Faculty Bibliography

OBJECTIVE: There are limited published data on the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus from mothers to newborns through breastfeeding or from breast milk. The World Health Organization released guidelines encouraging mothers with suspected or confirmed COVID-19 to breastfeed as the benefits of breastfeeding outweighs the possible risk of transmission. The objective of this study was to determine if SARS-CoV-2 was present in the breast milk of lactating mothers who had a positive SARS-CoV-2 nasopharyngeal swab test prior to delivery, and the clinical outcomes for their newborns. STUDY DESIGN/METHODS:by two-step reverse transcription polymerase chain reaction. Additionally, the clinical characteristics of the maternal newborn dyad, results of nasopharyngeal SARS-CoV-2 testing, and neonatal follow-up data were collected. RESULTS: A total of 19 mothers were included in the study and their infants who were all fed breast milk. Breast milk samples from 18 mothers tested negative for SARS-CoV-2, and 1 was positive for SARS-CoV-2 RNA. The infant who ingested the breast milk that tested positive had a negative nasopharyngeal test for SARS-CoV-2, and had a benign clinical course. There was no evidence of significant clinical infection during the hospital stay or from outpatient neonatal follow-up data for all the infants included in this study. CONCLUSION/CONCLUSIONS: In a small cohort of SARS-CoV-2 positive lactating mothers giving birth at our institution, most of their breast milk samples (95%) contained no detectable virus, and there was no evidence of COVID-19 infection in their breast milk-fed neonates. KEY POINTS/CONCLUSIONS:· Breast milk may rarely contain detectable SARS-CoV-2 RNA and was not detected in asymptomatic mothers.. · Breast milk with detectable SARS-CoV-2 RNA from a symptomatic mother had no clinical significance for her infant.. · Breast feeding with appropriate infection control instructions appears to be safe in mother with COVID infection..

INTRODUCTION: Hypertensive disorders play a significant role in maternal morbidity and mortality. Limited data on prehypertension (preHTN) in pregnancy exists. We examine the risk of adverse outcomes in patients with preHTN in early (< 20 weeks) versus late pregnancy (> 20 weeks). MATERIALS AND METHODS: Retrospective cohort study of singleton gestations between August 2013 and June 2014. Patients were divided based on when they had the highest blood pressure in pregnancy, as defined per the Joint National Committee 7 (JNC-7). Groups were compared using Chi2, Fisher's exact, Student t-test and Mann-Whitney U test with p < 0.05 used as significance. RESULTS: There were 125 control, 95 early preHTN, 136 late preHTN and 21 chronic hypertension (CHTN). Early preHTN had an increased risk of pregnancy related hypertension (PRH) (OR 12.26, p < 0.01), and composite adverse outcomes (OR 2.32, p < 0.01). Late preHTN had an increased risk for PRH (OR 4.39, p = 0.02) compared to normotensive and decreased risk for PRH (OR 0.26, p = 0.02), and composite adverse outcomes (OR 0.379, p = 0.04) compared to CHTN. Compared to late preHTN, early preHTN had more PRH (OR 2.85, p < 0.01), and composite adverse outcomes (OR 1.68, p = 0.04). CONCLUSIONS: Early prehypertension increases the risk of adverse obstetrical outcomes. Other than an increased risk of PRH, patients with late prehypertension have outcomes similar to normotensive women.

The increase in the cesarean delivery (CD) rate, from 5% in 1970 to 32% in 2015, has been associated with an increase in cesarean scar pregnancies (CSP) approximately 1 in 1,800-2,500 pregnancies complicated by previous cesarean deliveries (CD). There is currently no consensus on the optimal management of CSP or recurrent CSP. We describe the case of a 35-year-old G7P2042 with two prior CD and four prior CSP with positive fetal heart activity, all treated with intra-gestational injection of methotrexate, in conjunction with the practice of favoring termination of CSP. Transabdominal and transvaginal ultrasound was used to perform serial 2D and 3D renderings. A live CSP was diagnosed on initial scan at 6 4/7 weeks as a gestational sac was noted to be at the cesarean scar niche with a mostly posterior placenta previa wrapping anteriorly to the level of the bladder. By 9 4/7 weeks the placenta had multiple lacunae and hypervascularity therefore a morbidly adherent placenta (MAP) was diagnosed. A placenta percreta was diagnosed by 17 5/7 weeks. An MRI was performed at 32 2/7 weeks with an impression of placenta previa with increta. Outpatient betamethasone course was given 48 hours prior to scheduled cesarean hysterectomy at 34 0/7 weeks. The pathology confirmed a MAP, placenta percreta. The details of this case highlight that although CSP is a rare pregnancy complication of CD, its frequency is mirroring the increasing CD rates. Cases of recurrent CSP are even more infrequent, and a fifth repeat has not been previously described and adds more to the mounting data that CSP is a precursor to MAP. Additionally, this case displays how the counseling of CSP has shifted over time; indicating that patients with CSP can be offered continuation of pregnancy with understanding the maternal risks, including uterine rupture and cesarean hysterectomy for MAP.

Objective Hypertensive disorders play a significant role in maternal morbidity and mortality. There is limited data on prehypertension (pre-HTN) during the first half of pregnancy. We sought to examine the risk of adverse pregnancy outcomes in patients with prehypertension in early pregnancy (<20 weeks' gestational age). Study Design A retrospective cohort study of 377 patients between 2013 and 2014. Patients were divided based on the highest blood pressure in early pregnancy, as defined per the JNC-7 criteria. There were 261 control patients (69.2%), 95 (25.2%) pre-HTN patients, and 21 (5.6%) chronic hypertension (CHTN) patients. The groups were compared using X2, Fisher's Exact, Student t-test, and Mann-Whitney U test with p < 0.05 used as significance. Results Patients with pre-HTN delivered earlier (38.8 +/- 1.9 weeks vs 39.3 +/- 1.7 weeks), had more pregnancy related hypertension (odds ratio [OR], 4.62; confidence interval [CI], 2.30-9.25; p < 0.01) and composite maternal adverse outcomes (OR, 2. 10; 95% CI, 1.30-3.41; p < 0.01), NICU admission (OR, 2.21; 95% CI, 1.14-4.26; p = 0.02), neonatal sepsis (OR, 6.12; 95% CI, 2.23-16.82; p < 0.01), and composite neonatal adverse outcomes (OR, 2.05; 95% CI, 1.20-3.49; p < 0.01). Conclusion Although women with pre-HTN are currently classified as normal in obstetrics, they are more similar to women with CHTN. Pre-HTN in the first half of pregnancy increases the likelihood of adverse outcomes.

Maternal cardiopulmonary arrest (MCPA) is a catastrophic event that can cause significant morbidity and mortality. A prepared, multidisciplinary team is necessary to perform basic and advanced cardiac life support specific to the anatomic and physiologic changes of pregnancy. MCPA is a challenging clinical scenario for any provider. Overall, it is an infrequent occurrence that involves 2 patients. However, key clinical intervention performed concurrently can save the life of both mother and baby.