The Association of Pregnancy With Outcomes Among Critically Ill Reproductive-Aged Women: A Propensity Score-Matched Retrospective Cohort Analysis.

BACKGROUND: The maternal mortality rate in the United States is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant vs nonpregnant critically ill patients show mixed results and are limited by small sample sizes. RESEARCH QUESTION: What is the association of pregnancy with critical illness outcomes? STUDY DESIGN AND METHODS: We performed a retrospective cohort study of women 18 to 55 years of age who received invasive mechanical ventilation (MV) on hospital day 0 or 1 or who demonstrated sepsis on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals from 2008 through 2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect. RESULTS: Three thousand ninety-three pairs were included in the matched MV cohort, and 13,002 pairs were included in the sepsis cohort. The characteristics of both cohorts were well balanced (all standard mean differences, < 0.1). Among matched pairs, unadjusted mortality was 8.0% vs 13.8% for MV and 1.4% vs 2.3% for sepsis among pregnant and nonpregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: OR, 0.50; 95% CI, 0.41-0.60; P < .001; sepsis: OR, 0.52; 95% CI, 0.40-0.67; P < .001). INTERPRETATION: In this large US cohort, critically ill pregnant women receiving MV or with sepsis showed better survival than propensity score-matched nonpregnant women. These findings must be interpreted in the context of likely residual confounding.

General Management Considerations for Placenta Accreta Spectrum.

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum.

BACKGROUND: The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE: In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN: This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS: A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION: The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

Searching for a biochemical correlate of critical illness in obstetrics: a descriptive study of maternal lactate in patients presenting for acute care in pregnancy.

Obstetric physiology may alter lactate metabolism and affect the ability to use lactate as a discriminator of critical illness in pregnancy. This prospective, cross-sectional study describes venous lactate levels in women presenting for acute care during pregnancy as well as characteristics associated with elevated lactate. Obstetric patients >20-week gestation presenting for acute evaluation were included and a venous lactate sample was drawn for each patient. Elevated lactate was defined as ≥2 mmol/L. One hundred two women were enrolled and venous lactate samples were obtained for 100 participants. Median lactate level was 1.22 (IQR 0.95-1.49) and 86% of patients had normal lactate. Six patients presented with infectious complaints, none of whom had sepsis or elevated lactate. Of the 14 patients with elevated lactate, all presented with labor complaints and 10 (71.4%) were admitted in labor. Elevated lactate level was significantly associated with labor complaints and admission in labor (p < .01). Thus, lactate may not be able to discriminate severe infection consistently in pregnancy as it is confounded by labor. Further research is necessary to clarify how lactate may be used more effectively in pregnant patients and to identify alternate strategies for sepsis screening.

An assessment of baseline risk factors for peripartum maternal critical care interventions.

BACKGROUND: Maternal morbidity presents a growing challenge to the American healthcare system and increasing numbers of patients are requiring higher levels of care in pregnancy. Identifying patients at high risk for critical care interventions, including intensive care unit admission, during delivery hospitalizations may facilitate appropriate multidisciplinary planning and lead to improved maternal safety. Baseline risk factors for critical care in pregnancy have not been well-described previously. OBJECTIVE: This study assesses baseline factors associated with critical care interventions that were present at admission for delivery. STUDY DESIGN: This is a secondary analysis of a multicenter observational registry of pregnancy after prior uterine surgery and primary cesarean delivery. All women with known gestational age were included. The primary outcome measure was a composite of critical care interventions that included postpartum intensive care unit admission, mechanical ventilation, central intravenous access, and arterial line placement. Risk for this critical care outcome measure was compared by selected baseline and obstetric characteristics known at the time of hospital admission, including maternal age, pre-pregnancy BMI, race, maternal co-morbidities, parity, and plurality. We evaluated these potential predictors and fit a multivariable logistic regression model to ascertain the most significant risk factors for critical care during a delivery hospitalization. RESULTS: 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 underwent a critical care intervention (0.7%). In the adjusted model, heart disease [aOR = 10.05, CI = 6.97 - 14.49], renal disease [aOR = 2.78, CI = 1.49 - 5.18], and connective tissue disease [aOR = 3.27, CI = 1.52 - 6.99], as well as hypertensive disorders of pregnancy [aOR = 2.04, CI = 1.31 - 3.17] were associated with the greatest odds of critical care intervention [p < .01] (Table 2). Other predictors associated with increased risk included maternal age, African American race, smoking, diabetes, asthma, anemia, nulliparity, and twin pregnancy. CONCLUSION: In this cohort, women with cardiac disease, renal disease, connective tissue disease and preeclampsia spectrum disorders were at increased risk for critical care interventions. Obstetric providers should assess patient risk routinely, ensure appropriate maternal level of care, and create multidisciplinary plans to improve maternal safety and reduce risk.

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

BACKGROUND: Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. OBJECTIVE: This study examined the association of maternal race with utilization of critical care interventions. STUDY DESIGN: This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. RESULTS: 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. CONCLUSION: This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.

Performing an urgent neonatal cardiac intervention safely during the COVID-19 pandemic.

The current pandemic has driven the medical community to adapt quickly to unprecedented challenges. Among these challenges is the need to minimize staff exposure to COVID-19 during neonatal cardiac procedures. In this report, we describe measures we have taken to protect health care workers while ensuring successful outcomes. These measures include wearing appropriate personal protective equipment, physical distancing, designating separate delivery and transport teams, and limiting the number of providers in direct contact with any patient who is infected or whose infection status is unknown. LEARNING OBJECTIVES: 1.To understand specific challenges caused by the COVID-19 pandemic for patients with congenital heart disease needing urgent neonatal intervention.2.To recognize measures that can be taken to minimize health care workers' exposures to the virus during high-risk neonatal cardiac procedures.3.To review the management of neonates with d-transposition of the great arteries and inadequate mixing.

Building an obstetric intensive care unit during the COVID-19 pandemic at a tertiary hospital and selected maternal-fetal and delivery considerations.

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.

Primed for a pandemic: Implementation of telehealth outpatient monitoring for women with mild COVID-19.

Close observation and rapid escalation of care is essential for obstetric patients with COVID-19. The pandemic forced widespread conversion of in-person to virtual care delivery and telehealth was primed to enable outpatient surveillance of infected patients. We describe the experience and lessons learned while designing and implementing a virtual telemonitoring COVID-19 clinic for obstetric patients. All patients with suspected for confirmed COVID-19 were referred and enrolled. Telehealth visits were conducted every 24 to 72 hours based on the severity of symptoms and care was escalated to in person when necessary. The outcome of the majority (96.1%) of telehealth visits was to continue outpatient management. With regard to escalation of care, 25 patients (26.6%) presented for in person evaluation and five patients (5.3%) required inpatient admission. A virtual telemonitoring clinic for obstetric patients with mild COVID-19 offers an effective surveillance strategy as it allows for close monitoring, direct connection to in person evaluation, minimization of patient and provider exposure, and scalability.

Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic.

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. KEY POINTS: · Telehealth for prenatal care is feasible.. · Telehealth may reduce coronavirus exposure during prenatal care.. · Telehealth should be tailored for high risk prenatal patients..

Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

Pulmonary embolism management in the critical care setting.

The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE. This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk. The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE.1 This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.

Abnormal placentation.

The term "morbidly adherent placenta" has recently been introduced to describe the spectrum of disorders including placenta accreta, increta and percreta. Due to excessive invasion of the placenta into the uterus there is associated significant maternal morbidity and mortality. Most significant risk factors for morbidly adherent placenta include history of prior cesarean delivery as well as placenta previa in the current pregnancy. Ultrasound remains the gold standard for antenatal diagnosis, however, in recent years MRI has assisted in identifying complex parametrial involvement. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multi-disciplinary team-based approach, and referral to an experienced center.

Cervical Length as a Predictor of Preterm Delivery in an Unselected Cohort of Women with Twin Pregnancies.

OBJECTIVE: To determine the risk of spontaneous preterm delivery (SPTD) associated with transvaginal cervical length (TVCL) in an unselected cohort. STUDY DESIGN: This is a retrospective study of serial TVCLs in unselected twin gestations. Receiver operator curves for SPTD were constructed from TVCLs at 18, 20, 22, and 24 weeks. Prediction thresholds were determined using a false discovery rate of 10%. The risk of SPTD was compared with previously published, prospective data from a meta-analysis. RESULTS: A total of 1,228 women were included. SPTD occurred prior to 35 weeks in 232 (18.9%), 126 (10.3%), and 24 (2.0%) women prior to 35, 32, and 28 weeks. TVCL was most predictive at 22 weeks (area under the curve = 0.67). TVCL thresholds for predicting SPTD prior to 35, 32, and 28 weeks were 3.1, 3.0, and 2.9 cm. Compared with a previous meta-analysis, the risk of SPTD < 34, 32, and 28 weeks was lower (positive likelihood ratio 9.0 vs. 5.4, 10.1 vs. 5.9, and 9.6 vs. 4.3). CONCLUSION: TVCL is modestly predictive of SPTD in twin gestations. Compared with previous prospective studies, this cohort has lower risk of SPTD at similar TVCLs.

SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care.

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.

Strategies to reduce disparities in maternal morbidity and mortality: Patient and provider education.

A reduction in racial disparities in maternal morbidity and mortality requires effective education of both patients and providers. Although providers seem to recognize that disparities exist, there is a widespread need for improving our understanding differences in health care and outcomes and the factors that contribute to them. There are increasingly more educational materials available for the purpose of augmenting disparities education among patients and providers. However, it is important to incorporate contemporary learning methodologies and technologies to address our current knowledge deficit. Collaborative educational models with a multi-disciplinary approach to patient education will be essential. Ultimately, the comprehensive education of providers and patients will require efforts on the part of numerous stakeholders within patient care delivery models. Further investigation will be necessary to determine how best to disseminate this information to maximize the impact of patient and provider educations with the goal of eliminating disparities in maternal morbidity and mortality.