The COVID-19 pandemic imparted important lessons, both through its direct impact on society and through the manner in which society’s response influenced the trajectory of other diseases. The ...decrements in the rates of infection and morbidity from influenza during 2020 were significant, which is particularly important for pregnant women. Despite past attempts by public health authorities to encourage nonpharmaceutical interventions for the prevention of influenza, preventive efforts have focused largely on the use of vaccines. The COVID-19 experience has demonstrated that basic nonpharmaceutical interventions can potentially make a difference in lowering the rates of influenza during future outbreaks. In this article, we discuss the prepandemic role of nonpharmaceutical interventions in disease prevention, the outcomes that were seen in the flu season of 2020, and the role obstetricians should play in using nonpharmaceutical interventions in future influenza disease prevention efforts.
Respect for autonomy is a key ethical principle. However, in some cultures other moral domains such as community (emphasizing the importance of family roles) and sanctity (emphasizing the sacred and ...the spiritual side of human nature) hold equal value. Thus, an American physician may sometimes perceive a conflict between the desire to practice ethically and the wish to be sensitive to the mores of other cultures. For example, a woman may appear to be making what the physician thinks is a bad clinical choice because her spouse is speaking on her behalf. That physician may find it difficult to reconcile the sense that the patient had not exercised freely her autonomy with the desire to be culturally sensitive. In this article, the means by which a physician can reconcile respect for other cultures with respect for autonomy is explored. The question of whether physicians must always defer to patients' requests solely because they are couched in the language of cultural sensitivity is also addressed.
The ARRIVE trial demonstrated the benefit of induction of labor at 39 weeks gestation. Obstetrics departments across the United States faced the challenge of adapting clinical practice in light of ...these data while managing logistical constraints.
To determine if there were changes in obstetrical practices and perinatal outcomes in the United States after the ARRIVE trial publication.
This was a population-based retrospective cohort study of low-risk, nulliparous women who initiated prenatal care by 12 weeks gestation with singleton, nonanomalous pregnancies delivering at ≥39 weeks. Data were obtained from the US Natality database. The pre-ARRIVE group were women who delivered between January 1, 2015 and December 31, 2017. The post-ARRIVE group consisted of women who delivered between January 1, 2019 and December 31, 2019. Births that occurred in 2018 were excluded. Practice outcomes were rates of induction of labor, timing of delivery, and cesarean delivery rate. Adverse maternal outcomes were blood transfusion and admission to medical intensive care unit. Adverse neonatal outcomes were need for assisted ventilation (immediate and >6 hours), 5-minute APGAR score <3, neonatal intensive care unit admission, seizures, and surfactant use. Univariate and multivariate analyses were performed. Trends were tested across the time period represented by the pre-ARRIVE group using Cochran–Armitage trend test.
There were 1,966,870 births in the pre-ARRIVE group and 609,322 in the post-ARRIVE group. The groups differed in age, race, body mass index, marital status, infertility treatment, and smoking history (P<.001). After adjusting for these differences, the post-ARRIVE group was more likely to undergo induction (36.1% vs 30.2%; adjusted odds ratio, 1.36 1.36–1.37) and deliver by 39+6 weeks of pregnancy (42.8% vs 39.9%; adjusted odds ratio, 1.14 1.14–1.15). The post-ARRIVE group had a significantly lower rate of cesarean delivery than the pre-ARRIVE group (27.3 % vs 27.9%; adjusted odds ratio, 0.94 0.93–0.94). Patients in the post-ARRIVE group were more likely to receive a blood transfusion (0.4% vs 0.3%; adjusted odds ratio, 1.43 1.36–1.50) and be admitted to medical intensive care unit (0.09% vs 0.08%; adjusted odds ratio, 1.20 1.09–1.33). Neonates in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs 2.8%; adjusted odds ratio, 1.28 1.26–1.30) and >6 hours (0.6% vs 0.5%; adjusted odds ratio, 1.36 1.31–1.41). The neonates in the post-ARRIVE group were more likely to have low 5-minute APGAR scores (0.4% vs 0.3%; adjusted odds ratio, 0.91 0.86–0.95). Neonatal intensive care unit admission did not differ between the 2 groups (4.9% vs 4.9%; adjusted odds ratio, 1.01 0.99–1.03). There were no differences in neonatal seizures (0.04% vs 0.04%; adjusted odds ratio, 0.97 0.84–1.13), and surfactant use (0.08% vs 0.07%; adjusted odds ratio, 1.05 0.94–1.17) between the 2 groups.
There were more inductions of labor, more deliveries at 39 weeks’ gestation, and fewer cesarean deliveries in the year after the ARRIVE trial publication. The small but statistically significant increase in some adverse maternal and neonatal outcomes should be explored to determine if they are related with concurrent changes in obstetrical practices.
Both the rates of cesarean section and the rates and payouts from obstetrical malpractice suits have risen in past decades, albeit not always in tandem. A great deal of evidence suggests that ...physicians practice defensive medicine, and many obstetricians acknowledge that a more liberal recourse to cesarean section is one such behavior in which they sometimes engage. However the degree to which fear of litigation actually is a contributor to, or perhaps even a driver of, the rising cesarean section rate is not as clearly known. In this article I will discuss the research that has been performed that attempts to epidemiologically assess the link between lawsuits, malpractice premiums and cesarean section rates. I will also consider factors beyond dollars and cents (e.g., cognitive biases, changing risk tolerance of doctors and patients) that may lie at the base of the relationship. Finally I will offer a brief discussion of how professional ethics should inform the actions that physicians take in these difficult circumstances.
Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean ...section are important, yet less common, risk factors for PAS.
This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff.
Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.
Both coronavirus disease 2019 (COVID-19) and maternal mortality disproportionately affect minorities. However, direct viral infection is not the only way that the former can affect the latter. Most ...adverse maternal events that end in hospitals have their genesis upstream in communities. Hospitals often represent a last opportunity to reverse a process that begins at a remove in space and time. The COVID-19 pandemic did not create these upstream injuries, but it has brought them to national attention, exacerbated them, and highlighted the need for health care providers to move out of the footprint of their institutions. The breach between community events that seed morbidity and hospitals that attempt rescues has grown in recent years, as the gap between rich and poor has grown and as maternity services in minority communities have closed. COVID-19 has become yet another barrier. For example, professional organizations have recommended a reduced number of prenatal visits, and the platforms hospitals use to substitute for some of these visits are not helpful to people who either lack the technology or the safe space in which to have confidential conversations with providers. Despite these challenges, there are opportunities for departments of obstetrics and gynecology. Community-based organizations including legal professionals, health-home coordinators, and advocacy groups, surround almost every hospital, and can be willing partners with interested departments. COVID-19 has made it clearer than ever that it is time to step out of the footprint of our institutions, and to recognize that the need to find upstream opportunities to prevent downstream tragedies. KEY POINTS: · COVID-19 will exacerbate disparities in perinatal outcomes.. · The virus, per se, is not the pandemic's biggest threat to the health of minority women.. · The solution to maternal mortality cannot be found within the walls of hospitals..
To compare serum müllerian inhibiting substance (MIS) levels between white, black, and Hispanic women to determine whether ovarian aging occurs at a different time course for women of different ...racial groups.
Longitudinal study of serum MIS levels in women of different race and ethnicity over two different time points.
Women's Interagency HIV Study, a multicenter prospective cohort study.
Serum samples obtained from 809 participants (122 white, 462 black, and 225 Hispanic women).
Comparison of serum MIS between women of different race and ethnicity at two time points (median age 37.5 years and 43.3 years).
Variation in MIS by race and ethnicity over time, controlling for age, body mass index, HIV status, and smoking.
Compared with white women, average MIS values were lower among black (25.2% lower) and Hispanic (24.6% lower) women, adjusting for age, body mass index, smoking, and HIV status.
There is an independent effect of race and ethnicity on the age-related decline in MIS over time.
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