COVID-19 in Pregnant Women: Case Series from One Large New York City Obstetrical Practice.

OBJECTIVE: This study aimed to report a case series of pregnant women in New York City with confirmed or presumed coronavirus disease (COVID-19) infection. STUDY DESIGN: Beginning March 22, 2020, all pregnant women from one large obstetrical practice in New York City were contacted regularly to inquire about symptoms of COVID-19 (fever, cough, shortness of breath, malaise, anosmia), or sick contacts. A running log was kept of these patients, as well as all patients who underwent COVID-19 testing. For this report, we included every patient with suspected COVID-19 infection, which was defined as at least two symptoms, or a positive COVID-19 nasopharyngeal polymerase chain reaction test. RESULTS: From March 22, 2020 until April 30, 2020, 757 pregnant women in our practice were evaluated and 92 had known or suspected COVID-19 (12.2%, 95% confidence interval [CI]: 10.0-14.7%). Of these 92 women, 33 (36%) had positive COVID-19 test results. Only one woman required hospital admission for 5 days due to COVID-19 (1.1%, 95% CI: 0.2-5.9%). One other woman received home oxygen. No women required mechanical ventilation and there were no maternal deaths. One woman had an unexplained fetal demise at 14 weeks' gestation around the time of her COVID-19 symptoms. Twenty one of the 92 women have delivered, and all were uncomplicated. CONCLUSIONS: Among 92 women with confirmed or presumed COVID-19, the overall morbidity was low. These preliminary results are encouraging for pregnant women during the COVID-19 pandemic. KEY POINTS: · Coronavirus disease (COVID-19) is prevalent in New York City.. · In this case series, COVID-19 in pregnant women had a very low morbidity and no mortality.. · This preliminary data is reassuring for pregnant women at risk of COVID-19..

Induction of Labor versus Cesarean Delivery in Twin Pregnancies.

OBJECTIVE: This study was aimed to compare maternal and neonatal outcomes between women with twin pregnancies who underwent induction of labor with those women who had planned Cesarean delivery (CD). STUDY DESIGN: This is a retrospective cohort study of women with twin pregnancies ≥ 24 weeks with an indication for delivery but not in labor. Two groups were examined, women who underwent induction and women who underwent planned CD. Maternal and neonatal outcomes were compared between groups both for deliveries at gestational age ≥ 37 weeks and < 37 weeks. RESULTS: A total of 453 patients were included. Overall, 212 (46.8%) women underwent induction and 241 (53.2%) underwent planned CD. Women who underwent induction of labor had a high rate of VD, both in the term and preterm groups (69.8 and 73.6%, respectively). Women who underwent induction of labor had reduced maternal length of stay, neonatal length of stay, and blood loss, without any increase in adverse outcomes. Neonatal ventilation of either twin delivered < 37 weeks was higher in the CD compared with induction group (27.5 vs. 9.4%, p < 0.01), but this was not significant on adjusted odds ratio analysis (aOR = 0.71, 95% CI: 0.19-2.66). CONCLUSION: Labor induction in twin gestations have improved maternal outcomes and similar neonatal outcomes compared with planned CD.

The Association between Intended Mode of Delivery and Maternal Morbidity in Twin Pregnancies.

OBJECTIVE: To compare maternal morbidity between women undergoing delivery of twins who intend to labor with those women who do not intend to labor. STUDY DESIGN: This was a retrospective cohort study of women undergoing delivery of twins in a single maternal-fetal medicine practice between January 2005 and February 2018. We identified women with a twin delivery at gestational age ≥24 weeks and determined if they intended or did not intend to labor. Maternal outcomes were compared between the groups. RESULTS: A total of 788 patients were included, of whom 404 (51.3%) intended to labor and 384 (48.7%) did not intend to labor. Women who intended to labor had a high rate of vaginal delivery (VD; 79.7%). Overall, 45 (5.7%) women required blood transfusion; this was not significantly different between the groups (6.2 vs. 5.2%, p = 0.54). Women who intended to labor had a shorter hospital stay and lower blood loss. There were no significant differences for all other maternal outcomes. CONCLUSION: In patients undergoing twin delivery, women who intend to labor have similar maternal morbidity compared with women who do not intend to labor. This supports current guidelines recommending providers offer a trial of VD for twin pregnancies.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries.

OBJECTIVE: To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique. METHODS: We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups. RESULTS: There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86). CONCLUSION: For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

The association between maternal race and adverse outcomes in twin pregnancies with similar healthcare access.

OBJECTIVE: To compare twin pregnancy outcomes between white and nonwhite women with similar access to health care. METHODS: Retrospective cohort study of all twin pregnancies delivered by a single maternal-fetal medicine practice from 2005-2016. All patients had private health insurance and equal access to physician care. Outcomes were compared between white and nonwhite women using logistic regression to adjust for differences at baseline. RESULTS: Of the 858 women included, 730 (85.1%) were white and 128 (14.9%) were nonwhite. Univariate analysis demonstrated that nonwhite women had higher rates of preterm birth <32 weeks (12.5 versus 6.7%, p = .022), cesarean delivery (78.1% versus 61.4% of all women, p < .001 and 43.5% versus 16.1% of women who attempted labor, p < .001), preeclampsia (22.4% versus 14.5%, p = .029) and gestational diabetes (23.2% versus 7.3%, p < .001). On adjusted analysis, nonwhite race remained significantly associated with cesarean delivery in women who attempted labor (aOR 2.27, 95% CI: 1.09, 4.71) and gestational diabetes (aOR 2.61, 95% CI: 1.53, 4.45). CONCLUSIONS: Nonwhite women with twin pregnancies have an increased risk of adverse outcomes that cannot be explained by access to care. Although improving access to care is an important goal for health care systems, our data suggest that this alone will not eliminate all disparities in health care outcomes between women of different races.

Labor and Delivery of Twin Pregnancies.

Obstetricians who care for twin pregnancies should be aware of the challenges that may arise during the labor and delivery. With recognition of these issues and proper training, providers should be able to help women with twin pregnancies achieve a safe delivery for them and their babies. With the use of breech extraction of the second twin and active management of the second stage of labor, women with twin pregnancies can also achieve a high vaginal delivery rate of both twins.

Risk factors for blood transfusion in patients undergoing high-order Cesarean delivery.

BACKGROUND: The objective was to identify risk factors associated with blood transfusion in patients undergoing high-order Cesarean delivery (CD). STUDY DESIGN AND METHODS: This was a retrospective cohort study of patients undergoing third or more CD by a single maternal-fetal medicine practice between 2005 and 2016. We compared risk factors between women who did and did not receive a red blood cell transfusion during the operation or before discharge. Repeat analysis was performed after excluding women with placenta previa. RESULTS: A total of 514 patients were included, 18 of whom (3.5%; 95% confidence interval [CI], 2.2%-5.5%) received a blood transfusion. Placenta previa was the most significant risk factor for transfusion (61.1% of patients who received a transfusion vs. 1% of patients who did not; p < 0.001). Patients with a placenta previa had a 68.8% likelihood of requiring a blood transfusion. After women who had placenta previa were excluded, the incidence of blood transfusion was seven of 498 (1.4%; 95% CI, 0.7%-2.9%). Risk factors significantly associated with blood transfusion in the absence of previa were prophylactic anticoagulation during pregnancy and having labored. The incidence of transfusion in patients with no placenta previa, no anticoagulation, and no labor was 0.7% (95% CI, 0.3%-2.1%). Placenta previa was the most predictive risk factor for transfusion with a positive predictive value of 68.8% and a negative predictive value of 98.4%. CONCLUSION: In patients undergoing a third or more CD, only placenta previa, prophylactic anticoagulation during pregnancy, and having labored are independently associated with requiring a blood transfusion. These data can be used to guide physician ordering of prepared blood products preoperatively.

Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery.

OBJECTIVE: The purpose of this study was to estimate independent risk factors for cesarean delivery in patients with twin pregnancies who attempt vaginal delivery. STUDY DESIGN: This was an historic cohort of twin pregnancies that were delivered in 1 practice from June 2005 to February 2014. Baseline characteristics were compared between women who delivered vaginally and women who underwent cesarean delivery in labor. Logistic regression analysis was performed to estimate independent risk factors for cesarean delivery. RESULTS: Two hundred eighty-six women with twin pregnancies who had attempted vaginal delivery were included in the study. The overall modes of delivery were vaginal delivery (82.2%), cesarean delivery (17.8%), and combined vaginal-cesarean delivery (0%). The most common indication for cesarean delivery in labor was an arrest disorder (82.4%). The risk factors that were associated independently with cesarean delivery were nulliparity (adjusted odds ratio, 5.78; 95% confidence interval, 2.24-14.88) and advanced maternal age of ≥35 years (adjusted odds ratio, 2.36; 95% confidence interval, 1.16-4.80). The patients at highest risk for cesarean delivery (nulliparous, advanced maternal age, induced labor) still had a 48.6% likelihood of vaginal delivery. CONCLUSION: In patients with twin pregnancies who attempt labor, nulliparity and advanced maternal age are associated independently with cesarean delivery in labor. However, even the patients at highest risk for cesarean delivery have nearly a 50% likelihood of successful vaginal delivery and therefore should be allowed to attempt vaginal delivery if it is desired and not otherwise contraindicated.

The effect of maternal obesity on outcomes in patients undergoing tertiary or higher cesarean delivery.

OBJECTIVE: To estimate the association between maternal obesity and adverse outcomes in patients without placenta previa or accreta undergoing a tertiary or higher cesarean delivery. STUDY DESIGN: Retrospective cohort of patients cared for by a single MFM practice undergoing a tertiary or higher cesarean delivery from 2005 to 2013. Patients attempting vaginal delivery and patients with placenta accreta and/or placenta previa were excluded. We estimated the association of maternal obesity (prepregnancy BMI ≥ 30 kg/m(2)) and maternal outcomes. The primary outcome was a composite of severe maternal morbidity (uterine rupture, hysterectomy, blood transfusion, cystotomy requiring repair, bowel injury requiring repair, intensive care unit admission, thrombosis, re-operation, or maternal death). RESULTS: Three hundred and forty four patients met inclusion criteria, 73 (21.2%) of whom were obese. The composite outcome was significantly higher in the obese group (6.8% versus 1.8%, p = 0.024, aOR 4.36, 95% CI 1.21, 15.75). The incidence of several individual adverse outcomes were also increased in obese women, including blood transfusion (4.1% versus 0.7%, p = 0.033, aOR 7.36, 95% CI 1.19, 45.34), wound separation or infection (20.5% versus 5.9%, p < 0.001, aOR 4.05, 95% CI 1.75, 9.36) and 1-min Apgar score less than 7 (6.8% versus 1.9%, p = 0.024, aOR 4.40, 95% CI 1.21, 15.94). CONCLUSIONS: In patients undergoing a tertiary or higher cesarean delivery without placenta previa or accreta, obesity increases the risk of adverse outcomes. Obese patients are at risk for blood transfusion, low 1-min Apgar scores and postoperative wound complications.