The impact of the ARRIVE trial on elective inductions at a tertiary academic center

Objective: The ARRIVE Trial (2018) has potentially changed the practice of scheduling elective inductions of labor. Our goal was to demonstrate how the publication of the trial impacted one tertiary care center’s practice of scheduling elective inductions and affected the resulting labor outcomes. Study Design: We conducted a retrospective cohort study obtaining information about the births at an academic tertiary care center during the 18-month period prior to publication of the ARRIVE Trial (Feb 1 2017 - Aug 1 2018) and the 18 months after publication (Sep 1 2018 - Mar 1 2020) and before the lockdown necessitated by the COVID-19 pandemic. We included women ≥18 years with elective inductions between 39 and 41 weeks gestation, defined as having no medical indication for induction. Chi-squared tests and two sample t-tests were used for comparison of group characteristics and birth outcomes before and after trial publication. Results: A total of 3213 births were included, with 1542 from the pre-ARRIVE period and 1671 from post-ARRIVE. The rate of elective inductions increased from 9.9% of total births pre-ARRIVE to 27.4% of births post-ARRIVE for a 2.8 times increase. After the trial publication, elective inductions occurred at an earlier gestational age (p < 0.001) and among women who were slightly younger (p=0.03), had higher BMI (p=0.002), and lower parity (p < 0.001) on average. The rate of cesarean delivery among electively induced women increased from 6.5% pre-ARRIVE to 14.8% post-ARRIVE (p=0.01). The post-ARRIVE cohort also had longer hospital stays (p=0.002), increased blood loss (p=0.001), and lower birth weights (p=0.005). Conclusion: The publication of the ARRIVE trial significantly impacted the scheduling of elective inductions at our institution, resulting in more than a twofold increase. After publication, elective inductions were performed earlier and resulted in a higher rate of unscheduled cesarean deliveries and other adverse labor outcomes. [Formula presented] [Formula presented]

Postpartum depression in cohorts before and after the start of the COVID-19 pandemic

Objective: The start of quarantine for the COVID-19 pandemic in March 2020 began a prolonged period of isolation from family and crucial social support for many pregnant and postpartum patients throughout the country. The objective of this study was to compare the score of the Edinburgh Postnatal Depression Scale (EPDS), breastfeeding, and compliance with postpartum gestational diabetes follow-up in cohorts before and after the beginning of the COVID-19 pandemic. Study Design: This was a historical cohort study of women presenting for postpartum care in March through May of 2019 and 2020 at a tertiary academic medical center. Demographic information, parity, delivery routes, EPDS scores, maternal mental health history, partner status, and postpartum diabetes screening completion were ed from the electronic medical record. Results were compared between the 2019 and 2020 cohorts. Results: There were 579 women with postpartum visits in the study timeframe, with 260 in 2019 and 319 in 2020. Age, gestational age at delivery, pre-gravid BMI, and partner status were similar between cohorts. (Table 1) There was no difference in history of a mental health diagnosis, history of mental health medication use, or mental health treatment during pregnancy between cohorts. There were more nulliparous patients, cesarean deliveries, African American patients, and Asian patients in 2020. The mean EPDS score was similar between cohorts;there was no difference in breastfeeding or 2-hour glucose tolerance test compliance in women who had gestational diabetes. (Table 2) There was a non-significant trend toward more new postpartum depression treatment in 2020. Conclusion: In our population, the start of the COVID-19 pandemic and resulting social disruption was not associated with a difference between EPDS scores, breastfeeding, completion of gestational diabetes follow up or incidence of initiation of mental health treatment in the postpartum period in our population. [Formula presented] [Formula presented]

ACE inhibitors, angiotensin receptor blockers and endothelial injury in COVID-19.

BACKGROUND: COVID-19 is caused by the coronavirus SARS-CoV-2, which uses angiotensin-converting enzyme 2 (ACE-2) as a receptor for cellular entry. It is theorized that ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) may increase vulnerability to SARS-CoV-2 by upregulating ACE-2 expression, but ACE-I/ARB discontinuation is associated with clinical deterioration. OBJECTIVE: To determine whether ACE-I and ARB use is associated with acute kidney injury (AKI), macrovascular thrombosis and in-hospital mortality. METHODS: A retrospective, single-centre study of 558 hospital inpatients with confirmed COVID-19 admitted from 1 March to 30 April 2020, followed up until 24 May 2020. AKI and macrovascular thrombosis were primary end-points, and in-hospital mortality was a secondary end-point. RESULTS: AKI occurred in 126 (23.1%) patients, 34 (6.1%) developed macrovascular thrombi, and 200 (35.9%) died. Overlap propensity score-weighted analysis showed no significant effect of ACE-I/ARB use on the risk of occurrence of the specified end-points. On exploratory analysis, severe chronic kidney disease (CKD) increases odds of macrovascular thrombi (OR: 8.237, 95% CI: 1.689-40.181, P = 0.009). The risk of AKI increased with advancing age (OR: 1.028, 95% CI: 1.011-1.044, P = 0.001) and diabetes (OR: 1.675, 95% CI: 1.065-2.633, P = 0.025). Immunosuppression was associated with lower risk of AKI (OR: 0.160, 95% CI: 0.029-0.886, P = 0.036). Advancing age, dependence on care, male gender and eGFR < 60 mL min-1 /1.73 m2 increased odds of in-hospital mortality. CONCLUSION: We did not identify an association between ACE-I/ARB use and AKI, macrovascular thrombi or mortality. This supports the recommendations of the European and American Societies of Cardiology that ACE-Is and ARBs should not be discontinued during the COVID-19 pandemic.

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study.

The current international COVID-19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air-purifying respirators and powered air-purifying respirators during simulated difficult airway scenarios. Twenty-five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.