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Fibroid size and number and risk of postpartum hemorrhage [Letter]

Yaghoubian, Yasaman C; Prasannan, Lakha; Alvarez, Alejandro; Gerber, Rachel P; Galagedera, Nirupa; Blitz, Matthew J
PMID: 37172925
ISSN: 1097-6868
CID: 5544642

Obstetrical Outcomes After Implementation of Laborist Model During the COVID-19 Pandemic

Prasannan, Lakha; Gerber, Rachel; Gulersen, Moti; Shan, Weiwei; Blitz, Matthew J; Rochelson, Burton
OBJECTIVE:The COVID-19 pandemic prompted labor and delivery units to establish ways to decrease viral exposure to healthcare workers while continuing to deliver optimal patient care. A laborist model was implemented to improve safety at our tertiary care hospital in Long Island. The aim of the study is to determine whether implementation of a laborist model during the COVID-19 pandemic is associated with a change in the frequency of cesarean birth. METHODS:The retrospective cohort study included patients who delivered at a single tertiary center during March 2019 to May 2019 and March 2020 to May 2020 when our laborist model was initiated. The primary outcome compared the frequency of a cesarean delivery between both models. Secondary outcomes were the frequency of adverse obstetrical complications, which included intensive care unit admission, shoulder dystocia, intra-amniotic infection, hemorrhage, and need for blood transfusion. Statistical analysis included multivariable regression to adjust for potential confounders. RESULTS:A total of 1506 patients were included. Baseline characteristics were similar between the 2 groups. After adjusting for potential confounders, there was no significant difference in the frequency of cesarean births between both models (37% versus 35%; adjusted odds ratio, 1.003; 95% confidence interval, 0.46-2.89). Similarly, there were no significant differences in adverse outcomes between the study populations (adjusted odds ratio, 1.064; 95% confidence interval, 0.68-1.59). CONCLUSIONS:A change in practice behavior during a pandemic was not associated with an increase in frequency of cesarean births or adverse obstetrical outcomes.
PMID: 35858475
ISSN: 1549-8425
CID: 5279192

Preterm birth among women with and without severe acute respiratory syndrome coronavirus 2 infection

Blitz, Matthew J; Gerber, Rachel P; Gulersen, Moti; Shan, Weiwei; Rausch, Andrew C; Prasannan, Lakha; Meirowitz, Natalie; Rochelson, Burton
INTRODUCTION/BACKGROUND:Studies directly comparing preterm birth rates in women with and without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are limited. Our objective was to determine whether preterm birth was affected by SARS-CoV-2 infection within a large integrated health system in New York with a universal testing protocol. MATERIAL AND METHODS/METHODS:This retrospective cohort study evaluated data from seven hospitals in New York City and Long Island between March 2020 and June 2021, incorporating both the first and second waves of the coronavirus disease 2019 (COVID-19) pandemic in the USA. All patients with live singleton gestations who had SARS-CoV-2 polymerase chain reaction (PCR) testing at delivery were included. Deliveries before 20 weeks of gestation were excluded. The rate of preterm birth (before 37 weeks) was compared between patients with positive and negative SARS-CoV-2 test results. This analysis was performed separately for resolved prenatal infections and infections at delivery, with the latter group subdivided by symptom status. Multiple logistic regression analysis was used to examine the association between SARS-CoV-2 infection and preterm birth, adjusting for maternal age, race-ethnicity, parity, history of preterm birth, body mass index, marital status, insurance type, medical co-morbidities, month of delivery, and wave of pandemic. RESULTS:A total of 31 550 patients were included and 2473 (7.8%) had laboratory-confirmed infection. Patients with symptomatic COVID-19 at delivery were more likely to deliver preterm (19.0%; adjusted odds ratio 2.76, 95% CI 1.92-3.88) compared with women with asymptomatic infection (8.8%) or without infection (7.1%). Among preterm births associated with symptomatic infection, 72.5% were medically indicated compared with 44.1% among women without infection (p < 0.001). Risk of preterm birth in patients with resolved prenatal infection was unchanged when compared with women without infection. Among women with infection at delivery, preterm birth occurred more frequently during the second wave compared with the first wave (13.6% vs. 8.7%, respectively; p < 0.006). However, this was not significant on multiple regression analysis after adjusting for other explanatory variables. CONCLUSIONS:Pregnant women with symptomatic COVID-19 are more than twice as likely to have a preterm delivery than patients without infection. Asymptomatic infection and resolved prenatal infection are not associated with increased risk.
PMID: 34546577
ISSN: 1600-0412
CID: 5019962

Social determinants of health and coronavirus disease 2019 in pregnancy

Prasannan, Lakha; Rochelson, Burton; Shan, Weiwei; Nicholson, Kaitlin; Solmonovich, Rachel; Kulkarni, Aparna; Lewis, Dawnette; Greenberg, Meir; Nimaroff, Michael; Blitz, Matthew J
BACKGROUND:The social and physical environments in which people live affect the emergence, prevalence, and severity of both infectious and noninfectious diseases. There are limited data on how such social determinants of health, including neighborhood socioeconomic conditions, affect the risk of severe acute respiratory syndrome coronavirus 2 infection and severity of coronavirus disease 2019 during pregnancy. OBJECTIVE:Our objective was to determine how social determinants of health are associated with severe acute respiratory syndrome coronavirus 2 infection and the severity of coronavirus disease 2019 illness in hospitalized pregnant patients in New York during the global coronavirus disease 2019 pandemic. STUDY DESIGN:This cross-sectional study evaluated all pregnant patients who delivered and had polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 between March 15, 2020, and June 15, 2020, at 7 hospitals within Northwell Health, the largest academic health system in New York. During the study period, universal severe acute respiratory syndrome coronavirus 2 testing protocols were implemented at all sites. Polymerase chain reaction testing was performed using nasopharyngeal swabs. Patients were excluded if the following variables were not available: polymerase chain reaction results, race, ethnicity, or zone improvement plan (ZIP) code of residence. Clinical data were obtained from the enterprise electronic health record system. For each patient, ZIP code was used as a proxy for neighborhood. Socioeconomic characteristics were determined by linking to ZIP code data from the United States Census Bureau's American Community Survey and the Internal Revenue Service's Statistics of Income Division. Specific variables of interest included mean persons per household, median household income, percent unemployment, and percent with less than high school education. Medical records were manually reviewed for all subjects with positive polymerase chain reaction test results to correctly identify symptomatic patients and then classify those subjects using the National Institutes of Health severity of illness categories. Classification was based on the highest severity of illness throughout gestation and not necessarily at the time of presentation for delivery. RESULTS:A total of 4873 patients were included in the study. The polymerase chain reaction test positivity rate was 11% (n=544). Among this group, 359 patients (66%) were asymptomatic or presymptomatic, 115 (21%) had mild or moderate coronavirus disease 2019, and 70 (13%) had severe or critical coronavirus disease 2019. On multiple logistic regression modeling, pregnant patients who had a positive test result for severe acute respiratory syndrome coronavirus 2 were more likely to be younger or of higher parity, belong to minoritized racial and ethnic groups, have public health insurance, have limited English proficiency, and reside in low-income neighborhoods with less educational attainment. On ordinal logit regression modeling, obesity, income and education were associated with coronavirus disease 2019 severity. CONCLUSION:Social and physical determinants of health play a role in determining the risk of infection. The severity of coronavirus disease 2019 illness was not associated with race or ethnicity but was associated with maternal obesity and neighborhood level characteristics such as educational attainment and household income.
PMID: 33757936
ISSN: 2589-9333
CID: 5019952

Histopathologic evaluation of placentas after diagnosis of maternal severe acute respiratory syndrome coronavirus 2 infection

Gulersen, Moti; Prasannan, Lakha; Tam Tam, Hima; Metz, Christine N; Rochelson, Burton; Meirowitz, Natalie; Shan, Weiwei; Edelman, Morris; Millington, Karmaine A
Background:The impact of maternal severe acute respiratory syndrome coronavirus 2 infection on placental histopathology is not well known. Objective:To determine if any significant placental histopathologic changes occur after the diagnosis of severe acute respiratory syndrome coronavirus 2 infection during pregnancy and whether these changes are correlated with the presence or absence of symptoms associated with the infection. Study Design:value of <.05. Results:A total of 50 placentas after the diagnosis of maternal severe acute respiratory syndrome coronavirus 2 infection and 50 historical controls were analyzed. Among the placentas from patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection, 3 (6%) were preterm (33 3/7, 34 6/7, and 36 6/7 weeks of gestation), 16 (32%) were from patients with typical symptoms related to the infection, and 34 (68%) were from patients without typical symptoms related to the infection. All patients had received a diagnosis of severe acute respiratory syndrome coronavirus 2 infection in the third trimester. Decidual vasculopathy was not visualized in any of the placentas from patients diagnosed as having severe acute respiratory syndrome coronavirus 2 infection. There was no statistically significant difference in placental histopathologic characteristics between the groups. Severe acute respiratory syndrome coronavirus 2 test results for all neonates at 24 hours of life were negative. Conclusion:Based on the results of this study, there are no significant placental histopathologic changes that occur after the diagnosis of severe acute respiratory syndrome coronavirus 2 infection in women during the third trimester of pregnancy compared with a gestational age-matched historical control group. Similar incidences of histopathologic findings were also discovered when comparing placentas from patients with severe acute respiratory syndrome coronavirus 2 infection with or without the presence of symptoms typically related to the infection.
PMID: 32838277
ISSN: 2589-9333
CID: 5019922

Racial and ethnic disparity and spatiotemporal trends in severe acute respiratory syndrome coronavirus 2 prevalence on obstetrical units in New York

Blitz, Matthew J; Rochelson, Burton; Prasannan, Lakha; Shan, Weiwei; Chervenak, Frank A; Nimaroff, Michael; Bornstein, Eran
PMID: 32838278
ISSN: 2589-9333
CID: 5019932

Perinatal outcome after persistence of abnormal umbilical artery Doppler indices in the growth-restricted fetus following betamethasone administration

Prasannan, Lakha; Blitz, Matthew J; Augustine, Stephanie; Kohn, Nina; Rochelson, Burton; Pessel, Cara
BACKGROUND:An optimal approach for providing sufficient antenatal surveillance for fetal growth restriction (FGR) has yet to be elucidated. Moreover, there is scant literature on the fetal response to betamethasone and its effect on fetal Dopplers. OBJECTIVE:To compare persistence of umbilical artery Doppler abnormalities after corticosteroid administration and adverse perinatal outcome in growth restricted fetuses. METHODS:Retrospective cohort study (2008-2018) of singleton gestations with FGR (EFW <10th percentile) and umbilical artery Doppler abnormalities (absent or reversed end diastolic velocity) between 24 and 34 weeks of gestation at two institutions. Included patients had Dopplers performed before betamethasone administration and again within 1 week. Excluded were multiple gestations, chromosomal abnormalities, fetal anomalies, or missing outcome information. Pregnancies with persistently abnormal Dopplers were compared with those in which an improvement of Dopplers was noted. The primary outcome was a composite that consisted of indicated preterm birth <32 weeks, 1 or 5 min APGAR score <7, intrauterine fetal demise, and neonatal demise. Secondary outcomes included length of NICU stay, ventilator support, gestational age at delivery, interval between steroids and delivery, and birth weight. RESULTS: = 17). No difference in the frequency of the primary outcome was observed between the persistently abnormal Doppler and improved Doppler groups (72.2% vs. 70.6%, respectively), and there was no difference in any of the secondary outcomes. CONCLUSIONS:Perinatal outcomes in FGR pregnancies were not affected by improved versus persistently abnormal umbilical artery Dopplers after betamethasone administration.
PMID: 33108909
ISSN: 1476-4954
CID: 5019942

Maternal mortality among women with coronavirus disease 2019 admitted to the intensive care unit [Letter]

Blitz, Matthew J; Rochelson, Burton; Minkoff, Howard; Meirowitz, Natalie; Prasannan, Lakha; London, Viktoriya; Rafael, Timothy J; Chakravarthy, Shruti; Bracero, Luis A; Wasden, Shane W; Pachtman Shetty, Sarah L; Santandreu, Orlando; Chervenak, Frank A; Schwartz, Benjamin M; Nimaroff, Michael
PMID: 32553910
ISSN: 1097-6868
CID: 5019912

Adherence and Acceptability of Telehealth Appointments for High Risk Obstetrical Patients During the COVID-19 Pandemic

Jeganathan, Sumithra; Prasannan, Lakha; Blitz, Matthew J; Vohra, Nidhi; Rochelson, Burton; Meirowitz, Natalie
Background/UNASSIGNED:Telehealth has been successfully implemented for the delivery of obstetrical care. However, little is known regarding the attitudes and acceptability of patients and providers in high risk obstetrics and if implementation improves access to care in non-rural settings. Objective/UNASSIGNED:The study aims to: 1) Describe patient and provider attitudes toward telehealth for delivery of high risk obstetrical care in a large health care system with both urban and suburban settings. 2) Determine if implementation of a telehealth model improves patient adherence to scheduled appointments in this patient population.Study DesignTwo self-administered surveys were designed. The first survey was sent to all high-risk obstetrical patients who received a telehealth visit between March 1, 2020 and May 30, 2020. The second survey was designed for providers who participated in these visits. We also compared the attended, cancelled and no show visit rates before (March 1-May 30, 2019) and after (March 1-May 30, 2020) telehealth implementation, as well as telehealth versus in person visits in 2020. We reviewed scheduled high-risk prenatal care appointments, diabetes education sessions, and genetic counseling and Maternal- Fetal Medicine consultations. Results/UNASSIGNED:A total of 91 patient surveys and 33 provider surveys were analyzed. Overall, 86.9% of patients were satisfied with the care they received and 78.3% would recommend telehealth visits to others. 87.8% of providers reported having a positive experience using telehealth, and 90.9% believed that telehealth improved patients' access to care. When comparing patient and provider preference regarding future obstetrical care after experiencing telehealth, 73.8% of patients desired a combination of in person and telehealth visits during their pregnancy. However, a significantly higher rate of providers preferred in-person visits (56% vs 23% respectively). When comparing visits between 2019 and 2020, there was a significantly lower rate of no-show appointments, patient-cancelled appointments, and patient same-day cancellations with the implementation of telehealth. There was also a significantly lower rate of patient-cancelled appointments, and patient same-day cancellations with those receiving telehealth visits compared to in person visits in 2020. Conclusion/UNASSIGNED:Implementation of telehealth in high risk obstetrics has the potential to improve access to high risk obstetrical care, by reducing the rate of missed appointments. Both patients and providers surveyed expressed a high rate of satisfaction with telehealth visits and a desire to integrate telehealth into the traditional model of high risk obstetrical care.
PMID: 32984803
ISSN: 2589-9333
CID: 4616472

Scheduled versus as-needed postpartum analgesia and oxycodone utilization

Blitz, Matthew J; Rochelson, Burton; Prasannan, Lakha; Stoffels, Guillaume J; Pappas, Karalyn; Palleschi, Greg T; Marchbein, Harvey
Background: An optimal approach for providing sufficient postpartum analgesia while minimizing the risk of opioid misuse or diversion has yet to be elucidated. Moreover, there is scant literature on the efficacy of around-the-clock (ATC) scheduled dosing of opioid analgesia compared to pro re nata (PRN; as-needed) dosing for postpartum pain management. Here we evaluate a quality improvement intervention that aimed to proactively provide pain relief with a multimodal analgesic regimen that includes oxycodone at scheduled time intervals. This new protocol stands in stark contrast to many contemporary postpartum pain management regimens in which oral opioid medications are reserved for treating breakthrough pain.Objective: Our aim was to determine how inpatient oxycodone use is affected by as-needed compared to ATC scheduled dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications. We also sought to determine the effect of each modality on patient satisfaction with pain control.Methods: Retrospective cohort study of singleton deliveries at ≥37 weeks of gestation at a tertiary hospital from 2013 to 2016. In month 21 of the 48-month study period, a new institutional protocol for postpartum pain management was implemented which consisted of scheduled dosing of a multimodal analgesic regimen. Prior to this, patients received pain relief only as needed, by reporting elevated pain scores to nursing staff. Patients were excluded for the following: NSAID or opioid allergies, protocol deviations, transition month deliveries, history of drug abuse, positive urine toxicology, delivery with general anesthesia, prolonged hospitalization, postpartum hemorrhage, hypertensive disorders of pregnancy, incomplete records. Outcomes evaluated were the percentage of patients receiving oxycodone and mean oxycodone use per inpatient day (milligrams). Segmented regression analysis of interrupted time series was performed to estimate linear time trends of oxycodone consumption pre- and post-protocol implementation. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) standardized survey were also compared before and after implementation.Results: A total of 19,192 deliveries were included. After adjusting for confounders, a significant downward trend in the percentage of patients receiving oxycodone was noted among both cesarean (0.004% decrease per month; p < .006) and vaginal deliveries (0.005% decrease per month; p < .0001) before implementation of the scheduled pain management protocol. Among cesarean deliveries, there was no shift at the time of implementation, and no change in the slope of the trend after implementation. Among vaginal deliveries, there was an upward shift at implementation (+7.4%, p < .0001) but no change in the slope of the trend after implementation. Regardless of mode of delivery, no trend in monthly mean oxycodone consumption per day existed before or after implementation of the new protocol, and there was no shift at the time of implementation. Scheduled multimodal analgesia was associated with an improvement in HCAHPS scores for patient reported pain control after cesarean section (63 versus 71% reporting "Always" well controlled; p < .001) but had no effect after vaginal delivery.Conclusion: After cesarean delivery, scheduled multimodal analgesia that includes ATC dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications, does not increase the percentage of women who receive oxycodone or mean oxycodone consumption per inpatient day compared to as-needed analgesia. After vaginal delivery, scheduled multimodal analgesia is associated with an increase in the percentage of women who receive oxycodone but no change in mean oxycodone consumption per inpatient day.
PMID: 32193961
ISSN: 1476-4954
CID: 4469642