Faculty Bibliography

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.

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.

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.

Objective: In October 2018 a measles (rubeola) outbreak was identified in New York City (NYC) & Rockland County (RC). A public health emergency was declared with a focus on increasing MMR (measles, mumps, and rubella) vaccination uptake. Childhood MMR vaccination is 97% effective but antibody titers decrease over time. Screening for immunity has not been a routine part of prenatal care. NYU Langone Health created a communication and prevention program at the start of the outbreak and non-immune women were encouraged to take the MMR vaccination postpartum during hospitalization. We aimed to describe the prevalence of rubeola immunity in pregnant women and the change in uptake of postpartum MMR vaccination before and during the measles outbreak.
Study Design: This was a retrospective cohort, quality improvement study. The control group was women who delivered at NYU Langone Health prior to the outbreak (PO) from 7/1/2016 to 7/1/2017. The study group was women who delivered during the outbreak (DO) from 7/1/18 to 7/1/19. Primary outcome was acceptance of MMR vaccination in non-immune women during the postpartum period. Serologic evidence of rubeola immunity was defined based on lab reference values. Statistical analysis was done using chi-square and T-test.
Result(s): 19585 patients were analyzed. 9,162 women delivered PO and 10,423 delivered DO. Of these, 2589 (13.2%) were documented as living in a high-risk ZIP code. 14,731 women (75.2%) were tested for rubeola immunity and 3270 (22.2%) of those tested were not immune. In the year DO, a higher proportion of women had rubeola immunity documented with serum titers than in the year PO (81% vs. 69%, p< 0.001). Inpatient compliance with postpartum MMR administration was greater DO than PO (100% v. 88.2%, p< 0.001).
Conclusion(s): 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 measles immunity. It also led to an increase in uptake of the immediate postpartum MMR vaccine. [Formula presented]
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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