A Prospective Study of Lactate Levels in Uncomplicated Spontaneous and Induced Labor.

OBJECTIVE: Maternal pushing can yield lactate levels that are above the normal range for nonpregnant individuals. Many hospitals require lactate levels as part of sepsis bundles, and this can confuse the clinicians when measured during labor. The objective of this study was to observe lactate levels in uncomplicated labor. STUDY DESIGN: This was a prospective study of patients presenting to Labor and Delivery in early labor. Patients met inclusion criteria if they presented at 37 weeks' gestation or greater and were either 3 to 4 cm dilated, in early labor with rupture of membranes less than 12 hours, or were being induced for oligohydramnios or postdates gestation. A baseline maternal lactate level was collected at enrollment. Further levels were collected at complete cervical dilation and every 30 minutes during the second stage of labor up to 3 hours or until delivery. RESULTS: From January 7, 2021, through December 30, 2021, a total of 148 screened patients met the inclusion criteria and 38 were enrolled. Eight (21%) patients withdrew after baseline lactate level was drawn. Twenty-three (61%) patients had a level drawn at complete dilation. Of the 12 (32%) patients with a lactate level drawn at complete and after 30 minutes of pushing, the mean change in lactate level was 2.0 ± 1.8 mmol/L or 0.07 ± 0.06 mmol/L/min (p < 0.01). This change is more pronounced in the second stage of labor for patients with chorioamnionitis (2.6 mmol/L), although this difference is not statistically significant (p = 0.41). CONCLUSION: Lactate levels increase significantly once a patient reaches complete cervical dilation within 30 minutes of pushing. This increase is more pronounced, although significantly, in patients with chorioamnionitis. As sepsis is one of the leading causes of maternal morbidity and mortality, this pilot study is relevant for providers to see the natural course of lactate levels in labor. KEY POINTS: · The change in lactate level during normal labor is unknown.. · We measured lactate levels in uncomplicated labor.. · Lactate levels can be elevated in uncomplicated labor..

Update on syphilis in pregnancy: marrying basic science advances and clinical perseverance to solve an ancient public health problem.

PURPOSE OF REVIEW: While the clinical disease of syphilis, its consequences in pregnancy, and its sensitivity to penicillin treatment have remained relatively unchanged for a century or more, new technologies and basic discoveries in syphilis research have translated into tangible advances in clinical diagnosis, treatment, and prevention. The purpose of this review is to help the reader understand some of the recent relevant scientific publications on syphilis and its causative organism in a clinical obstetric context. RECENT FINDINGS: Rates of adult and congenital syphilis have risen dramatically in the last decade despite public health efforts. Penicillin shortages and lack of screening or adequate treatment have all contributed to global disease burden. Advances in genomic and microbiological characterization of this spirochete have led to new developments in serologic and molecular diagnosis as well as evaluation of potential vaccine candidates. Until a syphilis vaccine is available, substance use disorders and lack of screening in pregnancy are associated with increased congenital syphilis, and these challenges will require novel solutions to fully address this public health crisis. SUMMARY: Addressing the burden of congenital syphilis demands that obstetricians stay well informed of new tools and resources for diagnosis, treatment, and prevention of syphilis now and in the future.

Optimal Delivery Management for the Prevention of Early Neonatal SARS-CoV-2 Infection: Systematic Review and Meta-analysis.

OBJECTIVE: Delivery management interventions (DMIs) were recommended to prevent delivery-associated transmission of maternal SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to infants without evidence of effect on early neonatal SARS-CoV-2 infection (ENI) and neonatal death <28 days of life (ND). This systematic review describes different DMI combinations and the frequency of ENI and ND. STUDY DESIGN: Individual patient data were collected from articles published from January 1, 2020 to December 31, 2021 from Cochrane review databases, Medline, and Google Scholar. Article inclusion criteria were: documented maternal SARS-CoV-2 polymerase chain reaction (PCR)-positive status 10 days before delivery or symptomatic at delivery with a positive test within 48 hours, known delivery method, and known infant SARS-CoV-2 PCR result. Primary outcomes were ENI (positive PCR at 12 hours to 10 days) and ND. All characteristics were pooled using the DerSimonian-Laird inverse variance method. Primary outcome analyses were performed using logit transformation and random effect. Pooled results were expressed as percentages (95% confidence intervals). Continuity correction was applied for all pooled results if any included study has 0 event. RESULTS: A total of 11,075 publications were screened. 117 publications representing 244 infants and 230 mothers were included. All publications were case reports. ENI and ND were reported in 23.4% (18.2-29.18) and 2.1% (0.67-4.72) of cases, respectively. Among cases with available information, DMIs were reported for physical environment (85-100%), delivery-specific interventions (47-100%), and infant care practices (80-100%). No significant comparisons could be performed between different DMI combinations due to small sample size. CONCLUSION: The evidence supporting any DMI in SARS-CoV-2-infected mothers to prevent ENI or ND is extremely limited. Limitations of this meta-analysis include high risk of bias, small sample size, and large confidence intervals. This identifies the need for multinational database generation and specific studies designed to provide evidence of DMI guidelines best suited to prevent transmission from mother to neonate. KEY POINTS: · In this review we analyzed 2 years of maternal SARS-CoV-2 published cases.. · We assessed association of delivery management interventions with infant SARS-CoV-2 infection.. · We found no evidence supporting any DMI for that purpose..

Kratom (Mitragyna speciosa): A Case Review of Use Before and During Pregnancy.

Kratom (Mitragyna speciosa) is a plant-based substance with psychoactive properties similar to opioids but is not currently classified as an opioid. One of its more prevalent uses is to treat opioid dependency and withdrawal symptoms. Opioid use disorder is a leading cause of pregnancy-associated maternal mortality, and pregnant women may be using kratom as a substitute or alternative to opioids. Prevalence of kratom use is increasing rapidly, but scientific evidence specific to therapeutic and adverse effects is lacking overall, and the implications of its use in pregnancy and on the fetus-newborn are limited to a few case reports. Kratom is a legal substance by federal law, although some states have banned its use. The lack of regulation is concerning. Significant illness and associated deaths have been reported with kratom use. Lack of disclosure by people using kratom and limited laboratory testing options are major challenges for health care providers and public health.

Diverging Maternal and Cord Antibody Functions From SARS-CoV-2 Infection and Vaccination in Pregnancy.

Maternal immunity impacts the infant, but how is unclear. To understand the implications of the immune exposures of vaccination and infection in pregnancy for neonatal immunity, we evaluated antibody functions in paired peripheral maternal and cord blood. We compared those who in pregnancy received mRNA coronavirus disease 2019 (COVID-19) vaccine, were infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the combination. We found that vaccination enriched a subset of neutralizing activities and Fc effector functions that was driven by IgG1 and was minimally impacted by antibody glycosylation in maternal blood. In paired cord blood, maternal vaccination also enhanced IgG1. However, Fc effector functions compared to neutralizing activities were preferentially transferred. Moreover, changes in IgG posttranslational glycosylation contributed more to cord than peripheral maternal blood antibody functional potency. These differences were enhanced with the combination of vaccination and infection as compared to either alone. Thus, Fc effector functions and antibody glycosylation highlight underexplored maternal opportunities to safeguard newborns.

Vaginal Compared With Oral Misoprostol Induction at Term: A Cluster Randomized Controlled Trial.

OBJECTIVE: To evaluate efficacy in achieving vaginal delivery with a standardized vaginal compared with oral misoprostol regimen for labor induction at term. METHODS: In this single-center, cluster randomized trial, we randomized induction method by week among individuals with gestational age of 37 weeks or more, cervical dilation of 2 cm or less, intact membranes, and indication for delivery to either oral (100 micrograms every 4 hours for up to two doses), or vaginal (25 micrograms every 3 hours for up to five doses) misoprostol regimens, followed by a standardized oxytocin protocol. Individuals with an antepartum stillbirth, major fetal anomalies, malpresentation, ruptured membranes, nonreassuring fetal status, or contraindication to prostaglandin were excluded. The primary outcome was vaginal delivery at first induction attempt. Secondary outcomes included time to delivery, need for oxytocin, chorioamnionitis, and adverse maternal and neonatal outcomes. Outcomes were recorded at the individual level and adjusted for clustering, with analysis by intention to treat. RESULTS: Between May 24, 2021, to September 19, 2022, 1,322 women were randomized to vaginal misoprostol in 33 clusters and 1,224 to oral misoprostol in 37 clusters. Demographic characteristics or initial cervical dilation did not differ between groups. The primary outcome did not differ between induction regimens and occurred in 1,032 (78.1%) of the vaginal misoprostol arm and 945 (77.2%) of the oral misoprostol arm (adjusted relative risk [RR] 1.01, 95% CI, 0.97-1.05). Tachysystole with fetal heart rate changes occurred less frequently with vaginal compared with oral misoprostol (3.5% vs 5.9%, adjusted RR 0.59, 95% CI, 0.40-0.87). Time to delivery did not differ between groups. Oxytocin was less frequently required before delivery in the vaginal misoprostol group (68.8% vs 78.4%, adjusted RR 0.88, 95% CI, 0.84-0.92). CONCLUSION: Induction of labor with vaginal compared with oral misoprostol protocols did not increase the frequency of vaginal delivery at term but did reduce the need for oxytocin use before delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04755218.

Use of integrase inhibitors vs protease inhibitors is associated with improved HIV viral suppression.

BACKGROUND: Current guidelines for antiretroviral therapy in pregnancy include the use of a dual-nucleoside reverse transcriptase inhibitor with either an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, although there is no designation of which is the preferred option. OBJECTIVE: This study aimed to compare viral suppression at delivery among patients on dual-nucleoside reverse transcriptase inhibitors combined with either an integrase strand transfer inhibitor or a protease inhibitor. A hypothesis was made that the incidence of viral suppression is higher with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with an integrase strand transfer inhibitor than with the use of a dual-nucleoside reverse transcriptase inhibitor backbone combined with a protease inhibitor. STUDY DESIGN: This study was an observational study of pregnant patients living with HIV who received prenatal care and delivered after 20 weeks of gestation at an urban safety net hospital. All pregnant patients with HIV were referred to a centralized clinic for HIV counseling, medication management, and prenatal care. Antiretroviral therapy was continued or initiated according to protocols based on national guidance. Among patients on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor vs protease inhibitor at delivery, we compared the demographics and HIV disease characteristics, including year of diagnosis, viral load, and antiretroviral therapy class. The outcome of interest was viral suppression at delivery, defined as a viral load of <50 copies/mL. RESULTS: From January 2011 to December 2021, 604 patients on dual-nucleoside reverse transcriptase inhibitor met the inclusion criteria, including 411 patients (68%) on protease inhibitor and 193 patients (32%) on integrase strand transfer inhibitor at delivery. Demographic distribution was similar, and prenatal care was initiated at 12 weeks of gestation. Among the integrase strand transfer inhibitor group, 101 (17%) were on antiretroviral therapy at initiation of prenatal care compared with 169 (28%) in the protease inhibitor group. At delivery, the frequency of viral load suppression was higher among those on an integrase strand transfer inhibitor (147/193 [76%]) than among those on a protease inhibitor (275/411 [67%]) (odds ratio, 1.59; 95% confidence interval, 1.08-2.33). Among those with a detectable virus, quantitative viral load was not different. During the study period, the use of a protease inhibitor decreased, whereas the use of an integrase strand transfer inhibitor increased. CONCLUSION: Among pregnant patients living with HIV, viral suppression was more common among those on a dual-nucleoside reverse transcriptase inhibitor backbone combined with integrase strand transfer inhibitor than among those on a dual-nucleoside reverse transcriptase inhibitor backbone protease inhibitor at delivery. Our results support the use of dual-nucleoside reverse transcriptase inhibitor with integrase strand transfer inhibitor as a first-line antiretroviral therapy regimen in pregnancy.

Diverging maternal and infant cord antibody functions from SARS-CoV-2 infection and vaccination in pregnancy.

Immunization in pregnancy is a critical tool that can be leveraged to protect the infant with an immature immune system but how vaccine-induced antibodies transfer to the placenta and protect the maternal-fetal dyad remains unclear. Here, we compare matched maternal-infant cord blood from individuals who in pregnancy received mRNA COVID-19 vaccine, were infected by SARS-CoV-2, or had the combination of these two immune exposures. We find that some but not all antibody neutralizing activities and Fc effector functions are enriched with vaccination compared to infection. Preferential transport to the fetus of Fc functions and not neutralization is observed. Immunization compared to infection enriches IgG1-mediated antibody functions with changes in antibody post-translational sialylation and fucosylation that impact fetal more than maternal antibody functional potency. Thus, vaccine enhanced antibody functional magnitude, potency and breadth in the fetus are driven more by antibody glycosylation and Fc effector functions compared to maternal responses, highlighting prenatal opportunities to safeguard newborns as SARS-CoV-2 becomes endemic.

Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum.

Importance: Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective: To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants: This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures: ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures: The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results: From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance: In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.

Neuraxial Anesthesia during the COVID-19 Pandemic: Report from a Large Academic Medical Center.

OBJECTIVE: Three primary neuraxial techniques reduce labor pain: epidural, dural puncture epidural (DPE), and combined spinal-epidural (CSE). This study aims to determine whether neuraxial analgesia techniques changed after the onset of the coronavirus disease 2019 (COVID-19) pandemic. Given that a dural puncture confirms neuraxial placement, we hypothesized that DPE was more frequent in women with concerns for COVID-19. STUDY DESIGN: A single-center retrospective cohort study comparing neuraxial analgesia techniques for labor and delivery pain management before and after the onset of the COVID-19 pandemic and in patients with and without SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) at a maternity hospital in Dallas, Texas, with a large delivery service. Statistical analyses included the Chi-square test for categorical and Kruskal-Wallis test for nonparametric ordinal comparisons. The Cochran-Mantel-Haenszel test was used to assess the association between neuraxial technique and accidental dural puncture or postdural puncture headache. RESULTS: Of 10,971 patients who received neuraxial analgesia for labor, 5,528 were delivered in 2019 and 5,443 in 2020. Epidural analgesia was the most common neuraxial technique for labor pain in 2019 and 2020. There was no difference in the frequency of neuraxial analgesia techniques or the rates of accidental dural puncture or postdural puncture headaches comparing all deliveries in 2019 to 2020. Despite a significant increase in DPEs relative to epidurals in the SARS-CoV-2-positive group compared with the SARS-CoV-2-negative group in 2020, there was no significant difference in postdural puncture headaches or accidental dural punctures. CONCLUSION: The advantages of a DPE, specifically the ability to confirm epidural placement using a small gauge spinal needle, likely led to an increase in the placement of this neuraxial in SARS-CoV-2-positive patients. There was no effect on the frequency of postdural puncture headaches or accidental dural punctures within the same period. KEY POINTS: · Epidural analgesia was the most common neuraxial technique for labor pain management.. · Dural puncture epidural placements increased in SARS-CoV-2-positive patients.. · Rates of postdural puncture headaches and accidental dural puncture after neuraxial placement did not change..

Examining the impact of trimester of diagnosis on COVID-19 disease progression in pregnancy.

BACKGROUND: COVID-19 infection is associated with increased morbidity in pregnancy and adverse maternal and neonatal outcomes. Little is currently known about how the timing of infection during pregnancy affects these outcomes. OBJECTIVE: This study aimed to evaluate the effect of trimester of COVID-19 infection on disease progression and severity in pregnant patients. STUDY DESIGN: This was a prospective cohort study of pregnant patients diagnosed with COVID-19 infection who delivered at a single urban hospital. Universal testing for SARS-CoV-2 was performed at hospital admission and for symptomatic patients in inpatient, emergency department, and outpatient settings. Disease severity was defined as asymptomatic, mild, moderate, severe, or critical on the basis of National Institutes of Health criteria. We evaluated disease progression from asymptomatic to symptomatic infection and from asymptomatic or mild infection to moderate, severe, or critical illness, and stratified by trimester of COVID-19 diagnosis. Primary outcomes included progression of COVID-19 disease severity and a composite obstetrical outcome, which included delivery at <37 weeks, preeclampsia with severe features, abruption, excess blood loss at delivery (>500 mL for vaginal or >1000 mL for cesarean delivery), and stillbirth. RESULTS: From March 18, 2020 to September 30, 2021, 1326 pregnant patients were diagnosed with COVID-19 and delivered at our institution, including 103 (8%) first-, 355 (27%) second-, and 868 (65%) third-trimester patients. First-trimester patients were older and had more medical comorbidities; 86% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 3 of 18 (17%) first-trimester, 20 of 47 (43%) second-trimester, and 34 of 574 (6%) third-trimester patients were admitted for the indication of COVID-19 illness. Across all trimesters, 1195 (90%) of 1326 COVID-19 infections were asymptomatic or mild, and 45 (10%) of 436 initially asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 4 (4%) of 93 first-, 18 (5%) of 337 second-, and 49 (6%) of 836 third-trimester patients developed moderate, severe, or critical illness (P=.80). There was no significant difference in composite obstetrical outcome with respect to trimester of COVID-19 diagnosis (24% first-trimester, 28% second-trimester, 28% third-trimester patients; P=.69). CONCLUSION: Moderate, severe, or critical illness develops in almost 10% of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.

A comparison of acute pain management strategies after cesarean delivery.

BACKGROUND: There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited. OBJECTIVE: To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain. STUDY DESIGN: This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges-Lehman shift, with a P value <.05 being considered significant. RESULTS: During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria-378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14-41] morphine milligram equivalents vs 128 [86-174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001). CONCLUSION: Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

Comparison Between In-Person and Audio-Only Virtual Prenatal Visits and Perinatal Outcomes.

Importance: Ensuring access to prenatal care services in the US is challenging, and implementation of telehealth options was limited before the COVID-19 pandemic, especially in vulnerable populations, given the regulatory requirements for video visit technology. Objective: To explore the association of audio-only virtual prenatal care with perinatal outcomes. Design, Setting, and Participants: This cohort study compared perinatal outcomes of women who delivered between May 1 and October 31, 2019 (n = 6559), and received in-person prenatal visits only with those who delivered between May 1 and October 31, 2020 (n = 6048), when audio-only virtual visits were integrated into prenatal care during the COVID-19 pandemic, as feasible based on pregnancy complications. Parkland Health and Hospital System in Dallas, Texas, provides care to the vulnerable obstetric population of the county via a high-volume prenatal clinic system and public maternity hospital. All deliveries of infants weighing more than 500 g, whether live or stillborn, were included. Exposures: Prenatal care incorporating audio-only prenatal care visits. Main Outcomes and Measures: The primary outcome was a composite of placental abruption, stillbirth, neonatal intensive care unit admission in a full-term (≥37 weeks) infant, and umbilical cord blood pH less than 7.0. Visit data, maternal characteristics, and other perinatal outcomes were also examined. Results: The mean (SD) age of the 6559 women who delivered in 2019 was 27.8 (6.4) years, and the age of the 6048 women who delivered in 2020 was 27.7 (6.5) years (P = .38). Of women delivering in 2020, 1090 (18.0%) were non-Hispanic Black compared with 1067 (16.3%) in 2019 (P = .04). In the 2020 cohort, 4067 women (67.2%) attended at least 1 and 1216 women (20.1%) attended at least 3 audio-only virtual prenatal visits. Women who delivered in 2020 attended a greater mean (SD) number of prenatal visits compared with women who delivered in 2019 (9.8 [3.4] vs 9.4 [3.8] visits; P < .001). In the 2020 cohort, 173 women (2.9%) experienced the composite outcome, which was not significantly different than the 195 women (3.0%) in 2019 (P = .71). In addition, the rate of the composite outcome did not differ substantially when examined according to the number of audio-only virtual visits attended. Conclusions and Relevance: Implementation of audio-only virtual prenatal visits was not associated with changes in perinatal outcomes and increased prenatal visit attendance in a vulnerable population during the COVID-19 pandemic when used in a risk-appropriate model.