Changes in the Antenatal Utilization of High-Risk Obstetric Services and Stillbirth Rate during the COVID-19 Pandemic.

OBJECTIVE: The primary objective of this study was to evaluate coronavirus 2019 (COVID-19) pandemic-related changes in the antenatal utilization of high-risk obstetric services. Our secondary objective was to characterize change in stillbirth rate during the pandemic. STUDY DESIGN: This is a retrospective, observational study performed at a single, tertiary care center. Maternal-Fetal Medicine (MFM) visits, ultrasounds, and antenatal tests of fetal well-being during the pandemic epoch (2020), which spans the first 12 weeks of the year to include pandemic onset and implementation of mitigation efforts, were compared with the same epoch of the three preceding years visually and using general linear models to account for week and year effect. An analysis of stillbirth rate comparing the pandemic time period to prepandemic was also performed. RESULTS: While there were decreased MFM visits and antenatal tests of fetal well-being during the pandemic epoch compared with prepandemic epochs, only the decrease in MFM visits by year was statistically significant (p < 0.001). The stillbirth rate during the pandemic epoch was not significantly different when compared with the prepandemic period and accounting for both week (p = 0.286) and year (p = 0.643) effect. CONCLUSION: The COVID-19 pandemic resulted in a significant decrease in MFM visits, whereas obstetric ultrasounds and antenatal tests of fetal well-being remained unchanged. While we observed no change in the stillbirth rate compared with the prepandemic epoch, our study design and sample size preclude us from making assumptions of association. Our findings may support future work investigating how changes in prenatal care for high-risk obstetric patients influence perinatal outcomes. KEY POINTS: · MFM visits significantly decreased during the COVID-19 pandemic epoch.. · The overall stillbirth rate during the COVID-19 pandemic epoch was not significantly changed.. · Larger studies are needed to capitalize on these changes to evaluate rare outcomes such as stillbirth..

Defining the risk profile of women with stage 1 hypertension: a time to event analysis.

BACKGROUND: Chronic hypertension complicates up to 5% of pregnancies and is increasing in prevalence. Women with hypertension have increased risks of serious maternal morbidity and mortality in pregnancy, including the development of preeclampsia. In 2017, new guidelines reclassified blood pressure into the following 4 categories: normal (<120/<80 mm Hg), elevated (120-129/<80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), and stage 2 hypertension (>140/>90 mm Hg). This new classification doubles the number of reproductive-aged women with hypertension. Furthermore, studies have demonstrated that women entering pregnancy with stage 1 hypertension have an increased risk of developing hypertensive disorders of pregnancy compared with their normotensive counterparts, but the time course to the development of hypertensive disorders of pregnancy in these women remains uncertain. OBJECTIVE: We sought to evaluate the risk of developing a hypertensive disorder of pregnancy and the time to the development of these disorders in women with stage 1 hypertension vs both normotensive women and those with stage 2 hypertension. STUDY DESIGN: This was a retrospective cohort study of all patients from a single tertiary care center with singleton gestations from 2014 to 2016. Patients at prenatal visits before 20 weeks of gestation were classified into 3 blood pressure groups: normotensive (<130/80 mm Hg), stage 1 hypertension (130-139/80-89 mm Hg), or stage 2 hypertension (≥140/90 or a history of chronic hypertension). The primary outcome, time to the development of a hypertensive disorder of pregnancy, was compared among groups using Kaplan-Meier curves and the log-rank test. Cox proportional-hazards models were used to adjust for age, race and ethnicity, pregestational diabetes mellitus, and body mass index. In addition, multiple secondary obstetrical, maternal, and neonatal outcomes were assessed. RESULTS: Of the 3000 women in our cohort, 2370 (79.0%) were categorized in the normotensive group, 315 (10.5%) were categorized in the stage 1 hypertension group, and 315 (10.5%) were categorized in the stage 2 hypertension group. The gestational age at diagnosis was significantly earlier in gestation among blood pressure groups (normotensive [38.7 (37.0-39.7)] vs stage 1 hypertension [38.0 (36.4-39.4)] vs stage 2 hypertension [36.4 (33.7-37.8)]; P<.001). When the analysis was restricted to only those patients diagnosed with preeclampsia with severe features, the same findings were observed. Women with stage 1 hypertension exhibited a 2-fold increased risk of developing hypertensive disorders of pregnancy compared with normotensive women. Compared with women with stage 2 hypertension, women with stage 1 hypertension exhibited a milder phenotype of hypertensive disorders of pregnancy and exhibited significantly less risk of maternal and neonatal morbidities. CONCLUSION: Women with stage 1 hypertension are at increased risk of developing hypertensive disorders of pregnancy at earlier gestational ages compared with normotensive women; however, their development of a hypertensive disorder of pregnancy is skewed toward milder diseases compared with women with stage 2 hypertension. These new insights into the graded risk profile of obstetrical hypertensive diseases associated with new blood pressure categories can better inform our antepartum counseling and monitoring and surveillance plans near term and in the postpartum period.

A new definition of gestational hypertension? New-onset blood pressures of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation.

BACKGROUND: Diagnostic criteria for hypertensive disorders in pregnancy have historically been based on the American Heart Association and American College of Cardiology's definition of hypertension, previously defined as a blood pressure of ≥140/90 mm Hg. With the recent redefinition of hypertension, blood pressures of 130 to 139/80 to 89 mm Hg are now considered abnormal. OBJECTIVE: In this study, we aimed to test whether the new-onset blood pressure elevations of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation in previously normotensive women are associated with increased risk for adverse pregnancy outcomes, specifically the development of hypertensive disorders in pregnancy. STUDY DESIGN: We performed a retrospective cohort study at a single tertiary care center of all women who delivered singleton gestations after 20 weeks of gestation from January 01, 2014, to June 08, 2016. Normotensive patients were defined as having maximum blood pressure of <130/80 mm Hg before 20 weeks of gestation and no previous diagnosis of chronic hypertension. Patients who remained normotensive for the remainder of pregnancy were then compared with patients who developed new-onset blood pressure elevations of 130 to 139/80 to 89 mm Hg after 20 weeks of gestation before delivery admission. The primary outcome was the development of a hypertensive disorder in pregnancy at hospital admission or during delivery. Clinical outcomes were assessed using χ2 test and multivariable logistic regression. RESULTS: Of the 2090 normotensive women from our cohort who were analyzed, 1318 (63.0%) remained normotensive for their entire antenatal course before delivery admission and 772 (37.0%) had new-onset blood pressure elevations between 130 and 139/80 and 89 mm Hg. Women with new-onset blood pressure elevations between 130 and 139/80 and 89 mm Hg after 20 weeks of gestation have a significantly increased risk for developing a hypertensive disorder in pregnancy at admission or during delivery (adjusted relative risk, 2.41; 95% confidence interval, 2.02-2.85) including an almost 3-fold increased risk for preeclampsia with severe features, even after adjusting for confounders. There were no differences in other secondary obstetrical outcomes. CONCLUSION: Normotensive women with new-onset blood pressures elevations between 130 and 139/80 and 89 mm Hg after 20 weeks of gestation are more likely to experience hypertensive disorders in pregnancy and preeclampsia with severe features at or during their delivery hospitalization. These more modest blood pressure elevations may be an early indicator of disease and call into question our current blood pressure threshold for diagnosis of hypertensive disorders in pregnancy.

Modified frailty index is predictive of wound complications in obese patients undergoing gynecologic surgery via a midline vertical incision.

OBJECTIVES: There are limited methods to identify which obese patients will experience wound complications after undergoing gynecologic surgery. We sought to determine the association between frailty and postoperative wound complications and to develop a prediction model for wound complications in this patient population. METHODS: We reviewed prospectively collected data of obese patients undergoing laparotomy though midline vertical incisions from 7/2013-3/2016. Modified frailty index (mFI) was calculated using 11 comorbidities previously validated. The primary outcome was the composite rate of postoperative wound complication. Data was analyzed using Fisher exact test or Chi-square and t-tests or Kruskal-Wallis tests. Poisson regression models were used to generate relative risks. Prediction models were created with receiver-operator characteristic curve analysis. RESULTS: Of 163 patients included, 56 (34%) were considered frail. Wound complications occurred in 52 patients (31.9%): 28 (50%) frail and 24 (22.4%) non-frail patients (RR 2.23, 95%CI 1.29-3.85). Frail patients had significantly greater frequencies of wound breakdown (37.5% vs 15%, RR 2.51, 95%CI 1.31-4.81). After controlling for BMI, tobacco use, and maximum postoperative glucose, frailty remained an independent predictor of wound complication (aRR 1.88, 95%CI 1.04-3.40). The area under the curve for the predictive model incorporating frailty was 0.73 for wound complications. CONCLUSION: Frailty is associated with wound complications in obese patients undergoing gynecologic surgery via a midline vertical incision and is a useful tool in identifying the most high risk patients. Further prospective research is necessary to incorporate mFI into preoperative planning and counseling.

Clinical implications of umbilical artery Doppler changes after betamethasone administration†.

Background: Betamethasone (BMZ) is commonly administered to patients with fetal growth restriction (FGR) and abnormal umbilical artery Doppler (UAD) velocimetry due to the increased risk of preterm delivery; however, the clinical impact of UAD changes after BMZ exposure is unknown.Objective: To test the hypothesis that lack of UAD improvement after BMZ administration is associated with shorter latency and greater neonatal morbidity in patients with FGR.Study design: This was a retrospective cohort study of pregnancies complicated by FGR and abnormal UAD between 240 and 336 weeks gestation. Abnormal UAD included the following categories of increasing severity: elevated (pulsatility index >95%), absent end diastolic flow (EDF), or reversed EDF improvement was defined as any improvement in category of UAD within two weeks of BMZ. Sustained improvement was defined as improvement until the last ultrasound before delivery, whereas transient improvement was considered as unsustained. The primary outcome was latency, defined as interval from betamethasone administration to delivery. Secondary outcomes were gestational age at delivery, umbilical artery pH, and a composite of neonatal morbidity (intubation, necrotizing enterocolitis, ionotropic support, intraventricular hemorrhage, total parenteral nutrition, neonatal death). Outcomes were compared between (a) patients with and without UAD improvement and (b) patients with sustained and unsustained improvement, using univariable, multivariable and time-to-event analyses.Results: Of the 222 FGR pregnancies with abnormal UAD, 94 received BMZ and had follow-up ultrasounds. UAD improved in 48 (51.1%), with 27 (56.3%) having sustained improvement. Patients with hypertension and drug use were less likely to have UAD improvement. Patients without UAD improvement had shorter latency (21.5 days [interquartile range (IQR) 8,45] versus 35 [IQR 22,61], p = .02) and delivered at an earlier gestational age (34 weeks [IQR 31,36] versus 37 [IQR 33,37], p < .01) than those with improvement. There were no differences in umbilical artery pH between groups. Composite neonatal morbidity was higher in patients without UAD improvement, but this was not statistically significant after adjusting for confounders (aOR 2.0; 95% CI 0.08-5.1). There were no differences in outcomes between patients with sustained versus unsustained improvement.Conclusions: UAD improved in half of patients following BMZ. Lack of UAD improvement was associated with shorter latency and earlier gestational age at delivery, but no difference in composite neonatal morbidity. UAD response to BMZ may be useful to further risk stratify FGR pregnancies.

The effect of a multidisciplinary palliative care initiative on end of life care in gynecologic oncology patients.

OBJECTIVES: To evaluate the effect of palliative care (PC) consultation on hospice enrollment and end-of-life care in gynecologic oncology patients. METHODS: A retrospective chart review of gynecologic oncology patients who died 1year before and after 2014 implementation of a PC initiative for patients at a single NCI-designated comprehensive cancer center. Patient demographics, admission and procedural history, anti-cancer therapy, and end-of- life care were collected retrospectively. Data was analyzed using Student's t-test, Mann-Whitney U test, Chi-Square test, or Fisher's exact test. RESULTS: We identified 308 patients. Median age at death was 63years (range 17 to 91). Most patients were white (78.2%), married (47.4%), and had ovarian (35.7%) or uterine cancers (35.4%). Introduction of the PC initiative was associated with increased PC consultations (40%, 53%, p=0.02), increased hospice enrollment (57%, 61%, p=0.29), and fewer procedures in the last 30days of life (44%, 31%, p=0.01). The rate of enrollment to inpatient hospice doubled from 12.5% to 25.7% (p=0.02) while time from inpatient hospice enrollment to death increased from 1.9 to 6.0days (p=0.02). Time from outpatient hospice enrollment to death increased from 26.2 to 35.4days (p=0.18). PC consultation was associated with a doubling of outpatient (40%) and inpatient (80%) hospice enrollment. CONCLUSIONS: The PC quality improvement initiative was associated with more palliative care consults, increased rates of inpatient and outpatient hospice utilization, increased time on hospice, and fewer procedures in the last 30days of life, although most women were not enrolled until the last days of life.

Associations between allergic conditions and pediatric brain tumors in Neurofibromatosis type 1.

Individuals with Neurofibromatosis type 1 (NF1) are at increased risk for pediatric brain tumors (PBTs), especially optic gliomas; however, factors influencing their development are largely unknown. Extensive research suggests that allergic conditions protect against brain tumors, particularly gliomas in individuals without NF1. In this large cross-sectional study, we employed two different data sources to evaluate evidence for the hypothesis that allergic conditions (allergies, asthma, and eczema) may protect against PBT development in individuals with NF1. We used self- and parent/legal guardian reported questionnaire data from participants in the NF1 Patient Registry Initiative (NPRI, n = 1660) born from 1933 to 2014 to ascertain allergic condition and PBT diagnosis histories. Medical records (MRs) of 629 NF1 patients at a large medical center born from 1930 to 2012 were also reviewed for PBT and allergic condition diagnoses to evaluate additional evidence for our hypothesis. We used logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between allergic condition diagnoses and PBTs. Both data sources provided limited to no support for a protective effect of allergies or eczema on PBT development. Non-significant inverse associations between asthma and PBTs were observed (NPRI: OR = 0.80, 95% CI 0.55-1.17; MR: OR = 0.71, 95% CI 0.40-1.28) with stronger associations for optic gliomas specifically. Additionally, a significant inverse association was observed in an NPRI subgroup analysis where the reported asthma diagnosis age was younger than the reported PBT diagnosis age (OR = 0.57; 95% CI 0.36-0.89). Our study supports the hypothesis that asthma protects against PBT development in NF1.

Racial/Ethnic Differences in Pediatric Brain Tumor Diagnoses in Patients with Neurofibromatosis Type 1.

OBJECTIVE: To evaluate evidence for differences in pediatric brain tumor diagnoses by race and ethnicity using a cross-sectional study design in individuals with neurofibromatosis type 1 (NF1). STUDY DESIGN: Subjects with NF1 were ascertained from the NF1 Patient Registry Initiative and through a clinical record database of patients at a large academic medical center. Logistic regression was employed to calculate ORs and 95% CIs to analyze differences in the odds of brain tumor diagnosis by race (White, Black, Asian, other/unknown) and ethnic (Hispanic vs non-Hispanic) groups. RESULTS: Data from a total of 1546, 629, and 2038 individuals who were ascertained from the NF1 Patient Registry Initiative, clinical records, and pooled datasets were analyzed, respectively. After adjusting for birth year, we observed a significantly reduced odds of brain tumor diagnoses in individuals self-identified or clinically reported as Black (OR = 0.13, 95% CI 0.05-0.31), Asian (OR = 0.15, 95% CI 0.04-0.64), and other/unknown (OR = 0.61, 95% CI 0.41-0.93) race compared with those with reported as White race. There was no significant difference in the odds of pediatric brain tumor diagnosis by Hispanic ethnicity. CONCLUSIONS: Consistent with prior smaller studies, these data suggest that pediatric brain tumor diagnoses vary by race in individuals with NF1. Reasons underlying observed differences by race warrant further investigation.