Social determinants of health and coronavirus disease 2019 in pregnancy.

BACKGROUND: The social and physical environments in which people live affect the emergence, prevalence, and severity of both infectious and noninfectious diseases. There are limited data on how such social determinants of health, including neighborhood socioeconomic conditions, affect the risk of severe acute respiratory syndrome coronavirus 2 infection and severity of coronavirus disease 2019 during pregnancy. OBJECTIVE: Our objective was to determine how social determinants of health are associated with severe acute respiratory syndrome coronavirus 2 infection and the severity of coronavirus disease 2019 illness in hospitalized pregnant patients in New York during the global coronavirus disease 2019 pandemic. STUDY DESIGN: This cross-sectional study evaluated all pregnant patients who delivered and had polymerase chain reaction testing for severe acute respiratory syndrome coronavirus 2 between March 15, 2020, and June 15, 2020, at 7 hospitals within Northwell Health, the largest academic health system in New York. During the study period, universal severe acute respiratory syndrome coronavirus 2 testing protocols were implemented at all sites. Polymerase chain reaction testing was performed using nasopharyngeal swabs. Patients were excluded if the following variables were not available: polymerase chain reaction results, race, ethnicity, or zone improvement plan (ZIP) code of residence. Clinical data were obtained from the enterprise electronic health record system. For each patient, ZIP code was used as a proxy for neighborhood. Socioeconomic characteristics were determined by linking to ZIP code data from the United States Census Bureau's American Community Survey and the Internal Revenue Service's Statistics of Income Division. Specific variables of interest included mean persons per household, median household income, percent unemployment, and percent with less than high school education. Medical records were manually reviewed for all subjects with positive polymerase chain reaction test results to correctly identify symptomatic patients and then classify those subjects using the National Institutes of Health severity of illness categories. Classification was based on the highest severity of illness throughout gestation and not necessarily at the time of presentation for delivery. RESULTS: A total of 4873 patients were included in the study. The polymerase chain reaction test positivity rate was 11% (n=544). Among this group, 359 patients (66%) were asymptomatic or presymptomatic, 115 (21%) had mild or moderate coronavirus disease 2019, and 70 (13%) had severe or critical coronavirus disease 2019. On multiple logistic regression modeling, pregnant patients who had a positive test result for severe acute respiratory syndrome coronavirus 2 were more likely to be younger or of higher parity, belong to minoritized racial and ethnic groups, have public health insurance, have limited English proficiency, and reside in low-income neighborhoods with less educational attainment. On ordinal logit regression modeling, obesity, income and education were associated with coronavirus disease 2019 severity. CONCLUSION: Social and physical determinants of health play a role in determining the risk of infection. The severity of coronavirus disease 2019 illness was not associated with race or ethnicity but was associated with maternal obesity and neighborhood level characteristics such as educational attainment and household income.

Effect of Chorionicity on Umbilical Cord Blood Acid-Base Analysis of the Second Twin.

Our objective was to determine whether chorionicity affects umbilical cord blood acid-base parameters of the second twin. This was a retrospective cohort of twin pregnancies delivered at ≥23 weeks of gestation at a tertiary hospital from 2010 to 2016. Patients were included if arterial and venous umbilical cord gas results were available for both newborns and chorionicity was confirmed histologically. Exclusion criteria included intrauterine fetal demise of either twin prior to labor, major fetal anomalies, monoamnionicity, uncertain chronicity and twin-to-twin transfusion syndrome. The primary outcome evaluated was the umbilical artery (UA) pH of the second twin. A total of 593 dichorionic (DC) and 86 monochorionic (MC) twin pregnancies were included. No difference in UA pH was observed between MC and DC twins. Among vaginal deliveries (n = 97), the UA pH of the first twin was higher than the second twin (7.26 vs. 7.24; p = .01). Twin-to-twin delivery interval (TTDI) ≥20 min was associated with a higher UA pH in the first twin compared to the second twin (7.25 vs. 7.16, respectively; p = .006). Multivariable logistic regression was used to predict arterial pH < 7.20 for the second twin; the most predictive factors were arterial pH < 7.20 for the first twin, chronic hypertension and prolonged TTDI. Chorionicity was not associated with any acid-base parameter of umbilical cord blood in either the first or second twin. No differences in neonatal outcomes were observed based on chorionicity or birth order. Populations with a lower cesarean delivery rate may yield different findings.

Twin pregnancy and risk of postpartum hemorrhage.

Objective: To identify maternal and peripartum characteristics in twin gestations that are associated with postpartum hemorrhage (PPH) in which one or more units of packed red blood cells (PRBCs) were either administered or recommended but declined (PPH + PRBC).Methods: This retrospective cohort study evaluated all women with twin gestations who delivered at greater than 23 weeks of gestational age at a single, tertiary medical center from 2011 to 2016. Patients were included if they had documentation of estimated blood loss (EBL) at delivery and complete inpatient medical records available for review. Patients with incomplete records or an intrauterine fetal demise of one or both twins were excluded. The primary outcome was PPH + PRBC. Secondary outcomes included PPH with delivery EBL ≥1500 ml, PPH with atony and uterotonic administration, PPH with maternal hemorrhagic morbidity (MHM), and PPH with severe maternal morbidity (SMM). MHM was a composite outcome defined as PPH associated with any of the following: atony requiring uterotonics, any PRBC transfusion (≥1 unit), uterine or hypogastric artery ligation, hysterectomy, compression sutures, intrauterine balloon tamponade, uterine artery embolization, and/or exploratory laparotomy. SMM was a composite outcome defined as PPH associated with any of the following: administration of ≥4 units of PRBC, administration of ≥2 units of PRBC, and ≥2 units of fresh frozen plasma (FFP), return to operating room for any major procedure (excludes dilation and curettage), any peripartum hysterectomy, uterine artery embolization, intrauterine balloon tamponade or compression suture placed and administration of ≥2 units of PRBC, and/or intensive care unit (ICU) admission for invasive monitoring/treatment. A multivariable logistic regression analysis was performed.Results: A total of 1081 women with twin gestations were included. PPH + PRBC occurred in 4.4% (n = 48), delivery EBL ≥1500 ml occurred in 3.9% (n = 42), and atony with uterotonic administration occurred in 12.1% (n = 131) of the study population. The rate of MHM and SMM were 13.9% (n = 150) and 1.9% (n = 20), respectively. Although the rate of cesarean delivery was high overall (83.2%), it was nearly universal in the PPH + PRBC group (97.9%; p < .02). PPH + PRBC occurred at a rate of 0.5% (n = 1/182) among vaginally delivered twins compared to 5.2% (n = 47/899) among those delivered by cesarean (p < .03). The final multivariable logistic regression model to predict PPH + PRBC identified six significant maternal and peripartum factors: nulliparity, either pregestational or gestational diabetes, intrapartum magnesium sulfate, admission hematocrit <30%, admission platelets <100 000/µL and administration of general anesthesia.Conclusions: A number of maternal and peripartum factors are associated with PPH in twin gestations. Optimization of maternal hematologic parameters and chronic medical conditions, and reduction in the rate of cesarean delivery in twin pregnancies may decrease the risk of postpartum hemorrhage.

Recurrence of extreme serum analytes in consecutive pregnancies and association with obstetrical outcomes.

OBJECTIVE: To evaluate if presence of extreme maternal serum biochemical analytes recurs in consecutive pregnancies. We hypothesized that presence of >1 extreme analyte in prior pregnancy is associated with increased risk of adverse pregnancy outcome in subsequent pregnancy. METHODS: Retrospective cohort study of singleton pregnancies evaluated and delivered in 2 consecutive pregnancies (2011-2015). Adverse outcomes were defined as indicated preterm delivery before 37 completed weeks due to preeclampsia, fetal growth restriction or other complications. RESULTS: First and second trimester maternal serum analytes were assessed in 1434 patients in 2 consecutive pregnancies. The presence of >1 extreme serum analyte in prior pregnancy significantly increased likelihood of >1 extreme analyte in subsequent pregnancy. The likelihood increased as number of prior extreme markers increased. In patients with normal outcomes and 2 or more extreme serum analytes in prior pregnancy, there was an increased incidence of adverse pregnancy outcomes in subsequent pregnancy with relative risk (RR) of 5.42 [95% CI 1.6-18.3]. CONCLUSIONS: The presence of more than 1 extreme serum marker in one pregnancy increases likelihood of recurrence in subsequent pregnancies. Risk of adverse outcomes in subsequent pregnancy can be evaluated based on biochemistry results as well as prior pregnancy outcomes.

Effect of Maternal Body Mass Index and Amniotic Fluid Index on the Accuracy of Sonographic Estimation of Fetal Weight in Late Gestation.

OBJECTIVE: The objective of this study was to determine the effect, if any, of maternal body mass index (BMI) and amniotic fluid index (AFI) on the accuracy of sonographic estimated fetal weight (EFW) at 40 to 42 weeks' gestation. METHODS: This was a retrospective cohort study of singleton gestations with ultrasound performed at 40 to 42 weeks from 2010 to 2013. In this study, patients with documented BMI and sonographic EFW and AFI, concurrently, within 7 days of delivery were included. Chronic medical conditions and fetal anomalies were excluded from this study. The primary variable of interest was the rate of substantial error in EFW, defined as absolute percentage error (APE) >10%. RESULTS: A total of 1,000 pregnancies were included. Overall, the APE was 6.0 ± 4.5% and the rate of substantial error was 17.4% (n = 174). There was no significant difference in APE or rate of substantial error between BMI groups. In the final multivariable logistic regression model, the rate of substantial error was increased in women with oligohydramnios (OR 1.79; 95% CI: 1.10-2.92). Furthermore, oligohydramnios was significantly more likely to overestimate EFW while polyhydramnios was more likely to underestimate EFW. Maternal BMI did not affect the accuracy of sonographic EFW. CONCLUSION: Sonographic EFW may be affected by extremes of AFI in the postdates period. Maternal BMI does not affect EFW accuracy at 40 to 42 weeks.

Maternal Body Mass Index and Amniotic Fluid Index in Late Gestation.

OBJECTIVES: To determine the effect, if any, of an increasing maternal body mass index (BMI) on sonographically diagnosed oligohydramnios in late gestation and how it subsequently affects obstetric and neonatal outcomes. METHODS: This retrospective cohort study evaluated all women with singleton gestations who had a sonographic examination at 40 to 42 weeks' gestational age at North Shore University Hospital from 2010 through 2013. Underweight women (prepregnancy BMI < 18.5 kg/m2 ) were excluded because of higher rates of oligohydramnios and fetal growth restriction. Patients were classified into 5 groups by late-pregnancy BMI. The primary variable of interest was the diagnosis of oligohydramnios (amniotic fluid index < 5 cm). Secondary variables of interest included the mode of delivery and indication for primary cesarean delivery. A multivariable logistic regression analysis was performed. RESULTS: Oligohydramnios was identified in 189 of 1671 patients (11.3%). There was no significant difference in the amniotic fluid index between BMI groups. The rate of primary cesarean delivery increased with each successive BMI group (P < .001) such that women in the class III obesity group had an approximately 3-fold higher rate of primary cesarean delivery than women in the normal BMI group and a 2-fold higher rate than women in the overweight BMI group. In the final multivariable logistic regression model, a high BMI, nulliparity, and excessive gestational weight gain were associated with primary cesarean delivery. However, oligohydramnios did not contribute significantly to the model. CONCLUSIONS: The maternal BMI is not associated with oligohydramnios in late gestation. An increasing maternal BMI significantly increases the risk of primary cesarean delivery.

Uterine fibroids at routine second-trimester ultrasound survey and risk of sonographic short cervix.

OBJECTIVE: To determine whether women with sonographically identified uterine fibroids are at higher risk for a short cervix. METHODS: This retrospective cohort study evaluated all women with singleton gestations who had a routine second-trimester ultrasound at 17-23 weeks gestational age from 2010 to 2013. When fibroids were noted, their presence, number, location and size were recorded. Exclusion criteria included a history of cervical conization or loop electrosurgical excision procedure (LEEP), uterine anomalies, maternal age greater than 40 years, and a previously placed cerclage. The primary variable of interest was short cervix (<25 mm). Secondary variables of interest included gestational age at delivery, mode of delivery, indication for cesarean, malpresentation, birth weight, and Apgar scores. A multivariable logistic regression analysis was performed. RESULTS: Fibroids were identified in 522/10 314 patients (5.1%). In the final multivariable logistic regression model, short cervix was increased in women with fibroids (OR 2.29, 95% CI: 1.40, 3.74). The number of fibroids did not affect the frequency of short cervix. Fibroids were significantly associated with preterm delivery (<37 weeks), primary cesarean, breech presentation, lower birth weight infants, and lower Apgar scores. CONCLUSIONS: Women with uterine fibroids may be at higher risk for a short cervix. Fibroids are also associated with several adverse obstetric and neonatal outcomes.