Faculty Bibliography

OBJECTIVE:In October 2018, a measles (rubeola) outbreak was identified in New York City (NYC) & Rockland County (RC) and a public health campaign and hospital policy changes were made to increase awareness of the importance of vaccination and increase vaccination rates. We describe the prevalence of rubeola immunity in pregnant women and the change in uptake of postpartum MMR vaccination before and during the measles outbreak. METHODS:A multi-pronged intervention was developed by the health system with the intent of raising awareness of the outbreak, identifying patients at risk of contracting measles during pregnancy, and limiting exposure of inpatients to the disease. This was a quality improvement study to assess the impact of the intervention and public health policy on the rates of documentation of rubeola immunity and rubeola vaccination rates in non-immune women. Women who delivered at NYU Langone Health prior to the outbreak (7/1/2016 to 7/1/2017) were compared to women who delivered during the outbreak (7/1/18 to 7/1/19). The primary outcome was acceptance of MMR vaccination in non-immune women during the postpartum period. Analysis was conducted using logistic regression and chi-square tests, and alpha was set at 0.05. RESULTS:19585 patients were analyzed. 9,162 women delivered prior to outbreak and 10,423 delivered during the outbreak. Of these, 2589 (13.2%) were documented as living in a high-risk ZIP code, which were areas at the epicenter of the measles outbreak. 14,731 women (75.2%) were tested for rubeola immunity and 3270 (22.2%) of those tested were not immune. In the year of the outbreak, a higher proportion of women had rubeola immunity documented with serum titers than in the year prior to the outbreak (81% vs. 69%, p<0.001). Inpatient compliance with postpartum MMR administration was greater during the outbreak than prior to it (76% vs 59%, p <.001) for patients from both low risk and high-risk ZIP codes. CONCLUSION/CONCLUSIONS:The NYC & RC measles outbreak, together with implementation of a health system wide education program and a change in public health policy led to an increase in the proportion of pregnant women being screened for rubeola immunity. It also led to an increase in uptake of the immediate postpartum MMR vaccine.

BACKGROUND:Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus. OBJECTIVE:This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes. STUDY DESIGN:This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course. RESULTS:A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity. CONCLUSION:Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.

BACKGROUND:There is a growing body of evidence that sonographic signs of placenta accreta spectrum can be observed in the first trimester of pregnancy. The most significant marker is placental location next to or in the scar niche in women with a prior cesarean delivery. OBJECTIVE:This study aimed to assess the performance of transvaginal ultrasound in the early prediction of placenta accreta spectrum in women with a prior cesarean delivery. STUDY DESIGN/METHODS:This was a retrospective cohort of women with a history of cesarean delivery who had transvaginal ultrasound at 11 to 14 weeks' gestation between September 2016 and May 2018. Ultrasound reports were reviewed and graded for suspicion of placenta accreta spectrum as follows: Grade 0 (no suspicion) if the placenta is not next to the scar; Grade 1 (intermediate suspicion) if the placenta is next or on the scar; Grade 2 (high suspicion) if the placenta was inside the scar niche. In addition, all images were reviewed and graded by trained specialists blinded to the outcome. The primary outcome was a histologic diagnosis of placenta accreta spectrum. Sensitivity, specificity, positive predictive value, and negative predictive value of first-trimester transvaginal ultrasound to detect placenta accreta spectrum were assessed. RESULTS:In this study, 467 patients were included, and 8 (1.7%) had placenta accreta spectrum at delivery. Using the original report, 442 patients (94.6%) were Grade 0, 20 (4.3%) Grade 1, and 5 (1.1%) Grade 2. The revised grading had 456 patients (97.6%) with Grade 0, 5 (1.1%) with Grade 1, and 6 (1.3%) with Grade 2. Patients with Grade 2 yielded a sensitivity of 62.5% (95% confidence interval, 24.5-91.5), specificity of 100% (95% confidence interval, 99.2-100.0), positive predictive value of 100% (95% confidence interval, 97.0-100.0), and negative predictive value of 99.4% (95% confidence interval, 98.4-99.7). Any sonographic suspicion of placenta accreta spectrum (Grade 1 or Grade 2) had a sensitivity of 75% (95% confidence interval, 34.9-96.8), specificity of 95.9% (95% confidence interval, 93.6-97.5), positive predictive value of 24% (95% confidence interval, 14.8-36.4), and negative predictive value of 99.6% (95% confidence interval, 98.5-99.9). The blinded image review yielded a better specificity (99.1% vs 95.9%; P=.001) and a positive predictive value (63.6% vs 24%; P=.02) with similar sensitivity (87.5% vs 75%; P=.52) and negative predictive value (99.8% vs 99.6%; P=.55). CONCLUSION/CONCLUSIONS:Transvaginal ultrasound between 11 and 14 weeks' gestation in women a with prior cesarean delivery can identify at least 3 of 4 cases of placenta accreta spectrum. A finding of placental implantation within the scar niche has high positive predictive value for placenta accreta spectrum. Prospective studies are needed to assess routine screening for placenta accreta spectrum at 11 to 14 weeks' gestation in women with a prior cesarean delivery.

Recently, a novel coronavirus, precisely severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), that causes the disease novel coronavirus disease 2019 (COVID-19) has been declared a worldwide pandemic. Over a million cases have been confirmed in the United States. As of May 5, 2020, New York State has had over 300,000 cases and 24,000 deaths with more than half of the cases and deaths occurring in New York City (NYC). Little is known, however, of how this virus impacts pregnancy. Given this lack of data and the risk for severe disease in this relatively immunocompromised population, further understanding of the obstetrical management of COVID-19, as well as hospital level preparation for its control, is crucial. Guidance has come from expert opinion, professional societies and public health agencies, but to date, there is no report on how obstetrical practices have adapted these recommendations to their local situations. We therefore developed an internet-based survey to elucidate the practices put into place to guide the care of obstetrical patients during the COVID-19 pandemic. We surveyed obstetrical leaders in four academic medical centers in NYC who were implementing and testing protocols at the height of the pandemic. We found that all sites made changes to their practices, and that there appeared to be agreement with screening and testing for COVID-19, as well as labor and delivery protocols, for SARS-CoV-2-positive patients. We found less consensus with respect to inpatient antepartum fetal surveillance. We hope that this experience is useful to other centers as they formulate their plans to face this pandemic. KEY POINTS: · Practices changed to accommodate public health needs.. · Most practices are screened for novel coronavirus disease 2019 (COVID-19) on admission.. · Fetal testing in COVID-19 patients varied..

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.

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.