Case report of pregnancy complicated by severe pulmonary hypertension from mitral stenosis and placenta accreta spectrum disorder: management of two life-threatening conditions.

Background: Antenatal cardiovascular disease is a major cause of maternal morbidity and mortality. Severe rheumatic mitral stenosis is especially poorly tolerated during pregnancy. Case Summary: We present a young woman with severe pulmonary hypertension secondary to rheumatic mitral stenosis. She presented at 25 weeks 4 days gestation for evaluation of a pregnancy complicated by placenta accreta spectrum disorder. Invasive hemodynamic testing was carried out to delineate her hemodynamics, and a multidisciplinary cardio-obstetrics team collaborated closely with the patient and her partner to create a management plan. Ultimately, the patient was initiated on veno-arterial extracorporeal membrane oxygenation and underwent caesarean section delivery followed by hysterectomy and subsequent valve replacement surgery. Discussion: This case describes the treatment options considered to balance the risk of decompensation in the setting of severe pulmonary hypertension with hemorrhage associated with placenta accreta spectrum disorder. It highlights the importance of a multidisciplinary, team-based approach to the management of high-risk cardiac conditions throughout pregnancy.

Parametric Solid Models of the At-Term Uterus From Magnetic Resonance Images.

Birthing mechanics are poorly understood, though many injuries during childbirth are mechanical, like fetal and maternal tissue damage. Several biomechanical simulation models of parturition have been proposed to investigate birth, but many do not include the uterus. Additionally, most solid models rely on segmenting anatomical structures from clinical images to generate patient geometry, which can be time-consuming. This work presents two new parametric solid modeling methods for generating patient-specific, at-term uterine three-dimensional geometry. Building from an established method of modeling the sagittal uterine shape, this work improves the uterine coronal shape, especially where the fetal head joins the lower uterine wall. Solid models of the uterus and cervix were built from five at-term patients' magnetic resonance imaging (MRI) sets. Using anatomy measurements from MRI-segmented models, two parametric models were created-one that employs an averaged coronal uterine shape and one with multiple axial measurements of the coronal uterus. Through finite element analysis, the two new parametric methods were compared to the MRI-segmented high-fidelity method and a previously published elliptical low-fidelity method. A clear improvement in the at-term uterine shape was found using the two new parametric methods, and agreement in principal Lagrange strain directions was observed across all modeling methods. These methods provide an effective and efficient way to generate three-dimensional solid models of patient-specific maternal uterine anatomy, advancing possibilities for future research in computational birthing biomechanics.

Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions.

OBJECTIVE: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis. METHODS: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure. RESULTS: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum. CONCLUSION: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Outcomes associated with peripartum hysterectomy in the setting of placenta accreta spectrum disorder.

BACKGROUND: Although peripartum hysterectomy for placenta accreta spectrum disorder is known to be associated with complications at the time of delivery, there are limited data on postpartum outcomes and readmission risk in this population. OBJECTIVE: This study aimed to analyze risks for adverse outcomes and postpartum readmissions in the setting of peripartum hysterectomy for placenta accreta spectrum disorder by severity of placenta accreta spectrum disorder subcategory. STUDY DESIGN: Using the 2016-2020 Nationwide Readmissions Database, this retrospective cohort study identified peripartum hysterectomies with a diagnosis of placenta accreta spectrum disorder. The primary exposure was placenta accreta spectrum disorder, subcategorized as placenta accreta vs increta/percreta. The primary outcome was readmission rate and delivery complications. Complications evaluated included the following: (1) nontransfusion severe maternal morbidity (ntSMM), (2) venous thromboembolism, (3) reoperation, (4) intraoperative complications, (5) hemorrhage, (6) sepsis, and (7) surgical site complications. We additionally evaluated delivery hospitalization and readmission mean length of stay, and hospital costs. Unadjusted and adjusted logistic regression models were fit for outcomes adjusting for clinical, demographic, and hospital factors. The association measures were expressed as unadjusted and adjusted odds ratios with 95% confidence intervals. RESULTS: Between 2016 and 2020, 7864 hysterectomies during a delivery hospitalization with a diagnosis of placenta accreta spectrum disorder were identified (66.5% with placenta accreta and 33.5% with placenta increta/percreta diagnoses). The overall 60-day all-cause readmission rate was 7.3%. Most readmissions (57.2%) occurred within 10 days of hospital discharge. Compared with peripartum hysterectomy with a diagnosis of placenta accreta, hysterectomies with placenta increta/percreta diagnoses carried significantly increased risk of 60-day readmission (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.71), inpatient mortality (odds ratio, 13.23; 95% confidence interval, 3.35-52.30), nontransfusion severe maternal morbidity (adjusted odds ratio, 1.43; 95% confidence interval, 1.20-1.71), intraoperative complications (adjusted odds ratio, 2.31; 95% confidence interval, 1.93-2.77), and surgical site complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.23-1.95). The median length of stay during delivery hospitalization was longer for placenta increta/percreta (5.8 days; 95% confidence interval, 5.4-6.1) than for placenta accreta (4.2 days; 95% confidence interval, 4.1-4.3; P<.05). In addition, delivery hospitalization costs were higher in cases of placenta increta/percreta (median, $30,686; 95% confidence interval, $28,922-$32,449) than placenta accreta (median, $21,321; 95% confidence interval, $20,480-$22,163). CONCLUSION: Complication and readmission risks after peripartum hysterectomy with placenta accreta spectrum disorder are high. Compared with patients with placenta accreta, patients with placenta increta/percreta had increased risk for delivery and postoperative complications and postpartum readmission, and increased costs and length of stay.

Association between SARS-CoV-2 infections during pregnancy and preterm live birth.

We examined associations between mild or asymptomatic prenatal SARS-CoV-2 infection and preterm live birth in a prospective cohort study. During August 2020-October 2021, pregnant persons were followed with systematic surveillance for RT-PCR or serologically confirmed SARS-CoV-2 infection until pregnancy end. The association between prenatal SARS-CoV-2 infection and preterm birth was assessed using Cox proportional-hazards regression. Among 954 pregnant persons with a live birth, 185 (19%) had prenatal SARS-CoV-2 infection and 123 (13%) had preterm birth. The adjusted hazard ratio for the association between SARS-CoV-2 infection and preterm birth was 1.28 (95% confidence interval 0.82-1.99, p = 0.28), although results did not reach statistical significance.

Assessment of Neurodevelopment in Infants With and Without Exposure to Asymptomatic or Mild Maternal SARS-CoV-2 Infection During Pregnancy.

Importance: Associations between prenatal SARS-CoV-2 exposure and neurodevelopmental outcomes have substantial public health relevance. A previous study found no association between prenatal SARS-CoV-2 infection and parent-reported infant neurodevelopmental outcomes, but standardized observational assessments are needed to confirm this finding. Objective: To assess whether mild or asymptomatic maternal SARS-CoV-2 infection vs no infection during pregnancy is associated with infant neurodevelopmental differences at ages 5 to 11 months. Design, Setting, and Participants: This cohort study included infants of mothers from a single-site prospective cross-sectional study (COVID-19 Mother Baby Outcomes [COMBO] Initiative) of mother-infant dyads and a multisite prospective cohort study (Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 in Pregnancy and Infancy [ESPI]) of pregnant individuals. A subset of ESPI participants was subsequently enrolled in the ESPI COMBO substudy. Participants in the ongoing COMBO study were enrolled beginning on May 26, 2020; participants in the ESPI study were enrolled from May 7 to November 3, 2021; and participants in the ESPI COMBO substudy were enrolled from August 2020 to March 2021. For the current analysis, infant neurodevelopment was assessed between March 2021 and June 2022. A total of 407 infants born to 403 mothers were enrolled (204 from Columbia University Irving Medical Center in New York, New York; 167 from the University of Utah in Salt Lake City; and 36 from the University of Alabama in Birmingham). Mothers of unexposed infants were approached for participation based on similar infant gestational age at birth, date of birth, sex, and mode of delivery to exposed infants. Exposures: Maternal symptomatic or asymptomatic SARS-CoV-2 infection. Main Outcomes and Measures: Infant neurodevelopment was assessed using the Developmental Assessment of Young Children, second edition (DAYC-2), adapted for telehealth assessment. The primary outcome was age-adjusted standard scores on 5 DAYC-2 subdomains: cognitive, gross motor, fine motor, expressive language, and receptive language. Results: Among 403 mothers, the mean (SD) maternal age at delivery was 32.1 (5.4) years; most mothers were of White race (240 [59.6%]) and non-Hispanic ethnicity (253 [62.8%]). Among 407 infants, 367 (90.2%) were born full term and 212 (52.1%) were male. Overall, 258 infants (63.4%) had no documented prenatal exposure to SARS-CoV-2 infection, 112 (27.5%) had confirmed prenatal exposure, and 37 (9.1%) had exposure before pregnancy or at an indeterminate time. In adjusted models, maternal SARS-CoV-2 infection during pregnancy was not associated with differences in cognitive (ß = 0.31; 95% CI, -2.97 to 3.58), gross motor (ß = 0.82; 95% CI, -1.34 to 2.99), fine motor (ß = 0.36; 95% CI, -0.74 to 1.47), expressive language (ß = -1.00; 95% CI, -4.02 to 2.02), or receptive language (ß = 0.45; 95% CI, -2.15 to 3.04) DAYC-2 subdomain scores. Trimester of exposure and maternal symptom status were not associated with DAYC-2 subdomain scores. Conclusions and Relevance: In this study, results of a novel telehealth-adapted observational neurodevelopmental assessment extended a previous finding of no association between prenatal exposure to maternal SARS-CoV-2 infection and infant neurodevelopment. Given the widespread and continued high prevalence of COVID-19, these data offer information that may be helpful for pregnant individuals who experience asymptomatic or mild SARS-CoV-2 infections.

Trends in delivery hospitalizations with pregestational and gestational diabetes mellitus and associated outcomes: 2000-2019.

BACKGROUND: Pregestational diabetes mellitus and its associated risks may be increasing in the obstetrical population. OBJECTIVE: This study aimed to characterize the trends in delivery hospitalizations with pregestational diabetes mellitus, the prevalence of chronic diabetes complications, and the risk for adverse outcomes. STUDY DESIGN: This repeated, cross-sectional study used the United States National Inpatient Sample to identify delivery hospitalizations with pregestational diabetes mellitus between 2000 and 2019. Trends in delivery hospitalizations with pregestational diabetes mellitus were assessed using joinpoint regression to determine the average annual percent change. Trends in chronic diabetes complications, including chronic kidney disease, neuropathy, peripheral vascular disease, and diabetic retinopathy, were also analyzed. The risk for adverse obstetrical outcomes was compared between patients with and those without pregestational diabetes mellitus using adjusted logistic regression models that were adjusted for demographic, clinical, and hospital characteristics with adjusted odds ratios with 95% confidence intervals as measures of association. RESULTS: Of 76.7 million delivery hospitalizations, 179,885 (0.23%) had type 1 diabetes mellitus, 430,544 (0.56%) had type 2 diabetes mellitus, and 99,327 (0.13%) had unspecified diabetes mellitus. From 2000 to 2019, the prevalence of diabetes mellitus increased from 1.8 to 7.3 per 1000 deliveries for type 2 diabetes mellitus (average annual percent change, 8.0%; 95% confidence interval, 6.9%-9.2%), from 1.5 to 3.2 per 1000 deliveries for unspecified diabetes mellitus (average annual percent change, 3.9%; 95% confidence interval, 1.4%-6.3%), and from 2.7 in 2000 to 2.8 per 1000 deliveries (average annual percent change, 0.2%; 95% confidence interval, -0.8% to 1.3%) for type 1 diabetes mellitus. The prevalence of chronic diabetes mellitus complications increased from 2.7% to 5.6% over the study period (average annual percent change, 5.9%; 95% confidence interval, 3.7%-8.0%). Pregestational diabetes mellitus was associated with severe maternal morbidity, cesarean delivery, hypertensive disorders of pregnancy, preterm birth, and shoulder dystocia. CONCLUSION: Pregestational diabetes mellitus increased over the study period, driven by a quadrupling in the prevalence of type 2 diabetes mellitus. Notably, the prevalence of chronic diabetes mellitus complications doubled concomitantly. Pregestational diabetes mellitus was associated with a range of adverse outcomes. These findings are further evidence that pregestational diabetes mellitus is an important contributor to maternal risk and that optimizing diabetes care in women of childbearing age will continue to be of major public health importance.

Silent Reactivation of Varicella Zoster Virus in Pregnancy: Implications for Maintenance of Immunity to Varicella.

We encountered two cases of varicella occurring in newborn infants. Because the time between birth and the onset of the illness was much shorter than the varicella incubation period, the cases suggested that the infection was maternally acquired, despite the fact that neither mother experienced clinical zoster. Thus, we tested the hypothesis that VZV frequently reactivates asymptomatically in late pregnancy. The appearance of DNA-encoding VZV genes in saliva was used as an indicator of reactivation. Saliva was collected from 5 women in the first and 14 women in the third trimesters of pregnancy and analyzed at two different sites, at one using nested PCR and at the other using quantitative PCR (qPCR). No VZV DNA was detected at either site in the saliva of women during the first trimester; however, VZV DNA was detected in the majority of samples of saliva (11/12 examined by nested PCR; 7/10 examined by qPCR) during the third trimester. These observations suggest that VZV reactivation occurs commonly during the third trimester of pregnancy. It is possible that this phenomenon, which remains in most patients below the clinical threshold, provides an endogenous boost to immunity and, thus, is beneficial.

Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum.

BACKGROUND: The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE: In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN: This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS: A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION: The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

Association of Birth During the COVID-19 Pandemic With Neurodevelopmental Status at 6 Months in Infants With and Without In Utero Exposure to Maternal SARS-CoV-2 Infection.

Importance: Associations between in utero exposure to maternal SARS-CoV-2 infection and neurodevelopment are speculated, but currently unknown. Objective: To examine the associations between maternal SARS-CoV-2 infection during pregnancy, being born during the COVID-19 pandemic regardless of maternal SARS-CoV-2 status, and neurodevelopment at age 6 months. Design, Setting, and Participants: A cohort of infants exposed to maternal SARS-CoV-2 infection during pregnancy and unexposed controls was enrolled in the COVID-19 Mother Baby Outcomes Initiative at Columbia University Irving Medical Center in New York City. All women who delivered at Columbia University Irving Medical Center with a SARS-CoV-2 infection during pregnancy were approached. Women with unexposed infants were approached based on similar gestational age at birth, date of birth, sex, and mode of delivery. Neurodevelopment was assessed using the Ages & Stages Questionnaire, 3rd Edition (ASQ-3) at age 6 months. A historical cohort of infants born before the pandemic who had completed the 6-month ASQ-3 were included in secondary analyses. Exposures: Maternal SARS-CoV-2 infection during pregnancy and birth during the COVID-19 pandemic. Main Outcomes and Measures: Outcomes were scores on the 5 ASQ-3 subdomains, with the hypothesis that maternal SARS-CoV-2 infection during pregnancy would be associated with decrements in social and motor development at age 6 months. Results: Of 1706 women approached, 596 enrolled; 385 women were invited to a 6-month assessment, of whom 272 (70.6%) completed the ASQ-3. Data were available for 255 infants enrolled in the COVID-19 Mother Baby Outcomes Initiative (114 in utero exposed, 141 unexposed to SARS-CoV-2; median maternal age at delivery, 32.0 [IQR, 19.0-45.0] years). Data were also available from a historical cohort of 62 infants born before the pandemic. In utero exposure to maternal SARS-CoV-2 infection was not associated with significant differences on any ASQ-3 subdomain, regardless of infection timing or severity. However, compared with the historical cohort, infants born during the pandemic had significantly lower scores on gross motor (mean difference, -5.63; 95% CI, -8.75 to -2.51; F1,267 = 12.63; P<.005), fine motor (mean difference, -6.61; 95% CI, -10.00 to -3.21; F1,267 = 14.71; P < .005), and personal-social (mean difference, -3.71; 95% CI, -6.61 to -0.82; F1,267 = 6.37; P<.05) subdomains in fully adjusted models. Conclusions and Relevance: In this study, birth during the pandemic, but not in utero exposure to maternal SARS-CoV-2 infection, was associated with differences in neurodevelopment at age 6 months. These early findings support the need for long-term monitoring of children born during the COVID-19 pandemic.

Placental response to maternal SARS-CoV-2 infection.

The coronavirus disease 2019 (COVID-19) pandemic affected people at all ages. Whereas pregnant women seemed to have a worse course of disease than age-matched non-pregnant women, the risk of feto-placental infection is low. Using a cohort of 66 COVID-19-positive women in late pregnancy, we correlated clinical parameters with disease severity, placental histopathology, and the expression of viral entry and Interferon-induced transmembrane (IFITM) antiviral transcripts. All newborns were negative for SARS-CoV-2. None of the demographic parameters or placental histopathological characteristics were associated with disease severity. The fetal-maternal transfer ratio for IgG against the N or S viral proteins was commonly less than one, as recently reported. We found that the expression level of placental ACE2, but not TMPRSS2 or Furin, was higher in women with severe COVID-19. Placental expression of IFITM1 and IFITM3, which have been implicated in antiviral response, was higher in participants with severe disease. We also showed that IFITM3 protein expression, which localized to early and late endosomes, was enhanced in severe COVID-19. Our data suggest an association between disease severity and placental SARS-CoV-2 processing and antiviral pathways, implying a role for these proteins in placental response to SARS-CoV-2.

Extracellular Matrix Rigidity Modulates Human Cervical Smooth Muscle Contractility-New Insights into Premature Cervical Failure and Spontaneous Preterm Birth.

Spontaneous preterm birth (sPTB), a major cause of infant morbidity and mortality, must involve premature cervical softening/dilation for a preterm vaginal delivery to occur. Yet, the mechanism behind premature cervical softening/dilation in humans remains unclear. We previously reported the non-pregnant human cervix contains considerably more cervical smooth muscle cells (CSMC) than historically appreciated and the CSMC organization resembles a sphincter. We hypothesize that premature cervical dilation leading to sPTB may be due to (1) an inherent CSMC contractility defect resulting in sphincter failure and/or (2) altered cervical extracellular matrix (ECM) rigidity which influences CSMC contractility. To test these hypotheses, we utilized immunohistochemistry to confirm this CSMC phenotype persists in the human pregnant cervix and then assessed in vitro arrays of contractility (F:G actin ratios, PDMS pillar arrays) using primary CSMC from pregnant women with and without premature cervical failure (PCF). We show that CSMC from pregnant women with PCF do not have an inherent CSMC contractility defect but that CSMC exhibit decreased contractility when exposed to soft ECM. Given this finding, we used UPLC-ESI-MS/MS to evaluate collagen cross-link profiles in the cervical tissue from non-pregnant women with and without PCF and found that women with PCF have decreased collagen cross-link maturity ratios, which correlates to softer cervical tissue. These findings suggest having soft cervical ECM may lead to decreased CSMC contractile tone and a predisposition to sphincter laxity that contributes to sPTB. Further studies are needed to explore the interaction between cervical ECM properties and CSMC cellular behavior when investigating the pathophysiology of sPTB.

Fetal growth velocity in diabetics and the risk for shoulder dystocia: a case-control study.

INTRODUCTION: Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia. METHODS: We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on the year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (<0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise. RESULTS: Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, p = .01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR = 1.8, 95% confidence interval (CI) = 0.9-3.3; OR = 1.6, 95% CI = 0.8-3.2; OR = 1.7, 95% CI = 0.7-3.9; and OR = 1.8, 95% CI = 0.6-5.3; respectively); however, this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR = 3.3, 95% CI = 1.5-7.1, OR = 4.8, 95% CI = 1.3-17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls. CONCLUSION: Future research is required to determine if fetal growth velocity proves to be a useful tool in identifying women at increased risk for shoulder dystocia. Larger studies are required for precise estimates of risk, and associated neonatal outcomes.

Obstetric outcomes among women with a liver transplant.

BACKGROUND: Women with liver transplants may be at increased risk for adverse outcomes. OBJECTIVE: The objectives of this study were to evaluate trends and provide recent data on outcomes for women with a liver transplant. STUDY DESIGN: The National (Nationwide) Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project from 1998 to 2014 was used for this repeated cross-sectional analysis. Women aged between 15 and 54 years, with a history of liver transplant who underwent delivery, antepartum, or postpartum hospitalizations were identified. Temporal trends in deliveries of women with liver transplants were analyzed. The risk for severe maternal morbidity (SMM) excluding transfusion based on criteria from the Centers for Disease Control and Prevention (CDC), as well as for individual outcomes including hypertensive diseases of pregnancy, postpartum hemorrhage, placental abruption, liver rejection, cesarean delivery, preterm delivery, and coagulopathy during delivery hospitalizations were analyzed. Risks of SMM during antepartum and postpartum hospitalizations were also analyzed. An adjusted log-linear regression model for SMM during delivery hospitalizations including demographic factors, hospital characteristics, and underlying comorbidity was performed. The chi-squared or Fisher's exact test was used for comparisons. Temporal trends were analyzed with the Cochran-Armitage trend test. Population weights were applied to create national estimates. RESULTS: From 1998 to 2014, an estimated 1165 births occurred by women with a liver transplant. The number of births occurring by women with liver transplants increased over the study period from 1.0 per 100,000 in 1998-2000 to 2.8 per 100,000 in 2012-2014 (p < .01). The risk for CDC SMM excluding transfusion was significantly higher during delivery hospitalizations among women with compared to without liver transplant (8.0 versus 0.5%, p < .01, unadjusted risk ratio 15.4, 95% CI 12.7-18.6). Women with liver transplant were also at significantly higher risk for abruption (2.5 versus 1.0%, p = .03), hypertensive diseases of pregnancy (27.8 versus 6.9%, p < .01), postpartum hemorrhage (8.0 versus 2.8%, p = .01), cesarean delivery (51.7 versus 29.5%, p < .01), preterm delivery (27.5 versus 7.0%, p < .01), and coagulopathy (3.1 versus 0.3%, p < .01). A diagnosis of liver rejection was present during 4.1% of delivery hospitalizations for women with liver transplant. In the adjusted analysis for severe morbidity excluding transfusion risk was retained with liver transplant associated with increased likelihood of this adverse outcome (aRR 8.49, 95% CI 5.59-12.87). Women with liver transplants were at significantly higher likelihood of undergoing antepartum and postpartum admissions, and of experiencing SMM during these hospitalizations. CONCLUSION: In this analysis of antepartum, delivery, and postpartum hospitalizations, women with liver transplant were at significantly higher risk for both SMM during all hospitalizations and for a range of adverse outcomes including placental abruption, hypertensive diseases of pregnancy, postpartum hemorrhage, cesarean delivery, and coagulopathy delivery during delivery hospitalizations. While deliveries to women with liver transplant were rare, these births became more frequent over the study period.

Hypertensive disorders of pregnancy in twin gestations complicated by gestational diabetes.

Objective: Gestational diabetes (GDM) in singleton pregnancies is known to be associated with an increased risk for hypertensive disorders of pregnancy. The data are mixed regarding the effect of GDM on the risk for hypertensive disorders of pregnancy in twin gestations. The objective of our study was to assess the rate of hypertensive disorders of pregnancy in twin gestations complicated by GDM.Methods: This is a secondary analysis of a multicenter randomized trial in which twin gestations were assigned to weekly intramuscular injections of progesterone in order to reduce the rate of preterm birth. We included all twin pregnancies with and without GDM. Women with pregestational diabetes, chronic hypertension, twin pregnancies complicated by twin to twin transfusion syndrome and congenital fetal anomalies were excluded. Our primary outcome was the rate of hypertensive disorders in twin pregnancies complicated by GDM. Our secondary outcomes included the rate of cesarean section, number of neonates who were small for gestational age, Apgar scores, and a composite adverse neonatal outcome. Logistic regression analysis was used to control for confounding variables.Results: Six hundred fourteen twin pregnancies were included, 570 (93%) without GDM and 44 (7%) with GDM. The group with GDM had a significantly higher prepregnancy body mass index (BMI) and maternal age, and were more likely to have undergone in vitro fertilization (IVF). The rate of hypertensive disorders of pregnancy in the GDM group was significantly higher when compared to the non-GDM group (31.8 versus 17.9%, p = .033, RR 1.78 [95% CI = 1.11-2.84]); however, after adjusting for maternal age, IVF treatment and prepregnancy BMI, this association lost its statistical significance (aRR = 1.36 [95% CI = 0.83-2.21]). The cesarean section rate was higher in the GDM group as compared to the non-GDM group and after adjusting for confounders, the rate of cesarean section was still higher in the GDM group (77.3 versus 61.1%, p = .003, aRR = 1.27 [95% CI = 1.06-1.50]). Neonates born to women in the GDM group were more likely to experience the adverse composite outcome (26.4 versus 8.2%, p = 0.02, RR = 1.81 [95% CI = 1.09-2.99]).Conclusion: In this prospective cohort of twin pregnancies, the rate of hypertensive disorders of pregnancy did not differ between women with and without gestational diabetes after adjusting for maternal age, IVF treatment, race, and prepregnancy BMI. To better target complications associated with GDM in twin gestations, large prospective studies evaluating the effect of GDM on outcomes specifically in twin pregnancies are warranted.

Conducting research during the COVID-19 pandemic.

The highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected every aspect of medical practice and has all but ceased clinical, translational and basic science research. Pregnant women appear to be similarly affected by the virus as non-pregnant adults. As obstetricians, not only do we have a duty to care for pregnant women and their fetuses, but to continue to conduct research, inclusive of that which would guide us in delivering care during a pandemic. Conducting such research has its challenges. The objective of this chapter is to review the impact of SARS-CoV-2 on ongoing and new pregnancy research during the pandemic, describe the challenges encountered and summarize the key strategies necessary for a successful research environment.

Third-trimester placentas of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive women: histomorphology, including viral immunohistochemistry and in-situ hybridization.

AIMS: The wide variety of affected organ systems associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection highlights the need for tissue-specific evaluation. We compared placentas from SARS-CoV-2-positive and SARS-CoV-2-negative women in our hospital in New York City, which became the epicenter of the coronavirus disease 2019 pandemic in March 2020. To date, some limited studies have been published on placentas from SARS-CoV-2-positive women. The aim of our study, in addition to describing histomorphology, was to utilize in-situ hybridization (ISH) for the S-gene encoding the spike protein and immunohistochemistry (IHC) with the monoclonal SARS-CoV-2 spike antibody 1A9 for placental evaluation. METHODS AND RESULTS: In this study, 51 singleton, third-trimester placentas from SARS-CoV-2-positive women and 25 singleton, third-trimester placentas from SARS-CoV-2-negative women were examined histomorphologically according to the Amsterdam Criteria and with ISH and/or IHC. The corresponding clinical findings and neonatal outcomes also were recorded. Although no specific histomorphologic changes related to SARS-CoV-2 were noted in the placentas, evidence of maternal-fetal vascular malperfusion was identified, with placentas from SARS-CoV-2-positive women being significantly more likely to show villous agglutination (P = 0.003) and subchorionic thrombi (P = 0.026) than placentas from SARS-CoV-2-negative women. No evidence of direct viral involvement was identified with ISH and IHC. CONCLUSIONS: In this study, third-trimester placentas from SARS-CoV-2-positive women were more likely to show evidence of maternal-fetal vascular malperfusion; however, ISH and IHC provided no evidence of direct viral involvement or vertical transmission.

Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

Adding to the Denominator: A Case Report of Neuraxial Anesthesia for Cesarean Delivery in the Setting of Hemolysis, Elevated Liver Enzyme, Low Platelet, Thrombocytopenia, and Pulmonary Hypertension.

The acceptable platelet count for the safe provision of neuraxial anesthesia in obstetric patients is unknown. Comorbidities may sway a provider to perform neuraxial anesthesia, despite thrombocytopenia, as the putative risk of spinal-epidural hematoma may not outweigh the risks associated with general anesthesia. The case of a 22-year-old nulliparous woman undergoing a cesarean delivery with a new diagnosis of pulmonary hypertension and right heart failure, compounded with thrombocytopenia and possible Hemolysis, Elevated Liver Enzyme, and Low Platelet (HELLP) syndrome, is presented. Risks and benefits of general versus neuraxial anesthesia in this specific setting are reviewed.

Oral Opioid Use during Vaginal Delivery Hospitalizations.

OBJECTIVE: This study aimed to determine the receipt of short-acting opioid medications during vaginal delivery hospitalizations. STUDY DESIGN: The Perspective database was analyzed to evaluate patterns of short-acting oral opioid use during vaginal delivery hospitalizations from January 2006 to March 2015. Unadjusted and adjusted models evaluating the role of demographic and hospital factors were created evaluating use of opioids. Hospital-level rates of opioid use were evaluated. Opioid receipt among women with opioid abuse or dependence was evaluated based on overall hospital rates of opioid use. RESULTS: Of 3,785,396 vaginal delivery hospitalizations from 2006 to 2015, 1,720,899 (45.5%) women received an oral opioid for pain relief. Opioid use varied significantly among the 458 hospitals included in the analysis, with one-third of hospitals providing opioids to <38% of patients, one-third to 38 to <59% of patients, and one-third to ≥59% of patients. When hospitals were stratified by overall opioid administration rates, women with opioid abuse or dependence were less likely to be given opioids in hospitals with low overall opioid rates. DISCUSSION: The use of opioid pain medications during vaginal delivery hospitalizations varied significantly among hospitals, suggesting that standardization of pain management practices could reduce opioid use.