Faculty Bibliography

BACKGROUND:- There is a paucity of data describing the effects of COVID-19, especially in asymptomatic patients, on placental pathology. Although the pathophysiology of COVID-19 is not completely understood, there is emerging evidence that it causes a severe systemic inflammatory response and results in a hypercoagulable state with widespread microthrombi. We hypothesized that it is plausible that a similar disease process may occur in the fetal-maternal unit. OBJECTIVE:- The aim of this study was to determine whether COVID-19 in term patients admitted to Labor and Delivery, including women without COVID-19 symptomatology, is associated with increased placental injury compared to a cohort of COVID-19 negative controls. STUDY DESIGN/METHODS:- This was a retrospective cohort study performed at NYU Winthrop Hospital between 3/31/2020 and 6/17/2020. During the study period all women admitted to Labor and Delivery were routinely tested for SARS-CoV-2 regardless of symptomatology. The placental histopathological findings of COVID-19 patients (n=77) who delivered a singleton gestation at term were compared to a control group of term patients without COVID-19 (n=56). Controls were excluded if they had obstetric or medical complications including fetal growth restriction, oligohydramnios, hypertension, diabetes, coagulopathy or thrombophilia. Multivariable logistic regression models were performed for variables that were significant in univariable analyses. A subgroup analysis was also performed comparing asymptomatic COVID-19 cases to negative controls. RESULTS:- In univariable analyses, COVID-19 cases were more likely to have evidence of fetal vascular malperfusion, i.e. presence of avascular villi and/or mural fibrin deposition (32.5% (25/77) vs. 3.6% (2/56), p<0.0001) and villitis of unknown etiology (20.8% (16/77) vs. 7.1% (4/56), p=0.030). These findings persisted in a subgroup analysis of asymptomatic COVID-19 cases compared to COVID-19 negative controls. In a multivariable model adjusting for maternal age, race/ethnicity, mode of delivery, preeclampsia, fetal growth restriction and oligohydramnios, the frequency of fetal vascular malperfusion abnormalities remained significantly higher in the COVID-19 group (OR= 12.63, 95% CI [2.40, 66.40]). While the frequency of villitis of unknown etiology was more than double in COVID-19 cases compared to controls, this did not reach statistical significance in a similar multivariable model (OR=2.11, 95% CI [0.50, 8.97]). All neonates of mothers with COVID-19 tested negative for SARS-CoV-2 by PCR. CONCLUSIONS:- Despite the fact that all neonates born to mothers with COVID-19 were negative for SARS-CoV-2 by PCR, we found that COVID-19 in term patients admitted to Labor and Delivery is associated with increased rates of placental histopathologic abnormalities, particularly fetal vascular malperfusion and villitis of unknown etiology. These findings appear to occur even among asymptomatic term patients.

OBJECTIVE:The objectives of our study were to: (1) evaluate the prevalence of cesarean delivery due to maternal request among nulliparous, term, singleton, vertex (NTSV) patients; (2) identify the clinical profile, if any, of these patients; and (3) compare the perinatal outcomes between NTSV patients who requested a cesarean delivery versus patients who did not request cesarean delivery. STUDY DESIGN/METHODS:This was a retrospective case control study performed at a single institution between November 2018 and July 2019. All NTSV patients who had a cesarean delivery due to maternal choice were identified and compared to the next two NTSV patients in labor who delivered vaginally or by medically indicated cesarean delivery following a cesarean delivery by maternal choice. The primary outcome was composite neonatal morbidity. Secondary outcomes were individual components of composite neonatal and maternal morbidity. RESULTS: < .01). There was no significant difference in composite neonatal morbidity between cases and controls (6.6% vs. 5.7%, adjusted odds ratio [aOR] 0.96, 95% CI 0.25-3.61). The risk for postpartum hemorrhage requiring blood transfusion was higher (but not statistically significant) in the study group (5.0% vs. 0.0%, aOR 6.43, 95% CI: 0.65-63.24). Patients who chose cesarean delivery during the intrapartum period had a higher (but not statistically significant) composite neonatal morbidity (14.3% vs. 5.7%, aOR 2.24, 95% CI 0.52-9.78) and composite maternal morbidity (28.6% vs.11.8%, aOR 2.90, 95% CI 0.92-9.16) and significantly higher transfusion rate (aOR 16.93, 95% CI 1.53-187.74). CONCLUSION/CONCLUSIONS:Cesarean delivery by maternal choice in NTSV patients is not associated with improved neonatal outcomes; in contrast, it is associated with increased composite maternal morbidity and increased transfusion rate.

OBJECTIVE:Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg, confirmed 15 min apart. ACOG recommends that acute-onset, severe hypertension be treated with first line-therapy (IV labetalol, IV hydralazine or PO nifedipine) within 60 minutes to reduce risk of maternal morbidity and mortality. Therefore, our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN/METHODS:A retrospective cohort study was performed comparing women appropriately treated within 60 minutes versus those with delay in first line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension or preeclampsia using ICD-10 codes and obstetric antihypertensive usage in a pharmacy database at one academic institution from January 2017 - June 2018. 267 subjects (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within two days of delivery. 213 subjects were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon ran-sum and sample t-tests were used to compare the two groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed, C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at p<0.05. RESULTS:Of the 213 women, 110 (51.6%) had delayed treatment vs. 103 (48.4%) who were treated within 60 min. Patients who had delayed treatment were 3.2 times more likely to present with an initial BP in the non-severe range vs those who had timely treatment (OR=3.24, 95% CI:1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms-- patients without pre-eclampsia symptoms were 2.7 times more likely to have delayed treatment (OR=2.68, 95%CI:1.50-4.80). Patients with HTN emergencies that occurred overnight between 10pm-6am were 2.7 times more likely to have delayed treatment vs. those that occurred between 6am-10pm (OR 2.72, 95% CI: 1.27-5.83). Delayed treatment also had an association with race, with Caucasian patients being 1.8 times more likely to have delayed treatment (OR=1.79; 95% CI: 1.04-3.08). Patients treated under 60 min had a lower gestational age at presentation vs those with delayed treatment (34.6±5wk vs. 36.6±4wks, respectively, p <0.001). For every 1 week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (OR 1.11; 95%CI:1.04-1.19). Another factor associated with delay of treatment was presenting complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (OR=2.17; 95%CI: 1.07-4.41). CONCLUSION/CONCLUSIONS:Initial blood pressure in non-severe range, absence of preeclampsia symptoms, presentation overnight, Caucasian race, presenting complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to delay in treatment of obstetric hypertensive emergency. Quality improvement initiatives targeting these barriers should be instituted to improve timely treatment.

Patient safety has remained one of the most important priorities over the past decade, particularly in hospital settings. Implementation of patient safety measures has focused not only on reducing medication and surgical errors but also on the development of a culture of safety, including enhanced communication among all healthcare stakeholders. Academic medicine may further contribute to the culture of safety if all relevant clinical article submissions address patient safety. In order to improve communication between the authors of clinical research articles and practicing physicians, we propose that each clinical research article may be accompanied by a clear statement from the authors regarding practice implications and patient safety.

INTRODUCTION/BACKGROUND:Postpartum hemorrhage is a major cause of maternal morbidity and mortality throughout the world and uterine atony is the leading cause of postpartum hemorrhage. The B-Lynch brace suture is a fertility-sparing approach to treating intractable uterine atony at the time of cesarean delivery. However, many obstetricians lack confidence to perform this procedure, which they may not have performed during residency. In order to train all residents to perform the B-Lynch brace suture, we developed a realistic model by using a flank steak to imitate a gravid uterus. METHODS:A convenience sample of obstetrics-gynecology faculty and residents at different levels of training at a single large hospital participated in this pilot project. Each physician reported self-perceived understanding of and confidence in performing the B-Lynch procedure before and immediately after practicing the technique using the flank-steak model, via a Likert-type survey (scale 1  =  low, 5  =  high). A Wilcoxon matched-pairs signed rank test was used to compare the before and after responses. RESULTS:Thirty-four participants completed the flank-steak model training and pretraining/posttraining surveys. The median score (range) for self-perceived understanding was 4 (2-5) and increased to 5 (4-5) (P < .01) after exposure to the training model. The confidence scores rose from 3 (1-5) to 5 (4-5) (P < .01) after training. CONCLUSION/CONCLUSIONS:The flank-steak model for teaching the B-Lynch suture significantly improved resident and faculty self-perceived understanding of and confidence in performing this procedure, which is otherwise rarely practiced in residency.