Can Prenatal Ultrasound Predict Adverse Neonatal Outcomes in SARS-CoV-2 Affected Pregnancies?

BACKGROUND: Based on available data, at least one ultrasound assessment of pregnancies recovering from SARS-CoV-2 infection is recommended. Reports, however, on prenatal imaging findings and potential associations with neonatal outcomes following SARS-CoV-2 infection in pregnancy have been inconclusive. OBJECTIVE: We aim to describe the sonographic characteristics of pregnancies after confirmed SARS-CoV-2 infection and assess the association of prenatal ultrasound (US) findings with adverse neonatal outcomes (ANO). STUDY DESIGN: This is an observational prospective cohort study of pregnancies diagnosed with SARS-CoV-2 by reverse transcription polymerase chain reaction between March 2020 and May 2021. Prenatal US evaluation was performed at least once after diagnosis of infection with the following parameters measured: standard fetal biometric measurements, umbilical and middle cerebral artery Dopplers, placental thickness, amniotic fluid volume, and anatomic survey for infection-associated findings. The primary outcome was composite ANO, defined as one or more of the following: preterm birth, NICU admission, small for gestational age (SGA), respiratory distress, intrauterine fetal demise, neonatal demise, or other neonatal complications. Secondary outcomes were sonographic findings stratified by trimester of infection and severity of SARS-CoV-2 infection. Prenatal US findings were compared with neonatal outcomes, severity of infection, and trimester of infection. RESULTS: A total 103 SARS-CoV-2 affected mother-infant pairs with prenatal US evaluation were identified; 3 cases were excluded due to known major fetal anomalies. Of the 100 included cases, neonatal outcomes were available in 92 pregnancies (97 infants); of these, 28 (29%) had a composite ANO. Twenty-three (23%) had at least one abnormal prenatal US finding. The most common abnormalities seen on US were placentomegaly (11/23, 47.8%) and fetal growth restriction (FGR) (8/23, 34.8%). FGR was associated with a higher rate of a composite ANO (25% vs 1.5%; aOR: 22.67; 95% 95% CI, 2.63-194.91; p<0.001), even when SGA was removed from the composite ANO. Cochran-Mantel Haensel test controlling for possible FGR confounders continued to show this association (relative risk, 3.7; 95% confidence interval, 2.6-5.9; p<0.001). Median estimated fetal weight (EFW) and birthweight were lower in patients with a composite ANO (p<0.001). Infection in the third trimester was associated with lower median percentile of EFW (p=0.019). An association between placentomegaly and third trimester SARS CoV-2 infection was noted (p=0.045). CONCLUSION: In our study of SARS-CoV-2 affected maternal-infant pairs, rates of FGR were comparable to the general population. However, composite ANO rates were high. Pregnancies with FGR after SARS-CoV-2 infection were associated with an increased risk for ANO and may require close surveillance.

Neutralizing Monoclonal Antibodies for Coronavirus Disease 2019 (COVID-19) in Pregnancy: A Case Series.

OBJECTIVE: To describe outcomes associated with monoclonal antibody use in pregnant persons with mild-to-moderate coronavirus disease 2019 (COVID-19). METHODS: We present a retrospective case series of pregnant patients who received anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) monoclonal antibody infusions at a single center from April 1, 2021, through October 16, 2021. Pregnant patients who had a positive SARS-CoV-2 polymerase chain reaction (PCR) test result and mild-to-moderate COVID-19 symptoms were eligible for monoclonal antibody infusion. Exclusion criteria for administration included need for supplemental oxygen, hospitalization due to COVID-19, and positive SARS-CoV-2 PCR test result more than 7 days before screening. All patients received either bamlanivimab plus etesevimab or casirivimab plus imdevimab based on availability and dosing instructions of the product and emerging resistance patterns in the community. RESULTS: During the study period, monoclonal antibody infusions were administered to 450 individuals at our institution, of whom 15 were pregnant. Of the 15 pregnant persons receiving monoclonal antibody, six (40%) had full-vaccination status at the time of infusion. Two individuals (13%, CI 0-31%) experienced systemic reactions during the infusion, both resulting in temporary changes in the fetal heart rate tracing that recovered with maternal and intrauterine resuscitative efforts. One patient delivered after infusion for worsening maternal and fetal status; the remainder of the patients did not require admission for COVID-19. CONCLUSION: In this case series, pregnant persons who received anti-SARS-CoV-2 monoclonal antibody infusions had generally favorable outcomes.

An Intervention to Increase Outdoor Play in Early Childhood Education Centers (PROmoting Early Childhood Outside): Protocol for a Pilot Wait-list Control Cluster Randomized Trial.

BACKGROUND: Participation in outdoor play has been extensively documented as beneficial for the health, well-being, and development of children. Canadian early childhood education centers (ECECs) are important settings in young children's lives and provide opportunities to participate in outdoor play. However, there are barriers to the provision of outdoor play opportunities at ECECs, such as adverse weather conditions, poorly designed outdoor spaces, outdoor time policies, and early childhood educator comfort levels. OBJECTIVE: The PROmoting Early Childhood Outside (PRO-ECO) study is a wait-list control cluster randomized trial that evaluates the impact of the PRO-ECO intervention, an innovative outdoor play intervention, on children's outdoor play behavior. The purpose of this paper was to provide a detailed overview of the pilot study protocol and the methods that will be used to develop, implement, and evaluate the PRO-ECO intervention. METHODS: A total of 8 ECECs delivering licensed care to children aged 2.5 to 6 years in the Greater Vancouver region of British Columbia, Canada, and operated by the YMCA of Greater Vancouver (YMCA GV) are included in this study. Using a wait-list control cluster randomized trial design, we randomly allocated ECECs to either the PRO-ECO intervention arm (n=4) or the wait-list control arm (n=4). The primary outcome measures include changes in the proportion and diversity of observed outdoor play behavior during dedicated outdoor times at the ECECs as measured through observational behavior mapping. Secondary outcome measures include changes in educator attitudes; quality of ECECs' outdoor play space; and children's psychosocial strengths, physical activity levels, and social behaviors. A process evaluation of the acceptability of the PRO-ECO intervention in the 8 YMCA GV ECECs will also be assessed. Outcome data will be collected at baseline, 6-month follow-up, and 12-month follow-up. Mixed effect models will test the effect of the PRO-ECO intervention on quantitative outcomes. Baseline and postintervention data will be included in the analysis, controlling for the cluster design. Qualitative data will support quantitative findings and provide evidence for the acceptability of implementation. RESULTS: Participant recruitment for this study began in August 2021, and baseline data collection was completed at all 8 ECECs in November 2021. As of April 2022, a total of 130 children have been recruited to participate in this study. CONCLUSIONS: The PRO-ECO pilot study will develop, implement, and evaluate the PRO-ECO intervention within 8 YMCA GV ECECs in the Vancouver region of British Columbia, Canada. The findings of this study will be useful for early childhood educators, ECEC providers, and policy makers to consider means for enhancing outdoor play provision and assessing the sustainability of the intervention in ECEC settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05075580; https://clinicaltrials.gov/ct2/show/NCT05073380. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38365.

Faculty and applicant perceptions of virtual interviews on subspecialty fellowship match in obstetrics and gynecology.

BACKGROUND: In response to COVID-19, the AAMC recommended that hospitals conduct interviews in a virtual setting. OBJECTIVE: To evaluate whether fellowship video conference interviews (VCIs) are an acceptable alternative to in-person interviews from both the applicant and program perspectives. METHODS: Applicants and faculty from a single academic institution with five OBGYN subspecialty fellowship programs were invited to complete surveys regarding their experience using VCIs during the 2020 interview season. Survey responses used a 5-point Likert scale (strongly disagree to strongly agree). Comparative analyses between faculty and applicants responses to survey questions were performed with two-tailed Student's t-tests. RESULTS: 45 faculty members and 131 applicants received the survey. Response rate for faculty members and applicants was 95.6% (n = 43) and 46.6% (n = 61), respectively. Faculty and applicants agreed that the VCIs allowed them to accurately represent themselves (83.7% vs. 88.6%, p = 0.48). Most applicants (62.3%, n = 38) reported a fundamental understanding of the fellowship's culture. The majority of applicants (77.1%, n = 47) and faculty (72.1%, n = 31) agreed that they were able to develop connections during the virtual interview (p = 0.77). Faculty and applicants stated that VCIs assisted them in determining whether the candidate or program, respectively, was a good fit (83.7% vs. 67.2%, p = 0.98). CONCLUSIONS: The VCI fellowship recruitment process allowed OBGYN fellowship applicants and programs to accurately represent themselves compared to in-person interviews. Most applicants and faculty were able to develop relationships over the virtual platform. Although not explicitly assessed, it is possible that the virtual interviews can achieve a suitable match between applicant and program across all OBGYN subspecialty fellowships. The VCI process may be a long-term resolution to minimize both the financial burden and time commitment presented by traditional in-person interviews. Follow-up studies should assess the performance of the virtually selected fellows compared to those selected in previous years using traditional in-person interviews.

A Web-Based Risk-Reframing Intervention to Influence Early Childhood Educators' Attitudes and Supportive Behaviors Toward Outdoor Play: Protocol for the OutsidePlay Study Randomized Controlled Trial.

BACKGROUND: Early learning and childcare centers (ELCCs) can offer young children critical opportunities for quality outdoor play. There are multiple actual and perceived barriers to outdoor play at ELCCs, ranging from safety fears and lack of familiarity with supporting play outdoors to challenges around diverse perspectives on outdoor play among early childhood educators (ECEs), administrators, licensing officers, and parents. OBJECTIVE: Our study objective is to develop and evaluate a web-based intervention that influences ECEs' and ELCC administrators' perceptions and practices in support of children's outdoor play at ELCCs. METHODS: The development of the fully automated, open-access, web-based intervention was guided by the intervention mapping process. We first completed a needs assessment through focus groups of ECEs, ELCC administrators, and licensing officers. We identified key issues, needs, and challenges; opportunities to influence behavior change; and intervention outcomes and objectives. This enabled us to develop design objectives and identify features of the OutsidePlay web-based intervention that are central to addressing the issues, needs, and challenges of ECEs and ELCC administrators. We used social cognitive theory and behavior change techniques to select methods, applications, and technology to deliver the intervention. We will use a two-parallel-group randomized controlled trial (RCT) design to evaluate the efficacy of the intervention. We will recruit 324 ECEs and ELCC administrators through a variety of web-based means, including Facebook advertisements and mass emails through our partner networks. The RCT study will be a purely web-based trial where outcomes will be self-assessed through questionnaires. The RCT participants will be randomized into the intervention group or the control group. The control group participants will read the Position Statement on Active Outdoor Play. RESULTS: The primary outcome is increased tolerance of risk in children's play, as measured by the Teacher Tolerance of Risk in Play Scale. The secondary outcome is self-reported attainment of a self-developed behavior change goal. We will use mixed effects models to test the hypothesis that there will be a difference between the intervention and control groups with respect to tolerance of risk in children's play. Differences in goal attainment will be tested using logistic regression analysis. CONCLUSIONS: The OutsidePlay web-based intervention guides users through a personalized journey that is split into 3 chapters. An effective intervention that addresses the barriers to outdoor play in ELCC settings has the potential to improve children's access to outdoor play and support high-quality early childhood education. TRIAL REGISTRATION: ClinicalTrials.gov NCT04624932; https://clinicaltrials.gov/ct2/show/NCT04624932. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31041.

Evaluation of Respiratory Emissions During Labor and Delivery: Potential Implications for Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

OBJECTIVE: To characterize respiratory emissions produced during labor and vaginal delivery vis-à-vis the potential for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: Observational study of three women who tested negative for SARS-CoV-2 and had uncomplicated vaginal deliveries. Using background-oriented schlieren imaging, we evaluated the propagation of respiratory emissions produced during the labor course and delivery. The primary outcome was the speed and propagation of breath over time, calculated through processed images collected throughout labor and delivery. RESULTS: In early labor with regular breathing, the speed of the breath was 1.37 meters/s (range 1.20-1.55 meters/s). The breath appeared to propagate faster with a cough during early labor at a speed of 1.69 meters/s (range 1.22-2.27 meters/s). During the second stage of labor with Valsalva and forced expiration, the propagation speed was 1.79 meters/s (range 1.71-1.86 meters/s). CONCLUSION: Labor and vaginal delivery increase the propagation of respiratory emissions that may increase risk of respiratory transmission of SARS-CoV-2.

Clinical guidance and perinatal care in the era of coronavirus disease 2019 (COVID-19).

Pregnant women may be at risk for more severe manifestations and sequelae of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At this time, there remain significant evidence gaps to allow for comprehensive counseling of pregnant women and their families, specifically regarding the risks of gestational-age specific maternal outcomes and potential risks of intrauterine or peripartum viral transmission to the fetus or newborn. As maternal fetal medicine providers and consultants, we are uniquely positioned to mitigate the risks associated with maternal infection and to guide the care for infected pregnant women by being able to provide the most current evidence-based recommendations. Such care requires incorporating the rapidly evolving data regarding this virus and its impact on pregnancy, as well as taking a stand to advocate for best scientific and clinical practices to optimize both women's health and public health during this pandemic.

Obstetrical Unit Response to the COVID-19 Pandemic: OUR Study.

OBJECTIVE: This study aimed to describe the response of labor and delivery (L&D) units in the United States to the novel coronavirus disease 2019 (COVID-19) pandemic and determine how institutional characteristics and regional disease prevalence affect viral testing and personal protective equipment (PPE). STUDY DESIGN: A cross-sectional survey was distributed electronically through the Society for Maternal-Fetal Medicine e-mail database (n = 584 distinct practices) and social media between April 14 and 23, 2020. Participants were recruited through "snowballing." A single representative was asked to respond on behalf of each L&D unit. Data were analyzed using Chi-square and Fisher's exact tests. Multivariable regression was performed to explore characteristics associated with universal testing and PPE usage. RESULTS: A total of 301 surveys (estimated 51.5% response rate) was analyzed representing 48 states and two territories. Obstetrical units included academic (31%), community teaching (45%) and nonteaching hospitals (24%). Sixteen percent of respondents were from states with high prevalence, defined as higher "deaths per million" rates compared with the national average. Universal laboratory testing for admissions was reported for 40% (119/297) of units. After adjusting for covariates, universal testing was more common in academic institutions (adjusted odds ratio [aOR] = 1.73, 95% confidence interval [CI]: 1.23-2.42) and high prevalence states (aOR = 2.68, 95% CI: 1.37-5.28). When delivering asymptomatic patients, full PPE (including N95 mask) was recommended for vaginal deliveries in 33% and for cesarean delivery in 38% of responding institutions. N95 mask use during asymptomatic vaginal deliveries remained more likely in high prevalence states (aOR = 2.56, 95% CI: 1.29-5.09) and less likely in hospitals with universal testing (aOR = 0.42, 95% CI: 0.24-0.73). CONCLUSION: Universal laboratory testing for COVID-19 is more common at academic institutions and in states with high disease prevalence. Centers with universal testing were less likely to recommend N95 masks for asymptomatic vaginal deliveries, suggesting that viral testing can play a role in guiding efficient PPE use. KEY POINTS: · Heterogeneity is seen in institutional recommendations for viral testing and PPE.. · Universal laboratory testing for COVID-19 is more common at academic centers.. · N95 mask use during vaginal deliveries is less likely in places with universal testing..