Evaluating Standard of Care and Obstetrical Outcomes in a Reduced Contact Prenatal Care Model in the COVID-19 Pandemic.

INTRODUCTION: We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes. METHODS: This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior. RESULTS: Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005). DISCUSSION: Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations.

Risk Factors for Measles Nonimmunity in Rubella-Immune Pregnant Patients.

OBJECTIVES: Measles immunity testing, unlike that for rubella, is not currently part of prenatal screening even though immunity to both is conferred by the measles-mumps-rubella (MMR) vaccine. Although endemic transmission of measles was declared eliminated in the United States in 2001, outbreaks have continued to occur. Given the risks associated with measles infection during pregnancy, we sought to identify risk factors for measles nonimmunity (MNI) in rubella-immune (RI) pregnant individuals. METHODS: We performed a retrospective observational cross-sectional study of patients receiving prenatal care and delivering at two university hospitals and a county hospital in Southern California from April 1, 2019 to February 1, 2021. Inclusion criteria were pregnant individuals ≥18 years old who had serological testing for rubella and measles during pregnancy. Demographic data were extracted from electronic medical records, including results of serological testing and chronic medical conditions. All subjects were rubella immune, and we compared measles-immune (MI) with MNI groups. RESULTS: In total, 1,813 RI individuals were identified, with 1,467 (81%) MI and 346 (19%) MNI individuals. Variables associated with an increased risk of MNI included having public health insurance (adjusted relative risk [aRR]: 1.56; 95% confidence interval [CI]: 1.24, 1.97) and Hispanic ethnicity (aRR: 1.37; 95% CI: 1.06, 1.78). Black race was associated with a decreased risk of MNI (aRR: 0.52; 95% CI: 0.29, 0.91). Birth year before 1989 demonstrated a trend toward increased risk of MNI, but this did not reach statistical significance (aRR 1.23; 95% CI: 1.00, 1.52). No differences were seen between the two groups for medical comorbidities. CONCLUSION: Our study is the first to demonstrate risk factors for measles MNI in patients with documented rubella immunity. In the absence of universal measles serological screening recommendations, the risk factors identified could help guide clinicians in selective screening for those at risk of needing postpartum MMR vaccination. KEY POINTS: · The rate of measles nonimmunity is higher than previously reported.. · Hispanic ethnicity and use of public insurance are risk factors for measles nonimmunity.. · The current recommendation for history-based screening for measles immunity is likely insufficient..

Favorable Simplified Bishop Score after cervical ripening associated with decreased cesarean birth rate.

BACKGROUND: A favorable Simplified Bishop Score (>5) before the induction of labor is associated with successful vaginal birth. Patients with an unfavorable Simplified Bishop Score (≤5) undergo cervical ripening before the administration of oxytocin. However, data are limited regarding the utility of the Simplified Bishop Score after cervical ripening. OBJECTIVE: The objective of this study was to determine if the Simplified Bishop Score before oxytocin induction but after cervical ripening is associated with cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study on patients undergoing induction of labor from the Consortium on Safe Labor. The patients with a singleton term pregnancy who initially underwent cervical ripening were included. Those with a history of cesarean delivery were excluded. The outcomes of patients with a favorable Simplified Bishop Score after cervical ripening were compared with those with an unfavorable Simplified Bishop Score. The primary outcome was the mode of birth. A log-binomial regression was performed to calculate the relative risk and control for confounders such as admission Simplified Bishop Score and parity. RESULTS: A total of 5807 patients met the criteria to be included in the study. 4235 (73%) patients had a favorable cervix, and 1572 (27%) patients had an unfavorable cervix after cervical ripening. The favorable group had a decreased rate of cesarean delivery than the unfavorable group (risk ratio, 0.35; 95% confidence interval, 0.30-0.40). Both the groups had low rates of maternal chorioamnionitis, though the patients with an unfavorable cervix were at a higher risk. There was no significant difference in the rates of postpartum hemorrhage or neonatal intensive care unit admission. Lower rates of cesarean delivery among the favorable group persisted when stratifying by parity (nulliparous: risk ratio, 0.37; 95% confidence interval, 0.31-0.43; multiparous: risk ratio, 0.22; 95% confidence interval, 0.14-0.36). After controlling for maternal age, prepregnancy body mass index, parity, gestational age, and Simplified Bishop Score at admission, a favorable cervix remained significantly associated with fewer cesarean births (risk ratio, 0.55; 95% confidence interval, 0.46-0.66). CONCLUSION: In women undergoing labor induction, a favorable Simplified Bishop Score after cervical ripening and before the start of oxytocin is associated with a decreased rate of cesarean delivery, even after adjusting for parity and Simplified Bishop Score at admission. Moreover, the Simplified Bishop Score assigned after cervical ripening could be used to inform the timing of oxytocin initiation. However, further research is necessary to determine the ideal endpoint of cervical ripening.

Gender representation of speakers at the Society for Maternal-Fetal Medicine postgraduate courses: a 20-year review.

BACKGROUND: The percentage of female physicians has grown significantly in past decades, with women currently making up 56% of the Society for Maternal-Fetal Medicine's board-certified membership. OBJECTIVE: We aimed to describe trends in the gender of invited speakers at postgraduate courses, panels, and debates at the annual meetings of the Society for Maternal-Fetal Medicine over the last 2 decades. STUDY DESIGN: We performed a retrospective observational study examining annual meetings of the Society for Maternal-Fetal Medicine in 1999, 2009, and 2015-2019. Invited speakers were identified through publicly available programs and examined by gender, degree, and the session of involvement. Postgraduate lectures (including courses, workshops, and forums), panels, and debates were examined. Speakers with Medicinae Doctor (or equivalent) degrees and obstetrics and gynecology training were included. RESULTS: Among the 3 time points 1999, 2009, and 2019, there were 330 speaker slots. There was a significant difference in gender representation in the 3 time points; female representation was 25% in 1999, 21.5% in 2009, and 55.7% in 2019 (P<.001). There were significantly higher odds of having a female speaker in 2019 than in 2009 (odds ratio, 4.58; 95% confidence interval, 2.40-8.72; P<.001). Between 2015 and 2019, 813 speaker slots were identified, with a significant positive correlation between increasing year and increasing female representation (correlation coefficient=0.099; P=.005). When controlling for type of session, there were higher odds of having a female speaker with a later year (adjusted odds ratio, 1.16; 95% confidence interval, 1.05-1.28; P=.003). There was a significant difference in gender representation among different sessions (P=.028), with females listed in 51.2% of lecture slots but only 42.4% of panels and 38.0% of debates. Male moderators resulted in an average female representation of 29.8%±23.7% in a given session, whereas female moderators and a combination of both genders as moderators had average female representations of 71.6%±25.0% and 43.3%±19.4%, respectively, in a given session (P<.001). There was no correlation between the gender of the postgraduate course chair and either moderator or speaker gender. CONCLUSION: There was a significant increase in the percentage of speaker slots allocated to females over the past 2 decades, a trend that moves toward reflecting the gender composition of the Society for Maternal-Fetal Medicine membership.

Allopurinol inhibits excess glucose-induced trophoblast IL-1ß and ROS production.

Pre-gestational diabetes is a risk factor for preeclampsia, a condition associated with inflammatory markers, a dysregulated angiogenic profile, and impaired placentation. Using an in vitro model, we previously reported that hyperglycemic levels of glucose induced a pro-inflammatory (IL-1ß, IL-8, RANTES, GRO-α), anti-angiogenic (sFlt-1) and anti-migratory profile in a human trophoblast cell line. The IL-1ß response to excess glucose was mediated by uric acid-induced activation of the NLRP3 inflammasome. Allopurinol is a xanthine oxidase inhibitor that inhibits uric acid and reactive oxygen species (ROS) production. Thus, we sought to test the effects of allopurinol on the IL-1ß and other inflammatory, angiogenic and migratory responses that are triggered in the trophoblast by excess glucose. Under excess glucose conditions, allopurinol significantly inhibited trophoblast secretion of inflammatory IL-1ß; caspase-1 activity; IL-8; RANTES; and GRO-α. Allopurinol also significantly inhibited excess glucose-induced trophoblast secretion of anti-angiogenic sFlt-1. The presence of IL1Ra significantly inhibited excess glucose-induced trophoblast IL-8 and GRO-α secretion but had no effect on RANTES or sFlt-1. Conversely, DPI, a ROS inhibitor, significantly inhibited excess glucose-induced trophoblast GRO-α and sFlt-1 secretion, but had no effect on IL-8 or RANTES. Together, our findings indicate that the xanthine oxidase inhibitor allopurinol inhibited excess glucose-induced trophoblast IL-1ß secretion. Additionally, through its inhibition of both IL-1ß and ROS production by the trophoblast, allopurinol reduced the additional pro-inflammatory and anti-angiogenic responses to excess glucose. Thus, allopurinol may be a candidate medication to prevent placental dysfunction and adverse pregnancy outcomes, such as preeclampsia, in pregnant women with diabetes.