The optimal gestational age to deliver patients with chronic hypertension on antihypertensive therapy.

OBJECTIVE: To identify the optimal gestational age of planned delivery in pregnancies complicated by chronic hypertension requiring antihypertensive medications that minimizes the risk of adverse perinatal events and maternal morbidity. METHODS: Retrospective cohort study of singleton pregnancies after 37 weeks of gestation complicated by chronic hypertension on antihypertensive medication, delivered at 7 hospitals within an academic health system in New York from 12/1/2015 to 9/3/2020. Two comparisons were made (1) planned deliveries at 37-376/7 weeks versus expectant management, (2) planned deliveries at 38-386/7 weeks versus expectant management. Patients with other maternal or fetal conditions were excluded. The primary outcome was a composite of adverse perinatal outcomes including stillbirth, neonatal death, assisted ventilation, cord pH < 7.0, 5-minute Apgar ≤5, diagnosis of respiratory disorder, and neonatal seizures. The secondary outcomes included preeclampsia, eclampsia, primary cesarean delivery, postpartum readmission, and infant stay greater than 5 days. Odds ratios were estimated with multiple logistic regression and adjusted for confounding effects. RESULTS: A total of 555 patients met inclusion criteria. Patients who underwent planned delivery at 37 weeks compared to expectant management did not appear to be at higher risk of adverse perinatal outcomes (14.9% vs 10.4%, aOR 1.49, 95% CI: 0.77-2.88). Similarly, we did not find a difference in the primary outcome in patients who underwent planned delivery at 38 weeks versus those expectantly managed (9.7% vs 10.1%, (aOR 0.84, 95% CI: 0.39-1.76). There were no differences in the rates of primary cesarean or preeclampsia at 37 and 38 weeks. CONCLUSION: Our findings suggest that there is no difference in neonatal or maternal outcomes for chronic hypertensive patients on medication if delivery is planned or expectantly managed at 37 or 38 weeks' gestation.

Sociodemographic risk factors associated with patient follow-up after implementation of a CardioObstetrics program.

Given the association of adverse pregnancy outcomes with risk of developing cardiovascular disease and cardiac events later in life, our institution launched a CardioObstetrics (CardioOB) program aimed to provide long-term care for patients at risk. We performed a retrospective cohort study in order to investigate which patient characteristics were associated with CardioOB follow-up following the inception of the program. We identified several sociodemographic factors and pregnancy characteristics such as increased maternal age, non-English language preferred, married marital status, referral during the antepartum period, and discharged with antihypertensive medications after delivery associated with a higher likelihood of CardioOB follow-up.

Nonadherence to treatment protocol for severe hypertension in pregnancy.

BACKGROUND: Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality and severe morbidity. The American College of Obstetricians and Gynecologists recommends treatment of persistent severe hypertension because this has been shown to improve overall outcomes. Treatment remains inconsistent and may be influenced by patient-level sociodemographic and clinical characteristics. OBJECTIVE: This study aimed to identify which factors are associated with nonadherence to an institutional protocol for the treatment of severe hypertension in pregnancy. STUDY DESIGN: Retrospective cohort study of patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg and/or diastolic blood pressures >110 mm Hg between 15 and 60 minutes apart) during their delivery hospitalization in 3 hospitals within an integrated health system from February 1, 2018 to March 1, 2020. Adherence to an institutional protocol was defined as receiving antihypertensive medication within 1 hour of a second severe blood pressure measurement. Demographic information, medical comorbidities, and delivery hospitalization characteristics were compared between women who received treatment based on institutional protocol and those who did not. Patient zone improvement plan codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey to extract socioeconomic characteristics. A multivariable logistic regression was performed to evaluate factors associated with delayed treatment while adjusting for potential confounders. RESULTS: Of the 996 patients included, 449 (45%) received treatment within 60 minutes and 547 (55%) did not. Having an elevated, nonsevere range blood pressure (adjusted odds ratio, 0.55; 95% confidence interval, 0.38-0.79) or a severe range blood pressure (adjusted odds ratio, 0.25; 95% confidence interval, 0.16-0.38) on admission, persistent severe hypertension ≥1 hour before or after delivery (adjusted odds ratio, 0.27; 95% confidence interval, 0.27-0.45), and chronic hypertension (adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.93) were associated with timely treatment. Hospital site (adjusted odds ratio, 1.97; 95% confidence interval, 1.18-3.28) and increasing gestational age (adjusted odds ratio, 1.14; 95% confidence interval, 1.07-1.21) were associated with nonadherence to treatment protocol. A subanalysis evaluating treatment in 344 (35%) patients who had a nonelevated blood pressure on admission showed that White race, persistent severe hypertension within 1 hour of delivery, increasing gestational age, body mass index, twin gestation, preferred language other than English or Spanish, and a higher neighborhood unemployment rate were associated with nonadherence to treatment protocol. CONCLUSION: Several factors were associated with nonadherence to an institutional protocol for treatment of persistent severe hypertension. Provider bias may impact whether treatment is executed or not. Awareness of these risk factors may improve timely administration of antihypertensive medication in pregnant and postpartum patients.

Adherence and acceptability of telehealth appointments for high-risk obstetrical patients during the coronavirus disease 2019 pandemic.

Background: Telehealth has been successfully implemented for the delivery of obstetrical care. However, little is known regarding the attitudes and acceptability of patients and providers in high-risk obstetrics and whether the implementation of a telehealth model improves access to care in nonrural settings. Objective: This study aimed to describe patient and provider attitudes toward telehealth for the delivery of high-risk obstetrical care in a large healthcare system with both urban and suburban settings and to determine whether the implementation of a telehealth model improves patient adherence to scheduled appointments in this patient population. Study Design: Two self-administered surveys were designed. The first survey was sent to all high-risk obstetrical patients who received a telehealth visit between March 1, 2020, and May 30, 2020. The second survey was designed for providers who participated in these visits. We also compared the attended, cancelled, and no-show visit rates before (March 1 to May 30, 2019) and after (March 1 to May 30, 2020) the telehealth implementation and telehealth vs in-person visits in 2020. We reviewed scheduled high-risk prenatal care appointments, diabetes mellitus education sessions, and genetic counseling and Maternal-Fetal Medicine consultations. Results: A total of 91 patient surveys and 33 provider surveys were analyzed. Overall, 86.9% of patients were satisfied with the care they received and 78.3% would recommend telehealth visits to others. Notably, 87.8% of providers reported having a positive experience using telehealth, and 90.9% believed that telehealth improved patients' access to care. When comparing patient and provider preference regarding future obstetrical care after experiencing telehealth, 73.8% of patients desired a combination of in-person and telehealth visits during their pregnancy. However, a significantly higher rate of providers preferred in-person than telehealth visits (56% vs 23%, P=.024, respectively). When comparing visits between 2019 and 2020, there was a significantly lower rate of no-show appointments (8.49% vs 4.61%, P<.001), patient-cancelled appointments (7.06% vs 4.96%, P<.001), and patient same-day cancellations (2.30% vs 1.35%, P<.001) with the implementation of telehealth. There was also a significantly lower rate of patient-cancelled appointments (3.82% vs 5.44%, P=.021) and patient same-day cancellations (0.60% vs 1.65%, P=.002) with those receiving telehealth visits than in-person visits in 2020. Conclusion: The implementation of a telehealth model in high-risk obstetrics has the potential to improve access to high-risk obstetrical care, by reducing the rate of missed appointments. Both patients and providers surveyed expressed a high rate of satisfaction with telehealth visits and a desire to integrate telehealth into the traditional model of high-risk obstetrical care.

Conservative management of uterine rupture in gestational trophoblastic neoplasia.

•Uterine artery embolization as management of uterine rupture due to invasive GTN.•Fertility preservation for select cases of uterine rupture due to invasive GTN.•Conservative surgery and chemotherapy for invasive GTN with uterine rupture.