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Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia

Meyer, Jessica A; Roman, Ashley S; Limaye, Meghana; Grossman, Tracy B; Flaifel, Abdallah; Vaz, Michelle J; Thomas, Kristen M; Penfield, Christina A
OBJECTIVE/UNASSIGNED:SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS/UNASSIGNED: < 0.05 considered significant. RESULTS/UNASSIGNED: = 0.01). CONCLUSION/UNASSIGNED:In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.
PMID: 34542385
ISSN: 1476-4954
CID: 5012542

Predictors of severe and critical disease in pregnant women with SARS-CoV-2

Limaye, Meghana A; Roman, Ashley S; Trostle, Megan E; Venkatesh, Pooja; Lantigua Martinez, Meralis; Brubaker, Sara G; Chervenak, Judith; Wei, Lili S; Sahani, Parita; Grossman, Tracy B; Meyer, Jessica A; Penfield, Christina A
BACKGROUND/OBJECTIVE/UNASSIGNED:SARS-CoV-2 continues to spread widely in the US and worldwide. Pregnant women are more likely to develop severe or critical illness than their non-pregnant counterparts. Known risk factors for severe and critical disease outside of pregnancy, such as asthma, diabetes, and obesity have not been well-studied in pregnancy. We aimed to determine which clinical and pregnancy-related factors were associated with severe and critical COVID illness in pregnancy. STUDY DESIGN/UNASSIGNED: < .05. Multivariable logistic regression was performed including variables that were significantly different between groups. RESULTS/UNASSIGNED:< .01). After adjustment, history of smoking remained significantly predictive of severe/critical disease [aOR 3.84 (95% CI, 1.25-11.82)]. CONCLUSION/UNASSIGNED:Pregnant women with a history of smoking, asthma, or other respiratory condition, and COVID-19 diagnosis in the second trimester of pregnancy were more likely to develop severe/critical disease. These findings may be useful in counseling women on their individual risk of developing the severe or critical disease in pregnancy and may help determine which women are good candidates for vaccination during pregnancy.
PMID: 34470122
ISSN: 1476-4954
CID: 4999842

Arachnoid cysts: using prenatal imaging and need for pediatric neurosurgical intervention to better understand their natural history and prognosis

Grossman, Tracy B; Uribe-Cardenas, Rafael; Radwanski, Ryan E; Souweidane, Mark M; Hoffman, Caitlin E
OBJECTIVES/OBJECTIVE:Intracranial arachnoid cysts are commonly characterized as congenital. Evidence to support a congenital origin is scant and documented evolution during infancy also calls into question the genesis of these lesions. To improve our understanding of the natural history and the clinical significance of arachnoid cysts on prenatal ultrasound, we conducted a study to describe the fate of these cysts after initial diagnosis. METHODS:-value < .05 was considered significant. RESULTS: = .003). CONCLUSIONS:Arachnoid cysts are infrequently found on prenatal screening. Size greater than 2 cm on second trimester ultrasound and location outside of the interhemispheric fissure may indicate the need for further evaluation and eventual fenestration. Prenatally diagnosed arachnoid cysts are not typically associated with other anatomic or genetic abnormalities, although the presence of additional abnormalities usually leads to more intensive prenatal and postnatal investigations.
PMID: 33397177
ISSN: 1476-4954
CID: 4738632

Joint periviability counseling between neonatology and obstetrics is a rare occurrence

Reed, Rachel; Grossman, Tracy; Askin, Gulce; Gerber, Linda M; Kasdorf, Ericalyn
OBJECTIVE:To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC. STUDY DESIGN/METHODS:An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM. RESULTS:There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC. CONCLUSION/CONCLUSIONS:JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.
PMID: 32859941
ISSN: 1476-5543
CID: 4587012

Tricuspid Stenosis in Pregnancy: A Valve-in-Valve Conundrum [Case Report]

Adejumo, Oluwayemisi L; Hameed, Irbaz; Grossman, Tracy; Landres, Inna; Tam, Christopher; Villena-Vargas, Jonathan; Hill, Shanna Sykes; Feldman, Dmitriy N; Minutello, Robert M; Kim, Luke; Bergman, Geoffrey; Wong, Shing-Chiu; Salemi, Arash; Singh, Harsimran S
Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.).
PMID: 34317125
ISSN: 2666-0849
CID: 4965482

Abortion for Fetal Genetic Abnormalities: Type of Abnormality and Gestational Age at Diagnosis

Grossman, Tracy B; Chasen, Stephen T
Background  Advances in genetic screening can identify patients at high risk for common genetic conditions early in pregnancy and can facilitate early diagnosis and early abortion. Less common abnormalities might only be diagnosed with invasive testing is performed after structural abnormalities are identified. Objective  Our objective was to compare gestational age (GA) at diagnosis and abortion for genetic abnormalities identified based on screening with abnormalities that were not discovered after screening. Study Design  All prenatal diagnostic procedures from 2012 to 2017 were reviewed, and singleton pregnancies terminated following diagnosis of genetic abnormalities were identified. Cases diagnosed as the result of screening tests were compared with remaining cases. Conditions were considered "screened for" if they can be suspected by cell-free DNA testing, biochemistry, carrier screening, or if the patient was a known carrier of a single-gene disorder. When abnormal karyotype, microarray, or Noonan's syndrome was associated with abnormal NT, these cases were considered "screened for." GA at abortion was the primary outcome. Fisher's exact test and Mann-Whitney's U test were used for statistical comparison. Results  In this study, 268 cases were included. A total of 227 (85%) of abortions were performed for "screened for" disorders, with 210 (93%) of these for karyotype abnormalities, 5 (2%) for microarray abnormalities, and 12 (5%) for single-gene disorders. Forty-one (15%) of abortions were performed for conditions not included in screening, with 8 (19%) of those for karyotype abnormalities, 25 (61%) for microarray abnormalities, and 8 (19%) for single-gene disorders. Invasive testing and abortion occurred at earlier median GA for those with conditions that were screened for: 12 2/7 versus 15 5/7 weeks, p ≤0.001 and 13 5/7 versus 20 0/7 weeks; p ≤0.001. Conclusion  Most abortions were for abnormalities that can be suspected early in pregnancy. As many structural abnormalities associated with rare conditions are not identifiable until the mid-trimester, prenatal diagnosis and abortion occurred significantly later. Physicians and patients should be aware of the limitations of genetic screening.
PMID: 32190411
ISSN: 2157-6998
CID: 4368492

The use of silver in cesarean wound bandages: A new way to decrease infection and healthcare costs [Meeting Abstract]

Grossman, T; Fields, J; Chan-Akeley, R; Dayal, A
INTRODUCTION: Post-cesarean surgical site infection (SSI) occurs after 3.7-9.8% of cesarean deliveries and is associated with significant morbidity and healthcare costs. Silver has antimicrobial properties and bandages impregnated with it are associated with decreased rates of SSI in non-obstetric surgery. Our objective was to compare the rates of deep and superficial cesarean SSI before and after the institution of silver-impregnated bandages and to analyze related healthcare costs.
METHOD(S): This was a retrospective cohort study comparing the rates of cesarean-related SSI five months before and after the institution of silver-impregnated bandages and associated healthcare costs. Data was analyzed using chi-square and Fisher's exact test.
RESULT(S): There were 1,044 cesarean deliveries and 33 woundrelated emergency department (ED) presentations during the study period. The demographics of the standard-of-care (n=538) and silverbandage (n=506) groups were similar. The overall rates of deep and superficial SSI were 0.8% (n=8) and 0.6% (n=6) respectively. The use of silver-bandages was associated with a decrease in the rate of deep SSI (0.6% (n=3) vs 0.9% (n=5), P=.2) and superficial SSI (0.4% (n=2) vs 0.7% (n=4), P=.3). There were 24% fewer ED presentations in the silver-bandage group (13 vs 17) and one wound dehiscence requiring re-operation and negative-pressure wound-therapy, which was in the standard-of-care group. Healthcare costs related to SSI, ED presentations and long-term wound care were 29% less in the silver-bandage group.
CONCLUSION(S): The use of silver-impregnated bandages was associated with a decreased rate of cesarean SSI and decreased healthcare costs. Longer-term studies will likely yield statistically significant decreases in SSI and healthcare costs, as post-cesarean SSI is a rare outcome
ISSN: 1873-233x
CID: 4721102

Abnormal nuchal translucency: residual risk with normal cell-free DNA screening

Grossman, Tracy B; Bodenlos, Kimberly L; Chasen, Stephen T
OBJECTIVE:To determine the proportion of genetic abnormalities that could be identified by cell-free DNA screening in pregnancies with an abnormal nuchal translucency. METHODS:From 2015-2017, pregnancies with nuchal translucency ≥ 3.0 mm on ultrasounds were identified. Pregnancies with genetic testing results were included, whether or not cell-free DNA screening was performed. Comparisons of the proportion of genetic abnormalities detectable on cell-free DNA screening versus not detectable were made based on nuchal translucency values (3.0-3.4 mm; ≥3.5 mm) and maternal age (≥35 versus <35 years). Chi-square analysis, Fisher's exact test, and Mann-Whitney U were used for statistical comparison. RESULTS:One hundred ten patients were included, 60 had genetic abnormalities (54.5%), with 44 (73.3%) detectable on cell-free DNA screening and 16 (26.7%) not. In those with nuchal translucency ≥3.5 mm, only 40 of 56 (71.4%) of abnormalities could be detected by cell-free DNA screening. Cell-free DNA screening could identify 27 of 31 abnormalities with nuchal translucency ≥3.5 mm in women ≥35 years but could identify only 13 of 25 genetic abnormalities in younger women (87.1 versus 52.0%; p = .005). CONCLUSION/CONCLUSIONS:A significant proportion of abnormalities in those with nuchal translucency ≥3.5 mm would not be detected by cell-free DNA, especially in younger women.
PMID: 30669906
ISSN: 1476-4954
CID: 3897202

Isolated acute funisitis in the absence of acute chorioamnionitis: What does it mean?

Grossman, Tracy B; Heller, Debra S; Baergen, Rebecca N
OBJECTIVE:Acute funisitis (AF) is most commonly associated with acute chorioamnionitis (AC) and ascending infection. The significance of cases of AF without associated AC or isolated funisitis (IF) is unknown. Our objective was to evaluate clinical and pathologic features of IF and to determine its significance. STUDY DESIGN/METHODS:This was a retrospective review of placentas of patients delivering at our institution from 1997 to 2017. Placentas with the diagnosis of IF comprised the study population and placentas without either AF or AC served as controls. RESULTS:There were 156 cases and 181 controls identified. Maternal age, gestational age, birthweight and mode of delivery were similar in both groups. 132 (84.6%) of cases of IF had meconium, with 62 (47.0%) having meconium only in the membranes, 36 (27.3%) in the membranes and cord and 34 (25.6%) in the membranes and cord with associated myonecrosis. 72 (38.7%) of controls had microscopically identified meconium, with only one (1.4%) showing meconium in the cord. None had myonecrosis (p < .001). There was also a significantly higher rate of intrauterine fetal demise (IUFD) in the IF group (p = .027). but the rate of suspected Intrauterine growth restriction (IUGR) was significantly greater in the controls (p = .014). CONCLUSION/CONCLUSIONS:IF is highly associated with the presence of meconium discharge and meconium-associated myonecrosis of umbilical vessels. The inflammation in IF may be the result of damage to the muscle fibers of the cord due to meconium but additional studies are necessary to understand the significance of these findings.
PMID: 30712665
ISSN: 1532-3102
CID: 3897212

Delivery Outcomes of Patients with Acute Migraine in Pregnancy: A Retrospective Study

Grossman, Tracy B; Robbins, Matthew S; Govindappagari, Shravya; Dayal, Ashlesha K
OBJECTIVE:To describe labor and delivery outcomes in pregnant patients presenting to the hospital setting with an acute severe migraine headache attack earlier in the same gestation. METHODS:We retrospectively reviewed pregnancy and delivery records from a database of consecutive inpatient neurology consultations for acute headache in pregnant women over a 5 year period. RESULTS:We identified 86 pregnant women with acute migraine. The mean age was 29.3 (±6.4) years. Nearly half had migraine with aura (35/86 [40.7%]), 12.8% (12/86) had chronic migraine, and 31.4% (27/86) presented in status migrainosus. Complication rates included 54.7%([41/75], 95% CI 29.87, 52.13) for at least one adverse outcome, 28.0% ([21/75], 95% CI 11.78, 30.22) for preterm delivery, 21.3% ([16/75], 95% CI 7.7, 24.3) for preeclampsia, 30.6% ([23/75] 95% CI 13.48, 32.52) for cesarean delivery, and 18.7% ([14/75] 95% CI 6.15, 21.85) for low birthweight. CONCLUSIONS:Pregnant women seeking treatment for acute migraine headache experienced a higher rate of preterm delivery, preeclampsia, and low birthweight but a lower rate of cesarean delivery than the local and general populations. More than half (54.7% [41/75] 95% CI 29.87, 52.13) of the study patients experienced some type of adverse birth outcome, suggesting that pregnancies in migraine patients presenting to an acute care setting may benefit from more intense surveillance.
PMID: 28101987
ISSN: 1526-4610
CID: 3897192