Vertical Transmission of COVID-19 to the Neonate.

Objective: To estimate the incidence rate of vertical transmission of coronavirus disease 2019 (COVID-19) to the neonate during the third trimester. Study Design. We conducted a retrospective observational study of pregnant women diagnosed with COVID-19 during the third trimester, who delivered at Flushing Hospital Medical Centre (FHMC) or Jamaica Hospital Medical Centre (JHMC) between March 20, 2020, and April 30, 2020. The study participants were symptomatic pregnant women diagnosed with COVID-19 via positive SARS-CoV-2 RNA, real-time reverse transcription-polymerase chain reaction (SARS-CoV-2 rRT-PCR) test. Evidence of vertical transmission was assessed in the neonate via a SARS-CoV-2 rRT-PCR test, with nasopharyngeal swab samples collected on the neonates after 24 hours of birth. The exclusion criteria for this study were maternal or neonate records without SARS-CoV-2 rRT-PCR test results, neonates not delivered at FHMC or JHMC, and foetuses with suspected foetal anomalies or incomplete medical records. Results: We identified 19 symptomatic pregnant women diagnosed with COVID-19, including two women with twin pregnancies. Seven patients (36.8%) were delivered via cesarean. 12 patients (63.1%) presented in spontaneous labour, and 8 (38.1%) had preterm delivery. No maternal intensive care unit admission, maternal sepsis, or maternal mortality was observed. Twenty-one neonates were evaluated for COVID-19 after birth. SARS-CoV-2 rRT-PCR test results were negative in 100% of the neonates. Thirteen neonates (61.9%) were admitted to the neonatal intensive care unit. Prematurity was the most common cause of NICU admission 6 (46.1%), with a length of stay of 5.5 ± 6.4 days. No invasive mechanical ventilation, neonatal sepsis, or neonatal mortality was observed. Conclusion: In our cohort, symptomatic COVID-19 during the third trimester of pregnancy was not associated with vertical transmission to the neonate.

Impact of the ACOG guideline regarding low-dose aspirin for prevention of superimposed preeclampsia in women with chronic hypertension.

BACKGROUND: Patients with chronic hypertension are at increased risk for superimposed preeclampsia. The 2016 American College of Obstetricians and Gynecologists guideline recommended initiating 81 mg of daily aspirin for all pregnant women with chronic hypertension to prevent superimposed preeclampsia. OBJECTIVE: (1) To evaluate the rates of implementation of the 2016 American College of Obstetricians and Gynecologists guideline over time; and (2) to evaluate the effectiveness of aspirin for the prevention of superimposed preeclampsia and other adverse maternal and neonatal outcomes in women with chronic hypertension before and after this guideline. STUDY DESIGN: This is a retrospective study of women with chronic hypertension who delivered at Thomas Jefferson University Hospital from January 2014 through June 2018. This cohort of women with chronic hypertension was divided into 2 groups, before and after the American College of Obstetricians and Gynecologists recommendation published in September 2016. Daily 81 mg of aspirin was initiated between 12 and 16 weeks. We excluded multiple gestations and incomplete records. The primary outcome was incidence of superimposed preeclampsia, and secondary outcomes were incidence of superimposed preeclampsia with or without severe features, small for gestational age, and preterm birth <37 weeks. Subgroup analysis based on risk stratification was evaluated in women with chronic hypertension requiring antihypertensive medication, history of preeclampsia, and pregestational diabetes. RESULTS: We identified 457 pregnant women with chronic hypertension, 203 in the post-American College of Obstetricians and Gynecologists group and 254 in the pre-American College of Obstetricians and Gynecologists group. Aspirin 81 mg was offered to 142 (70%) in the post-American College of Obstetricians and Gynecologists group and 18 (7.0%) in the pre-American College of Obstetricians and Gynecologists group. Maternal demographics were not significantly different. The overall incidence of superimposed preeclampsia was not significantly different: 87 (34.3%) vs 72 (35.5%), P=.79, in the pre- and post-American College of Obstetricians and Gynecologists guideline groups, respectively. Superimposed preeclampsia with severe features significantly increased: 32 (12.6%) vs 9 (4.4%), P<.01, whereas superimposed preeclampsia without severe features significantly decreased: 55 (21.7%) vs 63 (31.0%), P=.03. There were no significant differences in small for gestational age neonates or preterm birth <37 weeks incidences between groups. There were no significant differences in the subgroup analysis based on the severity of chronic hypertension requiring antihypertensive medication, history of preeclampsia, or pregestational diabetes. CONCLUSION: After the adoption of the American College of Obstetricians and Gynecologists guidelines in 70% of the cohort, superimposed preeclampsia, small for gestational age, and preterm birth were not significantly decreased after implementation of aspirin 81 mg initiated between 12 and 16 weeks of gestation.

Genetic abnormalities seen on CVS in early pregnancy failure.

Objective: To determine the frequency and distribution of chromosome abnormalities in women with early pregnancy failure (EPF) detected by cytogenetic testing on chorionic villus sampling.Method: Retrospective observational cohort study of chromosomal analysis from transvaginal chorionic villus sampling (CVS) or reflex products of conception (POC) karyotype. CVS was offered as a training tool for Maternal Fetal Medicine fellows prior to manual vacuum aspiration for EPF 9-week gestation. POC were analyzed for cytogenetics if no results were obtained on CVS.Results: One hundred thirty samples were collected from December 2011 to April 2015. 33 (27.3%) cases had a normal karyotype and 88 (73.0%) cases had an abnormal karyotype. The most common group of abnormalities were trisomy, (n = 50, 41.3%), triploidy/tetraploidy, (n = 17, 14.0%), monosomy (n = 15, 12.4%), and structural rearrangements (n = 6, 5.0%). Nine (6.9%) samples were maternal decidua only. Abnormal karyotype in EPF was significantly increased in women by age group (p < .01) but not in women with a history of prior miscarriage (p = .5).Conclusion: Our cohort had a high detection rate of aneuploidy. The most common chromosomal abnormalities in EPF were: trisomy, followed by triploidy/tetraploidy, monosomy, and structural rearrangements. Maternal age had the strongest correlation with EPF associated with aneuploidy.

Stroke recurrence in pregnancy: Experience at a regional referral center.

BACKGROUND: Although stroke is more common with advancing age, especially in the elderly, women of reproductive age may still suffer from stroke, and from its deleterious consequences. Women of reproductive age who suffer a stroke may do so either due to a specific predisposition, or due to pregnancy-related hypertensive emergencies. OBJECTIVE: To assess the risk of stroke recurrence in pregnancy and the postpartum period in women who have suffered a stroke before pregnancy. STUDY DESIGN: This was a retrospective cohort study conducted at Thomas Jefferson University Hospital from January 2005 to December 2015. This is a tertiary referral center for high-risk obstetrics and one of the largest stroke referral centers for neurosurgery. All consecutive pregnant women that had a viable pregnancy (≥24 weeks of gestation) and a history of stroke prior to pregnancy were identified. The primary outcome of this study was stroke recurrence in pregnancy or the postpartum period defined as 6 weeks after delivery. RESULTS: Forty-eight pregnancies with a history of stroke before pregnancy were identified in 24 women. Thirty-one pregnancies (64.6%) had a history of an ischemic stroke, 11 (22.9%) had a history of transient ischemic attack, and 6 (12.5%) had a history of a hemorrhagic stroke. There was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke. In the ischemic stroke group, 8 (25.8%) had recurrence in the non-pregnant state compared to none in the TIA and the hemorrhagic stroke group. CONCLUSION: There was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke.

Nonsteroidal Antiinflammatory Drug Administration and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy.

OBJECTIVE: To evaluate whether postpartum nonsteroidal antiinflammatory drug (NSAID) administration is associated with increased blood pressure in women with hypertensive disorders of pregnancy and to estimate the association between NSAID administration and use of opioid medication. METHODS: We conducted a retrospective cohort study of women with hypertensive disorders of pregnancy. Patients were analyzed in two groups according to whether they received NSAIDs postpartum. Study participants were women delivered at a tertiary care center from 2008 to 2015. The primary outcome was change in mean arterial pressure during the postpartum period. Secondary outcomes were postpartum pain scores, cumulative postpartum opioid requirement, initiation or dose escalation of antihypertensive agents, and adverse postpartum outcomes including acute renal failure, change in hematocrit, and maternal readmission for hypertensive disorder. RESULTS: Two hundred seventy-six women with hypertensive disorders of pregnancy were included (129 NSAID-unexposed and 147 NSAID-exposed). Postpartum NSAID administration was not associated with a statistically significant change in mean arterial pressure compared with no NSAID administration (-0.7 vs -1.8; mean difference 1.10, 95% CI -1.44 to 3.64). Similarly, no difference was observed between the cohorts in terms of need for initiation or escalation in dose of antihypertensive agents or maternal readmission for hypertensive disorder. The study was underpowered to determine whether NSAID administration was associated with any difference in less frequent secondary outcomes (eg, incidence of acute renal insufficiency, need for postpartum transfusion) or cumulative opioid use. CONCLUSION: Nonsteroidal antiinflammatory drug administration to postpartum patients with hypertensive disorders of pregnancy is not associated with a change in blood pressure or requirement for antihypertensive medication.

Outpatient versus inpatient management for superimposed preeclampsia without severe features: a retrospective, multicenter study.

PURPOSE: To determine if women with preterm superimposed preeclampsia without severe features can be successfully and safely triaged to outpatient management. MATERIALS AND METHODS: This was a multicenter, retrospective, cohort study of singleton pregnancies with superimposed preeclampsia without severe features diagnosed before 37 weeks managed outpatient versus inpatient at Thomas Jefferson University (Philadelphia, PA) and at University of Naples (Naples, Italy) from January 2008 to July 2015. The attending physician made the decision to manage outpatient or inpatient at his or her discretion. The primary outcome was composite maternal morbidity defined as development of at least one of the following: severe features, HELLP syndrome, placental abruption, eclampsia, postpartum hemorrhage, intensive care unit admission, or maternal death. Logistic regression, presented as adjusted odds ratio (aOR) with the 95% of confidence interval (CI) was performed. RESULTS: A total of 365 women with superimposed preeclampsia without severe features before 37 weeks were analyzed. 198 (54.2%) were managed outpatient, and 167 (45.8%) were managed inpatient. Women managed as outpatients had a similar rate of maternal morbidity compared to those managed as inpatients (36.4% versus 41.3%, aOR 0.82, 95%CI 0.55-1.17). Fetuses from women in the outpatient group had a significantly lower risk of small for gestational age (17.7% versus 29.3%; aOR 0.53, 95%CI 0.30-0.84), and lower risk of admission to neonatal intensive care unit (40.4% versus 47.9%; aOR 0.72, 95%CI 0.39-0.95) compared to women managed as inpatients. CONCLUSIONS: Low risk women with superimposed preeclampsia without severe features can be triaged to outpatient management without increased maternal morbidity.

How many procedures does it take? Success of a CVS training program for Maternal Fetal Medicine fellows.

OBJECTIVES: To quantify the learning curve for a training program for Maternal Fetal Medicine (MFM) fellows in obtaining successful transvaginal chorionic villus sampling (CVS) results in women with early pregnancy failure (EPF). METHODS: Retrospective observational cohort study of transvaginal CVS and subsequent manual vacuum aspiration (MVA) performed by MFM fellows. CVS samples were sent for karyotype, and products of conception (POC) were sent if CVS sample did not yield a result. Success was defined as karyotype result on CVS specimen. RESULTS: A total of 130 women with EPF up to 9 weeks of gestation underwent transvaginal CVS and MVA from December 2011 to April 2015. CVS samples were successful in 53 (40.8%) cases, POC were analyzed for karyotype in 68 (52.3%) cases, and maternal decidua was obtained in 9 (6.9%) cases. Nine MFM fellows performed the CVS and MVA procedures. The mean number of procedures per fellow was 14 (5-24). The average success rate of transvaginal CVS sample was 33.3% after the first procedure and 50% at the 14th procedure. One procedure was performed per patient. CONCLUSIONS: Success increased over time from 33.3% to 50.0%. Given the gestational age and failed pregnancy status, this is a reasonable success rate for CVS at time of EPF. © 2016 John Wiley & Sons, Ltd.

Volatile Constituents from the Flowers of Spathodea campanulata from the Venezuelan Andes.

The chemical composition is reported of the essential oil obtained by hydrodistillation of Spathodea campanulata P. Beauv. (Bignoniaceae) flowers collected in the Andes region of Venezuela. Thirty compounds were characterized, representing 96.5% of the total oil composition; benzyl benzoate (17.5%) was the major constituent. Others major components were a mixture of geranyl acetone with a-humulene (12.7%), ß-caryophyllene (9.5%), farnesyl acetone (6.0%), aromadendrene (4.3%), α-gurjunene (3.9%) and tricosane (3.7%). This is the first report related to the chemical composition of the essential oil of S. campanulata flowers.