Faculty Bibliography

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.

Appendicitis in pregnancy is the most common nonobstetric surgical emergency. Pregnancy causes changes in anatomy, which could lead to uncertainty regarding the diagnosis of appendicitis. This case report describes a case of appendicitis presenting with peritoneovaginal fistula in a pregnant woman in the second trimester, with interesting finding of isolated appendiceal endometriosis on pathology. The importance of complete physical examination, including speculum examination, is emphasized in the pregnant patient presenting with acute-onset abdominal pain. Imaging criteria for diagnosis of appendicitis should be adjusted to account for the gravid uterus, which may cause appendiceal abscess to appear in a variety of locations, such as posterior to the cervix, as in this case.

Hispanic women have a higher prevalence of weight associated complications in pregnancy. This ethnic disparity is likely related to behavior patterns, social circumstances, environmental exposures, and access to healthcare, rather than biologic differences. The objective was to determine associations between sociodemographic characteristics, health behaviors, and psychosocial stressors and gestational weight gain (GWG) in low-income Hispanic women. During pregnancy, information on sociodemographic characteristics, health behaviors, and psychosocial stressors were collected. Linear regression estimated mean differences in GWG by selected predictors. Multinomial logistic regression estimated odds of inadequate and excessive GWG by selected predictors. Five-hundred and eight women were included, 38% had inadequate and 28% had excessive GWG; 57% with a normal pre-pregnancy BMI had inadequate GWG. Compared to women with normal BMI, women with overweight or obesity were more likely to have excessive GWG (aRRR = 1.88, 95% CI: 1.04, 3.40 and aRRR = 1.98, 95% CI: 1.08, 3.62, respectively). Mean total GWG was higher among women who were nulliparous (ß = 1.34 kg, 95% CI: 0.38, 2.29) and those who engaged in ≥3 h of screen time daily (ß = 0.98 kg, 95% CI: 0.02, 1.94), and lower among women who were physically active during pregnancy (ß = -1.00 kg, 95% CI: -1.99, -0.03). Eating breakfast daily was associated with lower risk of inadequate GWG (aRRR = 0.47, 95% CI: 0.26, 0.83). Depressive symptoms and poor adherence to dietary recommendations were prevalent, but none of the psychosocial or dietary variables were associated with GWG. In this cohort of primarily immigrant, low-income, Hispanic women, there were high rates of poor adherence to diet and physical activity recommendations, and a majority of women did not meet GWG guidelines. Modifiable health behaviors were associated with GWG, and their promotion should be included in prenatal care.

OBJECTIVE: The objective of this study is to evaluate whether the rate of cervical shortening after cerclage can predict spontaneous preterm birth (SPTB). METHODS: Women who had cervical length (CL) assessments after cerclage placement were identified. The rate of cervical shortening and its relationship with SPTB was established using a generalized linear regression model. Secondary outcomes included relationship between cervical shortening and risk of SPTB in those with a post-cerclage CL <25 mm versus >/=25 mm at 18-20 weeks; and the rate of cervical shortening in women who delivered preterm compared with those who delivered at term. RESULTS: One hundred thirty-four patients were included and 30 (22.4%) delivered at <36 weeks. A rate of cervical shortening of 1 mm/week conferred a risk of SPTB of 22%. Among women with cerclage who had a CL <25 mm at 18-20 weeks, 1 mm/week of cervical shortening was associated with a 59% risk of SPTB. Patients with cerclage who delivered at term had a slower rate of cervical shortening compared to those who delivered preterm (0.62 mm versus 1.40 mm per week, p = 0.008). CONCLUSIONS: The rate of cervical shortening after cerclage placement is associated with the risk of SPTB. Sonographic surveillance of the rate of cervical shortening may be useful in assessing risk for SPTB in patients with cerclage.

OBJECTIVES: Although cerclage has been shown to reduce the risk of recurrent preterm birth in a select patient population, the mechanism by which this occurs is not well understood. Our objective was to evaluate whether cerclage affects the rate of cervical shortening taking into account exposure to 17-hydroxyprogesterone and vaginal progesterone. METHODS: This is a retrospective cohort study of women who had serial cervical length measurements due to a history of spontaneous preterm delivery. Demographic data, obstetric history, progesterone administration, delivery information and serial cervical length measurements were collected. The rate of cervical shortening was compared in women with cerclage to those without cerclage. Subgroup analyses were performed to compare rates of cervical shortening by indication for cerclage (history indicated vs ultrasound-indicated) and outcome in the current pregnancy (cerclage vs no cerclage among those that delivered preterm). RESULTS: A total of 414 women were included of whom 32.4 % (n = 134) had a cerclage. There was no difference in the rate of cervical shortening between the cerclage (0.8 mm per week) and no cerclage groups (1.0 mm per week, P = 0.43). The rates of cervical shortening among history-indicated and ultrasound-indicated cerclage groups were similar (0.9 vs 1.3 mm per week respectively, p = 0.2). Among patients with a preterm delivery in the index pregnancy, the rate of cervical shortening among those with (1.31 mm per week), and without cerclage (1.28 mm per week, p = 0.78) was also similar. CONCLUSIONS: Cervical shortening among women with cerclage occurs at a similar rate as women without a cerclage, regardless of indication for cerclage or pregnancy outcome.

OBJECTIVES: To determine whether isolated abnormal Doppler indices before 28 weeks predict adverse pregnancy outcomes in uncomplicated monochorionic diamniotic (MCDA) twins. METHODS: A retrospective cohort study of MCDA twin pregnancies receiving antenatal testing at a single center between 2007 and 2013 was conducted. Sonographic surveillance, including Doppler velocimetric studies of the umbilical artery, ductus venosus, and middle cerebral artery of each twin, was initiated by 28 weeks and repeated at least every 2 weeks. All pregnancies were deemed "uncomplicated" at initial sonography, without evidence of polyhydramnios, oligohydramnios, intrauterine growth restriction, twin growth discordance of at least 20%, structural or chromosomal anomalies, or unclear chorionicity. Pregnancies were divided into 2 groups: those with isolated Doppler abnormalities before 28 weeks and those with normal Doppler indices. The primary outcome was a composite including twin-twin transfusion syndrome, intrauterine growth restriction of more than 1 twin, growth discordance of at least 20%, preterm delivery before 34 weeks for fetal indications, or demise of more than 1 fetus. RESULTS: Ninety-six patients were included, with 22 (22.9%) having isolated Doppler abnormalities before 28 weeks. The incidence of the primary outcome did not differ between groups (36.4% versus 28.4%; P = .47). The abnormal Doppler group underwent a greater number of sonographic examinations (15 versus 10; P= .001) and more antenatal admissions for fetal concerns (50.0% versus 12.2%; P < .001). CONCLUSIONS: Isolated Doppler abnormalities are commonly encountered in uncomplicated MCDA pregnancies before 28 weeks yet are not clearly predictive of twin-specific complications. Doppler abnormalities were associated with increased sonographic surveillance and antenatal hospitalizations, suggesting an influence on physician practice patterns. Data may not support Doppler studies before 28 weeks for routine MCDA twin monitoring.