The impact of the COVID-19 pandemic on clinical guidance, risk assessment and support for UK obstetric sonographers

UK obstetric sonographers adapted their working practices during the COVID-19 pandemic in response to new guidance issued by professional organisations, and requirements for on-going departmental risk assessments. This study aimed to provide an insight into the implementation of this guidance, completion of risk assessments and perception of support within UK obstetric ultrasound departments during the pandemic period. Obstetric sonographers working in the UK (n=138) used the Qualtrics XMTM platform to complete an anonymous, online, cross-sectional survey about their working experiences during the pandemic. Participants responded to closed questions about national guidance, risk assessments and their perception of support whilst providing fetal ultrasound screening services. Respondents provided additional detail about their experiences in these areas via free-text boxes. Over 90% of respondents were aware of, or had read guidance issued by professional organisations, although sonographers rated the overall usefulness of new guidelines at an average of 5.2/10 (where 0 = not useful at all, and 10 = extremely useful). Challenges for the implementation of guidance in departments were also identified, mostly related to the clinical working environment, including limitations of physical space (76.3%), time constraints (67.5%) and ventilation (61.3%). Most sonographers (77.2%) were aware that a departmental risk assessment had been undertaken, with waiting areas, scan rooms and clinically vulnerable staff highlighted as the most concerning factors. Sonographers felt most supported by their ultrasound colleagues (83.5%) and line managers (41.2%). They felt least supported by senior management and leadership personnel (60.8%), other antenatal colleagues (51.5%) and professional organisations (41.2%). Whilst most sonographers were aware of published COVID-19 guidance, challenges for its implementation in clinical departments were identified. Local risk mitigation strategies often did not prioritise the scan room environment, despite it being highlighted as a concern. Support from the wider, senior service team and professional organisations will be essential to facilitate post-pandemic recovery of the workforce.

Placental Thrombosis Resulting in Hypoxic Ischemic Encephalopathy in an Infant of a Mother with Covid-19

Case Report: Since the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, there has been much work to understand the negative effects of SARS-CoV-2 on tissues expressing the Angiotensin Converting Enzyme-2 (ACE2) receptor, including the placenta. However, there is limited information regarding placental pathology findings in mothers with COVID-19 and the effects of SARS-CoV-2 on the placenta. The available research reports effects on the fetus ranging from minimal to intrauterine fetal demise. Case Description: A 4680g baby boy was born at 38+1 weeks of gestation to 36y old G4P1021 female via repeat cesarian section. The pregnancy was complicated by advanced maternal age, chronic hypertension with superimposed pre-eclampsia with severe features, BMI of 80, and SARS-CoV-2 infection. The mother had mild COVID-19 symptoms and did not require hospitalization or oxygen support. Prenatal ultrasounds were limited due to body habitus. At the time of delivery, there was clear amniotic fluid. Upon delivery the infant was cyanotic and limp and was brought to the warmer immediately. Non-invasive positive pressure ventilation was initiated at 5 minutes of life with improvement in infant color and oxygen saturation. He was then admitted to the Neonatal Intensive Care Unit (NICU). APGARs were 2, 3, 5, and 7 at 1, 5, 10, and 15 minutes respectively. Cord gases showed severe metabolic acidosis. The patient was diagnosed with hypoxic-ischemic encephalopathy (HIE) and therapeutic hypothermia was initiated. Both the NICU and obstetric teams were unable to identify a clear perinatal cause of HIE in this patient. Later, the placenta pathology report revealed a large placenta for estimated gestational age corresponding to the 75th percentile, villous parenchyma with focal chorangiosis and thrombi, with unremarkable fetal membrane and three vessel umbilical cord. The cause of HIE was then thought to be due to the placental thrombi likely caused by SARS-CoV-2 infection. Discussion(s): Fetal vascular malperfusion and fetal vascular thrombus have been noted as a common finding in the placentas of pregnant women who test positive for SARS-CoV-2. There are various causes of HIE, from maternal, placental and fetal factors. This patient had no clinically evident hypoxic event, but information was limited due to the lack of monitoring of the fetus in utero. Given the mother's SARS-CoV-2 infection and the placental pathology findings, it is likely that the cause of this patient's HIE was related to the effects on the placenta from SARS-CoV-2. Conclusion(s): As more information comes to light about the effects of SARS-CoV-2 on the placenta, it is important to consider a maternal SARS-CoV-2 infection during pregnancy as a cause of HIE in a newborn.

Third level care experience during SARS-CoV-2 pandemic

Objective. As the SARS-CoV-2 Pandemic has widely changed pregnancy experience and assessment, the inpatient and outpatient services have had to be re-organized. Since March 2020, Careggi University Hospital (CUH) has provided a dedicated COVID-pathway: spaces for women with unknown swab status and a COVID-19 ward delivery room. The aim of this study is to analyze the inpatient and outpatient COVID-19 related activities in CUH. Materials and Methods. We prospectively collected data from consecutive COVID-19 pregnancies referred from 2020 to 2022, included in the local branch of the ItOSS surveillance. All patients experienced COVID-19 in pregnancy at various stages of severity and gestational ages. Results. From March 2020 to June 2022, 165 COVID-19 deliveries occurred (169 newborns), while 16 pregnant positive women were admitted without delivering. A single emergency C-section (CS) was performed because of Sars-CoV-2 related ARDS, 15 women experienced serious maternal morbidity and 5 needed ECMO. A single maternal death occurred four months after delivery (C-section). Considering ECMO supported cases during pregnancy or postpartum, the first one tested positive for COVID-19 during the second trimester. She developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a CS at term was performed following obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation and experienced a precipitous vaginal delivery at 31 weeks+6 days of gestation while on ECMO. She was discharged 1 month later in good general conditions. The third patient was an obese (BMI 38) 43-year-old woman who had performed an IVF with embryo donation;she tested positive at 38 weeks+2 days of gestation. A CS was performed because of the worsening of her condition. After the delivery she was admitted in ICU and she underwent ECMO. She died 143 days after the CS by sepsis and multiple organ failure (MOF). For all these pregnancies neonatal outcomes were positive. No perinatal death occurred and only one baby tested positive for SARS-CoV-2 infection at nasal swab sampling (case 3). The anesthesiology team performed neuroassial analgesia intrapartum in all the positive women who needed/requested it. Monoclonal Antibodies (mAbs) have been widely used to treat mild to moderate COVID-19 outpatients (NIH and RCOG recommendations) at risk for developing severe disease. Regarding this specifical therapy, an essential role in the management of the pregnant outpatient was played by the Infectious Disease Department. All patients above 28 weeks requiring hospitalization received LMWH prophylaxis, which was administrated under 28 weeks only in presence of additional risk factors (obesity, IVF, etc.). All new mothers received a ten days LMWH prophylaxis. On the outpatient side, we performed 22 teleconsultations, 43 obstetric ultrasounds (including I trimester screening), 90 obstetric checks with clinical evaluation and home therapy management, 32 fetal monitoring and 47 naso-pharingeal swabs. Conclusions. At Careggi Hospital Maternal Department an extensive re-organization of inpatient and outpatient services has been performed in order to guarantee good practice and management of all pregnant women during the SARS-CoV-2 pandemic. This was only possible thanks to a wide multidisciplinary group which enhanced every professional.

Massive Subchorionic Thrombohematoma and Maternal Cardiac Dysfunction: A Case Series

Background. Massive subchorionic thrombohematoma (MST), also known as Breus' mole, is a rare and poorly understood entity defined as a substantial collection of clotted blood in the intervillous space, immediately beneath the chorionic plate, measuring >1 cm in thickness with >50% involvement of the fetal surface of the placenta. The presumed pathophysiology is an aberrant collection of maternal blood, although this data is limited. MST has previously been associated with maternal thrombophilia and following thrombolytic therapy. Method(s): Four cases of MST diagnosed by pathological examination at our institution from 1/1/2021-7/1/2022 were identified using our laboratory information system. Maternal medical history, prenatal imaging, antenatal complications, gestation at delivery, and pregnancy outcome were extracted from the medical record. Result(s): We report a novel association of MST and maternal cardiac dysfunction, illustrated by four cases at a highrisk obstetric reference center covering a large portion of the southeastern United States. Two of these mothers had surgically repaired complex congenital heart disease, one had heart failure secondary to SARS-CoV-2 myocarditis, and one had longstanding high output heart failure due to severe sickle cell disease with resulting severe anemia. All of these pregnancies were complicated by intrauterine growth restriction (IUGR). Grossly, all four placentas had extensive fetal surface involvement by thrombohematoma (90-100%), but with variable degrees of placental volume replacement (range: 10-80%). Two of the four mothers had documented enoxaparin administration during pregnancy;however, there were no common medications given to all four mothers None had recognized thrombophilic disorders. Only one of four lesions was definitively identified on prenatal ultrasound. Of these four cases, three were live births, though only one infant survived past fifteen days of life. This surviving child had the least affected placenta grossly, was delivered at term, and was born to the only mother who did not require admission to the intensive care unit. Conclusion(s): We posit abnormal maternal hemodynamics are the final common pathway in the development of MST. Previous studies have shown blood within the thrombohematoma to be of maternal origin;furthermore, there is correlation within our case series between the largest lesions and the mothers with the most hemodynamic instability. IUGR is likely secondary to decreased placental reserve capacity from these space-occupying lesions. High fetal/neonatal morbidity and mortality rates underscore the need to further characterize this pathophysiologic process. That only one of four cases was detected on prenatal ultrasound illustrates the importance of both ante- and postnatal clinical and pathologic recognition.

Diagnosis Of Chronic Diseases During The COVID-19 Pandemic Through Telemedicine

Introduction. The diagnosis and management of chronic diseases during the coronavirus disease 2019 (COVID-19) pandemic was one of the biggest challenges facing healthcare systems globally, especially in low-income countries. Since basic health care for chronic diseases can overwhelm the capacity of conventional face-to-face healthcare services, there is growing interest in using information and communication technology and telemedicine to improve access to medical services that are often not consistently available in rural communities. In this context, telemedicine tools should be directed toward maintaining basic health services for patients with chronic conditions in rural and underserved hospitals. This study evaluated a telemedicine system in remote public hospitals in Paraguay to demonstrate how telemedicine improved access to tertiary level diagnostic services for patients with chronic conditions. Methods. This descriptive study evaluated the use of telemedicine for diagnosing patients in remote public hospitals to improve provision of basic health services to patients with chronic disease during the COVID-19 pandemic. The type and frequency of diagnostic studies performed were determined. Results. During the study 677,023 telediagnoses were performed in 67 hospitals. The 435,568 electrocardiograms performed in 61 hospitals indicated normal physiology (60.1%), unspecified arrhythmias (10.5%), and sinus bradycardia (8.4%). The 227,360 teletomography tests performed in 12 hospitals were undertaken on the head (52.4%) because of trauma (motorcycle accidents) and cerebrovascular diseases, chest (15.8 %), and other anatomical regions. The 14,076 electroencephalograms performed in 19 hospitals were undertaken for antecedents of seizure (53.3%), disease progression controls (14.0%), and headache (12.5%). Nineteen prenatal ultrasound scans were conducted. Conclusions. Although the results are promising for using telemedicine to bridge gaps and improve equity in the provision of basic health services for patients with chronic diseases in remote locations during the COVID-19 pandemic, a widespread use assessment should be undertaken before this tool is adopted.

Placenta Proteins of Women Infected SARS-COV-2 in the First Trimester of Pregnancy Remains Unchanged

Objectives: To compare the biochemical and biophysical parameters of non-invasive prenatal screening of women infected with SARSCOV-2 in the first trimester of pregnancy with those of healthy pregnant women.. Method(s): The study was conducted on a case-control model with 547 women who underwent a double test between May 21 and November 29, 2021. 136 of these 547 women were involved in the case group, which was exposed with SARS-COV-2 viral infection, and 411 were women recruited in the control group, concept form was obtained from all subjects who underwent the study. Subjects' SARSCOV-2 infection was confirmed by RT-PCR, and double tests were conducted on the recovered women. Result(s): The mean age of the SARS-COV-2 infected group was 30.9 years, and the mean age of the healthy group was 30.8 years (p > 0.05). 1. The mean (SD) of PAPP-A in the infected group was 1.94 (+/-2.66) MOM, in the non-infected group was 1.97 (+/-2.00) MOM. The mean (SD) of beta-hCG in the infected group was 1.67 (+/-3.33) MOM and in the non-infected group was 6.28 (+/-8.66) MOM. With a significance level of 0.05, there were no significant differences in the mean (p = 0.120) of serum proteins between the SARS-COV-2 group and the non-SARS group. 2. During the ultrasound examination of both groups, the mean (SD) of the infected group NT 1.60 (+/-0.56) MOM and the non-infected group NT 1.63 (+/-0.78) MOM, the infected group DV 1.04 (+/-0.19) MOM and the non-infected group DV 1.34 (+/-5.85) MOM, the infected group HR 166.27 (+/-47.85) MOM and the non-infected group HR 161.67 (+/-0.19) MOM. Nuchal translucency (NT) p = 0.620, venous flow (DV) p = 0.54, and fetal heart rate (HR) p = 0.076. There were no significant differences. Conclusion(s): There were no significant differences between serum PAPP-A, free beta-hCG protein, and fetal ultrasound in women with SARS-COV-2 during the first trimester of pregnancy.

MATERNAL SARS-COV-2 INFECTION IN THE SECOND TRIMESTER AND VENTRICULOMEGALY AND DEVELOPMENTAL DELAY IN AN INFANT

Case Report History: Mother is a 23 year old gravida 4 para 1021, with a history of type 1 diabetes since 12 years of age. Prenatal sonogram at 20 weeks of gestation showed normal fetal anatomy with an EFW 21st percentile & 2-vessel cord. She was admitted at 23 weeks of gestation for acute hypoxic respiratory failure secondary to SARS-CoV-2 pneumonia, diabetic ketoacidosis & acute kidney failure. She refused intubation in spite of saturations in low 80s & was treated with high flow nasal cannula, non-rebreather mask, & nasal CPAP. She received convalescent plasma, Remdesivir, Tocilizumab, steroids, hydroxychloroquine, ceftriaxone & azithromycin, and was discharged home on oxygen after 29 days. Prenatal sonogram at 29 weeks of gestation demonstrated severe IUGR (abdominal & head circumference, fetal weight and femur length all < 3rd percentile), ventriculomegaly & a 2-vessel cord. Fetal MRI showed severe lateral ventriculomegaly of the brain, diffuse white matter parenchymal edema, bilateral germinal matrix & intraventricular hemorrhage & severe parenchymal volume loss. Mother was lost to follow up until time of delivery. Physical examination An infant female was born at 39 weeks of gestation via repeat cesarean-section. She was admitted to NICU for severe IUGR. The newborn's birth weight was 2126 g, head circumference 30 cm, length 43.5 cm (all <3rd percentile). Baby had mild hypertonia and tremors, rest of the exam was normal. The newborn was treated for TTN with NCPAP, hypoglycemia requiring IVF and hyperbilirubinemia requiring phototherapy and was extremely slow to feed. Diagnostic work-up CBC, BMP, LFT & CSF microscopy were normal, SARS-CoV-2 PCR was negative. SARS-CoV-2 IgM was negative in serum & CSF, but IgG was positive in serum & CSF. Baby's titers were slightly higher than mother's. US & MRI confirmed ventriculomegaly due to volume loss, a component of hydrocephalus was suspected due to presence of intraventricular hemorrhage, however there was no evidence of raised ICP. Retinal exam, hearing and BAER were normal. Chromosome analysis was normal & Zika titers were negative. The newborn was discharged home after 20 days with weighing 2580 g and head circumference of 32 cm. Placental was 222 g with <10% infarction and moderate acute chorioamnionitis. Infant has significant developmental delay at 1 year of age. Discussion There is definitive evidence of adverse neonatal outcomes in third trimester maternal SARS-CoV-2 infection, effects of earlier infections are not well reported. In our case the neurological injury can't be attributed definitively to fetal SARS-CoV-2 infection as IgM was negative, but the interval of 16 weeks between maternal infection and delivery need to be taken into account. Maternal illness likely contributed to severe acute on chronic fetal hypoxia which resulted in IUGR and in utero IVH with resultant CNS tissue loss and ventriculomegaly. (Figure Presented).

eP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

Background: Freeman-Sheldon syndrome [distal arthrogryposis type 2A (OMIM #193700), DA2A, Freeman-Burian syndrome] is a rare autosomal dominant multiple pterygium syndrome caused by alterations in MYH3. The phenotypic features, particularly of the face, are distinct and easily recognizable, and the diagnosis can be confirmed with molecular gene analysis. Fetal ultrasound imaging may provide important diagnostic clues to facilitate the diagnostic process. Informed consent and parental permission were provided by the parents. Case presentation: The infant’s mother presented for a Maternal Fetal Medicine genetic counseling telehealth appointment (due to COVID-19 pandemic restrictions) as a G7P2132, 32-year old female who had insulin-dependent diabetes and thrombocytosis. Her partner was a 24-year old male with a history of hearing loss, a V-shaped palate, and a lower lip cleft. Gestational age was 14 4/7 weeks and the indications were: increased nuchal translucency, paternal complex medical history, maternal G6PD heterozygote, and recurrent pregnancy loss. During the genetic counseling session, the following were addressed: 1) Maternal heterozygote status for G6PD indicated that if the fetus was male, there was a 50% chance he would be affected with G6PD-deficiency;2) Increased nuchal translucency on fetal ultrasound (US) with measurement at 98th percentile is associated with an increased risk of chromosomal abnormalities, microdeletion/duplications, and Noonan syndrome. The patient reportedly had low risk cell-free DNA but results were not available to the counselor at the time of consult. The option for additional genetic screening and diagnostic testing was declined;3) Three first trimester pregnancy losses with the father of this baby (FOB) were addressed, and parents deferred chromosome analyses at the time;4) Mother shared FOB’s complex history of bilateral sensorineural hearing loss, V-shaped cleft palate, lower lip cleft, and micrognathia. However, father was not present during the telehealth encounter. Mother was counseled regarding the possibility of an autosomal dominant condition with the potential risk to the pregnancy of up to 50%. It was recommended that the FOB have a clinical genetics evaluation, which could potentially provide a specific diagnosis and inform recurrence risk and management guidance. Follow-up MFM genetic counseling telephone visit occurred with the mother at 31 6/7 weeks gestation due to multiple congenital anomalies evident on fetal ultrasound. A 25 week fetal ultrasound revealed hypotelorism and a thickened nuchal translucency. A repeat study at 29 weeks revealed a V-shaped palate with a possible cleft, micrognathia, and midline mandibular cleft. FOB’s history was revisited. It was determined that he had 3 previous “no shows” to Genetics clinic appointments and did not pursue evaluation after the last counseling appointment. Again, it was emphasized that in order to best make a diagnosis for the family, an affected person would need to undergo a thorough evaluation, including medical and family history review, physical examination, and any indicated genetic testing. The parents were comfortable with the likelihood that the baby had the same condition as the father, but variable expressivity and broad range pf phenotypic presentation were explained. Recommendations for postnatal evaluation of the infant and pertinent genetic testing were provided. Consultative Genetics evaluation of the infant at 2 days of age revealed a short, broad forehead with supraorbital fullness leading to a horizontal brow indentation;mask-like facial appearance;hypotelorism;very deep set eyes with blepharophimosis;deep, creased nasal bridge;small, upturned nose with hypoplastic alae and narrow nares;microstomia with pursed lips;glossoptosis;micrognathia;2 deep vertical chin creases;short neck with excess nuchal skin;inverted and wide spaced nipples;clenched hands with 5th digits overlying 4th and 2nd overlying 3rd, bilaterally;bilateral vertical talus;2nd toes longer and overlying rd toes;clinodactyly of 4th and 5th toes bilaterally;and deep gluteal crease with no visible sinus. There were no evident contractures. The father has a complex history with no medical assessments prior to age 18. He reported that he did “not look like anyone else” in his family. He has a diagnosis of autistic spectrum disorder, a submucous cleft, vision issues, hearing loss necessitating a hearing aid on the left, and a history of cholesteatomas and of mastoidectomy. On brief examination, he had a mask-like face, blepharophimosis, left microphthalmia, left esotropia, narrowing of his midface, deep vertical crease on the mandibular region, microstomia, broad great toes, single flexor creases on the thumbs, and contracture of right thumb. Maxillofacial CT of the infant revealed hypoplastic mandibular body, ramus, and condyles bilaterally with micrognathia and retrognathia;hypoplastic maxilla bilaterally;and enophthalmos with retracted appearance of globes in the bony orbits bilaterally. Multiple facial bone abnormalities were seen, including microsomia, micrognathia, retrognathia, orbital hypotelorism and enophthalmos Genetic testing was performed via a custom Whole Exome Slice at GeneDx laboratories and included the MYH3 and TNNI2 genes. Results revealed a heterozygous pathogenic change in MYH3 (c.2015 G>A;p. R6724) consistent with the diagnosis of Freeman-Sheldon syndrome. Conclusion: The presentation of “midline mandibular cleft” on fetal ultrasound was the most specific prenatal finding. This is a very rare fetal finding. Thus, it should prompt further evaluation to assess for true clefting versus ridging or creasing. Additionally, targeted assessment for other findings or clinical clues for Freeman-Sheldon syndrome, such as contractures, “windmill vane” hand, and mouth size, could aid in the differential diagnosis considerations and the diagnostic process. Admittedly, these are position and quality dependent, and are challenging to assess even in ideal situations. The phenotype of the father was immediately recognizable. However, due to COVID-19 pandemic restrictions, prior to the infant’s birth, only telehealth visits were conducted and the father’s participation was by telephone. This limited the ability to narrow the differential diagnosis without visualization of his distinct phenotypic features. Finally, missed opportunities to diagnose the father prior to this pregnancy occurred. Many clinics send “no show” letters to referring providers and patients, as we do. Emphasizing the importance of diagnosis prior to pregnancy for individuals concerned about having a genetic disorder should be considered as part of the information shared in these letters.

Prenatal genetic screening and diagnostic testing during the COVID-19 pandemic in the Bronx, NY

Introduction: The Coronavirus Disease (COVID-19) pandemic has changed the landscape of both inpatient and outpatient healthcare. During the height of the pandemic, most elective and many nonelective procedures were halted. Prenatal care services including ultrasound and genetic screening and testing remained active (given gestational age dependence) while shifting from in-person towards telehealth counseling. NewYork Citywas at the epicenter of the pandemic fromMarch through June 2020. Elective procedures at Montefiore Medical Center, which serves a diverse urban population in the Bronx, NY,were cancelled from March 16, 2020 to June 20, 2020. Prenatal ultrasound shifted from a dating ultrasound and a nuchal translucency ultrasound to one first trimester ultrasound and anatomy scans were scheduled at 20–22 weeks gestation rather than 18–20 weeks. The majority of counseling sessions were conducted via telehealth and prenatal diagnostic procedures (including amniocentesis and chorionic villus sampling [CVS]) were performed with a limited team to adhere to COVID-19 protocols. We examined the impact of this shift on rates of prenatal genetic screening and diagnostic procedures before and during the COVID-19 pandemic. Previous literature has revealed that since the advent of noninvasive prenatal screening (NIPS), prenatal genetic diagnostic procedures rates have been on the decline.We hypothesized that the rate of genetic diagnostic procedure rates would decrease and NIPS would increase as compared to the similar period in 2019. Methods: Retrospective analysis of data collected in a secure institutional logbook at Montefiore Medical Center Department of Obstetrics & Gynecology and Women’s Health (Division of Reproductive and Medical Genetics and Division of Fetal Medicine and Ultrasound) from January 1, 2019–December 31, 2020. Collected data included number of procedures, gestational age, and indication for procedure (categorized as advanced maternal age (AMA), ultrasound anomalies, positive screening test, hereditary disease in the family possibly affecting fetus (including family history or genetic carrier), or other. Procedures for multiple gestations were considered as a single procedure.. Results: 503 diagnostic procedures (359 amniocenteses and 144 CVS) were included. Most common indication (ultrasound anomaly) and average gestational age (13 weeks for CVS and 19 weeks for amniocentesis) were the same in 2019 and 2020. In total, 275 procedures were performed in 2019 as compared to 228 in 2020 (20.6% decrease) ( p = 0.018). Specifically, amniocentesis decreased from 187 to 172 (8% decrease) ( p = 0.214) and CVS decreased from 88 to 56 (36% decrease) ( p = 0.004). NIPS increased from 1,312 tests in 2019 to 1727 tests in 2020 (31.6%) ( p < 0.001). The same data points were then analyzed during the four-month period at the height of the pandemic in New York City. We compared numbers of procedures from the period March 1, 2019–June 30, 2019 to March 1, 2020–June 30, 2020. Total prenatal diagnostic procedures during this period were 91 in 2019 and 81 in 2020 (12.3% decrease). This included 59 amniocenteses compared with 60 in the same period in 2020 (1.6% increase) and 32 CVS in 2019 compared to 21 in 2020 (34.3% decrease). Noninvasive prenatal screening increased from 348 to 510 (increase of 46.5%) during this period. Discussion: At Montefiore Medical Center in the Bronx, NY, prenatal genetic diagnostic procedures decreased while NIPS rates increased during the pandemic. This trend may reflect patient’s concerns for a COVID-19 exposure during in-office procedures, shift to telehealth counseling, or be reflective of the overall trends seen since the widespread offering of NIPS to prenatal patients. The decrease in CVS may be explained by an intentional system delay of combining ultrasound and blood draw to a single visit at the end of the first trimester. Future studies should investigate how access to care and gestational age at the time of presentation influenced prenatal genetic screening and testing cho ces during the pandemic, in order to better explain the identified trends.

Mimickers of Hit Antibodies in Critically Ill COVID Patients

Introduction: Infection with SARS CoV2 leads to respiratory failureand can lead to support of extracorporeal oxygenation (ECMO)leading to exposure to heparin. Exposure to heparin and developmentof thrombocytopenia raises the suspicion of HIT. The strong positiveIgG PF4-heparin antigen test by immunochromatography is followedby platelet aggregation test in our center. We present a case of covid-19 in which HIT was strongly positive on gel agglutination butfunctional assay was negative. Review of literature shows that this could be due to circulating platelet immune complexes in critically illcovid patients which simulate HIT antibodies.Aims &Objectives: Materials &Methods: 7 months pregnantfemale, non-vaccinated, asthmatic, COVID 19 positive patient wasadmitted to our hospital. On admission her fetal ultrasound wasnormal and was started on non-invasive ventilation along with supportive care. However she deteriorated and shifted to veno-arterialextracorporeal membrane oxygenation support (ECMO). Her plateletcount dropped by>50% at day 6 of heparin exposure with anintermediate probability for HIT (4Tscore 5). HIT gel agglutinationtest was positive for IgG antibodies for antiheparin/PF4 antibodies butfunctional assay based on heparin-induced platelet aggregation(HIPA) revealed no increase in aggregation of patient serum with0.5U/ml and 1U/ml heparin dosage. Heparin induced thrombocytopenia was ruled out due to PAT and patient continued on ECMO.This could be due to increased platelet activating immune complexesor anti-PF4 antibodies mimicking antiheparin/PF4 antibodies. However, patient deteriorated and succumbed to the disease.Result: Heparin induced thrombocytopenia was ruled out due to PATand patient continued on ECMO. This could be due to increasedplatelet activating immune complexes or anti-PF4 antibodies mimicking antiheparin/PF4 antibodies. However, patient deteriorated andsuccumbed to the disease.Conclusions: Pathophysiology of Covid 19 disease in critical caseshas shown exacerbated immune reactions, increased endothelialinjury, which causes increased release of PF4 leading to plateletactivation.3 A recent work has also shown significantly increasedplatelet apoptosis, secondary to IgG-mediated FccRIIA signaling, incritically ill COVID-19 patients.4 It is also possible that the circulating immune complexes may be formed by corona virus-antibodycomplexes (as seen in H1N1 viral infection) 0.5 A high titre of antiPF4/heparin antibody test may not strongly predict the presence ofclinically relevant HIT antibodies, thus a confirmatory functional testshould be performed.