Faculty Bibliography

We present a case of a vein of Galen aneurysmal malformation (VGAM), a rare congenital arteriovenous malformation, in one fetus of a monochorionic-diamniotic twin pregnancy. The diagnosis was made with color Doppler ultrasonography at 28 weeks and the affected fetus was found to have worsening cardiomegaly on subsequent fetal echocardiograms. She was emergently delivered at 32 weeks for abnormal fetal heart rate tracing of the affected twin. Magnetic resonance imaging of the brain findings after delivery demonstrated severe neurological injury; therefore, postnatal embolization was not performed. The neonate died on day of life 9. The cotwin survived without neurological complications. This is the first case in the literature of a VGAM diagnosed prenatally in a monochorionic-diamniotic twin pregnancy and demonstrates the challenge of delivery timing with prenatal diagnosis in a twin pregnancy.

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..

PURPOSE/OBJECTIVE:The purpose of this narrative review was to assess the limited literature on fetal anomalies diagnosed in the second trimester of pregnancy and parental decision-making and identify sources of information deemed as facilitators and barriers to medical decisions. METHODS:This was a literature review of source material and information about fetal anomalies diagnosed in the second trimester of pregnancy, decision-making, decision tools or aids, and sources of information for anomalies. The search string used explored related peer-reviewed publications and systematic reviews between 2007 and 2024. We also reviewed references from publications meeting inclusion criteria. The search was conducted between June 2022 and February 2024. Exclusion criteria included conference abstracts, non-peer reviewed literature, and articles not available in English language. A total of 77 publications were identified by searching multiple databases using a predefined search string. The search encompassed full text articles from 2007 to 2024 and 11 full-text publications were ultimately included in the review. A list of 45 co-occurring keywords was generated from the included texts, with each keyword having a minimum of two co-occurrences. RESULTS:Key themes identified included (1) the role of the clinician and need for development of professional knowledge and empathy surrounding discussion of fetal anomalies with patients; (2) information gathering, with individuals reporting use of multiple strategies to obtain information; while the majority found information satisfying, they preferred more details on diagnosis, long-term outcomes of the fetus/child and management of the pregnancy or termination process; and (3) decision-making, the path and process of how individuals made decisions about the pregnancy including quality of life, future fertility, and seeking other people's experiences. CONCLUSION/CONCLUSIONS:Many factors contribute to an individual's decision-making after a diagnosis of a fetal anomalies diagnosed in the second trimester of pregnancy, ranging from personal beliefs and goals to shared experiences of others and access to care. Understanding how sources of information may be deemed both as facilitators and barriers to different individuals during the decision-making process is important for healthcare providers in order to understand how to most effectively support patients. There is a dearth of information on training healthcare professionals to provide support to patients facing these decisions.

BACKGROUND:Respiratory distress syndrome is strongly associated with prematurity, including late preterm births. Respiratory distress syndrome has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births. OBJECTIVE:We sought to determine the association between respiratory distress syndrome and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates. STUDY DESIGN/METHODS:This is a retrospective cohort study using California's linked vital statistics and patient discharge data (2008-2019). We included singleton, nonanomalous births with a gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal sepsis, length of hospital stay, neonatal death, and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of respiratory distress syndrome with outcomes at each gestational age. Adjusted risk ratio and 95% confidence interval values were estimated. RESULTS:A total of 242,827 births were included, of which 11,312 (4.7%) had respiratory distress syndrome. We found that among neonates with respiratory distress syndrome, necrotizing enterocolitis was higher at 35 weeks (adjusted risk ratio, 3.97 [95% confidence interval, 1.88-8.41]) and 36 weeks (adjusted risk ratio, 4.53 [95% confidence interval, 1.45-14.13]). Intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, and length of hospital stay were significantly higher at 34-36 weeks of gestation in neonates with respiratory distress syndrome. Neonatal death was significantly higher among neonates with respiratory distress syndrome at 35 weeks (adjusted risk ratio, 3.04 [95% confidence interval, 1.58-5.85]) and 36 weeks (adjusted risk ratio, 3.25; 95% confidence interval, 1.59-6.68). In addition, infant death was significantly higher at 35 weeks (adjusted risk ratio, 2.27 [95% confidence interval, 1.43-3.61]) and 36 weeks (adjusted risk ratio, 2.60 [95% confidence interval, 1.58-4.28]). CONCLUSION/CONCLUSIONS:We found that respiratory distress syndrome was associated with intraventricular hemorrhage, retinopathy of prematurity, and sepsis at 34-36 weeks of gestation, whereas respiratory distress syndrome was associated with neonatal death, infant death, and necrotizing enterocolitis at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing, the potential benefits of antenatal steroids in pregnancies in the late preterm period, and the management of respiratory distress syndrome in late preterm neonates.

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.

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.

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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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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