Faculty Bibliography

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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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.

Introduction Fetal cardiac disease is strongly associated with maternal anti-SSA/Ro antibodies, but gaps in our knowledge include the influence of antibody specificity and titer, maternal diagnosis, overall non-cardiac adverse pregnancy outcomes (APOs), optimal surveillance protocols, and efficacy of rapid treatment. Methods The multi-center Surveillance and Treatment To Prevent Fetal AV Block Likely to Occur Quickly (STOP BLOQ) study recruited pregnant women with commercially positive anti-Ro antibodies and stratified them into high and low titers of anti-Ro60 and Ro52 based on a research ELISA, using a cutoff defined by that obtained for 50 mothers with previous AVB offspring. Mothers with anti-Ro60 and/or 52 antibodies at or above 1,000 I.U. were trained to perform FHRM. From 17-25 weeks of gestation, FHRM was completed 3x/day in addition to weekly or biweekly fetal echocardiograms (echo). Mothers texted all audio sounds to the coordinating center. Texts deemed abnormal by mothers were immediately sent to an on call pediatric cardiologist who either reassured if FHRM was normal or referred for emergency fetal echo in < 6 hours if abnormal. Results 250 anti-Ro pregnant women (22% Hispanic, 50% white, 12% Black, 12% Asian, 4% other) have been consented, including 28 whose previous child had AVB. Of mothers tested to date, 153 were provided home monitors given high titer anti-Ro60 and/or 52 antibodies (26 high titer anti-Ro60 alone, 21 high titer anti-Ro52 alone,105 high titer antibodies to both antigens). The 83 patients with low titers were surveilled with echos per local standard of care. Regarding maternal diagnosis, of 161 assessed to date, 39% were asym/UAS, 11% RA, 31% SS, 19% SLE. Antibody titers did not significantly differ by ethnicity, race or diagnosis (table 1). Non-AVB APOs occurred in 18% and were not predicted by Ro60 or 52 titers but rather SLE diagnosis (table 2). In total, 24,759 FHRM audiotexts were received from 131 patients (90 of whom have delivered) during the monitoring period. Of these, 22 were evaluated by the on-call pediatric cardiologist, who prompted an emergency echo (all completed in < 6 hrs). In 11 cases, the emergency echo was normal. In 9, there were premature atrial contractions, confirming the mother's perception. In 2 with 2degree block on urgent echo (both treated per protocol with IVIG and dexamethasone), 1 reverted to normal sinus rhythm and the other progressed to 3degree block. In 2 others, the mother did not perceive abnormal FHRM for > 24 hrs, echo identified 3degree block, and retrospective cardiology review of FHRM audio captures identified an abnormality prior to obtaining the echo. All 4 AVB developed in fetuses of mothers with high titer antibodies to both Ro60 and 52 (mean 32,451 and 34,991 respectively). Of the 18 mothers with a previous AVB child who followed the 400mg hydroxychloroquine PATCH protocol, 1 developed AVB in accord with the results of Step 1 in that study. Conclusion These data support that APOs in this clinically diverse group of mothers are not influenced by anti-Ro titer or specificity, but rather SLE diagnosis. All conduction defects were initially identified by FHRM and in mothers with high titer anti-Ro60 and 52. Hydroxychloroquine continues to show efficacy in reducing the AVB recurrence rate with rapid intervention of emergent block being promising

OBJECTIVE/UNASSIGNED:SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS/UNASSIGNED: < 0.05 considered significant. RESULTS/UNASSIGNED: = 0.01). CONCLUSION/UNASSIGNED:In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.

BACKGROUND/OBJECTIVE/UNASSIGNED:SARS-CoV-2 continues to spread widely in the US and worldwide. Pregnant women are more likely to develop severe or critical illness than their non-pregnant counterparts. Known risk factors for severe and critical disease outside of pregnancy, such as asthma, diabetes, and obesity have not been well-studied in pregnancy. We aimed to determine which clinical and pregnancy-related factors were associated with severe and critical COVID illness in pregnancy. STUDY DESIGN/UNASSIGNED: < .05. Multivariable logistic regression was performed including variables that were significantly different between groups. RESULTS/UNASSIGNED:< .01). After adjustment, history of smoking remained significantly predictive of severe/critical disease [aOR 3.84 (95% CI, 1.25-11.82)]. CONCLUSION/UNASSIGNED:Pregnant women with a history of smoking, asthma, or other respiratory condition, and COVID-19 diagnosis in the second trimester of pregnancy were more likely to develop severe/critical disease. These findings may be useful in counseling women on their individual risk of developing the severe or critical disease in pregnancy and may help determine which women are good candidates for vaccination during pregnancy.

OBJECTIVE:Vaccination presents an important strategy to mitigate illness in this population. However, there is a paucity of data on vaccination safety and pregnancy outcomes because pregnant women were excluded from the initial phase III clinical trials. Our objective was to describe the maternal, neonatal, and obstetrical outcomes of women who received a messenger RNA (mRNA) COVID-19 vaccination while pregnant during the first 4 months of vaccine availability. STUDY DESIGN/METHODS:This was an institutional review board-approved descriptive study of pregnant women at New York University Langone Health who received at least 1 dose of an mRNA COVID-19 vaccination approved by the US Food and Drug Administration (FDA) (Pfizer-BioNTech or Moderna) from the time of the FDA Emergency Use Authorization to April 22, 2021. Eligible women were identified via search of the electronic medical record (EMR) system. Vaccine administration was ascertained via immunization records from the New York State Department of Health. Women were excluded if they were vaccinated before conception or during the postpartum period. Charts were reviewed for maternal demographics and pregnancy outcomes. Descriptive analyses were performed using the R software version 4.0.2 (The R Foundation, Boston, MA). RESULTS:We identified 424 pregnant women who received an mRNA vaccination. Of those, 348 (82.1%) received both doses and 76 (17.9%) received only 1 dose. The maternal characteristics and vaccination information are shown in Table 1. Of the included women, 4.9% had a history of a confirmed COVID-19 diagnosis before vaccination. After vaccination, no patient in our cohort was diagnosed with COVID-19. In terms of the pregnancy outcomes, 9 women had spontaneous abortions, 3 terminated their pregnancies, and 327 have ongoing pregnancies. Of the women included, 85 delivered liveborn infants. There were no stillbirths in our population. Of the 9 spontaneous abortions, 8 occurred during the first trimester at a range of 6 to 13 weeks' gestation. There was 1 second trimester loss. The rate of spontaneous abortion among women vaccinated in the first trimester was 6.5%. The 327 women with ongoing pregnancies have been followed for a median of 4.6 weeks (range, 0-17 weeks) following their most recent dose. A total of 113 (34.6%) women, initiated vaccination during the first trimester, 178 (54.4%) initiated vaccination during the second trimester, and 36 (11.0%) during the third trimester. Following the vaccination, 2 fetuses (0.6%) developed intrauterine growth restriction, whereas 5 (1.5%) were diagnosed with anomalies. Outcomes for the 85 women who delivered are shown in Table 2. Of the women who delivered, 18.8% were diagnosed with a hypertensive disorder of pregnancy. The rate of preterm birth was 5.9%. One preterm delivery was medically indicated, whereas the remaining 3 were spontaneous. A total of 15.3% of neonates required admission to the neonatal intensive care unit (NICU). Of the NICU admissions, 61.5% were because of hypoglycemia or an evaluation for sepsis. Other reasons for admission included prematurity, hypothermia, and transient tachypnea of the newborn. Of all the neonates, 12.2% were small for gestational age (SGA) per the World Health Organization standards. CONCLUSION/CONCLUSIONS:Our rate of pregnancy-related hypertensive disorders is higher than our baseline institutional rate of 9.5%, however, this may be because of the underlying characteristics of our study population or skewing of our small sample size. Our 12.2% rate of SGA neonates is near the expected value based on the definition that 10% of neonates will be SGA at birth. The NICU admission rate is at par with our institutional rate of 12%. To date, most women in this series have had uncomplicated pregnancies and have delivered at-term. Strengths of this study include using the EMR system to identify subjects and gather data. We did not rely on self-enrollment and self-report, thereby reducing selection and recall bias. By performing manual chart reviews, we obtained detailed and reliable information about individual patients. One limitation of this study is the lack of a matched control group consisting of unvaccinated pregnant women and therefore direct conclusions could not be drawn about the relative risks of complications. In addition, our cohort is small and may not be generalizable. Finally, many women included are healthcare workers who had early access to vaccinations. As more pregnant women become eligible for the COVID-19 vaccinations, there is an urgent need to report on the maternal, neonatal, and obstetrical outcomes of COVID-19 vaccinations during pregnancy. The results of this study can be used to counsel and reassure pregnant patients facing this decision.