Coronavirus disease 2019 pregnancy outcomes in a racially and ethnically diverse population.

Background: Older age and medical comorbidities are identified risk factors for developing severe coronavirus disease 2019. However, there are limited data on risk stratification, clinical and laboratory course, and optimal management of coronavirus disease 2019 in pregnancy. Objective: Our study aimed to describe the clinical course of coronavirus disease 2019, effect of comorbidities on disease severity, laboratory trends, and pregnancy outcomes of symptomatic and asymptomatic severe acute respiratory syndrome coronavirus 2-positive pregnant women. Study Design: This is a case series of pregnant and postpartum women who received positive test results for severe acute respiratory syndrome coronavirus 2 between March 3, 2020, and May 11, 2020, within 3 hospitals of the Yale New Haven Health delivery network. Charts were reviewed for basic sociodemographic and prepregnancy characteristics, coronavirus disease 2019 course, laboratory values, and pregnancy outcomes. Results: Of the 1567 tested pregnant and postpartum women between March 3, 2020, and May 11, 2020, 9% (n=141) had a positive severe acute respiratory syndrome coronavirus 2 result. Hispanic women were overrepresented in the severe acute respiratory syndrome coronavirus 2-positive group (n=61; 43.8%). In addition, Hispanic ethnicity was associated with a higher rate of moderate and severe diseases than non-Hispanic (18% [11/61] vs 3.8% [3/78], respectively; odds ratio, 5.5; 95% confidence interval, 1.46-20.7; P=.01). Of note, 44 women (31.2%) were asymptomatic, 37 of whom (26.2%) were diagnosed on universal screening upon admission for delivery. Moreover, 59% (n=83) were diagnosed before delivery, 36% (n=51) upon presentation for childbirth, and 5% (n=7) after delivery. Severe disease was diagnosed in 6 cases (4.3%), and there was 1 maternal death. Obese women were more likely to develop moderate and severe diseases than nonobese women (16.4% [9/55] vs 3.8% [3/79]; odds ratio, 4.96; 95% confidence interval, 1.28-19.25; P=.02). Hypertensive disorders of pregnancy were diagnosed in 22.3% of women (17/77) who delivered after 20 weeks' gestation. Higher levels of C-reactive protein during antepartum coronavirus disease 2019-related admission were more common in women with worse clinical course; however, this association did not reach statistical significance. Conclusion: Coronavirus disease 2019 in pregnancy may result in severe disease and death. Hispanic women were more likely to receive a positive test result for severe acute respiratory syndrome 2 than other ethnic groups. Obesity and Hispanic ethnicity represent risk factors for moderate and severe diseases.

Outcome after implementation of a modern management strategy for intrahepatic cholestasis of pregnancy.

OBJECTIVE: The aim of this study was to determine whether the institution of a modern management strategy affected pregnancy outcomes for intrahepatic cholestasis of pregnancy (ICP). METHODS: We performed a retrospective cohort study of women diagnosed with ICP at one hospital from 2005 to 2013. A new management protocol for ICP was instituted in 2009 for women with total bile acids >40 µmol/L at <36 weeks. This strategy included inpatient admission, continuous fetal heart rate monitoring, with delivery between 36 and 37 weeks. We compared maternal and neonatal outcomes prior and subsequent to the institution of this protocol. RESULTS: We identified 186 singleton gestations with bile acids >40 µmol/L and diagnosis <36 weeks. Patient demographics were similar between the groups, with the exception of greater maternal age and gestational diabetes in the newer cohort. The newer cohort demonstrated a significant reduction in the incidence of stillbirth 0% versus 3.4%, p= 0.035). There was no difference in the age at delivery, cesarean delivery rates or NICU admissions. CONCLUSION: Application of our management strategy for ICP reduced the stillbirth rate without adversely affecting other maternal and neonatal outcomes.

A randomized trial of Foley balloon induction of labor trial in nulliparas (FIAT-N).

BACKGROUND: With an increasing rate of induction of labor, it is important to choose induction methods that are safe and efficient in achieving a vaginal delivery. The optimal method for inducing nulliparous women with an unfavorable cervix is not known. OBJECTIVE: We sought to determine if induction of labor with simultaneous use of oxytocin and Foley balloon vs sequential use of Foley balloon followed by oxytocin decreases the time to delivery in nulliparous women. STUDY DESIGN: We conducted a randomized controlled trial of nulliparous women presenting for induction at a single institution from December 2013 through March 2015. After decision for induction was made by their primary provider, women with gestational age ≥24 weeks with a nonanomalous, singleton fetus in vertex presentation with intact membranes were offered participation. Exclusion criteria included history of uterine surgery, unexplained vaginal bleeding, latex allergy, or contraindication to vaginal delivery. Participants were randomized to either simultaneous (oxytocin and Foley balloon) or sequential (oxytocin after expulsion of Foley balloon) induction group. The primary outcome was time from induction to delivery. Secondary outcomes included mode of delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, and composite neonatal outcome. Maternal and neonatal outcomes were collected via chart review. Analyses were done on an intention-to-treat basis. RESULTS: A total of 166 patients were enrolled; 82 in the simultaneous and 84 in the sequential group. There were no differences in baseline characteristics in the 2 groups. Patients who received simultaneous oxytocin with insertion of a Foley balloon delivered significantly earlier (15.92 vs 18.87 hours, P = .004) than those in the sequential group. There was no difference in rate of cesarean delivery, estimated blood loss, postpartum hemorrhage, chorioamnionitis, or composite neonatal outcome. CONCLUSION: Simultaneous use of oxytocin and Foley balloon for induction of labor results in a significantly shorter interval to delivery in nulliparas.

Higher-order Multiples.

Higher-order multiple gestations have increased since the advent of advanced reproductive technologies. These pregnancies present unique risks to both mothers and fetuses. It is imperative that early diagnosis of chronicity be determined and that proper counseling is performed, so patients understand the risks, evaluation, and management needed.

Persistence of placenta previa in twin gestations based on gestational age at sonographic detection.

OBJECTIVES: The purpose of this study was to evaluate the gestational age at sonographic detection of placenta previa as a predictor of previa persistence until delivery in twin gestations. METHODS: A retrospective cohort of twin pregnancies with placenta previa in a single ultrasound unit was analyzed from 2005 to 2010. Pregnancies were ascertained from a database. Diagnoses were confirmed by transvaginal imaging. Previa was categorized as complete if the placenta completely covered the internal os or marginal if the inferior placental edge reached within 2 cm. Gestational ages were grouped into intervals from 15 to 35 weeks. The study outcome was placenta previa at delivery. Only twin pregnancies at 25 weeks' gestation and later were analyzed using nonparametric statistics as appropriate, with P < .05 as significant. RESULTS: Placenta previa was detected in 120 twin pregnancies in the second trimester: 32 complete and 88 marginal. Of those with placenta previa at 15 to 19, 20 to 23, 24 to 27, 28 to 31, and 32 to 35 weeks, previa persisted until delivery in 8.3%, 19.2%, 50%, 75%, and 92.5%, respectively. Only at 15- to 19- and 20- to 23-week intervals was complete previa more likely to persist than marginal previa (P < .001). CONCLUSIONS: The likelihood of placenta previa persistence in twins is dependent on the gestational age at sonographic detection. Only at earlier gestations does the type of previa affect its persistence. As gestational age advances, the likelihood of resolution of placenta previa diminishes regardless of the type noted.