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Ultrasound differential diagnosis between amniotic fluid sludge and blood clot from placental edge separation

Kantorowska, Agata; Kunzier, Nadia N B; Kidd, Jennifer J M; Vintzileos, Anthony M
PMID: 35490793
ISSN: 1097-6868
CID: 5215722

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes

Ramani, Sangeeta; Halpern, Tara A; Akerman, Meredith; Ananth, Cande V; Vintzileos, Anthony M
BACKGROUND:Cesarean rates have been used as obstetrical quality indicators. However, these approaches do not take into consideration the accompanying maternal and neonatal morbidity. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses pre-existing high-risk maternal factors, as well as associated maternal and neonatal morbidity that is universally acceptable to all stakeholders including patients, health care providers, payers, and governmental agencies. OBJECTIVES/OBJECTIVE:The objectives of this study were to: (i) establish a new single metric for obstetric quality improvement among nulliparous with term, singleton, vertex (NTSV) patients, which integrates cesarean rates adjusted for pre-existing high risk maternal factors with the associated maternal and neonatal morbidity; this single metric has been termed obstetric safety and quality index (OSQI); and (ii) determine if obstetrician quality ranking by this new metric is different as compared to the rating based on individual crude and/or risk-adjusted cesarean rates. STUDY DESIGN/METHODS:This is a cross-sectional study that identified all NTSV patients delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed including maternal high-risk factors, maternal and neonatal outcomes. Maternal and neonatal charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean rates, as well as rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the OSQI index for each obstetrician. The final ranking based on the OSQI was compared to the initial ranking by crude cesarean rates. Maternal and neonatal morbidities were analyzed as ≥1 and as well as ≥2 maternal and/or neonatal complications. RESULTS:These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05, 95% confidence interval -0.54, 0.60) to the final ranking based on the OSQI index. Eight of 12 obstetricians shifted their rank quartiles following adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 vs. ranking based on ≥2 CMM/CNM (rho=0.63, 95% confidence interval 0.08, 0.88). CONCLUSIONS:Ranking based on crude cesarean rates varies significantly after considering high-risk maternal conditions and the associated maternal and neonatal outcomes. Therefore, the OSQI is a single metric which may potentially help to identify ways to improve upon clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared towards patient safety balancing cesarean rates with maternal and neonatal mortality. This metric could potentially be also used to compare obstetric quality not only among individual obstetricians but also among hospitals which practice obstetrics.
PMID: 34634261
ISSN: 1097-6868
CID: 5030262

The role of the fetal biophysical profile in the management of fetal growth restriction

Baschat, Ahmet A; Galan, Henry L; Lee, Wesley; DeVore, Greggory R; Mari, Giancarlo; Hobbins, John; Vintzileos, Anthony; Platt, Lawrence D; Manning, Frank A
Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.
PMID: 35369904
ISSN: 1097-6868
CID: 5201542

Barriers to obstetric patient utilization of remote patient monitoring for blood pressure [Meeting Abstract]

Kidd, Jennifer; Patberg, Elizabeth; Kantorowska, Agata; Alku, Dajana; Akerman, Meredith; Vertichio, Rosanne; Wise, Anne-Marie; Vintzileos, Anthony; Heo, Hye
ISSN: 0002-9378
CID: 5208552

Use of Cervical Elastography at 18 to 22 Weeks Gestation in the Prediction of Spontaneous Preterm Birth

Patberg, Elizabeth; Wells, Matthew; Vahanian, Sevan; Zavala, Jose; Bhattacharya, Sarmistha; Richmond, Diana; Akerman, Meredith; Demishev, Michael; Kinzler, Wendy; Chavez, Martin R; Vintzileos, Anthony
OBJECTIVES/OBJECTIVE:To develop standard cervical elastography nomograms for singleton pregnancies at 18-22 weeks gestation using the E-cervix ultrasound application; assess intra-observer reliability of the E-cervix elastography parameters; and determine if these cervical elastography measurements can be used in the prediction of spontaneous preterm birth. METHODS:This was a prospective cohort study of pregnant women undergoing cervical length screening assessment via transvaginal ultrasound examination at 18 - 22 weeks gestation. A semi-automatic, cervical elastography application (E-cervix) was utilized during the transvaginal examination to calculate five quantitative parameters (Internal Os Stiffness, External Os Stiffness, Internal to External Os Stiffness Ratio, Hardness Ratio, Elasticity Contrast Index) and create a standard nomogram for each one of them. The intra-observer reliability was calculated using Shrout-Fliess reliability. Cervical elastography parameters were compared between those who delivered preterm (<37 weeks) spontaneously versus full term. A multivariable logistic regression model was performed to determine the ability of the cervical elastography parameters to predict spontaneous preterm birth. RESULTS:742 women were included of which 49 (6.6%) had a spontaneous preterm delivery. A standard nomogram was created for each of the cervical elastography parameters from those who had a full term birth in the index pregnancy (n=693). Intra-observer reliability was good or excellent (intraclass correlation (ICC) = 0.757 - 0.887) for each of the cervical elastography parameters except External Os Stiffness which was poor (ICC = 0.441). In univariate analysis, none of the cervical elastography parameters were associated with a statistically significant increased risk of spontaneous preterm birth. In a multivariable model adjusting for history of preterm birth, gravidity, ethnicity, cervical cerclage and vaginal progesterone use, increasing Elasticity Contrast Index was significantly associated with an increased risk of spontaneous preterm birth (OR 1.15, 95%CI [1.02, 1.30]; P=0.02). CONCLUSIONS:Cervical elastography parameters are reliably measured and are stable across 18-22 weeks gestation. Based on our findings, the Elasticity Contrast Index was associated with an increased risk for spontaneous preterm birth and may be the parameter useful for future research.
PMID: 34051170
ISSN: 1097-6868
CID: 4890612

Underestimation of SARS-CoV-2 infection in placental samples [Letter]

Hanna, Nazeeh; Lin, Xinhua; Thomas, Kristen; Vintzileos, Anthony; Chavez, Martin; Palaia, Thomas; Ragolia, Louis; Verma, Sourabh; Khullar, Poonam; Hanna, Iman
PMID: 34297970
ISSN: 1097-6868
CID: 4954872

Reply to "COVID-19 infection just before or during early pregnancy and the possible risk of placenta accreta spectrum or preeclampsia" [Letter]

Patberg, Elizabeth T; Vintzileos, Anthony M
PMID: 34146531
ISSN: 1097-6868
CID: 4917942

Reply to Letter to the Editor Regarding COVID-19 Infection and Placental Histopathology in Women Delivering at Term [Letter]

Patberg, Elizabeth T; Vintzileos, Anthony M; Khullar, Poonam
PMID: 34058172
ISSN: 1097-6868
CID: 4891012


Tozour, J N; Arnott, A J; Akerman, M; Vintzileos, A; Sung, L; Fritz, R
OBJECTIVE: The overuse of intracytoplasmic sperm injection (ICSI) in non-male factor infertility is well documented. ICSI is associated with higher costs, increase workload on embryology staff, and concern for adverse outcomes to offspring. The use of ICSI in non-male factor preimplantation genetic testing - aneuploidy (PGT-A) cycles currently is recommended when there is a concern for paternal contamination. Our objective is to evaluate whether significant differences exist in number of embryos suitable for transfer and pregnancy outcomes from PGT-A cycles derived from oocytes fertilized by in vitro fertilization (IVF) compared to ICSI using the SART-CORS database. MATERIALS AND METHODS: This is a retrospective cohort study evaluating fresh and thawed linked frozen embryo transfer (FET) cycles reported to SART from 1/1/2014 to 12/31/2017 undergoing PGT-A. Exclusion criteria included male factor infertility, embryos tested for monogenic disorders, structural rearrangements, or HLA-typing, cryopreserved or donor oocytes, blastomere or polar body biopsy, in vitro maturation, rescue ICSI, split IVF/ICSI cycles, gestational carriers, and >1 embryo transferred. Patient demographics, cycle characteristics, number of embryos suitable for transfer, and pregnancy outcomes in FET cycles were collected. Primary outcomes were percentage of embryos suitable for transfer and live birth (LB) rates. Sub-analysis of embryos suitable for transfer were performed on cycles with < and R 6 oocytes and < 35 y/o and R 35 y/o. Chi-square or Fisher's exact test, as appropriate, were used for categorical variables. Mann-Whiney test was used for continuous variables. Relevant confounders and multiple cycles within a subject were accounted for in a generalized linear mixed model. Results were considered statistically significant with a p-value <0.05.
RESULT(S): A total of 4,867 IVF and 25,579 ICSI cycles met criteria to evaluate for embryos suitable for transfer. Significant difference between the IVF and ICSI cohort existed in age (35.8 y/o vs. 36.8 y/o, respectively, p=0.03). No significant differences in percentage of embryos suitable for transfer were found between IVF vs. ICSI (42.1% vs 42.7%, respectively, p=0.28), within the subgroup of patients R 35 y/o (35.8% vs. 36.5%, respectively, p=0.32), and within subgroup with % 6 oocytes retrieved (32.9% vs. 35.3%, respectively p=0.44). Total of 3,412 IVF and 16,358 ICSI cycles met criteria for pregnancy outcomes evaluation. No significant differences in LB/ongoing pregnancy rate between IVF vs. ICSI (53.2% vs 53.0%, respectively, p=0.51) and pregnancy loss (18.5% vs 17.3%, p=0.11) were found.
CONCLUSION(S): There were no significant differences in rate of embryos suitable for transfer or pregnancy outcomes in PGT-A cycles derived from IVF and ICSI insemination. ICSI in non-male factor infertility cycles undergoing PGT-A does not provide an advantage over IVF. IMPACT STATEMENT: ICSI insemination in non-male factor cycles undergoing PGT-A does not yield superior outcomes compared to IVF insemination. IVF in non-male factor PGT-A cycles provides the benefit of time and cost savings
ISSN: 1556-5653
CID: 5250772

Application of telemedicine video visits in a maternal-fetal medicine practice at the epicenter of the COVID-19 pandemic

Tozour, Jessica N; Bandremer, Samantha; Patberg, Elizabeth; Zavala, Jose; Akerman, Meredith; Chavez, Martin; Mann, Devin M; Testa, Paul A; Vintzileos, Anthony M; Heo, Hye J
BACKGROUND:Telemedicine in obstetrics has mostly been described in the rural areas that have limited access to subspecialties. During the COVID-19 pandemic, health systems rapidly expanded telemedicine services for urgent and nonurgent healthcare delivery, even in urban settings. The New York University health system implemented a prompt systemwide expansion of video-enabled telemedicine visits, increasing telemedicine to >8000 visits daily within 6 weeks of the beginning of the pandemic. There are limited studies that explore patient and provider satisfaction of telemedicine visits in obstetrical patients during the COVID-19 epidemic, particularly in the United States. OBJECTIVE:This study aimed to evaluate both the patients' and the providers' satisfaction with the administration of maternal-fetal medicine services through telemedicine and to identify the factors that drive the patients' desire for future obstetrical telemedicine services. STUDY DESIGN/METHODS:A cross-sectional survey was administered to patients who completed a telemedicine video visit with the Division of Maternal-Fetal Medicine at the New York University Langone Hospital-Long Island from March 19, 2020, to May 26, 2020. A 10-question survey assessing the patients' digital experience and desire for future use was either administered by telephone or self-administered by the patients via a link after obtaining verbal consent. The survey responses were scored from 1-strongly disagree to 5-strongly agree. We analyzed the demographics and survey responses of the patients who agreed to vs those who answered neutral or disagree to the question "I would like telehealth to be an option for future obstetric visits." The providers also answered a similar 10-question survey. The median scores were compared using appropriate tests. A P value of <.05 was considered significant. RESULTS:A total of 253 patients participated in 433 telemedicine visits, and 165 patients completed the survey, resulting in a 65% survey response rate. Overall, there were high rates of patient satisfaction in all areas assessed. Those who desired future telemedicine had significantly greater agreeability that they were able to see and hear their provider easily (5 [4.5, 5] vs 5 [4, 5]; P=.014) and that the lack of physical activity was not an issue (5 [4, 5] vs 5 [4, 5]; P=.032). They were also more likely to agree that the telemedicine visits were as good as in-person visits (4 [3, 5] vs 3 [2, 3]; P<.001) and that telehealth made it easier for them to see doctors or specialists (5 [4, 5] vs 3 [2, 3]; P<.001). The patients seeking consults for poor obstetrical history were more likely to desire future telemedicine compared with other visit types (19 (90%) vs 2 (10%); P=.05). Provider survey responses also demonstrated high levels of satisfaction, with 83% agreeing that they would like telemedicine to be an option for future obstetrical visits. CONCLUSION/CONCLUSIONS:We demonstrated that maternal-fetal medicine obstetrical patients and providers were highly satisfied with the implementation of telemedicine during the initial wave of the COVID-19 pandemic and a majority of them desire telemedicine as an option for future visits. A patient's desire for future telemedicine visits was significantly affected by their digital experience, the perception of a lack of need for physical contact, perceived time saved on travel, and access to healthcare providers. Health systems need to continue to improve healthcare delivery and invest in innovative solutions to conduct physical examinations remotely.
PMID: 34450341
ISSN: 2589-9333
CID: 5030242