Advance Care Planning in Obstetrics: Effectiveness of a Didactic Intervention on Provider Comfort and Knowledge

INTRODUCTION: Within obstetrics care, it can be difficult to discuss death and advances directives (AD). Recent maternal illnesses and deaths secondary to COVID-19 highlight the importance of these conversations. There is little available research regarding AD in obstetrics, especially within medical education. This study aimed to establish a baseline of obstetric provider comfort and knowledge with this material, provide education, and then reassess comfort and knowledge. METHODS: Institutional review board committee approval was waived for this study. A pre-intervention survey, including a unique identifier to allow for pairing of pre/post-surveys, was emailed to residents of a large university obstetrics and gynecology department with questions assessing comfort and knowledge of AD. The intervention was a 45-minute lecture covering definitions and local state laws relating to AD. A postsurvey, with identical questions to the presurvey, was sent 2 weeks after the intervention. Only paired responses were analyzed, using paired t test. RESULTS: Twenty-three residents (96% of program) participated in the presurvey;17 (71%) participated in the postsurvey. All were matched to presurvey responses and analyzed. In the presurvey, 41% of respondents were usually or always comfortable identifying surrogate decision makers, which increased to 82% in the postsurvey, a 41% difference (P =.01). With regards to the knowledge-based questions, the mean correct response was 56% in the presurvey and 87% in the postsurvey, a 31% difference (P <.001). CONCLUSION: A simple didactic intervention showed improvement in comfort and knowledge surrounding topics of AD for ob-gyn residents. Additional research relating to patient awareness of AD during pregnancy could be explored. [ FROM AUTHOR] Copyright of Obstetrics & Gynecology is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Birthweight is increasing in the United States.

OBJECTIVE: The rates of obesity and diabetes mellitus have increased over the last several decades.1,2 This has resulted in a higher number of large-for-gestational-age (LGA) neonates.3 The US cesarean delivery rate has increased over the same period; LGA fetuses may be a contributing factor.4 This study aimed to establish whether birthweights in the United States have increased over time. STUDY DESIGN: This was a retrospective cohort study conducted using live birth data of singleton pregnancies from the US National Vital Statistics between January 1972 and December 2020. These data are deidentified and publicly available; therefore, the study was deemed exempt from our institutional review board. Singleton births between 37 0/7 and 42 6/7 weeks of gestation were included. Multiple pregnancies and deliveries which had unknown gestational age or birthweight, were excluded. The mean birthweight by each gestational age week for the years 1972-2020 was calculated at selected years (1972, 1982, 1992, 2002, 2012, 2018, and 2020). Of note, 2018 was included to account for differences in the dataset that might be due to the COVID-19 pandemic. Using R statistical software, a linear model was fit for each gestational age week. A t test was performed to determine whether the slope was statistically different from zero (indicating whether there was a trend of rising or decreasing birthweights over time). RESULTS: A total of 19,730,588 individuals met the inclusion criteria. However, <1% of the data were excluded because of missing data. Birthweight at 39, 40, 41, and 42 weeks of gestation showed a statistically significant increase over time (Figure). There was a significant decrease in birthweight at 37 weeks of gestation. Data on Hispanic ethnicity became available in 1992. After 1992, birthweight by race or ethnicity group was examined. Each race or ethnicity group echoes the overall trends observed. However, for 39, 40, 41, and 42 weeks of gestation, the non-Hispanic Black and Hispanic groups have higher increases in birthweight than the non-Hispanic White group. There were fluctuations in the overall combined mean for 37 to 42 weeks of gestation (Table). CONCLUSION: Although the overall mean birthweight did not increase over the study period, it increased for each gestational age week at ≥39 weeks of gestation. The birthweight at 37 weeks of gestation decreased. The reason for the decrease in birthweight is unclear. Contributing factors may include changes in guidelines on the timing of delivery and method of calculation of gestational age. Increases in the rates of obesity and diabetes mellitus could be contributing to the birthweight increase from 39 weeks of gestation.1,2 There was an increase in the rate of gestational diabetes mellitus from 3% to 8% in our study population from 1992 to 2020 and an increase in mean body mass index from 26.3 to 27.5 from 2012 to 2020. The publicly available birthweight data have limitations. Data collection evolved during the study period. The estimates for gestational age have become more accurate with first-trimester dating ultrasounds. In summary, birthweight is increasing among those born from 39 to 42 weeks of gestation. These increasing birthweights may be a factor in persistently high cesarean delivery rates despite national campaigns.5.

Comprehensive serologic profile and specificity of maternal and neonatal cord blood SARS-CoV-2 antibodies.

BACKGROUND: Initial studies on COVID-19 in pregnancy have demonstrated a range of neutralizing activity, but little has been published on the full profile of SARS CoV-2 related antibodies in maternal and cordblood. OBJECTIVE: This study aimed to describe the profile and specificity of maternal and neonatal cord blood antibody profiles in response to SARS-CoV-2 virus exposure. STUDY DESIGN: This was a prospective cohort study of delivering patients at Thomas Jefferson University Hospital from April 2020 to February 2021. The primary objective was to describe unique maternal and fetal antibody epitope titers and specificity in patients with COVID-19 history. Serologic profile was assessed with a multiplex platform. Antigens used were hemagglutinin trimer influenza A (Hong Kong H3); spike trimers for SARS-CoV-2, SARS-CoV-1, Middle East respiratory syndrome coronavirus, and betacoronaviruses HKU-1 and OC43; and spike N-terminal domain, spike receptor-binding domain, and nucleocapsid protein (full length) for SARS-CoV-2. RESULTS: Here, 112 maternal samples and 101 maternal and cord blood pairs were analyzed. Of note, 37 patients had a known history of COVID-19 (positive polymerase chain reaction test) during pregnancy. Of 36 patients, 16 (44%) were diagnosed with COVID-19 within 7 days of delivery. Moreover, 15 of the remaining 76 patients (20%) without a known diagnosis had positive maternal serology. For those with a history of COVID-19, we identified robust immunoglobulin G response in maternal blood to CoV-2 nucleocapsid, spike (full length), and spike (receptor-binding domain) antigens with more modest responses to the spike (N-terminal domain) antigen. In contrast, the maternal blood immunoglobulin M response seemed more specific to spike (full length) epitopes than nucleocapsid, spike (receptor-binding domain), or spike (N-terminal domain) epitopes. There were significantly higher maternal and cord blood immunoglobulin G responses not only to CoV-2 spike (127.1-fold; standard deviation, 2.0; P<.00001) but also to CoV-1 spike (21.1-fold higher; standard deviation, 1.8; P<.00001) and Middle East respiratory syndrome spike (6.9-fold higher; standard deviation, 2.5; P<.00001). In contrast, maternal immunoglobulin M responses were more specific to CoV-2 spike (15.8-fold; standard deviation, 2.1; P<.00001) but less specific to CoV-1 (2.5-fold higher; standard deviation, 0.71; P<.00001) and no significant difference for Middle East respiratory syndrome. Maternal and cord blood immunoglobulin G antibodies were highly correlated for both spike and nucleocapsid (R2=0.96 and 0.94, respectively). CONCLUSION: Placental transfer was efficient, with robust nucleocapsid and spike responses. Both nucleocapsid and spike antibody responses should be studied for a better understanding of COVID-19 immunity. Immunoglobulin G antibodies were cross-reactive with related CoV-1 and Middle East respiratory syndrome spike epitopes, whereas immunoglobulin M antibodies, which cannot cross the placenta to provide neonatal passive immunity, were more SARS-CoV-2 specific. Neonatal cord blood may have significantly different fine specificity than maternal blood, despite the high efficiency of immunoglobulin G transfer.

Effectiveness of community interventions for protecting and promoting the mental health of working-age adults experiencing financial uncertainty: a systematic review.

BACKGROUND: The COVID-19 pandemic has created a period of global economic uncertainty. Financial strain, personal debt, recent job loss and housing insecurity are important risk factors for the mental health of working-age adults. Community interventions have the potential to attenuate the mental health impact of these stressors. We examined the effectiveness of community interventions for protecting and promoting the mental health of working-age adults in high-income countries during periods of financial insecurity. METHODS: Eight electronic databases were systematically screened for experimental and observational studies published since 2000 measuring the effectiveness of community interventions on mental health outcomes. We included any non-clinical intervention that aimed to address the financial, employment, food or housing insecurity of participants. A review protocol was registered on the PROSPERO database (CRD42019156364) and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: From 2326 studies screened, 15 met our inclusion criteria. Five categories of community intervention were identified: advice services colocated in healthcare settings; link worker social prescribing; telephone debt advice; food insecurity interventions; and active labour market programmes. In general, the evidence for effective and cost-effective community interventions delivered to individuals experiencing financial insecurity was lacking. From the small number of studies without a high risk of bias, there was some evidence that financial insecurity and associated mental health problems were amenable to change and differences by subpopulations were observed. CONCLUSION: There is a need for well-controlled studies and trials to better understand effective ingredients and to identify those interventions warranting wider implementation.

Labor and delivery guidance for COVID-19.

This document addresses the current coronavirus disease 2019 (COVID-19) pandemic for providers and patients in labor and delivery (L&D). The goals are to provide guidance regarding methods to appropriately screen and test pregnant patients for COVID-19 prior to, and at admission to L&D reduce risk of maternal and neonatal COVID-19 disease through minimizing hospital contact and appropriate isolation; and provide specific guidance for management of L&D of the COVID-19-positive woman, as well as the critically ill COVID-19-positive woman. The first 5 sections deal with L&D issues in general, for all women, during the COVID-19 pandemic. These include Section 1: Appropriate screening, testing, and preparation of pregnant women for COVID-19 before visit and/or admission to L&D Section 2: Screening of patients coming to L&D triage; Section 3: General changes to routine L&D work flow; Section 4: Intrapartum care; Section 5: Postpartum care; Section 6 deals with special care for the COVID-19-positive or suspected pregnant woman in L&D and Section 7 deals with the COVID-19-positive/suspected woman who is critically ill. These are suggestions, which can be adapted to local needs and capabilities.