Increased Rates of Hypertensive Disorders of Pregnancy during the COVID-19 Pandemic.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) are common complications associated with severe maternal and neonatal morbidity. One goal of prenatal care, especially at term, is to screen for HDP. As treatment of HDP centers on delivery when appropriate, timely diagnosis is crucial. We postulated that reduced in-person visits during the coronavirus disease 2019 (COVID-19) pandemic may have resulted in delayed diagnosis of HDP with concomitant higher rates of maternal morbidity. We sought to investigate the prevalence of HDP during the COVID-19 pandemic, as well as median gestational age at time of delivery as compared with the prepandemic median. STUDY DESIGN: This was a retrospective cohort analysis comparing singleton deliveries at four large-volume hospitals during the COVID-19 pandemic (April-July 2020 during a statewide "stay-at-home" order) to those in a pre-COVID era (April-July 2019). Deliveries complicated by HDP were identified by International Classification of Disease, Tenth Revision codes. Rates of HDP and markers of severe disease were the primary outcomes compared between the groups; multivariate regression was used to calculate the odds ratio of severe disease among women with any diagnosis of HDP. RESULTS: The cohort included 9,974 deliveries: 5,011 in 2020 and 4,963 in 2019. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ significantly between the groups. There was an increase in HDP during the COVID era (9.0 vs. 6.9%; p < 0.01), which was significant even when controlling for patient parity (odds ratio 1.41, 95% CI 1.20-1.66). Among women with HDP, gestational age at delivery did not differ between the cohorts, nor did the proportion of patients with severe disease. CONCLUSION: We found a statistically significant increase in the rate of HDP during the COVID-19 pandemic. However, there was no change in the proportion of severe disease, suggesting that this increase did not significantly impact clinical morbidity. KEY POINTS: · Rates of HDP increased during the COVID-19 pandemic.. · There was no change in the proportion of severe HDP.. · HDP-related maternal/neonatal morbidity was unchanged..

Case series of tubo-ovarian abscesses after saline infusion sonohysterography: reconsidering antibiotic prophylaxis.

Saline infusion sonohysterography (SIS) is useful for evaluating intrauterine pathology, particularly for patients with abnormal uterine bleeding and during assessment of infertility. Infectious complications are relatively rare, and tubo-ovarian abscess (TOA) after SIS has only been reported once in the literature. We present two additional cases of TOA after SIS that presented to our institution. First, a 40-year-old female with known endometriosis and bilateral tubal occlusion, presented with ruptured TOA fifteen days after SIS during fertility evaluation. The second, a 45-year-old female with endometriomas and a hydrosalpinx identified on SIS, diagnosed with TOAs four days after SIS for abnormal uterine bleeding evaluation. While hysterosalpingogram has defined antibiotic prophylaxis criteria, and despite likely similar mechanisms for ascending infections, current guidelines do not recommend prophylaxis after SIS. These cases suggest infectious complications, such as TOA, after SIS may be more common than previously reported, and as demonstrated by these cases can have serious clinical consequences for patients. Furthermore, by comparing to a technically similar procedure as HSG, it may be reasonable to consider if certain patients at high risk of complication may benefit from antibiotic prophylaxis to prevent serious clinical infections.

Impact of a Hybrid Model of Prenatal Care on the Diagnosis of Fetal Growth Restriction.

OBJECTIVE: Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and screening via fundal height or ultrasound is routinely performed. During the novel coronavirus disease 2019 (COVID-19) pandemic, we developed a hybrid model of prenatal care which decreased the frequency of in-person visits and incorporated telemedicine visits. We sought to determine if prenatal FGR diagnoses decreased with this hybrid model compared with routine prenatal care. STUDY DESIGN: This was a retrospective cohort study of singleton nonanomalous neonates with birth weights <10th percentile at term. The "routine care" group was consisted of those who born between April and July 2019 with in-person prenatal care, and the "hybrid care" group was consisted of those who born between April and July 2020 with both in-person and telemedicine prenatal cares at a collaborative academic practice. The primary outcome was the rate of diagnosis of small for gestational age (SGA) as defined as infant birth weight <10th percentile without a prenatal diagnosis of FGR. The secondary outcome was timing of diagnosis of FGR. RESULTS: Overall, 1,345 and 1,296 women gave birth in the routine and hybrid groups, respectively. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7,727 in the hybrid period; 3,265 telemedicine visits occurred during the hybrid period. The total number of prenatal patients remained relatively stable at 3,993 and 3,753 between periods. Third trimester ultrasounds decreased from 2,929 to 2,014 between periods. Birth weights <10 percentile occurred in 115 (8.6%) births during the routine period and 79 (6.1%) births during the hybrid period. Of 115, 44 (38.3%) cases were prenatally diagnosed with FGR in the routine versus 28 of 79 (35.4%) in the hybrid group (p = 0.76). Median gestational age at diagnosis did not vary between groups (36 vs. 37 weeks, p = 0.44). CONCLUSION: A hybrid prenatal care model did not alter the detection of FGR. Future efforts should further explore the benefits of incorporating telemedicine into prenatal care. KEY POINTS: · Telemedicine visits can provide comprehensive prenatal care.. · FGR was diagnosed equally with hybrid versus routine prenatal care.. · FGR diagnosis was not delayed with hybrid care..

Investigating Decreased Rates of Nulliparous Cesarean Deliveries during the COVID-19 Pandemic.

OBJECTIVE: Preventing the first cesarean delivery (CD) is important as CD rates continue to rise. During the novel coronavirus disease 2019 (COVID-19) pandemic, quality improvement metrics at our hospital identified lower rates of CD. We sought to investigate this change and identify factors that may have contributed to the decrease. STUDY DESIGN: We compared nulliparous singleton deliveries at a large academic hospital during the COVID-19 pandemic (April through July 2020 during a statewide "stay-at-home" order) to those in the same months 1 year prior to the pandemic (April through July 2019). The primary outcome, mode of delivery, was obtained from the electronic medical record system, along with indication for CD. RESULTS: The cohort included 1,913 deliveries: 892 in 2019 and 1,021 in 2020. Patient characteristics (age, body mass index, race, ethnicity, and insurance type) did not differ between the groups. Median gestational age at delivery was the same in both groups. The CD rate decreased significantly during the COVID-19 pandemic compared with prior (28.9 vs. 33.6%; p = 0.03). There was a significant increase in the rate of labor induction (45.7 vs. 40.6%; p = 0.02), but no difference in the proportion of inductions that were elective (19.5 vs. 20.7%; p = 0.66). The rate of CD in labor was unchanged (15.9 vs. 16.3%; p = 0.82); however, more women attempted a trial of labor (87.0 vs. 82.6%; p = 0.01). Thus, the proportion of CD without a trial of labor decreased (25.1 vs. 33.0%; p = 0.04). CONCLUSION: There was a statistically significant decrease in CD during the COVID-19 pandemic at our hospital, driven by a decrease in CD without a trial of labor. The increased rate of attempted trial of labor suggests the presence of patient-level factors that warrant further investigation as potential targets for decreasing CD rates. Additionally, in a diverse and medically complex population, increased rates of labor induction were not associated with increased rates of CD. KEY POINTS: · Primary CD rate fell during COVID-19 pandemic.. · Decrease was driven by more women attempting labor.. · Higher rate of induction without rise in CD rate was found..

Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: Building a platform for ultimate sustainability in a resource-limited setting.

OBJECTIVE: Despite its near complete eradication in resource-rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center. METHODS: We describe the experience of consecutive annual visits to Rwanda since 2008 and report the outcomes of a collaborative approach to enable sustainable cardiac surgery in the region. The Ferrans and Powers Quality of Life Index tool's Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess the postoperative quality of life. RESULTS: Ten visits have been completed, performing 149 open procedures, including 200 valve implantations, New York Heart Association class III or IV, with 4.7% 30-day mortality. All procedures were performed with the participation of local Rwandan personnel, expatriate physicians, nurses, residents, and support staff. Early complications included cerebrovascular accident (n = 4), hemorrhage requiring reoperation (n = 6), and death (n = 7). Quality of life was assessed to further understand challenges encountered after cardiac surgery in this resource-limited setting. Four major domains were considered: health and functioning, social and economic, psychologic/spiritual, and family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0 to 30, for which higher scores indicated higher quality of life. Women had significantly lower "social and economic" subscores (16.81 ± 4.17) than men (18.64 ± 4.10) (P < .05). Patients who reported receiving their follow-up care in rural health centers also had significantly lower "social and economic" subscores (15.67 ± 3.81) when compared with those receiving follow-up care in urban health facilities (18.28 ± 4.16) (P < .005). Value afforded to family and psychologic factors remained high among all groups. Major postsurgical challenges faced included barriers to follow-up and systemic anticoagulation. CONCLUSIONS: This report represents the first account of a long-term humanitarian effort to develop sustainability in cardiac surgery in a resource-limited setting, Rwanda. With the use of volunteer teams to deliver care, transfer knowledge, and mentor local personnel, the results demonstrate superior outcomes and favorable indices of quality of life. The credibility gained over a decade of effort has created the opportunity for a partnership with Rwanda to establish a dedicated center of cardiac care to assist in mitigating the burden of cardiovascular disease throughout sub-Saharan Africa.