A Framework for Coordination between Obstetric and Pediatric Providers in Public Health Emergencies: Lessons Learned from the Zika Outbreak in the United States, 2015 to 2017.

Emergency response to emerging threats with the potential for vertical transmission, such as the 2015 to 2017 response to Zika virus, presents unique clinical challenges that underscore the need for better communication and care coordination between obstetric and pediatric providers to promote optimal health for women and infants. Published guidelines for routine maternal-infant care during the perinatal period, and models for transitions of care in various health care settings are available, but no broad framework has addressed coordinated multidisciplinary care of the maternal-infant dyad during emergency response. We present a novel framework and strategies to improve care coordination and communication during an emergency response. The proposed framework includes (1) identification and collection of critical information to inform care, (2) key health care touchpoints for the maternal-infant dyad, and (3) primary pathways of communication and modes of transfer across touchpoints, as well as practical strategies. This framework and associated strategies can be modified to address the care coordination needs of pregnant women and their infants with possible exposure to other emerging infectious and noninfectious congenital threats that may require long-term, multidisciplinary management. KEY POINTS: · Emerging congential threats present unique coordination challenges for obstetric and pediatric clinicians during emergency response.. · We present a framework to help coodinate care of pregnant women/infants exposed to congenital threats.. · The framework identifies critical information to inform care, health care touchpoints, and communication/information transfer pathways..

Ultrasound Findings Associated With Antepartum Viral Infection.

This article reviews the sonographic manifestations of fetal infection and the role of ultrasound in the evaluation of the fetus at risk for congenital infection. Several ultrasound findings have been associated with in utero fetal infections. For the patient with a known or suspected fetal infection, sonographic identification of characteristic abnormalities can provide useful information for counseling and perinatal management. Demonstration of such findings in the low-risk patient may serve to identify the fetus with a previously unsuspected infection. The clinician should understand the limitations of ultrasound in the prenatal diagnosis of congenital infection and discuss them with the patient.

Racial/Ethnic Differences in Labor Induction in a Contemporary US Cohort: A Retrospective Cohort Study.

OBJECTIVE: To examine labor induction by race/ethnicity and factors associated with disparity in induction. STUDY DESIGN: This is a retrospective cohort study of 143,634 women eligible for induction ≥24 weeks' gestation from 12 clinical centers (2002-2008). Rates of labor induction for each racial/ethnic group were calculated and stratified by gestational age intervals: early preterm (240/7-336/7), late preterm (340/7-366/7), and term (370/7-416/7 weeks). Multivariable logistic regression examined the association between maternal race/ethnicity and induction controlling for maternal characteristics and pregnancy complications. The primary outcome was rate of induction by race/ethnicity. Inductions that were indicated, non-medically indicated, or without recorded indication were also compared. RESULTS: Non-Hispanic black (NHB) women had the highest percentage rate of induction, 44.6% (p < 0.001). After adjustment, all racial/ethnic groups had lower odds of induction compared with non-Hispanic white (NHW) women. At term, NHW women had the highest percentage rate (45.4%) of non-medically indicated or induction with no indication (p < 0.001). CONCLUSION: Compared with other racial/ethnic groups, NHW women were more likely to undergo non-medically indicated induction at term. As labor induction may avoid the occurrence of stillbirth, whether this finding explains part of the increased risk of stillbirth for NHB women at term merits further research.

Zika Virus Infection with Prolonged Maternal Viremia and Fetal Brain Abnormalities.

The current outbreak of Zika virus (ZIKV) infection has been associated with an apparent increased risk of congenital microcephaly. We describe a case of a pregnant woman and her fetus infected with ZIKV during the 11th gestational week. The fetal head circumference decreased from the 47th percentile to the 24th percentile between 16 and 20 weeks of gestation. ZIKV RNA was identified in maternal serum at 16 and 21 weeks of gestation. At 19 and 20 weeks of gestation, substantial brain abnormalities were detected on ultrasonography and magnetic resonance imaging (MRI) without the presence of microcephaly or intracranial calcifications. On postmortem analysis of the fetal brain, diffuse cerebral cortical thinning, high ZIKV RNA loads, and viral particles were detected, and ZIKV was subsequently isolated.

Use of cell-free DNA in the investigation of intrauterine fetal demise and miscarriage.

OBJECTIVE: To estimate whether cell-free DNA is present in nonviable pregnancies and thus can be used in diagnostic evaluation in this setting. METHODS: We conducted a prospective cohort study of 50 participants at MedStar Washington Hospital Center, Washington, DC, between June 2013 and January 2014. Included were women with pregnancies complicated by missed abortion or fetal demise. All gestational ages were considered for study participation. Participants with fetal demise were offered the standard workup for fetal death per the American College of Obstetricians and Gynecologists. Maternal blood samples were processed to determine the presence of cell-free DNA, the corresponding fetal fractions, and genetic abnormalities. RESULTS: Fifty samples from nonviable pregnancies were analyzed. The average clinical gestational age was 16.9 weeks (standard deviation 9.2). The mean maternal body mass index was 30.3 (standard deviation 9.1). Seventy-six percent (38/50) of samples yielded cell-free DNA results, that is, had fetal fractions within the detectable range of 3.7-65%. Among the 38, 76% (29) were classified as euploid, 21% (8) as trisomies, and 3% (1) as microdeletion. A cell-free DNA result was obtained more frequently at ultrasonographic gestational ages of 8 weeks or greater compared with less than 8 weeks (87.9% [n=29/33, 95% confidence interval (CI) 72.7-95.2; and 52.9%, n=9/17, 95% CI 31.0-73.8] of the time, respectively, P=.012). Time from demise was not associated with obtaining a result. CONCLUSION: Among nonviable pregnancies, cell-free DNA is present in the maternal plasma with fetal fractions greater than 3.7% in more than three fourths of cases after an ultrasonographic gestational age of 8 weeks. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01916928. LEVEL OF EVIDENCE: III.

Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term.

OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks. Outcomes were analyzed using χ(2), Student t, or Wilcoxon rank sum tests as appropriate with a significance set at P < .05. RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.

Racial disparities in maternal and neonatal outcomes in HIV-1 positive mothers.

OBJECTIVE: To compare obstetric and neonatal outcomes between human immunodeficiency virus (HIV) positive (HIV+) and HIV negative (HIV-) women and to determine if racial disparities exist among pregnancies complicated by HIV infection. STUDY DESIGN: This was a retrospective analysis of data from the Consortium of Safe Labor between 2002 and 2008. Comparisons of obstetric morbidity, neonatal morbidity, and indications for cesarean delivery were examined. Included were singletons with documented HIV status, race, and antepartum admission. Chi-square, Fisher exact tests, and logistic regression were used for statistical analysis. RESULTS: Included were 178,972 patients (178,210 HIV-, 762 HIV+, 464 HIV+ black, 298 HIV+ nonblack). HIV+ women were more likely to have a cesarean delivery, preterm premature rupture of membranes, another sexually transmitted infection, and delivery at an earlier gestational age. Obstetric outcomes were similar between HIV+ black and HIV+ nonblack women. Neonates of HIV+ mothers had lower birth weights and higher rates of neonatal intensive care admissions. HIV+ black women had lower birth weight neonates than HIV+ nonblack women. CONCLUSION: HIV+ women have higher rates of obstetric complications and deliver at an earlier gestational age than HIV- mothers. Lower birth weight was the only notable complication among HIV+ black women compared with HIV+ nonblack women.

Accuracy of clinically estimated fetal weight in pregnancies complicated by diabetes mellitus and obesity.

OBJECTIVE: To determine the accuracy of clinically estimated fetal weight (CEFW) in patients with gestational diabetes (GDM), pregestational diabetes (DM), and obesity. STUDY DESIGN: This is a retrospective analysis of Consortium of Safe Labor data. Subjects were classified into six groups: DM, DM and obese, GDM, GDM and obese, nondiabetic obese, and controls. The mean difference between birth weight (BW) and CEFW, the percent of accurate CEFW (defined as < 10% difference), and the sensitivity for identifying BW > 4,000 g and > 4,500 g were calculated for each group. RESULTS: The accuracy of CEFW in our population was 54.3 to 64.4% and was significantly lower in patients with DM and obesity and patients with obesity but not diabetes. When CEFW was analyzed in the >4,000-g and > 4,500-g groups, its accuracy was 20 to 51% and 14 to 40%, respectively. CEFW overestimated BW more commonly in GDM, obese GDM, and obese groups. The sensitivity of CEFW for diagnosing BW > 4,000 g or > 4,500 g was 19.6% and 9.6%, respectively, and it improved in pregnancies complicated by diabetes. CONCLUSION: CEFW is a poor predictor of macrosomia in pregnancies complicated by obesity and diabetes.

Spontaneous preterm birth in African-American and Caucasian women receiving 17α-hydroxyprogesterone caproate.

OBJECTIVE: To determine if the rates of recurrent spontaneous preterm birth in women receiving 17α-hydroxyprogesterone caproate (17P) differ according to maternal race. STUDY DESIGN: Retrospective analysis of a cohort of women enrolled in outpatient 17P administration at < 27 weeks. Maternal characteristics, obstetric history, and rates of recurrent preterm birth were determined using chi-square and multivariable Cox proportional hazards regression at two-tailed α = 0.05. Primary study outcome was defined as having a spontaneous preterm birth < 34 weeks. RESULTS: African-American women initiated 17P injections later (19.6 versus 18.9 weeks, p < 0.001) and discontinued injections earlier (33.2 versus 34.1 weeks, p < 0.001) than Caucasian women. Spontaneous recurrent preterm birth < 34 weeks was higher in African-Americans versus Caucasians receiving 17P (odds ratio 2.1; 95% confidence interval 1.7, 2.4). After adjusting for other significant factors, African-American race retained the strongest association with recurrent spontaneous preterm birth < 34 weeks. Within each racial group, short cervical length < 25 mm before 27 weeks' gestation had the highest hazard of recurrent spontaneous preterm delivery. CONCLUSION: Despite treatment with 17P, African-American women have higher rates of recurrent preterm birth.

Timing and consequences of early term and late term deliveries.

OBJECTIVE: To examine the timing of elective delivery and neonatal intensive care unit (NICU) utilization of electively delivered infants from 2008 to 2011. METHODS: Analysis included 42,290 women with singleton gestation enrolled in a pregnancy education program, reporting uncomplicated pregnancies with elective labor induction (ELI) (n = 27,677) or scheduled cesarean delivery (SCD) (n = 14,613) at 37.0-41.9 weeks' gestation. Data were grouped by type and week of delivery (37.0-37.9, 38.0-38.9, and 39.0-41.9 weeks). ELI and SCD for each week of delivery from 2008 to 2011 and nursery utilization by delivery week were compared. RESULTS: During the 2008-2011 timeframe, a shift in timing of ELI and SCD toward ≥39.0 weeks was observed. In 2008, 80.9% of ELI occurred at ≥39.0 weeks versus 92.6% in 2011 (p < 0.001). In 2008, 60.5% of SCD occurred at ≥39.0 weeks versus 78.1% in 2011 (p < 0.001). NICU admission and prolonged nursery stays were highest at 37.0-37.9 weeks for both groups. CONCLUSIONS: We observed a shift toward later gestational age at elective delivery from 2008 to 2011 and increased NICU utilization for neonates born at <39 weeks' gestation.

Obstetric complications, neonatal morbidity, and indications for cesarean delivery by maternal age.

OBJECTIVE: To delineate adverse obstetric and neonatal outcomes as well as indications for cesarean delivery by maternal age in a contemporaneous large national cohort. METHODS: This was a retrospective analysis of electronic medical records from 12 centers and 203,517 (30,673 women aged 35 years or older) women with singleton gestations stratified by maternal age. Logistic regression was performed to investigate maternal and neonatal outcomes for each maternal age strata (referent group, age 25.0-29.9 years), adjusting for race, parity, body mass index, insurance, pre-existing medical conditions, substance and tobacco use, and site. Documented indications for cesarean delivery were analyzed. RESULTS: Neonates born to women aged 25.0-29.9 years had the lowest risk of birth weight less than 2,500 g (7.2%; P<.001), admission to neonatal intensive care unit (11.5%; P<.001), and perinatal mortality (0.7%; P<.001). Hypertensive disorders of pregnancy were higher in women aged 35 years or older (cumulative rate 8.5% compared with 7.8%; 25.0-29.9 years; P<.001). Previous uterine scar was the leading indication for cesarean delivery in women aged 25.0 years or older (36.9%; P<.001). For younger women, failure to progress or cephalopelvic disproportion (37.0% for those younger than age 20.0 years and 31.1% for those aged 20.0-24.9-years; P<.001) and nonreassuring fetal heart tracing (28.7% for those younger than 20.0 years and 21.2% for those aged 20.0-24.9-years; P<.001) predominated as indications. Truly elective cesarean delivery rate was 20.2% for women aged 45.0 years or older (adjusted odds ratio 1.85 [99% confidence interval 1.03-3.32] compared with the referent age group of 25.0-29.9 years). CONCLUSIONS: Maternal and obstetric complications differed by maternal age, as did rates of elective cesarean delivery. Women aged 25.0-29.9 years had the lowest rate of serious neonatal morbidity. LEVEL OF EVIDENCE: : II.

Intravenous Epoprostenol for Management of Pulmonary Arterial Hypertension during Pregnancy.

Background Pulmonary arterial hypertension carries a high risk of mortality in pregnancy. Recent advances in treatment may improve disease course and allow for successful management of the pregnancy. Case Report We present the case of a 20-year-old gravida 1, para 0 with diagnosis of severe primary pulmonary hypertension. The patient was managed with epoprostenol (prostacyclin) infusion via an indwelling catheter, which was initiated at 23 weeks' gestation. The dose was adjusted to the patient's symptoms and a successful vaginal delivery was achieved at 36 weeks' gestation. Although maternal postpartum course was uncomplicated, unexplained neonatal demise occurred at 11 days of life. Conclusion Successful management of pulmonary hypertension in pregnancy can be accomplished with a multidisciplinary approach and intensive therapy. Long-term effects of epoprostenol on fetal or neonatal well-being are unknown.

Primary cesarean delivery in the United States.

OBJECTIVES: To characterize the indications for primary cesarean delivery in a large national cohort and to identify opportunities to lower the U.S. primary cesarean delivery rate. METHODS: A retrospective cohort study of the 38,484 primary cesarean deliveries among the 228,562 deliveries at sites participating in the Consortium on Safe Labor from 2002 to 2008. RESULTS: The primary cesarean delivery rate was 30.8% for primiparous women and 11.5% for multiparous women. The most common indications for primary cesarean delivery were failure to progress (35.4%), nonreassuring fetal heart rate tracing (27.3%), and fetal malpresentation (18.5%), although frequencies for each indication varied by parity. Among women with failure to progress, 42.6% of primiparous women and 33.5% of multiparous women never progressed beyond 5 cm of dilation before delivery. Among women who reached the second stage of labor, 17.3% underwent cesarean delivery for arrest of descent before 2 hours and only 1.1% were given a trial of operative vaginal delivery. Of all primary cesarean deliveries, 45.6% were performed on primiparous women at term with a singleton fetus in cephalic presentation. CONCLUSION: Using 6 cm as the cut-off for active labor, allowing adequate time for the second stage of labor, and encouraging operative vaginal delivery, when appropriate, may be important strategies to reduce the primary cesarean delivery rate. These actions may be particularly important in the primiparous woman at term with a singleton fetus in cephalic presentation. LEVEL OF EVIDENCE: III.

Rates of recurrent preterm birth by maternal body habitus in women receiving 17α-hydroxyprogesterone caproate.

OBJECTIVE: To examine the influence of maternal pre-pregnancy body mass index (BMI) on the rates of recurrent spontaneous preterm birth (SPTB) in women receiving 17α-hydroxyprogesterone caproate (17P). METHODS: Retrospective analysis of a cohort of 6253 women with a singleton gestation and prior SPTB enrolled in 17P home administration program between 16.0 and 26.9 weeks. Data were grouped by pre-pregnancy BMI (lean <18.5 kg/m(2), normal 18.5-24.9 kg/m(2), overweight 25-29.9 kg/m(2) and obese ≥30.0 kg/m(2)). Delivery outcomes were compared using χ(2) and Kruskal-Wallis tests with statistical significance set at p < 0.05. RESULTS: SPTB<28 weeks was significantly lower in normal weight women. Rates of recurrent SPTB<37 weeks were highest in the group with BMI<18.5 kg/m(2). Lean gravidas were younger, more likely to smoke, and less likely to be African-American than those with normal or increased BMI. In logistic regression, after controlling for race and prior preterm birth <28 weeks, the risk of SPTB<37 weeks decreased 2% for every additional 1 kg/m(2) increase in BMI. CONCLUSIONS: Recurrent spontaneous preterm delivery<37 weeks in patients on 17P is more common in lean women (BMI<18.5 kg/m(2)), and less common in obese women (BMI ≥30 kg/m(2)) suggesting that the current recommended dosing of 17 P is adequate for women with higher BMI.

Asymmetric large for gestational age newborns in pregnancies complicated by diabetes mellitus: is maternal obesity a culprit?

OBJECTIVE: Evaluate the association between body mass index (BMI) and the delivery of an asymmetrically large for gestational age (A-LGA) newborn in women with diabetes. METHODS: Retrospective analysis of 306 pregnancies complicated by Type 1 and 55 by Type 2 diabetes. RESULTS: The prevalence of Type 1 and Type 2 diabetics delivering large for gestational age (LGA) infants was 42% and 49%, respectively. Of these 49% and 55% were A-LGA, respectively. Pre-pregnancy BMI was not associated with increased odds of delivering an A-LGA newborn in women with Type 1 or 2 diabetes. However, in Type 1 diabetics, each one-pound increase in maternal weight during pregnancy resulted in 4% increased odds of delivering an A-LGA newborn. For Type 2 diabetics, the odds of delivering an A-LGA infant was decreased by 10% for each 0.1 unit/kg increase in insulin dose. CONCLUSION: Although there is a known association between obesity and LGA in women with diabetes, we found that overweight and obese women with Type 1 or Type 2 diabetes do not have increased odds of delivering an A-LGA newborn. However, insulin dose in Type 2 diabetes and maternal weight gain in Type 1 diabetes were significantly associated with the odds of delivering an A-LGA neonate.

The 12th meeting of the Diabetes in Pregnancy Study Group of North America (DPSG-NA): introduction and overview.

The Diabetes in Pregnancy Study Group of North America (DPSG-NA) held its 12th meeting April 1-2, 2011 in Washington DC. The meeting, which was co-hosted by the Washington Hospital Center and the University of Maryland School of Medicine focused on five broad themes: (i) the prevention of diabetes and its risk factors, such as obesity, in pregnancy; (ii) the appropriate use of pharmacotherapies for managing diabetes in pregnancy; (iii) optimal glycemic control; (iv) the value of nutrition, exercise and limiting weight gain during pregnancy and (v) the diagnosis and consequences of diabetic fetopathy. These proceedings reflect peer-reviewed papers of data presented at the meeting. Time also was allocated to discuss the perceived barriers to using the one-step, 75 g oral glucose tolerance test as the first-line approach to diagnosing gestational diabetes mellitus. Responses from a survey of participants on perceived barriers to adopting this method into widespread clinical practice are discussed.

The impact of pre-pregnancy body mass index on the risk of gestational diabetes.

OBJECTIVE: To evaluate the effect of pre-pregnancy body mass index (BMI) on the risk of developing gestational diabetes mellitus (GDM) in a large unselected population. METHODS: We performed a case control study using data collected in The Consortium on Safe Labor database. The association between BMI and GDM was evaluated both using BMI weight categories adopted by the National Institute of Health, and separately using BMI as a continuous variable. Multiple logistic regression analyses were used to evaluate the effects of BMI, age, ethnicity, parity, chronic hypertension and antenatal steroid use on the risk of GDM. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to approximate relative risks of GDM. A p value of <0.05 was considered significant. RESULTS: After controlling for other factors, the risk of GDM increased with an increasing BMI across all weight categories. For each 1 kg/m(2) increase of BMI the OR of developing GDM was 1.08 (95% CI 1.08-1.09) and for each 5 kg/m(2) increase, the OR was 1.48 (95% CI 1.45-1.51). CONCLUSIONS: GDM is a multifactorial disorder and pre-pregnancy BMI plays an important role in that risk. Modest changes in pre-pregnancy BMI may decrease the risk of GDM substantially.

Spontaneous labor curves in women with pregnancies complicated by diabetes.

OBJECTIVE: To test the hypothesis that the first stage of labor will be longer in nulliparous and multiparous women with diabetes compared to non-diabetic counterparts. METHODS: A retrospective analysis was performed from 228,668 deliveries between 2002-2008 from the Consortium of Safe Labor (National Institute of Child Health and Human Development, National Institutes of Health). Patients with spontaneous onset of labor from 37 0/7-41 6/7 weeks gestation were included (71,282) and classified as nulliparous or multiparous. Pregnancies were further subdivided regarding presence of preexisting diabetes (preDM) or gestational diabetes (GDM) and normal controls. Labor curves were created matching for body mass index (BMI) and neonatal birth weight. Statistical analysis was performed on descriptive variables using χ(2) with significance designated as p < 0.05. RESULTS: Among nulliparous patients, there were 118 women with preDM and 475 women with GDM; 25,771 patients served as normal controls. Among multiparous women, there were 311 with preDM, 1,079 with GDM and 43,528 in the control group. Although differences in dilatation rates were observed in nulliparous and multiparous women with and without diabetes, labor progression was similar between the subgroups when matched for maternal BMI and birth weight. CONCLUSIONS: Labor curves of women with preDM and GDM approximate those of non-diabetics, regardless of BMI, birth weight, or parity.

Evaluation of the impact of resident work hour restrictions on resident outpatient clinical experience.

OBJECTIVE: To estimate the effect of work hour restrictions on resident outpatient clinical experience. STUDY DESIGN: Schedule templates from academic years 1998-1999 (before work hour restrictions), 2002-2003 (when night float rotation was added in anticipation of work hour restrictions), and 2008-2009 (during work hour restrictions) were compared for outpatient clinic experience before and after work hour restrictions were implemented. Actual clinics on specific rotations and estimated patient encounters per scheduled clinic were considered. RESULTS: Between academic year (AY) 1998-1999 and AY 2008-2009 there was a generalized downward trend in average outpatient encounters for postgraduate year (PGY)-2, PGY-3 and PGY-4 residents (45%, 34% and 36%, respectively). For obstetrics, gynecology and ambulatory rotations, there was a downward trend in average outpatient encounters for each rotation type (61%, 14% and 63%, respectively). The average number of scheduled clinics per week was slightly decreased when comparing AY 1998-1999 to either AY 2002-2003 or AY 2008-2009. CONCLUSION: Rotation schedules before and after work hour restrictions demonstrated a downward trend in the number of scheduled outpatient encounters. These findings indicate a potential negative impact on preparation for clinical practice.