Oxytocin versus oral misoprostol for PROM induction in nulliparas with unfavorable cervix: A randomized trial.

BACKGROUND: Induction of labor (IOL) is recommended following prelabor rupture of membranes (PROM). The optimal method for IOL and need for cervical ripening in those with PROM and an unfavorable cervical examination is unclear. OBJECTIVE: To determine if oxytocin or oral misoprostol results in a shorter time to delivery among nulliparous patients with an unfavorable cervical examination and PROM diagnosis and to evaluate patient satisfaction with both methods. STUDY DESIGN: This is a randomized clinical trial conducted at an urban tertiary care center from 2019-2023. Subjects were nulliparas ≥ 36 weeks with an unfavorable starting cervical exam (≤ 2 cm and Bishop < 8). The primary outcome was time from IOL to delivery in hours compared between oxytocin versus oral misoprostol. Secondary outcomes included suspected intraamniotic infection, cesarean delivery, composite maternal and neonatal morbidity, and patient satisfaction (assessed by Birth Satisfaction Scale-Revised (BSS-R)). Sub-group analyses for those with BMI ≥ 30kg/m2 and cervical dilation ≥ 1cm were performed. We required 148 subjects to have 80% power to detect a 2-hour difference in time to delivery. The study was stopped early by the DSMB due to feasibility concerns in recruiting desired sample size Results: 108 subjects were randomized: 56 oxytocin; 52 oral miso. The median gestational age at induction was 39.5 weeks; the mean starting cervical dilation was 1.1 cm. There was no statistical difference in time to delivery between groups overall: 14.9 hours oxytocin v. 18.1 hours oral misoprostol (p=0.06). In sub-group analyses, there was a 5h shorter time to delivery with oxytocin for those with a BMI ≥ 30kg/m2 (16.6 hours oxytocin v. 21.8 hours oral misoprostol, p 0.04) and 4.5h shorter time to delivery with oxytocin for those with cervix ≥ 1cm (12.9 hours oxytocin v. 17.3 hours oral misoprostol, p 0.04). There were no differences in intraamniotic infection, cesarean delivery, maternal or neonatal morbidity between the groups. Patient satisfaction was higher for those receiving oxytocin compared to misoprostol (29.0 vs. 26.3, p=0.03). CONCLUSIONS: Among nulliparas with PROM and an unfavorable cervix, there was no difference in overall time to delivery between oxytocin and oral misoprostol. This result should be interpreted with caution given early study discontinuation and inadequate power. However, a shorter time to delivery with oxytocin was noted in obese patients and those with cervical dilation of at least 1 cm. Furthermore, patient satisfaction was higher in the oxytocin group, and there was no increased risk of neonatal or maternal morbidity with oxytocin.

Genital VZV in a Third Trimester Pregnancy and the Critical Role of Interdisciplinary Planning.

Introduction: Herpes simplex (HSV) and varicella zoster (VZV) viruses are harmful infectious agents in pregnancy due to their ability to impact maternal-fetal dyads through various modalities including vertical transmission, neonatal infection, and maternal morbidity. As a result, accurate diagnosis and prompt treatment of these infections in pregnancy is critical. Case: A 19-year-old primigravida presented to our tertiary care center at 30 weeks' gestation with vulvar swelling, burning, and pain. Workup included direct PCR testing of a particularly erythematous area of the vulva which returned positive for VZV. The patient was treated with a 10-day course of acyclovir with resolution of her symptoms. She later had a full-term spontaneous vaginal delivery outside of the infectious window with no significant morbidity for either her or her neonate. Conclusion: Although a rare presentation, the presence of a genital lesion or labial swelling during pregnancy warrants workup for VZV, particularly among patients known to be varicella nonimmune. If genital VZV is diagnosed during pregnancy, the development of contingency plans through interdisciplinary collaboration should be pursued to ensure a safe delivery and postpartum course for both the maternal-fetal dyad as well as other patients on the unit and the provider care team.

Effects of Implementing a Routine Postpartum Fasting Blood Glucose on the Completion of the Gold Standard 2-Hour Oral Glucose Tolerance Test in Gestational Diabetics.

OBJECTIVE: Rates of completion of the gold standard 2-hour oral glucose tolerance test (OGTT) for impaired glucose intolerance postpartum in patients with gestational diabetes mellitus (GDM) are consistently less than 50%. Screening tests performed prior to hospital discharge, including fasting blood glucose (FBG) to detect persistent hyperglycemia, have been investigated. We lack evidence, however, on whether implementation of routine postpartum FBG impacts the likelihood of obtaining the routine 2-hour OGTT. We sought to retrospectively compare the rates of completion of the 2-hour OGTT pre- and postimplementation of a routine FBG screen. STUDY DESIGN: We performed a single-center retrospective cohort study comparing the completion of the 2-hour OGTT pre- and postimplementation of a routine FBG screen. Our primary outcome was the completion of the postpartum OGTT. Bivariate analyses assessed associations between demographic and preinduction clinical characteristics by pre- and post-implementation groups, as well as OGTT completion. Multivariable logistic regression was used to control for possible confounders. A sensitivity analysis was performed to account for the overlap with the coronavirus disease 2019pandemic. RESULTS: In total, 468 patients met the inclusion and exclusion criteria. In our post-intervention group, 64% of patients completed a postpartum FBG. For our primary outcome, completion of the 2-hour OGTT significantly decreased in our postintervention group from 37.1 to 25.9% (p = 0.009), adjusted odds ratio (aOR): 0.62, confidence interval (CI): 0.41-0.92. This difference was no longer statistically significant when excluding patients during the pandemic, from 40.3 to 33.1% (p = 0.228), aOR: 0.76, CI: 0.455-1.27. CONCLUSION: Implementation of a routine FBG was associated with a negative impact on patients completing a 2-hour OGTT. The difference was no longer significant when excluding patients who would have obtained the OGTT during the pandemic, which may have been due to the smaller cohort. Future work should investigate patient perceptions of the FBG and its impact on their decision-making around the OGTT. KEY POINTS: · Screening for postpartum glucose intolerance is imperative for gestational diabetics.. · A fasting blood glucose is recommended as a postpartum screen for hyperglycemia in GDM patients.. · Implementation of an FBG was associated with a decrease in completion of the gold standard OGTT..

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor.

OBJECTIVE: This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication. RESULTS: Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58). CONCLUSION: This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery. KEY POINTS: · Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

COVID-stasis of Pregnancy: An Increased Prevalence of COVID-19 in Patients with Cholestasis.

OBJECTIVE: To evaluate the relationship between intrahepatic cholestasis of pregnancy (ICP) and coronavirus disease 2019 (COVID-19). STUDY DESIGN: We performed a retrospective cohort study of pregnant women undergoing induction of labor (IOL) at a single institution between May 2020 to January 2021. Primary exposure was diagnosis of intrahepatic cholestasis of pregnancy (ICP). The primary outcome was the prevalence of COVID-19 as determined by reverse-transcriptase polymerase chain reaction testing on nasopharyngeal swabs for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) on routine admission testing. Secondary outcomes were abnormal laboratory values and adverse fetal outcomes. Logistic regression with log link analysis was performed comparing patients undergoing IOL for ICP compared with IOL for all other indications. The moderating effect of ethnicity was assessed by the interaction between ethnicity and ICP in a logistic regression model. The Wilcoxon rank-sum test and Fisher's exact test were performed for the secondary outcome analyses. RESULTS: Over the course of the study, 596 patients underwent IOL: 24 for ICP and 572 for other indications. The overall prevalence of COVID-19 positivity in the cohort was 5.5% (33 of 596). Those with ICP were more likely to test positive for COVID-19 compared with those with other IOL indications (29.2 vs. 4.5%, RR = 6.4, 95% CI: 2.8-12.5, p < 0.001). All patients with ICP who tested positive for COVID-19 were Hispanic. To analyze the moderating effect of ethnicity, the results of the logistic model found the interaction between ethnicity and ICP to not be significant (p = 0.991). In patients with ICP, the median AST (aspartate aminotransferase) was higher than those with COVID-19 (p = 0.0182). There were no adverse fetal outcomes in the ICP group. CONCLUSION: In this single-site retrospective cohort study, we demonstrated an increased prevalence of COVID-19 in those with ICP in general and among Hispanic patients specifically. Despite this difference, there was no increased risk of adverse fetal outcomes. KEY POINTS: · There is an increased prevalence of COVID-19 among Hispanic patients with ICP.. · The median AST of COVID-19-positive patients was significantly higher than COVID-19-negative patients.. · There was no increased risk of adverse fetal outcomes in with COVID-19 and ICP..

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance.

OBJECTIVE: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS: Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION: Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Trends in outcomes of pregnancy in patients with congenital heart disease.

PURPOSE OF REVIEW: This review aims to analyze the trends in the management of pregnant patients with congenital heart disease (CHD). RECENT FINDINGS: The literature that this article reviews specifically highlights the importance of multidisciplinary and specialized care, the unique and variable physiologic differences within the umbrella of CHD in pregnancy, and recommendations for obstetric and anesthetic care in the prenatal and peripartum period. SUMMARY: The findings that this article summarizes have profound implications for clinical practice and management of the patient with CHD, including the optimization of preoperative screening, facilitation of ideal prenatal care to include qualified specialists and resources, and recommendations for optimal anesthetic management during labor and delivery.

Elevated HbA1c on universal prenatal screening is associated with decreased postpartum weight retention.

OBJECTIVE: To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes. METHODS: This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c. RESULTS: 2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant (B = -0.86, p < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines. CONCLUSION: Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Text Message-Based Breastfeeding Support Compared With Usual Care: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether a postpartum text message-based communication platform improves breastfeeding rates. METHODS: In a randomized controlled trial, a control group receiving weekly text messages inquiring about infant feeding method was compared with an intervention group receiving educational text messages and personalized, text message-based breastfeeding support. The primary outcome was breastfeeding exclusivity at 6 weeks postpartum. Secondary outcomes included any breastfeeding and formula supplementation at 6 weeks postpartum. A sample size of 190 was planned to achieve 80% power to detect a 50% change in breastfeeding exclusivity from 40% baseline, with a two-sided alpha of 5%. Race was noted to be an effect modifier; therefore, results are presented overall and stratified by self-reported Black race compared with non-Black race. RESULTS: From January 2020 to January 2021, 300 patients were enrolled and 216 were randomized as follows: 110 to control and 106 to intervention. In the cohort, 52.8% were Black, 45.4% had public insurance, and 46.3% were nulliparous. There were no differences in demographic, delivery, or postpartum characteristics between groups. Among the 185 patients (85.6%) with data available for the primary outcome, there was no difference in breastfeeding exclusivity by treatment group (intervention 48.4% vs usual care 41.3%, P =.33). When stratified by race, Black patients in the intervention arm had 2.6 times higher odds of exclusively breastfeeding at 6 weeks postpartum compared with Black patients in the control arm (39.5% vs 20.0%, odds ratio 2.62, 95% CI 1.04-6.59). Enrollment in the intervention arm decreased the Black-non-Black disparity in the primary outcome (20.0% vs 66.7%, P <.001in usual care arm vs 39.5% vs 56.0%, P =.11 in intervention arm). There were no differences in other secondary outcomes. CONCLUSION: A text message-based communication platform was not associated with breastfeeding exclusivity at 6 weeks postpartum compared with usual care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04108533.

Adverse Pregnancy Outcomes in Nondiabetic Patients with an Elevated Early Pregnancy HbA1c.

OBJECTIVE: This study aimed to evaluate the impact of elevated early hemoglobin A1c (HbA1c) values on perinatal outcomes in patients without a diagnosis of diabetes or gestational diabetes. STUDY DESIGN: This is a retrospective study of patients with a singleton pregnancy who underwent universal HbA1c screening in early pregnancy at an urban tertiary care center between December 1, 2016, and December 31, 2018. Patients with pregestational diabetes mellitus (DM) and gestational DM (GDM) were excluded from analysis. The exposure of interest was HbA1c of 5.7 to 6.4% as measured on routine prenatal bloodwork at or during 16 weeks' gestation. The following pregnancy outcomes were assessed: preterm delivery <37 weeks, hypertensive disorders of pregnancy, shoulder dystocia, macrosomia (birth weight >4,000 g), small or large for gestational age neonate, operative vaginal delivery, third- or fourth-degree lacerations, cesarean delivery, neonatal intensive care unit (NICU) admission, neonatal hypoglycemia, and neonatal hyperbilirubinemia. Multivariable regression was performed to assess the relationship between HbA1c and selected adverse outcomes while controlling for potential confounders RESULTS: Of the 2,621 patients who met inclusion criteria, 334 (12.7%) had an elevated HbA1c of 5.7 to 6.4%. Patients with an elevated HbA1c were more likely to be older, Black, multiparous, publically insured, obese, or have chronic hypertension than patients with normal HbA1c values. In the unadjusted analysis, patients with an elevated HbA1c were less likely to deliver at term (84.7 vs. 92.4%, p = 0.006), but more likely to undergo cesarean section (32.8 vs. 27.6%, p = 0.038), develop hypertensive disorders of pregnancy (31.9 vs. 23.2%, p = 0.001), or deliver a macrosomic infant (10.5 vs. 6.8%, p = 0.016) than those with a normal A1c. After adjusting for race, body mass index, insurance status, nulliparity, and age, however, only the relationship between HbA1c and spontaneous preterm birth remained significant (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI]: 1.01-3.07). CONCLUSION: In our urban population, an elevated early HbA1c was associated with spontaneous preterm birth in nondiabetic patients KEY POINTS: · In nondiabetic patients, early pregnancy HbA1c was associated with selected adverse outcomes.. · Rates of preterm birth, pregnancy-induced hypertension, cesarean section, and macrosomia were higher in patients with an elevated HbA1c.. · The relationship between early pregnancy HbA1c and spontaneous preterm birth remained significant after adjustment..

Universal HbA1c screening and gestational diabetes: a comparison with clinical risk factors.

BACKGROUND: Screening strategies for gestational diabetes mellitus (GDM), particularly early GDM, have traditionally relied upon the use of clinical risk factors (CRFs). Although commonly used in nonpregnant patients, HbA1c screening is not widely used despite reports of abnormal HbA1c values being predictive of GDM development. The aims of this study are to assess the utility of universal HbA1c screening in predicting GDM and to compare universal screening to targeted CRF-based screening for the diagnosis of GDM. STUDY DESIGN: This is a retrospective cohort study of patients undergoing universal HbA1c screening at ≤16 completed weeks gestation with a singleton pregnancy between December 2016 and April 2018 at a single urban tertiary care center. Patients with preexisting diabetes (HbA1c ≥6.5%) or patients who did not have glucose tolerance testing were excluded. Patients with HbA1c 5.7-6.4% underwent early two-step GDM screening. Positive screens were diagnosed with early GDM. Normal early screeners underwent repeat 3rd trimester screening. Clinical risk factors for early GDM screening at our institution prior to universal screening were history of GDM, body mass index (BMI) ≥40 kg/m2, prior macrosomia (birth weight ≥4000 g) or stillbirth, and polycystic ovary syndrome. Multivariable regression was performed to assess the relationship between HbA1c and GDM. The predictive ability of universal HbA1c screening compared to that of CRFs was evaluated by testing for differences in the area under the curve (AUC) of receiver operating curves (ROCs). RESULTS: One thousand nine hundred and fifteen patients met inclusion criteria. Two hundred and thirty-one (12.1%) patients had an elevated HbA1c ≥5.7%. Patients with elevated HbA1c were more likely to be older, Black, or obese compared with patients with normal HbA1c values. After adjusting for Black race, BMI, age, and public insurance, the odds of GDM development are 3.50 (95%CI 2.26-5.39) times higher among patients with HbA1c ≥5.7% compared to those with a normal HbA1c. Clinical risk factors for early glucose screening were present in 33% of patients with an elevated HbA1c. The AUC of CRF screening and HbA1c ≥5.7% was 0.72 and 0.75, respectively (p= .07), after controlling for Black race, BMI, maternal age, and insurance. CONCLUSIONS: An elevated HbA1c is associated with an increased risk of GDM. Universal HbA1c screening performs as favorably as CRF based screening for the prediction of GDM.

A Pragmatic Approach to the Treatment of Women With Type 2 Diabetes in Pregnancy.

Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.

Universal testing for severe acute respiratory syndrome coronavirus 2 in 2 Philadelphia hospitals: carrier prevalence and symptom development over 2 weeks.

Background: The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 has challenged obstetrical care providers. Universal testing on labor and delivery units has been implemented by many hospitals to ensure patient and staff safety. Asymptomatic carrier rates are expected to vary based on geographic differences in disease prevalence, although differences within the same city have not been reported previously. In addition, clinical follow-up of women who had a negative result for severe acute respiratory syndrome coronavirus 2 during obstetrical hospitalization has not been included in any previous reports. Objective: This study aimed to describe the prevalence of positive severe acute respiratory syndrome coronavirus 2 test results among asymptomatic pregnant women at 2 Philadelphia obstetrical hospitals, characterize the clinical course of those who had a positive result, and report symptom development among all women tested in the 2 weeks after hospitalization. Study Design: This is an observational study of asymptomatic pregnant women who underwent severe acute respiratory syndrome coronavirus 2 testing at 2 academic health centers (Hospital of the University of Pennsylvania and Pennsylvania Hospital) in Philadelphia, Pennsylvania, between April 13, 2020, and April 26, 2020. All women tested were contacted via telephone for symptom follow-up at 1 and 2 weeks after discharge. Asymptomatic positive test rates are reported for the overall population and by hospital. The hospital and 2-week posthospital course are described for women who had a positive result for severe acute respiratory syndrome coronavirus 2. Posthospital symptom development among women who had a negative result for severe acute respiratory syndrome coronavirus 2 is also described. Results: A total of 318 asymptomatic women underwent severe acute respiratory syndrome coronavirus 2 testing during this 2-week period; 8 women had a positive result. The overall asymptomatic test positive rate was 2.5%. The rate at Hospital of the University of Pennsylvania was 3.8% compared with 1.3% at Pennsylvania Hospital (P=.283). Of note, 3 women (37.5%) who were initially asymptomatic developed mild symptoms in the 2 weeks after a positive test result. Repeat severe acute respiratory syndrome coronavirus 2 testing was performed in 14 of the 310 women (4.5%) who initially had a negative result; 2 women (0.6%) had a positive result on repeat testing. Moreover, 242 (78.1%) and 213 (68.7%) of the 310 women who had a negative result for severe acute respiratory syndrome coronavirus 2 at the time of the initial hospitalization were followed up via telephone at 1 and 2 weeks after admission, respectively. Viral symptoms, including fevers, chills, shortness of breath, or cough, were self-reported in 4.5% and 4.2% of these women at 1 and 2 weeks after discharge, respectively. Conclusion: The asymptomatic positive severe acute respiratory syndrome coronavirus 2 test rate among an obstetrical population in Philadelphia differed between 2 hospitals and was lower than that described in other geographic regions. This supports the importance of institution-specific testing protocols. The development of symptomatic severe acute respiratory syndrome coronavirus 2 infection after hospitalization among women with initial negative test results is uncommon.

The Psychological Experience of Obstetric Patients and Health Care Workers after Implementation of Universal SARS-CoV-2 Testing.

OBJECTIVE: This study was aimed to describe the hospitalization and early postpartum psychological experience for asymptomatic obstetric patients tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as part of a universal testing program and report the impact of this program on labor and delivery health care workers' job satisfaction and workplace anxiety. STUDY DESIGN: This is a cohort study of asymptomatic pregnant women who underwent SARS-CoV-2 testing between April 13, 2020 and April 26, 2020. Semistructured interviews were conducted via telephone at 1 and 2 weeks posthospitalization to assess maternal mental health. Depression screening was conducted using the patient health questionnaire-2 (PHQ-2). An online survey of labor and delivery health care workers assessed job satisfaction and job-related anxiety before and during the novel coronavirus disease 2019 (COVID-19) pandemic, as well as employees' subjective experience with universal testing. Patient and employee responses were analyzed for recurring themes. RESULTS: A total of 318 asymptomatic women underwent SARS-CoV-2 testing during this 2-week period. Six of the eight women (75%) who tested positive reported negative in-hospital experiences secondary to perceived lack of provider and partner support and neonatal separation after birth. Among the 310 women who tested negative, 34.4% of multiparous women reported increased postpartum anxiety compared with their prior deliveries due to concerns about infectious exposure in the hospital and lack of social support. Only 27.6% of women, tested negative, found their test result to be reassuring. Job satisfaction and job-related anxiety among health care workers were negatively affected. Universal testing was viewed favorably by the majority of health care workers despite concerns about delays or alterations in patient care and maternal and neonatal separation. CONCLUSION: Universal testing for SARS-CoV-2 in obstetric units has mixed effects on maternal mental health but is viewed favorably by labor and delivery employees. Ongoing evaluation of new testing protocols is paramount to balance staff and patient safety with quality and equality of care. KEY POINTS: · Women with SARS-CoV-2 had a negative hospital experience.. · A negative SARS-CoV-2 test was not reassuring for patients.. · COVID-19 negatively impacts healthcare workers' well-being..

Association between cell-free DNA fetal fraction and gestational diabetes.

OBJECTIVE: To determine the association between cell-free DNA (cfDNA) fetal fraction and gestational diabetes (GDM) in a cohort of women presenting for cfDNA screening for fetal aneuploidy. METHODS: A retrospective cohort study of women with singleton pregnancies who had cfDNA screening at a single institution at 10 to 20 weeks gestation between October 2011 and October 2017. Fetal fractions were adjusted for gestational age (GA) using multiples of the median (MoM). Multivariable logistic regression was used to estimate the odds ratio (OR) of GDM controlling for potential confounders. RESULTS: Two thousand six hundred twenty-three pregnancies met criteria. Women with GDM had a lower fetal fraction (0.93 MoM vs. 1.05 MoM, P = .002). However, the association between fetal fraction and GDM was not significant after adjusting for body mass index (BMI) [OR 0.84, 95% confidence interval (CI) 0.52-1.36; P = .48]. Since insulin resistance increases at later GAs, separate analysis on women with GA 14 to 20 weeks was performed. Again, the association between fetal fraction and GDM was not significant after adjusting for BMI, (OR 0.81, 95% CI 0.31-2.12; P = .67). CONCLUSION: Low or high fetal fraction of cfDNA was not associated with GDM. Although fetal fraction was lower among women diagnosed with GDM, this relationship was no longer statistically significant once maternal BMI was taken into account.

Validation of a Breastfeeding History Questionnaire for the Risk of In-Hospital Formula Supplementation Among Multiparous Women.

BACKGROUND: A woman's prior breastfeeding history may influence future decisions regarding infant feeding. Few quantitative tools utilizing this information have been demonstrated to predict breastfeeding success. RESEARCH AIM: To evaluate the efficacy of a prenatal breastfeeding history (BAP) questionnaire administered in prenatal care to predict in-hospital formula supplementation among multiparous women. METHODS: This is a prospective observational study of multiparous women with singleton pregnancies who presented to a Baby-Friendly urban tertiary care center for 1st prenatal visit at < 20 weeks' gestation. The BAP tool generates a numerical score, with higher score (≥ 2) indicating prior successful breastfeeding experiences. The primary outcome was occurrence of non-medically indicated formula supplementation during the postpartum hospital stay. Student's t test and Pearson's chi-square test were used to compare continuous and categorical variables. A multivariable logistic regression was performed to assess the relationship of BAP score to formula supplementation. Of 587 women screened, 433 (73.8%) mother-infant dyads were analyzed. RESULTS: Rates of formula supplementation in women with BAP scores ≤ 1 were 67% (156/234) compared with 37% (73/199) in women with higher scores (p < 0.0001). After controlling for race/ethnicity, insurance, and obesity, women with BAP scores of ≤ 1 were 2.6 times more likely to supplement formula than women with higher scores (aOR 2.62, 95% CI [1.70, 4.04], p < .0001). CONCLUSION: In this prospective validation study, women with negative prior breastfeeding experiences, as evidenced by a lower BAP score, were more likely to supplement formula during the postpartum hospital stay.

Interpregnancy Body Mass Index Changes: Distribution and Impact on Adverse Pregnancy Outcomes in the Subsequent Pregnancy.

OBJECTIVE: To examine the change in body mass index (BMI) categories between pregnancies and its effect on adverse pregnancy outcomes. STUDY DESIGN: We performed a retrospective cohort study of women with two consecutive deliveries from 2005 to 2010. Analysis was limited to women with BMI recorded at <24 weeks for both pregnancies. Standard BMI categories were used. Adverse pregnancy outcomes included preterm birth at <37 weeks, intrauterine growth restriction (IUGR), pregnancy-related hypertension, and gestational diabetes mellitus (GDM). Women with increased BMI category between pregnancies were compared with those who remained in the same BMI category. RESULTS: In total, 537 women were included, of whom 125 (23%) increased BMI category. There was no association between increase in BMI category and risk of preterm birth, IUGR, or pregnancy-related hypertension. Women who increased BMI category had an increased odds of GDM compared with women who remained in the same BMI category (6.4 vs. 2.2%; p = 0.018). The increased risk remained after controlling for age, history of GDM, and starting BMI (adjusted odds ratio: 8.2; 95% confidence interval: 2.1-32.7; p = 0.003). CONCLUSION: Almost one-quarter of women increased BMI categories between pregnancies. This modifiable risk factor has a significant impact on the risk of GDM.

Association of Fetal Fraction of Cell-Free DNA and Hypertensive Disorders of Pregnancy.

OBJECTIVE: The objective of this study is to examine the relationship between fetal fraction and hypertensive disorders of pregnancy. STUDY DESIGN: This is a retrospective cohort study of women with singleton pregnancies who had cell-free DNA (cfDNA) screening at 10 to 20 weeks of gestation. The primary outcome was the development of gestational hypertension (gHTN), preeclampsia (PEC), and PEC with severe features. Multinomial logistic regression was performed to assess the relationship between fetal fraction and pregnancy outcomes of interest while controlling for potential confounders. RESULTS: Among 2,701 women meeting inclusion criteria, 387 (14.3%) were diagnosed with hypertensive disorders of pregnancy. First-trimester fetal fraction was significantly lower in women diagnosed with hypertensive disorders of pregnancy (10.9 vs. 12.4, p < 0.0001). An increased risk of gHTN and PEC, PEC with severe features with delivery > 34 weeks, and PEC with severe features with delivery ≤ 34 weeks was seen with lower first-trimester fetal fractions (odds ratio [OR]: 0.55, 95% confidence interval [CI] [0.36-0.83], p = 0.005; OR: 0.59, 95% CI [0.35-0.99], p = 0.048; and OR: 0.27, 95% CI [0.08-0.96], p = 0.044). The relationship between fetal fraction and hypertensive disorders of pregnancy was not statistically significant after adjusting for maternal age, race, body mass index, and chronic hypertension. CONCLUSION: Fetal fraction of cfDNA at 10 to 20 weeks of gestation was not associated with the development of hypertensive disorders of pregnancy.

Screening for Aneuploidy in Multiple Gestations: The Challenges and Options.

As the incidence of multiple gestations increases, the need for effective aneuploidy screening grows. There are unique challenges associated with aneuploidy screening in twins, and the data supporting its use are limited. This article summarizes the risk of aneuploidy for twin gestations and the available screening methods, including nuchal translucency, first-trimester and second-trimester serum screening, and cell-free DNA screening.