Faculty Bibliography

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

INTRODUCTION: Patients with type O blood have been demonstrated to have lower von Willebrand levels than other ABO types. We evaluated whether O blood type is associated with an increased risk of early postpartum hemorrhage (PPH).
METHOD(S): We performed an Institutional Review Board approved retrospective cohort study of women aged 18-45 who had a vaginal or cesarean delivery of a live-born singleton infant at our institution from January 1, 2018 to December 31, 2018. The quantitative blood loss (QBL) from delivery and rates of early PPH were compared between patients with type O blood and those with non-type O blood. Early PPH was defined as 1,000 mL of blood loss or greater within 24 hours of delivery. Patient characteristics were compared. Chi square tests and student's t-tests were used to assess for statistical significance.
RESULT(S): There were 9,990 patients included with 4,422 (44.3%) in the O group and 5,568 (55.7%) in the non-O group. The groups were similar with regard to age, parity, gestational age at delivery, mode of delivery, rate of induction, episiotomy use, delivery anesthesia type, and birth weight. There was a higher proportion of grand multiparity (parity of 5 or greater) in the non-O group (6.16% versus 5.01%, P=.02). Rates of early PPH were similar in the type O and non-O groups (7.78% versus 7.22%, P=.29). There was no significant difference in the mean QBL between the groups (450.9 mL versus 434.7mL, P=.75).
CONCLUSION(S): In this analysis, O blood type was not associated with an increased risk for early PPH

Pregnancy-associated cardiomyopathy can present earlier in gestation than traditionally defined peripartum cardiomyopathy. Management and optimal delivery timing for these patients are not well defined. We present the case of a 30-year-old primigravid at 26 weeks who presented with new onset ventricular tachycardia, biventricular cardiac failure, and severe mitral regurgitation. She was medically stabilized for two weeks prior to delivery with modest improvement in her condition. Due to concern for life-threatening cardiac failure and pulmonary edema at the time of delivery, a percutaneous left ventricular assist device was inserted immediately prior to cesarean delivery. She remained on mechanical circulatory support for 36 h. We discuss considerations regarding use of a percutaneous left ventricular assist device as a novel therapy to support the hemodynamic changes following delivery in parturients with decompensated heart failure.

INTRODUCTION: Hypertensive disorders play a significant role in maternal morbidity and mortality. Limited data on prehypertension (preHTN) in pregnancy exists. We examine the risk of adverse outcomes in patients with preHTN in early (< 20 weeks) versus late pregnancy (> 20 weeks). MATERIALS AND METHODS: Retrospective cohort study of singleton gestations between August 2013 and June 2014. Patients were divided based on when they had the highest blood pressure in pregnancy, as defined per the Joint National Committee 7 (JNC-7). Groups were compared using Chi2, Fisher's exact, Student t-test and Mann-Whitney U test with p < 0.05 used as significance. RESULTS: There were 125 control, 95 early preHTN, 136 late preHTN and 21 chronic hypertension (CHTN). Early preHTN had an increased risk of pregnancy related hypertension (PRH) (OR 12.26, p < 0.01), and composite adverse outcomes (OR 2.32, p < 0.01). Late preHTN had an increased risk for PRH (OR 4.39, p = 0.02) compared to normotensive and decreased risk for PRH (OR 0.26, p = 0.02), and composite adverse outcomes (OR 0.379, p = 0.04) compared to CHTN. Compared to late preHTN, early preHTN had more PRH (OR 2.85, p < 0.01), and composite adverse outcomes (OR 1.68, p = 0.04). CONCLUSIONS: Early prehypertension increases the risk of adverse obstetrical outcomes. Other than an increased risk of PRH, patients with late prehypertension have outcomes similar to normotensive women.

Background: HIV infected (HIV+) Veterans 50+ years of age are more likely to fall than uninfected comparators. Whether they are at greater risk for serious injury after the fall is not known.
Method(s): We used data from the Veterans Aging Cohort Study (VACS). The primary exposures were HIV and falls. The outcome was serious injury as identified by ICD9 codes (hip fracture, fragility fracture, joint dislocation, traumatic brain injury (TBI), and head injury). We identified medically significant falls using Ecodes and a machine learning algorithm applied to radiology reports. After verifying that associations between HIV and each type of serious injury were similar, all injuries were merged into a composite outcome. An interaction term between HIV and falls assessed whether falls had a differential impact on the risk of injury among HIV+ and uninfected participants. The analytic unit was a six-month person-interval. Covariates assessed at the beginning of the interval were evaluated for associations with occurrence of a serious injury in that interval. Multivariable logistic regression was used to evaluate the associations of HIV and falls with serious injury with adjustment for risk factors for fall-related injury identified among older adults and for disease severity with the VACS Index.
Result(s): Our analysis included 73,283 Veterans who were 50+ years of age, 31% of whom were HIV+. Fall incidence was 46 per 1000 person-years (95% CI 45-47 per 1000 person-years) for HIV+ and 40 per 1000 person-years (95% CI 40-41 per 1000 person-years) for uninfected. In bivariate analyses, relative touninfected Veterans, joint dislocation and TBI were less common among HIV+ (1.2% vs 1.7%, p<0.001; and 1.2% vs 1.4%, p<0.001, respectively) whereas hip fracture and fragility fractures were more common (hip fractures: 1.3% vs 0.7%, p<0.001; fragility fractures: 8.0% vs 7.4%, p<0.001, respectively). In fully adjusted models, relative to those who did not fall, those who fell had a substantially increased risk of serious injury: HIV+ (OR 4.14; 95% CI 3.86, 4.44) and uninfected (OR 1.42; 95% CI 1.35, 1.49).
Conclusion(s): Among those 50+ years of age, HIV+ are more likely to fall and more likely to experience serious injury, commonly in the form of fracture, after they fall compared to uninfected individuals