Expedited postpartum discharge during the COVID-19 pandemic and acute postpartum care utilization.

BACKGROUND: Early postpartum discharges increased organically during the COVID-19 pandemic. It is not known if this 'natural experiment' of shorter postpartum hospital stays resulted in increased risk for postpartum readmissions and other acute postpartum care utilization such as emergency room encounters. OBJECTIVE: The objectives of this study were to determine which clinical factors were associated with expedited postpartum discharge and whether the expedited postpartum discharge was associated with increased risk for acute postpartum care utilization. METHODS: This retrospective cohort study evaluated birth hospitalizations at affiliated hospitals during two periods: (i) the apex of the 'first wave' of the COVID-19 pandemic in New York City (3/22/20 to 4/30/20) and (ii) a historical control period of one year earlier (3/22/19 to 4/30/19). Routine postpartum discharge was defined as ≥2 d after vaginal birth and ≥3 d after cesarean birth. Expedited discharge was defined as <2 d after vaginal birth and <3 d after cesarean birth. Acute postpartum care utilization was defined as any emergency room visit, obstetric triage visit, or postpartum readmission ≤6 weeks after birth hospitalization discharge. Demographic and clinical variables were compared based on routine versus expedited postpartum discharge. Unadjusted and adjusted logistic regression models were performed to analyze factors associated with (i) expedited discharge and (ii) acute postpartum care utilization. Unadjusted (ORs) and adjusted odds ratios (aORs) with 95% CIs were used as measures of association. Stratified analysis was performed restricted to patients with chronic hypertension, preeclampsia, and gestational hypertension. RESULTS: A total of 1,358 birth hospitalizations were included in the analysis, 715 (52.7%) from 2019 and 643 (47.3%) from 2020. Expedited discharge was more common in 2020 than in 2019 (60.3% versus 5.0% of deliveries, p < .01). For 2020, clinical factors significantly associated with a decreased likelihood of expedited discharge included hypertensive disorders of pregnancy (OR 0.40, 95% CI 0.27-0.60), chronic hypertension (OR 0.14, 95% CI 0.06-0.29), and COVID-19 infection (OR 0.51, 95% CI 0.34-0.77). Cesarean (OR 3.00, 95% CI 2.14-4.19) and term birth (OR 3.34, 95% CI 2.03, 5.49) were associated with an increased likelihood of expedited discharge. Most of the associations retained significance in adjusted models. Expedited compared to routine discharge was not associated with significantly different odds of acute postpartum care utilization for 2020 deliveries (5.4% versus 5.9%; OR 0.92, 95% CI 0.47-1.82). Medicaid insurance (OR 2.30, 95% CI 1.06-4.98) and HDP (OR 5.16, 95% CI: 2.60-10.26) were associated with a higher risk of acute postpartum care utilization and retained significance in adjusted analyses. In the stratified analysis restricted to women with hypertensive diagnoses, expedited discharge was associated with significantly increased risk for postpartum readmission (OR 6.09, 95% CI 2.14, 17.33) but not overall acute postpartum care utilization (OR 2.17, 95% CI 1.00, 4.74). CONCLUSION: Expedited postpartum discharge was not associated with increased risk for acute postpartum care utilization. Among women with hypertensive diagnoses, expedited discharge was associated with a higher risk for readmission despite expedited discharge occurring less frequently.

Clinical and Demographic Risk Factors for COVID-19 during Delivery Hospitalizations in New York City.

OBJECTIVE: This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19. STUDY DESIGN: This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19. RESULTS: Of 454 women delivered, 79 (17%) had COVID-19. Of those, 27.9% (n = 22) had symptoms such as cough (13.9%), fever (10.1%), chest pain (5.1%), and myalgia (5.1%). While women with COVID-19 were more likely to live in the ZIP codes quartile with the most cases (47 vs. 41%) and less likely to live in the ZIP code quartile with the fewest cases (6 vs. 14%), these comparisons were not statistically significant (p = 0.18). Women with COVID-19 were less likely to have a vaginal delivery (55.2 vs. 51.9%, p = 0.04) and had a significantly longer postpartum length of stay with cesarean (2.00 vs. 2.67days, p < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80). CONCLUSION: COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients. KEY POINTS: · COVID-19 symptoms were present in a minority of COVID-19-positive women admitted.. · COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York.. · Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients..

Factors Associated with Previable Delivery following Second Trimester Rupture of Membranes.

OBJECTIVE: To identify factors associated with previable delivery in second trimester preterm rupture of membranes (PROM). STUDY DESIGN: We conducted a single-center retrospective cohort study of women with pregnancies complicated by second trimester PROM (14.0-21.9 weeks' gestation) from 2000 to 2015 who elected expectant pregnancy management and achieved at least 24 hours latency. Maternal characteristics and clinical factors were compared among pregnancies that reached viability (≥ 23.0 weeks) and pregnancies delivered before viability (< 23.0 weeks) using appropriate statistical methods. RESULTS: Of 73 pregnancies complicated by second trimester PROM, 49 (67%) delivered before viability. Maternal race, history of preterm birth, and tobacco use were similar between women who delivered < 23 weeks versus ≥ 23 weeks. Gestational age at PROM, cervical dilation > 1cm, Group B streptococcus carrier status, bacterial vaginosis, and chlamydial infection during pregnancy were similar between groups. Median time to delivery was significantly shorter in women who delivered < 23 weeks compared with those who reached ≥ 23 weeks (6 vs. 46 days, p < 0.01). CONCLUSION: Previable delivery occurred in the majority of women with second trimester PROM. No maternal or clinical factors were associated with delivery prior to viability. Counseling women with second trimester PROM should include the inability to determine which pregnancies will reach viability.

Preclinical Labor-and-Delivery Shadowing: The Impact on Medical Students' Perceptions of Obstetrics and Gynecology.

Objective We sought to determine the impact of preclinical exposure (shadowing) to labor and delivery (L&D) on medical students' perceptions of obstetrics and gynecology (OB/GYN). Study Design We administered a written survey to rising third-year medical students at a single center prior to any clerkship. We described motivation/deterrents for shadowing among students, and experiences/perceptions of those students who shadowed. Results In total, 119/136 (86%) students completed the survey. Of those, 29% participated in shadowing on L&D. Participating students were more likely to be female (79 vs. 21%; p < 0.01) and in their first year (85%). Ninety-one percent participated because they wanted more exposure to OB/GYN, whereas only 53% they were interested in OB/GYN. Students who did not shadow indicated not having enough time as the main reason. After participation, 82% had more perspective on OB/GYN than prior to shadowing. Ninety-seven percent felt that the experience was worthwhile; 62% stated based on their experience that they were likely to consider a career in OB/GYN. All students who participated stated that they would opt to shadow again if given the opportunity. Conclusion Students who have L&D shadowing exposure report very positive experiences and express desire for increased opportunities. OB/GYN departments may consider increasing availability of L&D shadowing opportunities for preclinical medical students.

Maternal Gut Microbiome Biodiversity in Pregnancy.

OBJECTIVE: To measure maternal gut microbiome biodiversity in pregnancy. MATERIALS AND METHODS: In phase 1, maternal fecal samples were collected by rectal swab in 20 healthy pregnant women (14-28 weeks gestation) to measure bacterial abundance. In phase 2, fecal samples were collected from 31 women at enrollment (<20 weeks gestation, baseline) and at 36 to 39 weeks of gestation (follow-up). We assessed cluster analysis to assess bacterial community profiles at the phylum level longitudinally through pregnancy. DNA was extracted from swabs, followed by PCR of the bacterial 16s rRNA gene and multiplex high-throughput sequencing (Ion Torrent). RESULTS: In phase 1, 16 of 20 samples yielded usable data. White women (n = 10) had greater abundance of Firmicutes (23 ± 0.15 vs. 16% ± 0.75, p = 0.007) and Bacteroidetes (24 ± 0.14 vs. 19% ± 0.68, p = 0.015) compared with non-White women (n = 6). In the 11 paired specimens, Bacteroidetes increased in abundance from baseline to follow-up. Compared with women who gained weight below the median gestational weight gain (GWG, <15.4 kg), those who gained above the median GWG had increased abundance of Bacteroidetes (p = 0.02) and other phyla (p = 0.04). CONCLUSION: Maternal microbiome biodiversity changes as pregnancy progresses and correlates with GWG.

Maternal Morbidity After Previable Prelabor Rupture of Membranes.

OBJECTIVE: To identify risk factors for maternal morbidity after previable prelabor rupture of membranes (PROM). METHODS: We conducted a case-control study of singleton and twin pregnancies complicated by previable PROM (14.0-22.9 weeks of gestation) at a single tertiary care referral institution, 2000-2015. Pregnancies complicated by fetal anomalies, previable PROM within 2 weeks of chorionic villus sampling or amniocentesis, and those with contraindications to expectant management (eg, chorioamnionitis) were excluded. Cases were women with the primary outcome of composite maternal morbidity (defined as having at one or more of the following: sepsis, intensive care unit admission, acute renal insufficiency, uterine curettage, hysterectomy, deep vein thrombosis, pulmonary embolus, blood transfusion, readmission, or maternal death). Controls were women without the primary composite morbidity. Bivariate analysis compared demographic, clinical, and management characteristics of women in the case group and those in the control group. Multivariable logistic regression models were developed to quantify the association between maternal characteristics and composite severe maternal morbidity. RESULTS: During the study period, 174 women presented with by previable PROM and were candidates for expectant management. Sixty-five (37%) women opted for immediate delivery; 109 (63%) elected expectant management. Twenty-five of 174 (14%) experienced one or more components of the composite maternal morbidity (cases) and were compared with 149 (86%) women in the control group. Women in the case group were more not more likely to elect expectant management (68% compared with 59%, P=.40), but were more likely to be aged 35 years or older (40% compared with 14%, P=.002) or to be carrying twins (52% compared with 16%, P<.01). In the regression model, twin gestation and age 35 years or older were both significantly associated with increased odds of composite maternal morbidity (odds ratio [OR] 5.62, 95% confidence interval [CI] 2.21-14.3 and OR 4.00, 95% CI 1.48-10.8, respectively). CONCLUSION: Antenatal counseling of women with previable PROM should include that one in seven women experience significant morbidity. Although expectant management was not associated with increased risk in this cohort, women with twins or those aged 35 years or older were at substantially increased risk.

SIX2 Effects on Wilms Tumor Biology.

Wilms tumor (WT) blastema retains gene expression profiles characteristic of the multipotent nephron progenitor pool, or cap mesenchyme (CM), in the developing kidney. As a result, WT blastema and the CM are believed to represent contextual analogues of one another. Sine oculis homeobox 2 (SIX2) is a transcription factor expressed specifically in the CM, provides a critical mechanism for CM self-renewal, and remains persistently active in WT blastema, although its purpose in this childhood malignancy remains unclear. We hypothesized that SIX2, analogous to its function in development, confers a survival pathway to blastema, the putative WT stem cell. To test its functional significance in WT biology, wild-type SIX2 was overexpressed in the human WT cell line, WiT49. After validating this model, SIX2 effects on anchorage-independent growth, proliferation, invasiveness, canonical WNT pathway signaling, and gene expression of specific WNT pathway participants were evaluated. Relative to controls, WiT49 cells overexpressing SIX2 showed significantly enhanced anchorage-independent growth and early-passage proliferation representing surrogates of cell survival. Interestingly, overexpression of SIX2 generally repressed TCF/LEF-dependent canonical WNT signaling, which activates and coordinates both differentiation and stem pathways, but significantly heightened canonical WNT signaling through the survivin promoter, a mechanism that exclusively maintains the stem state. In summary, when overexpressed in a human WT cell line, SIX2 enhances cell survival and appears to shift the balance in WNT/ß-catenin signaling away from a differentiation path and toward a stem cell survival path.