Faculty Bibliography

BACKGROUND:In March 2020, as community spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) became increasingly prevalent, pregnant women appeared to be equally susceptible to developing Coronavirus Disease 2019 (COVID-19). While the disease course usually appears mild, severe and critical COVID-19 appears to lead to significant morbidity including ICU admission with prolonged hospital stay, intubation, mechanical ventilation and even death. Although there are recent reports regarding the impact of COVID-19 on pregnancy, information regarding the severity of COVID-19 in pregnant versus non-pregnant women remains unknown. OBJECTIVE:We aim to describe the outcomes of severe and critical COVID-19 infection in pregnant versus non-pregnant reproductive aged women. STUDY DESIGN/METHODS:This is a multi-center retrospective case-control study of women with laboratory confirmed SARS-CoV-2 infection hospitalized with severe or critical COVID-19 in four academic medical centers in NYC and one in Philadelphia between March 12 and May 5, 2020. The cases consist of pregnant women admitted specifically for severe or critical COVID-19 and not for obstetric indication. The controls consist of reproductive aged, non-pregnant women admitted for severe or critical COVID-19. The primary outcome is a composite morbidity including: death, need for intubation, extracorporeal membrane oxygenation (ECMO), non-invasive positive pressure ventilation or need for high flow nasal cannula oxygen supplementation. Secondary outcomes include ICU admission, length of stay, need for discharge to long term acute care facility and discharge with home oxygen requirement. RESULTS:Thirty-eight pregnant women with SARS-CoV-2 polymerase chain reaction (PCR) confirmed infection were admitted to five institutions specifically for COVID-19, 29 (76.3%) meeting criteria for severe disease and 9 (23.7%) meeting criteria for critical disease. The mean age and BMI were significantly higher in the non-pregnant control group. The non-pregnant cohort was also noted to have increased frequency of pre-existing medical comorbidities, including diabetes, hypertension and coronary artery disease. Pregnant women were more likely to experience the primary outcome when compared to the non-pregnant control group (34.2% vs. 14.9%, p=0.03, adjusted OR 4.6 [95% CI 1.2-18.2]). Pregnant patients experienced higher rates of ICU admission (39.5% vs. 17.0%, p<0.01, adjusted OR 5.2 [95% CI 1.5-17.5]). Among pregnant women that underwent delivery, 72.7% occurred via cesarean delivery and mean gestational age at delivery was 33.8 ±5.5 weeks in patients with severe disease and 35 ±3.5 weeks in patients with critical COVID-19. CONCLUSIONS:Pregnant women with severe and/or critical COVID-19 are at increased risk for certain morbidities when compared to non-pregnant controls. Despite the higher comorbidities of diabetes and hypertension in the non-pregnant controls, the pregnant cases were at increased risk for composite morbidity, intubation, mechanical ventilation and ICU admission. These findings suggest that pregnancy may be associated with a worse outcome in women with severe and critical COVID-19. Our study suggests that similar to other viral infections such as SARS-CoV and MERS-CoV, pregnant women may be at risk for greater morbidity and disease severity.

During the coronavirus disease 2019 (COVID-19) pandemic in New York City, telehealth was rapidly implemented for obstetric patients. Though telehealth for prenatal care is safe and effective, significant concerns exist regarding equity in access among low-income populations. We performed a retrospective cohort study evaluating utilization of telehealth for prenatal care in a large academic practice in New York City, comparing women with public and private insurance. We found that patients with public insurance were less likely to have at least one telehealth visit than women with private insurance (60.9 vs. 87.3%, p < 0.001). After stratifying by borough, this difference remained significant in Brooklyn, one of the boroughs hardest hit by the pandemic. As COVID-19 continues to spread around the country, obstetric providers must work to ensure that all patients, particularly those with public insurance, have equal access to telehealth. KEY POINTS: · Telehealth for prenatal care is frequently utilized during the COVID-19 pandemic.. · Significant concerns exist regarding equity in access among lower-income populations.. · Women with public insurance in New York City were less likely to access telehealth for prenatal care..

OBJECTIVE:To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020. METHODS:We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020. RESULTS:Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%). CONCLUSION/CONCLUSIONS:During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.

Background/UNASSIGNED:The COVID-19 pandemic has had an impact on healthcare systems around the world with 3.0 million infected and 208,000 resultant mortalities as of this writing. Information regarding infection in pregnancy is still limited. Objectives/UNASSIGNED:To describe the clinical course of severe and critical infection in hospitalized pregnant women with positive laboratory testing for SARS-CoV2. Study Design/UNASSIGNED:This is a cohort study of pregnant women with severe or critical COVID-19 infection hospitalized at 12 US institutions between March 5, 2020 and April 20, 2020. Severe infection was defined according to published criteria by patient reported dyspnea, respiratory rate > 30 per minute, blood oxygen saturation ≤ 93% on room air, partial pressure of arterial oxygen to fraction of inspired oxygen <300 and/or lung infiltrates >50% within 24 to 48 hours on chest imaging. Critical disease was defined by respiratory failure, septic shock, and/or multiple organ dysfunction or failure. Women were excluded if they had presumed COVID-19 infection but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results/UNASSIGNED:=0.01). For those who required it, intubation usually occurred around day 9, and peak respiratory support for women with severe disease occurred on day 8. In women with critical disease, prone positioning was performed in 20% of cases, the rate of ARDS was 70%, and re-intubation was necessary in 20%. There was one case of maternal cardiac arrest, but no cases of cardiomyopathy and no maternal deaths. Thirty-two (50%) women in this cohort delivered during their COVID-19 hospitalization (34% of severe and 85% of critical women). Eighty-eight percent (15/17) of pregnant women with critical COVID-19 who delivered during their disease course were delivered preterm, 94% of them via cesarean; in all, 75% (15/20) of critically ill women delivered preterm. There were no stillbirths or neonatal deaths, or cases of vertical transmission. Conclusion/UNASSIGNED:In hospitalized pregnant women with severe or critical COVID-19 infection, admission typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 severe versus 12 critical). Critically ill women had a high rate of ARDS, and there was one case of cardiac arrest, but there were no cases of cardiomyopathy, or maternal mortality. Hospitalization for severe or critical COVID-19 infection resulted in delivery during the course of infection in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.

Introduction/UNASSIGNED:findings that may indicate vertical transmission of the virus in utero. We report our experience with placental/membrane SARS-CoV2 RNA PCR swab results after delivery to a series of symptomatic mothers with confirmed COVID-19 infection in pregnancy. Methods/UNASSIGNED:The time interval from maternal diagnosis of COVID-19 to delivery was calculated in days. Infants were tested with nasopharyngeal swabs for SARS-CoV-2 PCR between days of life 1 and 5 while hospitalized. Hospitalized infants were also assessed for clinical signs and symptoms, including fever, cough, and nasal congestion. Results/UNASSIGNED:Of 32 COVID-19 positive pregnant patients who gave birth in this timeframe, placental or membrane swabs were sent from 11 patients (Table). Three of 11 swabs were positive. None of the infants tested positive for SARS-CoV2 on days of life 1 through 5, and none demonstrated symptoms of COVID-19 infection. Discussion/UNASSIGNED:Although all of our neonates tested negative in the first 5 days of life, many were born via cesarean deliveries with decreased length of exposure to these tissues, which may be associated with a decreased likelihood of vertical transmission. Additionally, nasopharyngeal testing immediately after delivery may not be the ideal approach to evaluate vertical transmission if exposure occurs at the time of delivery, as the virus may require a longer incubation period before these swabs convert to positive. In summary, the presence of viral RNA by RT-PCR in placenta/membranes at the time of delivery suggests the need for further research into the possibility of vertical transmission.

There is a current paucity of information about the obstetric and perinatal outcomes of pregnant novel coronavirus disease 2019 (COVID-19) patients in North America. Data from China suggest that pregnant women with COVID-19 have favorable maternal and neonatal outcomes, with rare cases of critical illness or respiratory compromise. However, we report two cases of pregnant women diagnosed with COVID-19 in the late preterm period admitted to tertiary care hospitals in New York City for respiratory indications. After presenting with mild symptoms, both quickly developed worsening respiratory distress requiring intubation, and both delivered preterm via caesarean delivery. These cases highlight the potential for rapid respiratory decompensation in pregnant COVID-19 patients and the maternal-fetal considerations in managing these cases.

Introduction: A diagnosis of a fetal anomaly is not an indication for cesarean delivery (CD) and in most cases vaginal delivery is considered safe. However, several studies have shown increased rates of CD in pregnancies complicated by fetal anomalies. We utilized national birth data to evaluate the prevalence of CD in women eligible for vaginal delivery, with pregnancies complicated by a fetus with congenital diaphragmatic hernia (CDH), cyanotic congenital heart disease (CCHD), anencephaly, gastroschisis or omphalocele.
Method(s): We performed a retrospective cohort study using the 2017 US National Vital Statistics Report. All women with a singleton, cephalic fetus who delivered at >24 weeks with fewer than two prior cesarean deliveries were included. We analyzed the CD rate in women with each fetal anomaly compared to the CD rate in those without the fetal anomaly. Additionally, in women with fetal anomalies and complete insurance data, we assessed if the rate of CD differed in women with public and private insurance. Chi-squared test was used to assess for statistical significance.
Result(s): 3,576,614 pregnancies were included. 333 were complicated by anencephaly, 352 by omphalocele, 427 by CDH, 1869 by CCHD and 869 by gastroschisis. The rate of CD in the population without fetal anomalies was 30.3%. The CD rate was significantly higher in all groups with fetal anomalies (p<0.01, Table 1). Specifically, the CD rate was 36.6% in pregnancies complicated by fetal anencephaly, 63.3% in omphalocele, 40.7% in CDH, 40.8% in CCHD and 45.9% in gastroschisis. Among women with fetal anomalies, the rate of CD did not differ between women with public and private insurance (Table 2).
Conclusion(s): In this national cohort, we found an increased rate of CD in women with fetal anomalies, suggesting that this population is likely an important target in efforts to decrease the CD rate. The CD rate did not differ by insurance type, suggesting that other factors are driving this disparity and should be investigated in future studies

OBJECTIVE:To evaluate the effect of ibuprofen on blood pressure in women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension during the immediate postpartum period. METHODS:In this double-blind controlled trial, we randomly assigned women with a diagnosis of hypertensive disorders of pregnancy and mild hypertension to receive a postpartum analgesic regimen with either ibuprofen or acetaminophen. The primary outcome was average mean arterial pressure during the postpartum hospital stay. Prespecified secondary outcomes included use of breakthrough opioid pain medications, length of hospital stay, and postpartum diuresis, defined as urine output of at least 200 mL/hour for 4 hours. A sample size of 56 participants was needed to detect a difference of 6 mm Hg in average mean arterial pressure between the study groups. RESULTS:From January 17, 2017, to February 24, 2018, 61 participants were randomized and completed the trial, 31 participants in the ibuprofen group and 30 in the control group. Baseline characteristics were similar between groups. Postpartum average arterial pressure did not differ between study groups (93±8 mm Hg for those in the ibuprofen group vs 93±7 mm Hg in the control group, P=.93). Breakthrough opioid medications were requested by 24% of the participants in the ibuprofen group compared with 30% in the control group (P=.62). The ibuprofen group did not have a longer length of stay (48 hours vs 43 hours in the control group) or decreased rate of postpartum diuresis (61% in ibuprofen group vs 77% in the control group, P=.2). CONCLUSION/CONCLUSIONS:In women with hypertensive disorders of pregnancy and mild hypertension, ibuprofen did not increase postpartum blood pressure compared with women not receiving nonsteroidal antiinflammatory drugs. CLINICAL TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03011567.

OBJECTIVE: To evaluate the prevalence of cesarean delivery in women with hypertensive disorders of pregnancy (HDP), and explore whether maternal, sociodemographic, or obstetric comorbidities contribute to cesarean delivery rates. STUDY DESIGN/METHODS: This is a retrospective cohort study of nulliparous, term, singleton, vertex women using the 2013 U.S. National Vital Statistics Report. We compared prevalence of risk factors for cesarean delivery between women with and without HDP, and then calculated probabilities of cesarean delivery after controlling for these risk factors. RESULTS: < 0.01). CONCLUSION/CONCLUSIONS: Even after controlling for multiple comorbidities, hypertension remained a significant risk factor for cesarean delivery in nulliparous women at term. Hypertensive women may therefore represent an important target population in efforts aimed at reduction of cesarean rates.