Faculty Bibliography

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.

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.

OBJECTIVE: Because of data published in 2009 demonstrating improved outcomes among early- vs. late-term infants,practice shifted toward delivering infants at later gestational ages. We examined the effects of this change on neonates with congenital heart disease. DESIGN: This was a retrospective cohort study. Neonates with congenital heart disease born between 2004 and 2008 were compared with those born in 2010. Patients born in 2009, considered to be a transitional year, were excluded. SETTING: Our study was conducted at a tertiary care level 4 neonatal intensive care unit with comprehensive cardiac service. PATIENTS: Study subjects consisted of neonates with significant congenital heart disease admitted between 2004 and 2010. OUTCOME MEASURES: Outcomes measures consisted of mode of delivery, length of stay, neonatal morbidity, and mortality. RESULTS: There were 878 infants with congenital heart disease born in 2004-2008 and 124 in 2010. The mean gestational age was higher in 2010 than in 2004-2008 (38.4 +/- 1.9 vs. 37.8 +/- 2.3 weeks, P = .001), and there were fewer preterm births in 2010 compared with 2004-2008 (P = .003, odds ratio [OR] = 0.4). Mean birth weight was also higher in 2010 (3134 +/- 675 vs. 2975 +/- 599 g, P = .008). In 2010, less than half as many infants were born via scheduled induction (P < .001, OR = 0.2) or scheduled cesarean delivery (P = .002, OR = 0.4) as in 2004-2008. However, in 2010, there were more urgent inductions (P = .002, OR = 3.1), cesarean deliveries after labor (P = .01, OR = 2.2),and unplanned cesarean deliveries in general (P = .02, OR = 1.7) compared with 2004-2008. In 2010, neonates were less likely to require preoperative vasopressors (P = .002), but there were no differences in 5 minutes APGAR,antibiotic administration, preoperative intubation, median length of stay, or mortality compared with 2004-2008.Conclusions. Despite increased gestational age and birth weight following the shift in delivery practice, there was no difference in length of stay, neonatal morbidity, or mortality in infants with congenital heart disease. The resultant increase in urgent cesarean delivery and urgent inductions may confer additional maternal morbidity.

OBJECTIVE: Perioperative antibiotics are recommended during cesarean delivery to reduce the risk of postoperative infections and resulting maternal morbidity. We examined the patterns of use and predictors of receipt of antibiotics in women undergoing cesarean delivery. METHODS: We identified a national cohort of women who underwent a cesarean delivery between 2003 and 2010 using a commercial hospitalization database. Women who received antibiotics on the day of cesarean delivery were classified as having received perioperative antibiotics. Multivariable regression models were developed to account for patient, obstetric, physician, and hospital factors on receipt of antibiotics. Between-hospital variation was calculated using generalized linear mixed models. RESULTS: Among 1,137,804 women who underwent cesarean delivery, 59.5% received perioperative antibiotics. The proportion of patients receiving antibiotics increased over time from 52.5% in 2003 to 63.1% in 2010 (P<.001) and varied significantly by geographic region. Women who did not labor were more likely to receive antibiotics than those who had a cesarean delivery after labor (66% compared with 44%, P<.001). Age, race, and insurance status were not major determinants of the use of perioperative antibiotics. CONCLUSION: Among women undergoing cesarean delivery, compliance with the recommendation for universal perioperative antibiotic prophylaxis is poor. Coordinated efforts are needed to enhance use of guideline-based perioperative antibiotic prophylaxis for women undergoing cesarean delivery. LEVEL OF EVIDENCE: III.