Obstetric Inpatient and Ultrasound Clinical Personnel Absences during the COVID-19 Pandemic in New York City.

OBJECTIVE: To review obstetric personnel absences at a hospital during the initial peak of coronavirus disease 2019 (COVID-19) infection risk in New York City from March 25 to April 21, 2020. STUDY DESIGN: This retrospective study evaluated absences at Morgan Stanley Children's Hospital. Clinical absences for (1) Columbia University ultrasonographers, (2) inpatient nurses, (3) labor and delivery operating room (OR) technicians, (4) inpatient obstetric nurse assistants, and (5) attending physicians providing inpatient obstetric services were analyzed. Causes of absences were analyzed and classified as illness, vacation and holidays, leave, and other causes. Categorical variables were compared with the chi-square test or Fisher's exact test. RESULTS: For nurses, absences accounted for 1,052 nursing workdays in 2020 (17.2% of all workdays) compared with 670 (11.1%) workdays in 2019 (p < 0.01). Significant differentials in days absent in 2020 compared with 2019 were present for (1) postpartum nurses (21.9% compared with 12.9%, p < 0.01), (2) labor and delivery nurses (14.8% compared with 10.6%, p < 0.01), and (3) antepartum nurses (10.2% compared with 7.4%, p = 0.03). Evaluating nursing assistants, 24.3% of workdays were missed in 2020 compared with 17.4% in 2019 (p < 0.01). For ultrasonographers, there were 146 absences (25.2% of workdays) in 2020 compared with 96 absences (16.0% of workdays) in 2019 (p < 0.01). The proportion of workdays missed by OR technicians was 22.6% in 2020 and 18.3% in 2019 (p = 0.25). Evaluating attending physician absences, a total of 78 workdays were missed due to documented COVID-19 infection. Evaluating the causes of absences, illness increased significantly between 2019 and 2020 for nursing assistants (42.6 vs. 57.4%, p = 0.02), OR technicians (17.1 vs. 55.9%, p < 0.01), and nurses (15.5 vs. 33.7%, p < 0.01). CONCLUSION: COVID-19 outbreak surge planning represents a major operational issue for medical specialties such as critical care due to increased clinical volume. Findings from this analysis suggest it is prudent to devise backup staffing plans. KEY POINTS: · 1) COVID-19 outbreak surge planning represents a major operational issue for obstetrics.. · 2) Inpatient obstetric volume cannot be reduced.. · 3) Staffing contingencies plans for nurses, sonographers, and physicians may be required..

The Association between Fetal Fibronectin, Cervical Length, and Amniotic Fluid Sludge with Histological Indicators of Placental Inflammation in Twin Gestations.

OBJECTIVE: The objective of this study was to evaluate the association of screening tests for preterm birth (short cervical length [CL], positive fetal fibronectin (FFN), and amniotic fluid [AF] sludge) in twin gestations with histologic evidence of placental inflammation. STUDY DESIGN: Historical cohort study of 596 twin gestations delivered in a single maternal-fetal medicine practice with CL and FFN testing from 22 to 256/7 weeks. A short CL was defined as ≤25 mm. Placental lesions evaluated were chronic and acute membrane inflammation and funisitis. Fischer's exact test and logistic regression were used. RESULTS: None of the screening tests was associated with chronic inflammation. All were associated with acute inflammation. On regression analysis, a short CL and positive FFN remained independently associated with acute inflammation (adjusted odds ratio [aOR]: 5.66 and 2.51, respectively) and funisitis (aOR: 5.66 and 7.17, respectively). AF sludge was not independently associated with acute inflammation nor funisitis. CONCLUSION: In twin gestations, a short CL and a positive FFN at 22 to 26 weeks are associated with acute but not chronic inflammation on placental histology. These findings imply that mechanisms underlying preterm birth in twins that result in positive screening tests weeks prior to delivery are not reflected as chronic placental inflammation. Therefore, pathologic interpretation of etiologic mechanisms for preterm birth may be limited using solely histologic reports.

Risk factors for blood transfusion in patients undergoing high-order Cesarean delivery.

BACKGROUND: The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD). STUDY DESIGN AND METHODS: This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa. RESULTS: A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p < 0.001). Patients with a placenta previa had a 68.8% likelihood of requiring a blood transfusion. After women who had placenta previa were excluded, the incidence of blood transfusion was seven of 498 (1.4%; 95% CI, 0.7%-2.9%). Risk factors significantly associated with blood transfusion in the absence of previa were prophylactic anticoagulation during pregnancy and having labored. The incidence of transfusion in patients with no placenta previa, no anticoagulation, and no labor was 0.7% (95% CI, 0.3%-2.1%). Placenta previa was the most predictive risk factor for transfusion with a positive predictive value of 68.8% and a negative predictive value of 98.4%. CONCLUSION: In patients undergoing a third or more CD, only placenta previa, prophylactic anticoagulation during pregnancy, and having labored are independently associated with requiring a blood transfusion. These data can be used to guide physician ordering of prepared blood products preoperatively.

The Independent Association of a Short Cervix, Positive Fetal Fibronectin, Amniotic Fluid Sludge, and Cervical Funneling with Spontaneous Preterm Birth in Twin Pregnancies.

Objective To estimate the independent association of a short cervical length (CL), positive fetal fibronectin (fFN), amniotic fluid (AF) sludge, and cervical funneling with spontaneous preterm birth in twin pregnancies. Methods Retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from June 2005 to February 2014. All patients underwent transvaginal sonographic CL and fFN testing. We reviewed all images from the first CL at 22(0/7) to 25(6/7) weeks for the presence of (1) a short CL, which is defined as ≤25 mm, (2) AF sludge, and (3) cervical funneling, and also recorded (4) the fFN result from that time. Image reviewers were blinded to pregnancy outcomes. Patients with cerclage were excluded. Using logistic regression, we calculated the independent association between these four biomarkers and spontaneous preterm birth. Results A total of 635 patients with twin pregnancies were included. The markers independently associated with spontaneous preterm birth <35 weeks were short CL (adjusted odds ratio [aOR]: 10.73; 95% confidence interval [CI]: 3.21-35.81), positive fFN (aOR: 3.25; 95% CI: 1.13-9.33), and AF sludge (aOR: 2.11; 95% CI: 1.04-4.27). Similarly, these three markers were independently associated with earlier gestational ages at delivery. Cervical funneling was not independently associated with spontaneous preterm birth <35 weeks nor gestational age at delivery. The risk of spontaneous preterm birth increased significantly with the number of positive biomarkers (short CL, positive fFN, and AF sludge). Conclusion In twin pregnancies, a short CL, positive fFN, and AF sludge are independently associated with spontaneous preterm birth. Cervical funneling is not independently associated with spontaneous preterm birth in twins.

Primed for a pandemic: Implementation of telehealth outpatient monitoring for women with mild COVID-19.

Close observation and rapid escalation of care is essential for obstetric patients with COVID-19. The pandemic forced widespread conversion of in-person to virtual care delivery and telehealth was primed to enable outpatient surveillance of infected patients. We describe the experience and lessons learned while designing and implementing a virtual telemonitoring COVID-19 clinic for obstetric patients. All patients with suspected for confirmed COVID-19 were referred and enrolled. Telehealth visits were conducted every 24 to 72 hours based on the severity of symptoms and care was escalated to in person when necessary. The outcome of the majority (96.1%) of telehealth visits was to continue outpatient management. With regard to escalation of care, 25 patients (26.6%) presented for in person evaluation and five patients (5.3%) required inpatient admission. A virtual telemonitoring clinic for obstetric patients with mild COVID-19 offers an effective surveillance strategy as it allows for close monitoring, direct connection to in person evaluation, minimization of patient and provider exposure, and scalability.

Childhood neurodevelopment after spontaneous versus indicated preterm birth.

BACKGROUND: Preterm birth is the leading cause of neonatal morbidity and mortality. Individuals who survive preterm birth are at a higher risk for many long-term adverse effects, including neurodevelopmental deficits. There are many well-established risk factors for worse neurologic outcomes spanning the prenatal and postnatal periods; however, investigators have yet to assess whether the cause of preterm birth has an impact on neurodevelopment. OBJECTIVE: Our objective was to assess whether neurologic outcomes differ by children born via indicated versus spontaneous preterm birth. STUDY DESIGN: We performed secondary analysis of a multicenter trial assessing magnesium for neuroprotection in women at risk for preterm delivery from 24 to 31 weeks. We included women with live, nonanomalous, singleton gestations who delivered preterm; we excluded women whose children were missing 2-year follow-up information for reasons other than perinatal demise. The primary exposure was type of preterm birth: (1) spontaneous if the child's mother presented with preterm labor or ruptured membranes, or (2) indicated if the child was delivered preterm iatrogenically. The primary outcome was death (including stillbirths, neonatal intensive care unit deaths, and deaths after discharge) or an abnormal Bayley II score by 2 years of age, defined as a Mental Developmental Index score or Psychomotor Developmental Index score 2 standard deviations below the mean. Secondary outcomes included death or Mental Developmental Index and Psychomotor Developmental Index scores 1 standard deviation or less, and neonatal morbidities associated with prematurity. Bivariate analyses of baseline characteristics by exposure were conducted. A logistic regression model was fitted to adjust for confounders. RESULTS: Of 1678 subjects, 1631 (97.2%) underwent spontaneous preterm birth and 47 (2.8%) underwent indicated preterm birth. Baseline maternal demographics and gestational age at delivery were similar between groups (29.6 weeks ± 7.8 versus 28.8 weeks ± 2.5, P = .07). A Psychomotor Developmental Index score 2 standard deviations or less below the mean or death occurred in 340 (20.9%) spontaneous preterm birth subjects and 17 (36.2%) indicated preterm birth subjects (P = .01). When adjusting for confounders, there remained an increased probability of a Psychomotor Developmental Index scores 2 standard deviations or less or death in indicated preterm birth subjects (P = .02). Although not statistically significant, indicated preterm birth was also associated with higher odds of Mental Developmental Index scores 2 standard deviations or less or death, Psychomotor Developmental scores 1 standard deviation or less or death, and Mental Developmental Index scores 1 standard deviation or less or death (1.76, 1.59, and 1.45, respectively). Limiting the analysis to small for gestational age infants, there was no difference in neurologic outcomes. The same was true for when we excluded small for gestational age infants from our analysis. However, after adjusting for small for gestational age, the odds of a Psychomotor Developmental Index score 2 standard deviations or less or death remained significant higher in the indicated preterm birth group (adjusted odds ratio, 1.98; 95% confidence interval, 1.01-3.88). CONCLUSION: In this cohort of pregnant women who delivered preterm, indicated deliveries were associated with worse psychomotor development than were spontaneous deliveries. Other outcomes appeared to be poor, but our numbers were limited. This finding should be confirmed in a larger cohort of women undergoing medically indicated preterm deliveries.

Preparation and redeployment of house staff during a pandemic.

The COVID-19 pandemic created unique issues for house staff physicians. Gaps in surgical experience due to canceled cases, a focus on obstetrics over gynecology during the spring months when many senior residents and fellows are completing their case requirements and the stress of working with patients infected with a highly communicable disease all contributed to an unprecedented challenge facing residency and fellowship programs. Our objective is to describe how the Obstetrics and Gynecology residency and fellowship programs at Columbia University Irving Medical Center adapted to their changing landscape, redeployed their residents and fellows while assuring ongoing trainee education, wellness and scholarship during the peak of the pandemic.

Noninvasive ventilation during pediatric interhospital ground transport.

OBJECTIVE: We report our use of noninvasive ventilation (NIV) during pediatric interhospital ground transport. METHODS: We retrospectively reviewed transport and hospital records for nonneonatal patients

Readiness: Utilizing bundles and simulation.

Postpartum hemorrhage is an important contributor to maternal morbidity, and is one of the most common worldwide causes of preventable maternal mortality. Preventing significant morbidity and mortality from postpartum hemorrhage necessitates preparedness on both a unit and patient level. Our objectives are to define a bundle, to review the elements of the Council on Patient Safety in Women's Healthcare Obstetric Hemorrhage Bundle and to highlight simulation-based training opportunities, focusing on readiness for this significant obstetric emergency.

Cloud Based Surveys to Assess Patient Perceptions of Health Care: 1000 Respondents in 3 days for US $300.

BACKGROUND: There are many challenges in conducting surveys of study participants, including cost, time, and ability to obtain quality and reproducible work. Cloudsourcing (an arrangement where a cloud provider is paid to carry out services that could be provided in-house) has the potential to provide vastly larger, less expensive, and more generalizable survey pools. OBJECTIVE: The objective of this study is to evaluate, using Amazon's Mechanical Turk (MTurk), a cloud-based workforce to assess patients' perspectives of health care. METHODS: A national online survey posted to Amazon's MTurk consisted of 33 multiple choice and open-ended questions. Continuous attributes were compared using t tests. RESULTS: We obtained 1084 responses for a total cost of US $298.10 in less than 3 days with 300 responses in under 6 hours. Of those, 44.74% (485/1084) were male and 54.80% (594/1084) female, representing 49 out of 50 states and aged 18 to 69 years. CONCLUSIONS: Amazon's MTurk is a potentially useful survey method for attaining information regarding public opinions and/or knowledge with the distinct advantage of cost, speed, and a wide and relatively good representation of the general population, in a confidential setting for respondents.