Indications for Maternal Echocardiography in Detecting Disease and the Impact on Pregnancy Management.

OBJECTIVE: Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines. STUDY DESIGN: This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings. RESULTS: Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034). CONCLUSION: Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors. KEY POINTS: · The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.. · Several clinical factors often prompt performance of echocardiography in pregnancy without merit.. · Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria..

ACES: Accurate Cervical Evaluation With Sonography.

OBJECTIVES: Transvaginal sonographic cervical length screening is an important tool for the evaluation of preterm labor. However, a structured curriculum is lacking in obstetrics and gynecology residency programs. The Accurate Cervical Evaluation with Sonography (ACES) program was developed to address this deficiency and combines an online didactic course with a standardized performance assessment of live scans. We sought to evaluate the effectiveness of the ACES program to teach residents sonographic cervical length assessment. METHODS: All obstetrics and gynecology residents at our institution were invited to participate from 2012 to 2013. The program consisted of an initial supervised transvaginal cervical evaluation, an online didactic course and written examination, and 5 subsequent supervised scans. The instructor performed an independent cervical length measurement at each encounter. The primary outcome was the difference in cervical length measurement between the resident and instructor. We hypothesized that this difference would decrease over time. At each visit, a 10-item checklist was used for skill assessment. Comparisons of checklist scores over time were also performed. RESULTS: Seventeen of 20 residents completed at least some of the training, and 10 completed the entire program. The median difference in cervical length measurement between residents and instructors at posttests 3, 4, and 5 improved significantly compared to the pretest scan (all P ≤ .02). Similarly, the checklist scores improved over time (all P ≤ .0008). CONCLUSIONS: Transvaginal cervical sonography is an important tool in the evaluation of preterm labor. The ACES program provides residents a structured curriculum for cervical evaluation and supervisors a standardized means of evaluating trainees' skills.

Severe acute respiratory distress syndrome in coronavirus disease 2019-infected pregnancy: obstetric and intensive care considerations.

Since the emergence of a novel coronavirus (severe acute respiratory syndrome coronavirus 2) in Wuhan, China, at the end of December 2019, coronavirus disease 2019 has been associated with severe morbidity and mortality and has left world governments, healthcare systems, and providers caring for vulnerable populations, such as pregnant women, wrestling with the optimal management strategy. Unique physiologic and ethical considerations negate a one-size-fits-all approach when caring for critically ill pregnant women with coronavirus disease 2019, and few resources exist to guide the multidisciplinary team through decisions regarding optimal maternal-fetal surveillance, intensive care procedures, and delivery timing. We present a case of rapid clinical decompensation and development of severe acute respiratory distress syndrome in a woman at 31 weeks' gestation to highlight these unique considerations and present an algorithmic approach to the diagnosis and management of the disease.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

Complexity analysis of fetal heart rate preceding intrauterine demise.

BACKGROUND: Visual non-stress test interpretation lacks the optimal specificity and observer-agreement of an ideal screening tool for intrauterine fetal demise (IUFD) syndrome prevention. Computational methods based on traditional heart rate variability have also been of limited value. Complexity analysis probes properties of the dynamics of physiologic signals that are otherwise not accessible and, therefore, might be useful in this context. OBJECTIVE: To explore the association between fetal heart rate (FHR) complexity analysis and subsequent IUFD. Our specific hypothesis is that the complexity of the fetal heart rate dynamics is lower in the IUFD group compared with controls. STUDY DESIGN: This case-control study utilized cases of IUFD at a single tertiary-care center among singleton pregnancies with at least 10min of continuous electronic FHR monitoring on at least 2 weekly occasions in the 3 weeks immediately prior to fetal demise. Controls delivered a live singleton beyond 35 weeks' gestation and were matched to cases by gestational age, testing indication, and maternal age in a 3:1 ratio. FHR data was analyzed using the multiscale entropy (MSE) method to derive their complexity index. In addition, pNNx, a measure of short-term heart rate variability, which in adults is ascribable primarily to cardiac vagal tone modulation, was also computed. RESULTS: 211 IUFDs occurred during the 9-year period of review, but only 6 met inclusion criteria. The median gestational age at the time of IUFD was 35.5 weeks. Three controls were matched to each case for a total of 24 subjects, and 87 FHR tracings were included for analysis. The median gestational age at the first fetal heart rate tracing was similar between groups (median [1st-3rd quartiles] weeks: IUFD cases: 34.7 (34.4-36.2); controls: 35.3 (34.4-36.1); p=.94). The median complexity of the cases' tracings was significantly less than the controls' (12.44 [8.9-16.77] vs. 17.82 [15.21-22.17]; p<.0001). Furthermore, the cases' median complexity decreased as gestation advanced whereas the controls' median complexity increased over time. However, this difference was not statistically significant [-0.83 (-2.03 to 0.47) vs. 0.14 (-1.25 to 0.94); p=.62]. The degree of short-term variability of FHR tracings, as measured by the pNN metric, was significantly lower (p<.005) for the controls (1.1 [0.8-1.3]) than the IUFD cases (1.3 [1.1-1.6]). CONCLUSIONS: FHR complexity analysis using multiscale entropy analysis may add value to other measures in detecting and monitoring pregnancies at the highest risk for IUFD. The decrease in complexity and short-term variability seen in the IUFD cases may reflect perturbations in neuroautonomic control due to multiple maternal-fetal factors.

Remembrance of time series past: simple chromatic method for visualizing trends in biomedical signals.

Analysis of biomedical time series plays an essential role in clinical management and basic investigation. However, conventional monitors streaming data in real-time show only the most recent values, not referenced to past dynamics. We describe a chromatic approach to bring the 'memory' of the physiologic system's past behavior into the current display window.The method employs the estimated probability density function of a time series segment to colorize subsequent data points.For illustrative purposes, we selected open-access recordings of continuous: (1) fetal heart rate during the pre-partum period, and (2) heart rate and systemic blood pressure from a critical care patient during a spontaneous breathing trial. The colorized outputs highlight changes from the 'baseline' reference state, the latter defined as the mode value assumed by the signal, i.e. the maximum of its probability density function.A colorization method may facilitate the recognition of relevant features of time series, especially shifts in baseline dynamics and other trends (including transient and longer-term deviation from baseline values) which may not be as readily noticed using traditional displays. This method may be applicable in clinical monitoring (real-time or off-line) and in research settings. Prospective studies are needed to assess the utility of this approach.

The utility of midtrimester ultrasound assessment of the subcutaneous space in predicting cesarean wound complications.

OBJECTIVE: To evaluate the association between cesarean wound complications and thickness of the subcutaneous space within the anterior abdomen at the midtrimester fetal anatomical survey. METHODS: In this case-control study, cases were identified using an ICD9 code for wound complications of cesarean delivery. For each case, we identified the woman with the next consecutive midtrimester ultrasound who had a cesarean delivery without a wound complication, matched on age and race, as the control. A blinded investigator measured subcutaneous space at three distinct suprapubic levels in the midsagital plane. RESULTS: Of 7228 women with a cesarean delivery, 123 (1.7%) had a wound complication. Seventy-nine cases were eligible. Midline suprapubic subcutaneous thickness did not differ between cases and controls at the superior, middle or inferior locations (p ≥ 0.35). Body mass index was moderately correlated with ultrasound-derived measurements (r ≥ 0.63; p < 0.001). The incidence of vertical skin incision, stapled skin closure and classical hysterotomy differed between groups (p ≤ 0.046). There was no significant increase in wound complication risk with increasing subcutaneous space thickness, even after adjustment (p ≥ 0.34). CONCLUSION: Prenatal ultrasound can quantify the subcutaneous space. Vertical skin incision, stapled wound closure, and a classical hysterotomy were associated with cesarean wound complication, but midtrimester subcutaneous thickness was not.

Association of third-trimester abdominal circumference with provider-initiated preterm delivery.

OBJECTIVE: Evaluate the association of a small third-trimester abdominal circumference (AC < 10th percentile) in the setting of a normal estimated fetal weight (EFW ≥ 10th percentile) with gestational age at delivery, indication for delivery and neonatal outcomes. METHODS: Retrospective cohort study at an academic hospital of women with singleton pregnancy seen for ultrasound from 28+0-33+6 weeks of gestation during 2009-2011. Outcomes were compared between two groups: normal AC (AC and EFW ≥ 10th percentile) and small AC (AC < 10th percentile and EFW ≥ 10th percentile). RESULTS: Among 592 pregnancies, fetuses in the small AC group (n = 55) experienced a higher incidence of overall preterm delivery (RR: 2.2, 95% CI: 1.3-3.7) and provider-initiated preterm delivery (RR: 3.7, CI: 1.8-7.5) compared to those in the normal AC group (n = 537). Neonates in the small AC group had a lower median birth weight whether delivered at term (p < 0.001) or preterm (p = 0.04), but were not more likely to experience intensive care unit admission or respiratory distress syndrome (all p ≥ 0.35). CONCLUSIONS: Small AC, even in the setting of an EFW ≥ 10th percentile, was associated with a higher incidence of overall and provider-initiated preterm delivery despite similar neonatal outcomes. Further investigation is warranted to determine whether these preterm deliveries could be prevented.

Complexity-loss in fetal heart rate dynamics during labor as a potential biomarker of acidemia.

BACKGROUND: Continuous fetal heart rate (FHR) monitoring remains central to intrapartum care. However, advances in signal analysis are needed to increase its accuracy in diagnosis of fetal hypoxia. AIMS: To determine whether FHR complexity, an index of multiscale variability, is lower among fetuses born with low (≤7.05) versus higher pH values, and whether this measure can potentially be used to help discriminate the two groups. STUDY DESIGN: Evaluation of a pre-existing database of sequentially acquired intrapartum FHR signals. SUBJECTS: FHR tracings, obtained from a continuous scalp electrocardiogram during labor, were analyzed using the multiscale entropy (MSE) method in 148 singletons divided in two groups according to umbilical artery pH at birth: 141 fetuses with pH>7.05 and 7 with pH≤7.05. A complexity index derived from MSE analysis was calculated for each recording. RESULTS: The complexity of FHR signals for the last two hours before delivery was significantly (p<0.004) higher for non-acidemic than for acidemic fetuses. The difference between the two groups remained significant (p<0.003) when FHR data from the last 30min before delivery were excluded. CONCLUSION: Complexity of FHR signals, as measured by the MSE method, was significantly lower for acidemic than non-acidemic fetuses. These results are consistent with previous studies showing that decreased nonlinear complexity is a dynamical signature of disrupted physiologic control systems. This analytic approach may have discriminative value in FHR analysis.

Clinical characterization and outcomes of preeclampsia with normal angiogenic profile.

OBJECTIVE: To compare the clinical characteristics and outcomes of preeclamptic women presenting with a normal plasma angiogenic profile with those subjects who are characterized by an abnormal angiogenic profile. METHODS: This was a secondary analysis of a prospective cohort study in women presenting to obstetrical triage at <37 weeks of gestation and diagnosed with preeclampsia within 2 weeks of enrollment and in whom angiogenic factors (sFlt1 and PlGF) measurements were available. Patients were divided into two groups based on their circulating levels of these factors described as a ratio; the sFlt1/PlGF ratio, non-angiogenic preeclampsia (sFlt1/PlGF ratio <85) and angiogenic preeclampsia (sFlt1/PlGF ratio ≥85). The data are presented by sFlt1/PlGF category using median and quartile 1-quartile 3 for continuous variables and by frequency and sample sizes for categorical variables. RESULTS: In our cohort, the patients with non-angiogenic preeclampsia (N = 46) were more obese [BMI: 35.2 (31.6, 38.7) versus 31.1 (28.0, 39.0), p = 0.04], more likely to have preexisting diabetes (21.7% versus 2.0%, p = 0.002) and presented at a later gestational age [35 (32, 37) versus 32 (29, 34) weeks, p < 0.0001] as compared with women with angiogenic preeclampsia (N = 51). Women with non-angiogenic preeclampsia had no serious adverse outcomes (elevated liver function tests/low platelets: 0% versus 23.5%, abruption: 0% versus 9.8%, pulmonary edema: 0% versus 3.9%, eclampsia: 0% versus 2.0 %, small for gestational age: 0% versus 17.7% and fetal/neonatal death: 0% versus 5.9%) as compared with women with angiogenic preeclampsia. The rate of preterm delivery <34 weeks was 8.7% in non-angiogenic preeclampsia compared with 64.7% in angiogenic preeclampsia (p < 0.0001). Interestingly, delivery between 34 and 37 weeks and resource utilization (hospital admission days) were similar in the two groups. CONCLUSION: In contrast to the angiogenic form, the non-angiogenic form of preeclampsia is characterized by little to no risk of preeclampsia-related adverse outcomes, other than iatrogenic prematurity. Incorporation of angiogenic biomarkers in the evaluation of preeclampsia may allow accurate and early identification of severe disease.

A modified fetal heart rate tracing interpretation system for prediction of cesarean section.

OBJECTIVE: To investigate whether a modified version of the 2008 National Institute of Child Health and Human Development (NICHD) interpretation system upon admission decreases cesarean delivery risk. METHODS: This retrospective cohort study ascribed a modified category to the first 30 min of fetal heart rate (FHR) tracings in labor. Category I was divided into two subsets (Ia and Ib) by the presence of accelerations. Category II was divided into four subsets (IIa-IId) based on baseline FHR, variability, response to stimulation and decelerations. Log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). RESULTS: A category was ascribed to 910 women. Most FHR tracings were Category Ia (65.8%), Ib (7.7%), IIb (11.8%) and IId (14.0%). Category Ib tracings (fewer than two accelerations) were 2.26 (95% CI: 1.13-4.52) times more likely to result in cesarean delivery for abnormal FHR tracing than Category Ia tracings. A similar increase in risk was seen when comparing Category IIb and Category IId with Category Ia. CONCLUSION: Application of a modified version of the 2008 NICHD FHR interpretation system to the initial 30 min of labor can identify women at increased risk of cesarean delivery for abnormal FHR tracing.

Management of abnormal serum markers in the absence of aneuploidy or neural tube defects.

OBJECTIVE: Few guidelines address the management of pregnancies complicated by abnormal maternal serum analytes (MSAs) in the absence of aneuploidy or neural tube defects (NTDs). Our objective was to gather preliminary data regarding current opinions and management strategies among perinatologists in the US. METHODS: This survey of Maternal Fetal Medicine (MFM) physicians and fellows used a secure electronic web-based data capture tool. RESULTS: A total of 545 potential participants were contacted, and 136 (25%) responded. The majority were experienced academic physicians with robust practices. Nearly all (97.7%) respondents reported a belief in an association between abnormal MSAs and adverse pregnancy outcomes other than aneuploidy or NTDs. Plasma protein A (PAPP-A) and α-fetoprotein (AFP) were most often chosen as markers demonstrating a strong association with adverse outcomes. Most (86.9%) respondents acknowledged that abnormal MSAs influenced their counseling approach, and the majority (80.1%) offered additional ultrasound examinations. Nearly half started at 28 weeks and almost one-third at 32 weeks. Respondents acknowledging a relevant protocol in their hospital or practice were more likely to offer additional antenatal testing (p = 0.01). CONCLUSIONS: Although most perinatologists were in agreement regarding the association of MSAs with adverse pregnancy outcomes, a lack of consensus exists regarding management strategies.