Faculty Bibliography

INTRODUCTION/UNASSIGNED:Platelet hyperreactivity is linked to inflammation and cardiovascular risk in nonpregnant populations, but its relationship to placentally mediated pregnancy outcomes is undefined. We prospectively evaluated platelet hyperreactivity in pregnancy and subsequent ischemic placental disease (IPD), and examined aspirin's (ASA) effect on platelet activity by baseline platelet phenotype. METHODS/UNASSIGNED: RESULTS/UNASSIGNED:Of 66 pregnant participants recruited, 61 had first-trimester LTA; 20 (32.8%) had platelet hyperreactivity. Participants with hyperreactivity were more likely to develop IPD than those without (55% versus 24%, adjusted odds ratio [aOR] 3.77 (95% CI [1.05-13.53]), with consistent directionality across individual components despite low event frequencies. Participants with platelet hyperreactivity showed greater platelet aggregation to ADP, collagen, and low-dose AA. Platelet transcriptomic profiling distinguished participants with versus without platelet hyperreactivity and revealed differential expression of pathways related to platelet activity, energy metabolism, and immune regulation. Among 45 high-risk participants recommended ASA, those with hyperreactivity exhibited higher AA-induced aggregation (24% vs 12.5% platelet aggregation, p=0.01) despite similar serum TxB2 levels. CONCLUSION/UNASSIGNED:First-trimester platelet hyperreactivity was present in approximately one-third of participants and was independently associated with increased risk of IPD. Participants with platelet hyperreactivity demonstrated distinct transcriptomic signatures and greater platelet aggregation despite ASA use. Together, these findings support a contributory role for platelets in placental ischemic pathology and highlight the need to elucidate mechanisms and develop platelet-targeted preventive strategies.

BACKGROUND:Cardiovascular disease in pregnant women is a leading cause of maternal mortality in the United States. Cardio-obstetrics experts focus on the intersection of pregnancy and cardiac disease, but structured educational opportunities and training pathways are lacking. PROJECT RATIONALE/UNASSIGNED:Working with the cardiovascular disease program leadership at a quaternary care center in New York City, we created a 2-week elective spanning multiple specialties to bolster cardio-obstetrics education. These included congenital cardiology, postpartum hypertension, maternal-fetal medicine, as well as the labor and delivery floors with the obstetrics and anesthesia teams. PROJECT SUMMARY/UNASSIGNED:Key lessons learned included the importance of communication and flexibility among the multidisciplinary groups. Building relationships across specialties and sharing expertise was an important outcome. TAKE-HOME MESSAGES/CONCLUSIONS:Structured training and education in cardio-obstetrics is lacking, although there is certainly a need. Cardiovascular fellows in training should feel empowered to create tailored educational experiences at their respective institutions to address this gap.

BACKGROUND/UNASSIGNED:Although infective endocarditis during pregnancy is rare, it carries significant morbidity and mortality for both mother and foetus. While professional societies provide recommendations for the treatment of infective endocarditis, there are no specific guidelines for the management of pregnancy-associated infective endocarditis. In this report, we present two cases of infective endocarditis presenting during the second trimester of pregnancy that required surgical intervention, focusing on the unique considerations when caring for pregnant individuals. CASE SUMMARIES/UNASSIGNED:Two patients in the second trimester of pregnancy presented with fevers and malaise. Both were found to have positive blood cultures and mitral valve vegetations, leading to diagnoses of mitral valve endocarditis. Their hospital courses were complicated by embolic strokes, and one patient required transcatheter embolization of a mycotic aneurysm. Both patients underwent surgical valve replacements with bioprosthetic valves. Ultimately, both patients delivered at term without complication. DISCUSSION/UNASSIGNED:In addition to the standard management of infective endocarditis, pregnancy-associated infective endocarditis requires multidisciplinary collaboration regarding the relative timing of cardiac surgery and delivery, the use of intraoperative foetal monitoring, and the choice of valve replacement and anticoagulation. Each of these decisions requires balancing the risk of morbidity and mortality to the patient, the risk of neonatal prematurity and associated complications and disability, and the risk of foetal death during cardiopulmonary bypass. We discuss our teams' decision-making processes with a focus on the relevant considerations for each of these challenging decisions.

BACKGROUND:The approach to prevent eclampsia in the postpartum period utilizes magnesium sulfate but there is no evidence-based standard to guide duration. OBJECTIVES/OBJECTIVE:To assess the cost-effectiveness of an abbreviated 12-hour postpartum magnesium sulfate regimen compared with a standard 24-hour regimen. STUDY DESIGN/METHODS:A decision-analytic model was constructed to compare a 12-hour regimen with a 24-hour regimen in a theoretical cohort of 45,800 patients with preeclampsia with severe features. Probabilities, costs, and utilities were derived from the literature. Primary outcomes included incremental cost per quality-adjusted life-year (QALY), cases of eclampsia, magnesium toxicity, and maternal death. The cost-effectiveness threshold was $100,000 per QALY. RESULTS:A 12-hour regimen in this theoretical cohort of 45,800 postpartum patients compared with a 24-hour regimen resulted in 86 more cases of eclampsia (398 vs 312) and 0.37 more deaths (10.87 vs 10.50). However, there were 656 fewer cases of magnesium toxicity (2089 vs 2745). Overall, a 12-hour regimen was a dominant strategy that resulted in decreased costs of $21.5 million and increased effectiveness of 17 QALYs. CONCLUSION/CONCLUSIONS:In our study, an abbreviated duration of postpartum magnesium sulfate prophylaxis for patients with preeclampsia with severe features was a dominant strategy (lower costs, better outcomes) and cost-effective compared with the standard 24-hour regimen.

OBJECTIVE:This study aimed to identify facilitators and barriers among sexual and gender minority (SGM) individuals in receiving reproductive healthcare. METHODS:Participants were recruited through social media and university groups across the US. Inclusion criteria consisted of self-identified SGM community members; aged 18-40. This included: cisgender women whose sexual orientation included gay, lesbian, bisexual, and/or queer and / or individuals whose gender identity does not align with their sex assigned at birth; transgender men, non-binary people with a uterus, cisgender queen woman, and transgender woman. An initial codebook was developed utilizing inductive coding to identify key themes. RESULTS:A total of 9 focus groups were held with 67 people,5-10 people per group. Six themes were identified: 1) Barriers to high quality reproductive care, 2) Facilitators to high quality reproductive care, 3) Negative prior experiences, 4) Physical/logistical access to adequate care, 5) Emotions/trust in disclosing SGM status, and 6) Knowledge levels on SGM reproductive healthcare. CONCLUSION/CONCLUSIONS:Quality reproductive health care for SGM individuals is hindered by individual, clinician, and institutional factors. The factors include individual barriers of knowledge, distrust, and dysphoria; clinician barriers knowledge gaps or discomfort; and institutional factors of false advertising of LGBTQ+ friendly practices. PRACTICE IMPLICATIONS/CONCLUSIONS:This study impacts clinical practice through providing focused areas to better improve training and education for healthcare providers. Findings support improving clinical training on cultural humility, creating a welcoming environment, maintaining trust, and utilizing sensitive terminology.

OBJECTIVE:To investigate the relationship between platelet indices (count, size and production/immaturity) and hypertensive disorders of pregnancy. STUDY DESIGN/METHODS:This was a secondary analysis of a prospective cohort of pregnant individuals followed from first trimester through delivery at an academic tertiary care institution. Routine platelet indices obtained prospectively during prenatal care and delivery were compared between those who developed a hypertensive disorder of pregnancy and those who did not. We assessed platelet count (by trimester), mean platelet volume, and immature platelet fraction measured as percent (%) and absolute count. Data were analyzed using Fisher's Exact test, chi-square test, and multivariable logistic regression. P < 0.05 was considered statistically significant. RESULTS: = 0.01) compared to those without a hypertensive disorder of pregnancy, after adjusting for age, race/ethnicity, obesity, nulliparity, and chronic hypertension. The prevalence and likelihood of a hypertensive disorder of pregnancy increased with increasing mean platelet volume, as well as with both the percent and absolute immature platelet fraction. There was no difference between groups in platelet count in the first trimester, second trimester, or at delivery. CONCLUSIONS:An increase in platelet size and immaturity was observed in those with a hypertensive disorder of pregnancy. These data support further investigation of platelets in the mechanisms of the development of hypertensive disorders of pregnancy and the use of platelet indices to better identify high risk groups in pregnancy.