Faculty Bibliography

Multisystem inflammatory syndrome in children (MIS-C), a new condition related to coronavirus disease 2019 (COVID-19) in the pediatric population, was recognized by physicians in the United Kingdom in April 2020. Given those up to the age of 21 years can be affected, pregnant adolescents and young adults are susceptible. However, there is scant information on how MIS-C may affect pregnancy and whether the presentation differs in the pregnant population. We report a case of a pregnant adolescent with COVID-19 and MIS-C with a favorable outcome. This case highlights the considerations in managing a critically ill pregnant patient with a novel illness and the importance of a multidisciplinary team in coordinating care.

OBJECTIVE: This study aimed to evaluate the rates of vaccination against infectious diseases (Tetanus, Diphtheria, and Pertussis [Tdap] and influenza) in pregnancy during the coronavirus disease 2019 (COVID-19) pandemic compared to contemporary historical controls. STUDY DESIGN/METHODS: < 0.05. RESULTS: In total, 1,713 pregnant people were included. Compared to historical controls, the COVID cohort differed in age, race, timing of initiation of prenatal care, insurance status, and medical comorbidities. After adjusting for these covariates, pregnant people were significantly more likely to accept influenza vaccine in the COVID cohort (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.27-2.29) and had similar Tdap acceptance (aOR 1.5, 95% CI 0.99-2.17). However, this trend was not observed for the entire obstetric population; public insurance status and medical comorbidities were associated with lower vaccine rates during the pandemic. For those who had public insurance, rates of influenza vaccination decreased from 83% in 2019 to 40% during COVID (aOR 0.16, 95% CI 0.10-0.24) and for Tdap rates decreased from 93 to 54% (aOR 0.13, 95% CI 0.08-0.21). CONCLUSION/CONCLUSIONS: During the COVID-19 pandemic era, pregnant people at large were more likely to accept the influenza vaccine. However, this trend did not apply to Tdap, and high-risk groups with public insurance and medical comorbidities. This study highlights potential disparities in vaccination rates, which need to be accounted for when evaluating national vaccine trends. These data support increased efforts in vaccine counseling for high-risk populations. KEY POINTS/CONCLUSIONS:· Antenatal flu vaccination increased during the pandemic.. · Antenatal Tdap vaccination was unchanged during the pandemic.. · High-risk pregnant patients had decreased vaccine uptake.. · High-risk subgroups were not included in overarching vaccination trends..

OBJECTIVE: This study aimed to evaluate the relationship between peripartum mean arterial pressure (MAP) and postpartum readmission for preeclampsia with severe features. STUDY DESIGN/METHODS: This is a retrospective case-control study comparing adult parturients readmitted for preeclampsia with severe features to matched nonreadmitted controls. Our primary objective was to evaluate the association between MAP at three time points during the index hospitalization (admission, 24-hour postpartum, and discharge) and readmission risk. We also evaluated readmission risk by age, race, body mass index, and comorbidities. Our secondary aim was to establish MAP thresholds to identify the population at highest risk of readmission. Multivariate logistic regression and chi-squared tests were used to determine the adjusted odds of readmission based on MAP. Receiver operating characteristic analyses were performed to evaluate risk of readmission relative to MAP; optimal MAP thresholds were established to identify those at highest risk of readmission. Pairwise comparisons were made between subgroups after stratifying for history of hypertension, with a focus on readmitted patients with new-onset postpartum preeclampsia. RESULTS: = 0.0018) were associated with increased risk of readmission. African American race and hypertensive disorder of pregnancy were independently associated with increased risk of readmission. Subjects with MAP > 99.5 mm Hg at admission or >91.5 mm Hg at 24-hour postpartum had a risk of at least 46% of requiring postpartum readmission for preeclampsia with severe features. CONCLUSION/CONCLUSIONS: Admission and 24-hour postpartum MAP correlate with risk of postpartum readmission for preeclampsia with severe features. Evaluating MAP at these time points may be useful for identifying women at higher risk for postpartum readmission. These women may otherwise be missed based on standard clinical approaches and may benefit from heightened surveillance. KEY POINTS/CONCLUSIONS:· Existing literature focuses on management of antenatal hypertensive disorders of pregnancy.. · Elevated peripartum MAP is associated with increased odds of readmission for preeclampsia.. · Peripartum MAP may predict readmission risk for de novo postpartum preeclampsia..

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

Purpose: The objective of this study was to compare maternal and neonatal outcomes when the diagnosis of FGR was based on isolated abdominal circumference < 10th percentile for gestational age (GA) (iAC group) versus overall estimated fetal weight < 10th percentile (EFW group). Methods: This was a retrospective cohort study of singleton gestations who underwent growth ultrasounds and delivered at a single health system from 1/1/19"“9/4/20. The study group was comprised of patients with AC < 10th percentile and EFW ≥ than the 10th percentile (iAC group). The control group included patients with overall EFW < 10th percentile (EFW group). Outcomes evaluated included GA at delivery, mode of delivery, fetal and neonatal outcomes. Data was analyzed using Mann Whitney U, X ², and Fisher exact tests with significance defined as p < 0.05. Results: 635 women met the inclusion criteria, 259 women in the iAC group and 376 women in the EFW group. The iAC group was noted to have a later GA at diagnosis and delivery. iAC was associated with lower rates of preterm birth (PTB), NICU admission, SGA at delivery and umbilical artery cord gas < 7.0. Conclusion: Using iAC as a definition of FGR increased the number of FGR cases by 1.69-fold over EFW criteria alone. However, obstetrical and neonatal outcomes for the iAC group appear to be significantly better than those in the EFW group, with low rates of PTB, NICU admission, and umbilical artery cord gas < 7.0.

Objective: To compare pregnancy latency achieved with oral labetalol versus extended-release nifedipine during expectant management of preterm preeclampsia with severe features (PEC-SF).
Study Design: This is a retrospective cohort study of patients initiated on antihypertensive therapy with oral labetalol or extended-release nifedipine during admission for expectant management of PEC-SF < 34 weeks between 1/2013 and 4/2022. Those on antihypertensive therapy prior to admission or with another indication for delivery < 34 weeks were excluded (monochorionic-monoamniotic twins, higher order multiples, absent or reversed umbilical artery Dopplers). Pregnancy latency (from oral agent initiation to delivery decision) was compared between groups. Secondary outcomes included need for initial agent dose uptitration, addition of second oral agent, acute antihypertensive therapy, and delivery for refractory hypertension. Linear and modified Poisson regression models were used to estimate adjusted mean differences (AMD) with 95% confidence intervals.
Result(s): The cohort included 78 patients (Table 1). Comparing those initiated on labetalol versus extended-release nifedipine (Table 2), there was no difference in latency (6.2 (7.5) vs 5.4 (7.4) days, AMD 1.1 days, 95% CI [-2.1, 4.4]), nor in the proportion of patients achieving 1 week latency (25.0% vs 23.8%, respectively, AMD 2.9%, 95% CI [-16.5, 22.3]). Those initiated on labetalol were less likely to require a second agent (16.7% vs 38.1% for nifedipine, AMD -18.4, 95% CI [-37.3, 0.5]). There were no differences in need for initial agent uptitration, acute antihypertensive therapy, or delivery for refractory hypertension.
Conclusion(s): There was no difference in pregnancy latency among patients with PEC-SF initiated on oral labetalol versus extended-release nifedipine. Patients on labetalol may be less likely to require a second antihypertensive agent, but comparative outcome estimates may be limited by small cohort size. Further investigations with a larger cohort should be performed to evaluate for any relative advantages of the two oral agents. [Formula presented] [Formula presented]
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Objective: To evaluate the impact of ibuprofen on postpartum (PP) blood pressure (BP) outcomes in pregnant patients with a new diagnosis of hypertensive disorders of pregnancy (HDP) and antenatal severe hypertension.
Study Design: In this double-blind randomized controlled trial, participants with HDP with antenatal severe hypertension (systolic BP >= 160 or diastolic >= 105mmHg) were assigned to receive a PP scheduled analgesic regimen with either ibuprofen or acetaminophen (control). Scheduled antihypertensive medications were started PP only as needed to maintain BP < 150/100. The primary outcome was prevalence of severe hypertension during PP stay. Prespecified secondary outcomes included need for PP anithypertensive medication, escalation of scheduled antihypertensive regimen, average PP mean arterial pressure (MAP), patient satisfaction, breakthrough pain medication, PP length of stay (LOS), and diuresis (urine output >= 200 ml/hour for 4 hours).
Result(s): From January 2017 to October 2019, 140 participants were randomized. Baseline characteristics were similar (Table 1). Prevalence of PP severe hypertension did not differ between groups (39.1% for those receiving ibuprofen vs 41.4% for controls, p=0.78, Table 2). There was no difference in PP antihypertensive medication use (35.7% in the ibuprofen group vs 40.0% for controls, p=0.60), nor escalation of scheduled antihypertensive regimen (15.7% in both groups, p=1.0). Mean MAP was similar between ibuprofen and control groups (95.7+/-8.2 vs 95.9+/-9.5, respectively, p=0.91). Diuresis occurred in 64.7% of the ibuprofen group vs 65.7% in controls (p=0.90). Patient satisfaction, breakthrough pain medication, and LOS were similar.
Conclusion(s): In patients with antenatal HDP and severe hypertension, PP ibuprofen use did not increase the prevalence of severe hypertension compared to those not receiving nonsteroidal antiinflammatory drugs (NSAIDs). Ibuprofen use did not impact other BP outcomes, pain control, or patient satisfaction. These findings from the largest trial to date support ACOG's recommendation that NSAIDs should be used preferentially over opioid analgesics. [Formula presented] [Formula presented]
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Background/UNASSIGNED:Hypertensive disorders in pregnancy are one of the most common causes of readmission postpartum. Due to the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable as hospitalization rates among COVID-infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown. Objective/UNASSIGNED:To compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy due to the COVID-19 pandemic. Study Design/UNASSIGNED:This is a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted due to hypertensive disorders in pregnancy at NYU Langone Health on 3/1/2019-2/29/2020 (control cohort) to 4/1/2020-3/31/2021 (COVID cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction of postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the postpartum hypertensive disorders in pregnancy readmission rates. Data were analyzed using Fisher's Exact test, chi-square test, and Wilcoxon rank-sum test with significance defined as p<0.05. Results/UNASSIGNED:There was no statistical difference in readmission rates for postpartum hypertensive disorders in pregnancy before versus after implementation of an early discharge policy (1.08% for control cohort vs 0.59% for COVID cohort). Demographics in each group were similar, as were median times to readmission (5.0 days, IQR 4.0-6.0 days vs 6.0 days, IQR 5.0-6.0 days, p=0.13) and median readmission lengths of stay (3.0 days, IQR 2.0-4.0 days vs 3.0 days, IQR 2.0-4.0 days, p=0.45). There was one ICU readmission in the COVID cohort and none in the control cohort (p=0.35). There were no severe maternal morbidities or maternal deaths. Conclusion/UNASSIGNED:These findings suggest policies reducing postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental in the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.