A strategy for disaster preparedness in obstetrics.

BACKGROUND: Many hospital units, including obstetric (OB) units, were unprepared when the novel coronavirus began sweeping through communities. National and international bodies, including the World Health Organization, Centers for Disease Control Prevention, and the American College of Obstetricians and Gynecologists, directed enormous efforts to present the latest evidence-based practices to healthcare institutions and communities. The first hospitals that were affected in China and the United States (US) did heroic work in assisting their colleagues with best practices they had acquired. Despite these resources, many US hospitals struggled with how to best incorporate and implement this new information into disaster plans, and many protocol changes had to be established de novo. In general, disaster planning for OB units lagged behind other disaster planning performed by specialties such as emergency medicine, trauma, and pediatrics. PARTICIPANTS: Fortunately, two pre-existing collaborative disaster groups, the OB Disaster Planning Workgroup and the Western Regional Alliance for Pediatric Emergency Management, were able to rapidly deploy during the pandemic due to their pre-established networks and shared goals. MAIN OUTCOME: These groups were able to share best practices, identify and address knowledge gaps, and disseminate information on a broad scale. The case will be made that the OB community needs to establish more such regional and national disaster committees that meet year-round. This will ensure that in times of urgency, these groups can increase the cadence of their meetings, and thus rapidly disperse time-sensitive policies and procedures for OB units nationwide. CONCLUSION: Given the unique patient population, it is imperative that OB units establish regional coalitions to facilitate a coordinated response to local and national disasters.

Rapid Deployment of a Drive-Through Prenatal Care Model in Response to the Coronavirus Disease 2019 (COVID-19) Pandemic.

Coronavirus disease 2019 (COVID-19) has been declared a public health emergency for the entire United States. Providing access to prenatal health care while limiting exposure of both obstetric health care professionals and patients to COVID-19 is challenging. Although reductions in the frequency of prenatal visits and implementation of telehealth interventions provide some options, there still remains a need for patient-health care professional visits. A drive-through prenatal care model was developed in which pregnant women would remain in their automobiles while being assessed by the health care professional, thus reducing potential patient, health care professional, and staff exposure to COVID-19. Drive-through prenatal visits would include key elements that some institutions cannot perform by telehealth encounters, such as blood pressure measurements for evaluation for hypertensive disorders of pregnancy, fetal heart rate assessment, and selected ultrasound-based measurements or observations, as well as face-to-face patient-health care professional interaction, thereby reducing patient anxiety resulting from the reduction in the number of planned clinic visits with an obstetric health care professional as well as fear of virus exposure in the clinic setting. We describe the rapid development of a drive-through prenatal care model that is projected to reduce the number of in-person clinic visits by 33% per patient compared with the traditional prenatal care paradigm, using equipment and supplies that most obstetric clinics in the United States can access.

Obstetrician-Gynecologists' Role Conflict in a Natural Disaster: Professional Versus Family Responsibilities.

OBJECTIVE: The purpose of this study was to evaluate role conflict between professional and familial responsibilities among obstetric health care providers during a natural disaster between those required to stay in the hospital versus those who were at home during a catastrophic weather event. METHODS: A survey was used of obstetric attending and resident physicians in the Baylor College of Medicine, Department of Obstetrics and Gynecology following Hurricane Harvey on August 26, 2017. RESULTS: Ninety one of 103 physicians (88%) completed the survey. Survey responses were compared between physicians who worked in the hospital (n = 47) versus those who were at home (n = 44) during the storm and its immediate aftermath. Physicians in the hospital and at home agreed (47% and 48%, respectively, P = 0.94) that professional duties conflicted with family obligations and felt torn (49% and 55%, respectively, P = 0.48) regarding family obligations. A majority of homebound health care providers disagreed with the statement that professional duties override family responsibilities, whereas less than half of in-hospital providers felt the same (68% at-home versus 47% of the hospital-team, P = 0.10). CONCLUSION: As organizations prepare for possible catastrophic situations, institutions must realize that obstetric health care providers will experience role conflict between professional and family responsibilities. (Disaster Med Public Health Preparedness. 2019;13:33-37).

Fetal Heart Rate Response to Maternal Exercise.

Current guidelines regarding recommended exercise in pregnancy appear consistent with reported research regarding fetal heart changes in response to maternal exercise. Fetal heart rate increases during pregnancy, but maternal exercise appears well tolerated if performed in uncomplicated pregnancies and not in the supine position. Maximal levels of exercise that are well tolerated by the fetus have not yet been well defined; however, recent literature suggests that sustained exercise during pregnancy may have beneficial effects on autonomic control of fetal heart rate and variability that may lead to long-term health benefits.

Geospatial analysis of food environment demonstrates associations with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is one of most common complications of pregnancy, with incidence rates varying by maternal age, race/ethnicity, obesity, parity, and family history. Given its increasing prevalence in recent decades, covariant environmental and sociodemographic factors may be additional determinants of GDM occurrence. OBJECTIVE: We hypothesized that environmental risk factors, in particular measures of the food environment, may be a diabetes contributor. We employed geospatial modeling in a populous US county to characterize the association of the relative availability of fast food restaurants and supermarkets to GDM. STUDY DESIGN: Utilizing a perinatal database with >4900 encoded antenatal and outcome variables inclusive of ZIP code data, 8912 consecutive pregnancies were analyzed for correlations between GDM and food environment based on countywide food permit registration data. Linkage between pregnancies and food environment was achieved on the basis of validated 5-digit ZIP code data. The prevalence of supermarkets and fast food restaurants per 100,000 inhabitants for each ZIP code were gathered from publicly available food permit sources. To independently authenticate our findings with objective data, we measured hemoglobin A1c levels as a function of geospatial distribution of food environment in a matched subset (n = 80). RESULTS: Residence in neighborhoods with a high prevalence of fast food restaurants (fourth quartile) was significantly associated with an increased risk of developing GDM (relative to first quartile: adjusted odds ratio, 1.63; 95% confidence interval, 1.21-2.19). In multivariate analysis, this association held true after controlling for potential confounders (P = .002). Measurement of hemoglobin A1c levels in a matched subset were significantly increased in association with residence in a ZIP code with a higher fast food/supermarket ratio (n = 80, r = 0.251 P < .05). CONCLUSION: As demonstrated by geospatial analysis, a relationship of food environment and risk for gestational diabetes was identified.

Support Desired by Women Following Termination of Pregnancy for a Fetal Anomaly.

With the rapidly evolving field of prenatal testing, there is a growing need to provide support for women pursuing termination of pregnancy following the discovery of a fetal anomaly. Previous studies have documented that women in this situation often feel unsupported, but the type of resources desired by this population remains undetermined. We studied the awareness and utilization of support resources in 51 women at the time of the procedure, at 6 weeks, and at 3 months following the event. Though largely knowledgeable of existing resources at the time of the procedure, only 50 % admitted contemplating their individualized need for support. Most expected to rely on the support of family and friends. Additionally, 50 % expressed the desire to commemorate the pregnancy, though none wanted direct contact with their healthcare provider(s). Responses from the 6 weeks and 3 months assessments were consistent with previous literature as many women indicated not coping as expected and were unprepared for the psychological consequences following the procedure. Our findings indicate that women in these situations may not realize what their long-term support needs will be. They further indicate that guidelines for routine follow-up care should be established among healthcare providers that respect this population's initial desires to avoid reminders of the pregnancy and promote a flexible timeframe for support uptake. Additional support resources that promote flexible uptake as well as meet the desires of anonymity and ease of access need to be developed for this population.

Cross-cultural barriers to health care.

Culturally sensitive health care represents a real ethical and practical need in a Western healthcare system increasingly serving a multiethnic society. This review focuses on cross-cultural barriers to health care and incongruent aspects from a cultural perspective in the provision of health care. To overcome difficulties in culturally dissimilar interactions and eventually remove cross-cultural barriers to health care, a culturally sensitive physician considers his or her own identity, values, and beliefs; recognizes the similarities and differences among cultures; understands what those similarities and differences mean; and is able to bridge the differences to accomplish clear and effective communication.

Is thrombin activation predictive of subsequent preterm delivery?

OBJECTIVE: To determine the relation between thrombin generation (measured by thrombin-antithrombin [TAT] complexes) early in pregnancy and subsequent preterm delivery. STUDY DESIGN: Select cohort of 731 women undergoing indicated second trimester amniocentesis prospectively followed to delivery. Primary outcome was preterm delivery. TAT levels were examined continuously and categorized by quartiles. Multivariable techniques were applied to adjust for potential confounders. Receiver operating characteristic curve analysis was used to determine a discriminatory cutoff level for TAT complexes. RESULTS: TAT concentration was significantly higher in women who delivered preterm (median, 98.9 mcg/L) than in those who did not (median, 66.3 mcg/L; P < .001). This difference persisted when 55 spontaneous preterm deliveries (median, 87.6 mcg/L) and 34 indicated preterm deliveries (median, 117.7 mcg/L) were separately compared with controls (P = .04 and P < .001, respectively). Crude and adjusted odds ratio for preterm delivery in the upper 2 TAT quartiles relative to the uppermost quartile relative to the lowest quartile were 2.45 (95% confidence interval [CI], 1.36-4.72; P = .004) and 2.31 (95% CI, 1.18-4.65; P = .017), respectively. Despite these distinct differences, the area under the receiver operating characteristic curve was only 0.62 (95% CI, 0.56-0.69), indicating poor performance of TAT concentration as a risk discriminator. CONCLUSION: Amniotic fluid levels of TAT complexes in the second trimester are elevated in women who subsequently deliver preterm, suggesting that thrombin generation may be involved in the various etiopathogenic mechanisms leading to preterm delivery.

Prospective investigation of second-trimester thrombin activation and preterm birth.

OBJECTIVE: We sought to determine if second-trimester amniotic fluid thrombin-antithrombin (TAT) complexes concentration correlates with subsequent preterm birth. STUDY DESIGN: A cohort of 550 women with singleton nonanomalous pregnancies undergoing second-trimester genetic amniocentesis was followed up to delivery and analyzed as a nested case-control study. Cases of preterm birth (n = 52) were compared with 104 term control subjects. Amniotic fluid collected at amniocentesis was tested for TAT. RESULTS: TAT concentrations were significantly higher in women who delivered preterm (median 115.9 µg/L) than in those who did not (median 62.2 µg/L; P < .001). This difference persisted when 31 spontaneous preterm births and 21 indicated preterm births were analyzed separately. The odds ratios for preterm birth in the highest TAT quartile relative to the lowest quartile was 4.98 (95% confidence interval, 1.17-22.01; P = .007). CONCLUSION: We found a difference in the pattern of intraamniotic thrombin generation between women destined to deliver at term and those who deliver preterm, regardless of the type of preterm birth.

Population standards of birth weight underestimate fetal growth abnormalities in diabetic pregnancies.

The objective of this study was to compare the frequency of abnormal fetal growth in women with diabetes mellitus (DM) using population-based birth weight (pop BW) percentiles compared with customized birth weight (cust BW) percentiles, which include adjustments for maternal race, parity, height, weight, and fetal sex. The study design comprised a retrospective cohort of singleton DM pregnancies delivered over a 1-year period (June 2007 to May 2008) from a single tertiary care university-based medical center. Inclusion criteria were gestational age >20 weeks at delivery, live birth, and absence of major chromosomal/structural abnormalities. Small for gestational age (SGA), <10th percentile, and large for gestational age (LGA), >90th percentile pregnancies were categorized based on pop BW or cust BW standards. There were significant differences in the rates of SGA (p < 0.004) and LGA (p < 0.001) between cust BW and pop BW methods. When comparing the two methods, pop BW did not identify 13/16 (81%) of SGA and 23/39 (59%) of LGA babies defined by cust BW methods. The use of cust BW calculation in a diabetic population identified a greater percentage of neonates with pathologic fetal growth compared with pop BW standards, suggesting that the population standard may underdiagnose abnormal fetal growth in diabetic pregnancies.

First-trimester screening and its impact on uptake of diagnostic testing.

OBJECTIVE: To determine the influence of first-trimester screening (FTS) on a patient's decision regarding prenatal diagnostic testing (PDT) and if the uptake rate of PDT has changed among women with advanced maternal age (AMA) following the January 2007 American College of Obstetricians and Gynecologists statement regarding FTS. METHODS: A database review was performed for the 2 years before and the 2 years after the January statement. A total of 7424 patient records were evaluated to determine the number of AMA women who obtained PDT, the number of positive and negative FTS results, and how many of those women had PDT. We then surveyed 53 patients and 23 referring physicians to determine what the patient understands about FTS, how patients utilize their FTS results, and how physicians educate their patients about FTS. RESULTS: We determined that there was a 19.6% decrease in the uptake of PDT since that statement. Prior to their counseling session (2009-2010), 43% of those surveyed were against having PDT. After counseling, only 9% were against PDT. Overall, 91% were either open to or wanted PDT after counseling. CONCLUSIONS: In addition to FTS results, we found that genetic counseling may be an influential factor in the patient's decision regarding PDT.

Excessive gestational weight gain in women with gestational and pregestational diabetes.

We sought to determine the frequency of excessive gestational weight gain (GWG) and its impact on perinatal outcomes in women with gestational (GDM) and pregestational diabetes mellitus (DM). A retrospective cohort of diabetic women was studied. GWG was categorized by the 2009 Institute of Medicine guidelines. Perinatal outcomes were compared between those women with and without excessive GWG. There were 153 women who met study criteria. There was no difference in excessive GWG between women with GDM and pregestational DM (44.4% versus 38.5%, P = 0.51) or based on White's class ( P = 0.17). After adjusting for confounders, excessive GWG was not associated with an increased rate of adverse perinatal outcomes (odds ratio 1.49, 95% confidence interval 0.56 to 2.35) and had similar associations with both pregestational DM and GDM. Although excessive GWG was common in our diabetic population, it was not associated with an increased rate of adverse perinatal outcomes.

Continuation of pregnancy after antenatal corticosteroid administration: opportunity for rescue?

OBJECTIVE: To determine the duration of continuing pregnancy after antenatal corticosteroid (AC) administration and to evaluate the potential opportunity for rescue AC. STUDY DESIGN: Retrospective analysis of women at 24-32 weeks' gestation who received AC at one institution. RESULTS: Six hundred ninety-two women received AC. Two hundred forty-seven (35.7%) delivered at > or = 34 weeks' gestation. Three hundred twenty-one (46.4%) delivered within 1 week of AC; 92 of those women (13.3%) delivered within 24 hours. Only 124 (17.9%) remained pregnant 1 week after AC and delivered at < 34 weeks. The latter were compared to women delivering > 2 week after AC but > or = 34 weeks. More likely to deliver at < 34 weeks were those women who received AC for premature preterm rupture of membranes (OR 3.83, 95% CI 2.06-7.17), twins (OR 2.90, 95% CI 1.42-5.95) or before 28 weeks (OR 2.21, 95% CI 1.38-3.52). CONCLUSION: Rescue AC may apply to only 18% of cases, and we identified subsets of more likely candidates.

Intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy: a practice survey.

OBJECTIVE: To assess practice patterns concerning intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy among members of the Association of Professors of Gynecology and Obstetrics (APGO). STUDY DESIGN: A 16-question survey regarding intraoperative fetal heart rate monitoring during nonobstetric surgery was delivered to the 1300 APGO members via email. Descriptive statistics were used to determine the reasons for fetal monitoring during nonobstetric surgery in pregnancy. RESULTS: Concerning intraoperative monitoring during nonobstetric surgery, 98% of respondents recorded the fetal heart rate pre-and post-surgery, and 43% of respondents reported they usually monitor intraoperatively. Of the 1151 physicians surveyed, 16% completed the survey. CONCLUSION: The majority of APGO members surveyed do not employ intraoperative fetal heart rate monitoring during nonobstetric surgery in pregnancy.

White's classification of diabetes in pregnancy in the 21st century: is it still valid?

White's classification system (WCS) was created 60 years ago to identify diabetic (DM) pregnancies at increased risk for perinatal morbidity and mortality. Our objective was to assess the association between WCS and adverse pregnancy outcome (APO) in contemporary DM pregnancies. We studied diabetic women with singleton pregnancies who delivered at >20 weeks at a single institution over a 1-year period (2007 to 2008). Perinatal outcomes were compared between WCS groups. APO was defined as any of the following: preterm birth <34 weeks, severe preeclampsia, shoulder dystocia, and neonatal respiratory disease. Presence of vascular disease was defined as presence of chronic hypertension, chronic renal insufficiency, retinopathy, coronary artery disease, or prior cerebrovascular event. One hundred ninety-six DM pregnancies met the criteria. No significant differences in APO existed between White's class groups among women with pregestational DM (32.7% class B versus 26.9% class C versus 57.1% class D to F; p = 0.46). Logistic regression revealed that vascular disease was associated with APO (odds ratio = 2.7, 95% confidence interval = 1.2 to 6.2). In our population, presence of vascular disease, rather than WCS, was a better predictor of APO in DM women.

Fetal trisomy 21 and the risk of preeclampsia.

OBJECTIVE: Microchimerism has been investigated as a possible contributor to the pathophysiology of preeclampsia. Although trisomy 21 is associated with pronounced microchimerism, it has not been connected with an increased risk of preeclampsia. Our objective was to readdress the relationship between preeclampsia and trisomy 21 in a large population. METHODS: Using the Texas Birth Defects Registry for 1999-2003, a cohort of 2995 pregnancies with a trisomy 21 fetus was identified and compared with a control cohort of 1959 pregnancies with fetal isolated oral clefts. Chi-square test was used to estimate the significance of observed difference in the proportion of preeclampsia between groups. The interactive and confounding effects of covariates were examined by stratified analysis and the Mantel-Haenszel method. RESULTS: We observed 84 cases of preeclampsia in the trisomy 21 cohort (3.7%) and 111 cases in the oral cleft cohort (5.7%). The crude OR for having preeclampsia in relation to trisomy 21 was 0.63 (95% CI 0.47-0.85). The OR estimates remained the same after adjustment for confounders. CONCLUSION: Pregnancies carrying a trisomy 21 fetus do not have an increased risk of preeclampsia. Besides epidemiologic significance, our data also have relevance for genetic counseling.

Utilization of obstetrical ultrasound in a referral population.

OBJECTIVE: To determine the number of ultrasounds performed prior to presentation to a maternal-fetal medicine (MFM) sub-specialist and the patient's perceived reason for referral. STUDY DESIGN: Women presenting for their first targeted ultrasound at an MFM unit in an urban center between November 2003 and April 2004 reported the number, location, and gestational age (GA) of prior ultrasounds and whether their insurance company had been billed for these studies. They also reported their current GA, insurance type, and perceived reason for referral. Pearson correlation and Kruskal-Wallis were used where appropriate; p < 0.05 was considered significant. RESULTS: Six hundred fifty-five women were invited to participate; 207 declined, leaving 448 available for the final analysis. The median number of prior ultrasounds was two (range 0-11). Twelve percent reported no prior ultrasound, 30% reported having had one, 28% reported having had two, and 29% reported having had three or more. Women presented at a mean GA of 21.3 +/- 5.4 weeks. They reported having had their first ultrasound at 9.9 +/- 2 weeks and their most recent prior ultrasound at 16.9 +/- 6.7 weeks. GA at presentation did not correlate with the number of prior ultrasounds (r = 0.17). Of 396 women with at least one prior ultrasound, 336 had at least one performed in their doctor's office and 74 had at least one performed in an ultrasound clinic; 183 stated that their insurance had been billed and 168 did not know if their insurance had been billed. The majority, 60%, had private insurance, 37% had Medicaid, and 2% had no insurance. Women with private insurance had a higher number of prior ultrasounds than women with Medicaid (2.3 +/- 1.4 vs. 1.5 +/- 1.3, p < 0.001). In response to the perceived reason for referral, 280 women stated their reason for referral to the MFM unit was for a routine ultrasound or to determine gender, 158 women reported that they were referred because their doctor was concerned about 'something', and 10 were unsure of their indication. CONCLUSION: Most women have at least one ultrasound prior to presenting to an MFM unit for a targeted scan. Many, especially those with private insurance, have had several prior ultrasounds. Patient education is needed about reasons for referral to an MFM unit for ultrasound and the possible increased financial burden of multiple ultrasounds.