal-Fetal Medicine consultations. Results: A total of 91 patient surveys and 33 provider surveys were analyzed. Overall, 86.9% of patients were satisfied with the care they received and 78.3% would recommend telehealth visits to others. Notably, 87.8% of providers reported having a positive experience using telehealth, and 90.9% believed that telehealth improved patients' access to care. When comparing patient and provider preference regarding future obstetrical care after experiencing telehealth, 73.8% of patients desired a combination of in-person and telehealth visits during their pregnancy. However, a significantly higher rate of providers preferred in-person than telehealth visits (56% vs 23%, P=.024, respectively). When comparing visits between 2019 and 2020, there was a significantly lower rate of no-show appointments (8.49% vs 4.61%, P<.001), patient-cancelled appointments (7.06% vs 4.96%, P<.001), and patient same-day cancellations (2.30% vs 1.35%, P<.001) with the implementation of telehealth. There was also a significantly lower rate of patient-cancelled appointments (3.82% vs 5.44%, P=.021) and patient same-day cancellations (0.60% vs 1.65%, P=.002) with those receiving telehealth visits than in-person visits in 2020. Conclusion: The implementation of a telehealth model in high-risk obstetrics has the potential to improve access to high-risk obstetrical care, by reducing the rate of missed appointments. Both patients and providers surveyed expressed a high rate of satisfaction with telehealth visits and a desire to integrate telehealth into the traditional model of high-risk obstetrical care.

Histopathologic evaluation of placentas after diagnosis of maternal severe acute respiratory syndrome coronavirus 2 infection.

Background: The impact of maternal severe acute respiratory syndrome coronavirus 2 infection on placental histopathology is not well known. Objective: To determine if any significant placental histopathologic changes occur after the diagnosis of severe acute respiratory syndrome coronavirus 2 infection during pregnancy and whether these changes are correlated with the presence or absence of symptoms associated with the infection. Study Design: A retrospective cohort study of women diagnosed as having severe acute respiratory syndrome coronavirus 2 infection who delivered at a single center from April 9, 2020 to April 27, 2020, and had placental specimens reviewed by the Department of Pathology. Women with singleton gestations and laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection were eligible for inclusion. Historical controls selected from a cohort of women who delivered 6 months before the study period were matched in a 1:1 fashion by weeks of gestation at delivery. Histopathologic characteristics were evaluated in each placenta, and the incidence of these findings was compared between placentas of those who received a diagnosis of maternal severe acute respiratory syndrome coronavirus 2 infection and historical controls, and between placentas from patients with or without typical symptoms related to the infection. Statistical analyses included the use of Wilcoxon rank-sum test and Fisher's exact test for the comparison of categorical and continuous variables. Statistical significance was defined as a P value of <.05. Results: A total of 50 placentas after the diagnosis of maternal severe acute respiratory syndrome coronavirus 2 infection and 50 historical controls were analyzed. Among the placentas from patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection, 3 (6%) were preterm (33 3/7, 34 6/7, and 36 6/7 weeks of gestation), 16 (32%) were from patients with typical symptoms related to the infection, and 34 (68%) were from patients without typical symptoms related to the infection. All patients had received a diagnosis of severe acute respiratory syndrome coronavirus 2 infection in the third trimester. Decidual vasculopathy was not visualized in any of the placentas from patients diagnosed as having severe acute respiratory syndrome coronavirus 2 infection. There was no statistically significant difference in placental histopathologic characteristics between the groups. Severe acute respiratory syndrome coronavirus 2 test results for all neonates at 24 hours of life were negative. Conclusion: Based on the results of this study, there are no significant placental histopathologic changes that occur after the diagnosis of severe acute respiratory syndrome coronavirus 2 infection in women during the third trimester of pregnancy compared with a gestational age-matched historical control group. Similar incidences of histopathologic findings were also discovered when comparing placentas from patients with severe acute respiratory syndrome coronavirus 2 infection with or without the presence of symptoms typically related to the infection.

The care of pregnant women during the COVID-19 pandemic - response of a large health system in metropolitan New York.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Shock index and vital-sign reference ranges during the immediate postpartum period.

OBJECTIVE: To determine reference ranges for patient vital signs during the immediate postpartum period. METHODS: A retrospective chart review collected data on the variables of interest for all women with 0-24-hour postpartum data available at two hospitals in the USA, between July 1, 2012, and January 31, 2015. Patients were excluded if they had received antihypertensives, uterotonics, or blood products. Regression lines, with 95% prediction intervals, were constructed for shock index, systolic blood pressure, heart rate, pulse pressure, and rate over pressure evaluation (ROPE) values. RESULTS: There were 8874 patients and 87 336 data measurements included in the analysis. During the 24 hours following delivery, an increase in ROPE values, and decreases in pulse pressure, heart rate, and systolic blood pressure were recorded for all patients; an increase in shock index was observed among patients who had cesarean deliveries. Anomalous values for the shock index (>1.0), and reference ranges for pulse pressure (21.09-69.32 mm Hg), ROPE (1.01-3.22 bpm/mm Hg), heart rate (51-112 bpm), and SBP (81-137 mm Hg) were generated. CONCLUSION: Specific reference ranges for patients during the postpartum period could be used in future studies to determine the parameters, or combinations of parameters, that perform best as early markers of hemodynamic compromise in women experiencing early postpartum hemorrhage.

Detecting Pulmonary Edema in Obstetric Patients Through Point-of-Care Lung Ultrasonography.

BACKGROUND: Point-of-care lung ultrasonography is used in critical care settings for evaluating respiratory symptoms. Lung ultrasonography is sensitive and specific for the diagnosis of pulmonary edema in nonpregnant patients but is not well-studied in pregnancy. TECHNIQUE: Lung ultrasonography was performed using a portable ultrasound machine with a 2- to 5-MHz curvilinear probe that is available on many labor and delivery units. EXPERIENCE: Lung ultrasonography guided management decisions in a case of shortness of breath after induction of labor for preeclampsia and a case of hemolysis, elevated liver enzymes, and low platelet count syndrome complicated by pulmonary edema. Findings expedited diagnosis and treatment in both cases. CONCLUSION: Lung ultrasonography has potential to be used in obstetrics for detecting pulmonary edema in preeclampsia. It is a well-established tool in critical care settings and use in obstetric patients should be studied given the availability of ultrasonography on labor and delivery and the importance of timely care for critically ill pregnant patients. It is a safe modality to evaluate pregnant women with respiratory symptoms and the necessary skills can be easily acquired by obstetric practitioners familiar with obstetric ultrasonography. Training of obstetric practitioners in this application of ultrasonography is needed.

Care bundles for management of obstetrical hemorrhage.

Peripartum hemorrhage is one of the most preventable causes of maternal mortality worldwide. Much effort has been directed toward creating programs that address deficits in maternity care responsible for preventable hemorrhage-related morbidity and mortality. To have a significant impact on outcomes, such programs must address both providers and processes involved in the delivery of maternity care. At the core of a successful program, are standardized care bundles integrating medical and surgical techniques for managing hemorrhage with principles of transfusion medicine and critical care. In this article, we review the components of the safety bundle for obstetric hemorrhage developed by ACOG District II Safe Motherhood Initiative.

Labor induction for premature rupture of membranes using vaginal misoprostol versus dinoprostone vaginal insert.

OBJECTIVE: To compare labor induction outcomes using vaginal misoprostol versus dinoprostone insert in women with premature rupture of membranes (PROM) and an unfavorable cervix. STUDY DESIGN: Charts of singleton gestations beyond 34 weeks with PROM and an unfavorable cervix from 2008 to 2011 were reviewed. Group assignment was determined by initial induction agent used. Dinoprostone was administered as a 10-mg vaginal insert left for up to 12 hours. Misoprostol was administered vaginally as a 25-µg tablet every 4 hours for up to six doses. Times to active labor, complete dilatation, and delivery and incidence of adverse outcomes (intrapartum fever, tachysystole, fetal heart rate abnormalities) were compared. RESULTS: Ninety-eight women were included. Baseline characteristics between groups were not different. Median times to active labor (7 versus 11 hours, p < 0.001) and complete dilatation (13.5 versus 19 hours, p < 0.001) were shorter in the misoprostol group. In the misoprostol group, 41.7 and 88.4% of patients delivered vaginally within 12 and 24 hours, respectively, compared with 20.8 and 58.0% in the dinoprostone group (p < 0.001). There was no difference in incidence of adverse outcomes. CONCLUSION: Vaginal misoprostol is more effective than dinoprostone insert for induction secondary to PROM without increasing the incidence of adverse outcomes.

Comprehensive perinatal safety initiative to reduce adverse obstetric events.

A comprehensive perinatal safety initiative (PSI) was incrementally introduced from August 2007 to July 2009 at a large tertiary medical center to reduce adverse obstetrical outcomes. The PSI introduced: (1) evidence-based protocols, (2) formalized team training with emphasis on communication, (3) standardization of electronic fetal monitoring with required documentation of competence, (4) a high-risk obstetrical emergency simulation program, and (5) dissemination of an integrated educational program among all healthcare providers. Eleven adverse outcome measures were followed prospectively via modification of the Adverse Outcome Index (MAOI). Additionally, individual components were evaluated. The logistic regression model found that within the first year, the MAOI decreased significantly to 0.8% from 2% (p<.0004) and was maintained throughout the 2-year period. Significant decreases over time for rates of return to the operating room (p<.018) and birth trauma (p<.0022) were also found. Finally, significant improvements were found in staff perceptions of safety (p<.0001), in patient perceptions of whether staff worked together (p<.028), in the management (p<.002), and documentation (p<.0001) of abnormal fetal heart rate tracings, and the documentation of obstetric hemorrhage (p<.019). This study demonstrates that a comprehensive PSI can significantly reduce adverse obstetric outcomes, thereby improving patient safety and enhancing staff and patient experiences.

Diagnosis of placental abscess in association with recurrent maternal bacteremia in a twin pregnancy.

BACKGROUND: Placental abscess formation is rarely recognized prenatally. We present a case detected ultrasonographically that developed from a central line infection and caused recurrent maternal bacteremia. CASE: A young woman with a 21-week twin gestation presented with recurrent fevers. She had received treatment for bacteremia due to Serratia marcescens. The initial source of the infection was a peripherally inserted central catheter line placed in the first trimester for hyperemesis gravidarum. Fevers continued throughout the second course of antibiotics. An abscess seen sonographically in twin A's placenta was aspirated using a spinal needle, revealing Serratia bacteria. Aspiration was performed at 22 weeks of gestation. Amniotic fluid samples obtained from both sacs were negative for infection. Over 4 weeks, the abscess enlarged and she was delivered. Twin A died of sepsis and twin B had a relatively favorable neonatal course. CONCLUSION: Prenatal diagnosis of placental abscess presents a difficult management dilemma. Traditional amniotic fluid studies did not predict the poor outcome of the affected fetus.

Collagen messenger RNA expression in the human amniochorion in premature rupture of membranes.

OBJECTIVE: It has been suggested that there is a decrease in the collagen content of the fetal membranes when there is premature rupture of the membranes before the onset of labor. This study was designed to determine whether decreased amniochorion collagen production (as measured by reduced amounts of messenger RNA) or alterations in relative production of different fibrillar and nonfibrillar collagens are associated with premature rupture of the membranes. STUDY DESIGN: Fetal membranes were collected after preterm (24-36 weeks of gestation) and term (> or =37 weeks of gestation) deliveries both with and without premature rupture of the membranes. Specimens with evidence of histologic chorioamnionitis were excluded. The messenger RNA levels for fibrillar collagen types I, III, and V and fibril-associated collagens with interrupted triple-helices types XII and XIV were measured with relative quantitative reverse transcriptase-polymerase chain reaction. RESULTS: The messenger RNA levels for fibrillar collagens decreased with advancing gestational age. Preterm premature rupture of membranes was associated with increased messenger RNA levels for fibrillar collagens and fibril-associated collagens with interrupted triple-helices collagen XII, but not type XIV. The greatest change in relative amounts of collagen messsenger RNA was demonstrated by an increased type I/XIV ratio, which was due to the up-regulation of type I levels, but not type XIV levels. CONCLUSION: A rise in fibrillar collagen production (messenger RNA) for types I, III, and V and fibril-associated collagens with interrupted triple-helices collagen type XII is observed with preterm premature rupture of the membranes. There is no evidence for a similar up-regulation of messenger RNA for fibril-associated collagens with interrupted triple-helices collagen type XIV. The rise in the collagen I/XIV messenger RNA ratio in preterm premature rupture of the membranes may result in collagen fibrils without enough stabilizing fibril-associated collagens with interrupted triple-helices type XIV on the fibril surface to maintain structural integrity.