Prenatal repair of myelomeningocele, the most common form of spina bifida, may result in better neurologic function than repair deferred until after delivery. We compared outcomes of in utero repair ...with standard postnatal repair.
We randomly assigned eligible women to undergo either prenatal surgery before 26 weeks of gestation or standard postnatal repair. One primary outcome was a composite of fetal or neonatal death or the need for placement of a cerebrospinal fluid shunt by the age of 12 months. Another primary outcome at 30 months was a composite of mental development and motor function.
The trial was stopped for efficacy of prenatal surgery after the recruitment of 183 of a planned 200 patients. This report is based on results in 158 patients whose children were evaluated at 12 months. The first primary outcome occurred in 68% of the infants in the prenatal-surgery group and in 98% of those in the postnatal-surgery group (relative risk, 0.70; 97.7% confidence interval CI, 0.58 to 0.84; P<0.001). Actual rates of shunt placement were 40% in the prenatal-surgery group and 82% in the postnatal-surgery group (relative risk, 0.48; 97.7% CI, 0.36 to 0.64; P<0.001). Prenatal surgery also resulted in improvement in the composite score for mental development and motor function at 30 months (P=0.007) and in improvement in several secondary outcomes, including hindbrain herniation by 12 months and ambulation by 30 months. However, prenatal surgery was associated with an increased risk of preterm delivery and uterine dehiscence at delivery.
Prenatal surgery for myelomeningocele reduced the need for shunting and improved motor outcomes at 30 months but was associated with maternal and fetal risks. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT00060606.).
Postpartum hemorrhage is the leading cause of maternal morbidity and mortality worldwide. The majority of maternal deaths associated with hemorrhage could be preventable. The accurate assessment of ...blood loss, identification of risk factors and timely recognition of postpartum hemorrhage remain major challenges in obstetrics. It is important to review available modalities for estimation and quantification of peripartum blood loss, the value of risk assessment tools as well as the challenges in early recognition of clinical signs and symptoms of postpartum hemorrhage.
To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March ...2020.
We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020.
Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%).
During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.
Limited data on vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and health outcomes of neonates born to mothers with symptomatic or asymptomatic ...coronavirus disease 2019 (COVID-19) are available. Studies are needed to inform evidence-based infection prevention and control (IP&C) policies.
To describe the outcomes of neonates born to mothers with perinatal SARS-CoV-2 infection and the IP&C practices associated with these outcomes.
This retrospective cohort analysis reviewed the medical records for maternal and newborn data for all 101 neonates born to 100 mothers positive for or with suspected SARS-CoV-2 infection from March 13 to April 24, 2020. Testing for SARS-CoV-2 was performed using Cobas (Roche Diagnostics) or Xpert Xpress (Cepheid) assays. Newborns were admitted to well-baby nurseries (WBNs) (82 infants) and neonatal intensive care units (NICUs) (19 infants) in 2 affiliate hospitals at a large academic medical center in New York, New York. Newborns from the WBNs roomed-in with their mothers, who were required to wear masks. Direct breastfeeding after appropriate hygiene was encouraged.
Perinatal exposure to maternal asymptomatic/mild vs severe/critical COVID-19.
The primary outcome was newborn SARS-CoV-2 testing results. Maternal COVID-19 status was classified as asymptomatic/mildly symptomatic vs severe/critical. Newborn characteristics and clinical courses were compared across maternal COVID-19 severity.
In total, 141 tests were obtained from 101 newborns (54 girls 53.5%) on 0 to 25 days of life (DOL-0 to DOL-25) (median, DOL-1; interquartile range IQR, DOL-1 to DOL-3). Two newborns had indeterminate test results, indicative of low viral load (2.0%; 95% CI, 0.2%-7.0%); 1 newborn never underwent retesting but remained well on follow-up, and the other had negative results on retesting. Maternal severe/critical COVID-19 was associated with newborns born approximately 1 week earlier (median gestational age, 37.9 IQR, 37.1-38.4 vs 39.1 IQR, 38.3-40.2 weeks; P = .02) and at increased risk of requiring phototherapy (3 of 10 30.0% vs 6 of 91 7.0%; P = .04) compared with newborns of mothers with asymptomatic/mild COVID-19. Fifty-five newborns were followed up in a new COVID-19 Newborn Follow-up Clinic at DOL-3 to DOL-10 and remained well. Twenty of these newborns plus 3 newborns followed up elsewhere had 32 nonroutine encounters documented at DOL-3 to DOL-25, and none had evidence of SARS-CoV-2 infection, including 6 with negative retesting results.
No clinical evidence of vertical transmission was identified in 101 newborns of mothers positive for or with suspected SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices.
Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease ...2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019–positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019–associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).
To evaluate the perioperative morbidity and mortality of patients with COVID-19 who undergo urgent and emergent surgery.
Although COVID-19 infection is usually associated with mild disease, it can ...lead to severe respiratory complications. Little is known about the perioperative outcomes of patients with COVID-19.
We examined patients who underwent urgent and emergent surgery at 2 hospitals in New York City from March 17 to April 15, 2020. Elective surgical procedures were cancelled throughout and routine, laboratory based COVID-19 screening was instituted on April 1. Mortality, complications, and admission to the intensive care unit were compared between patients with COVID-19 detected perioperatively and controls.
Among 468 subjects, 36 (7.7%) had confirmed COVID-19. Among those with COVID-19, 55.6% were detected preoperatively and 44.4% postoperatively. Before the routine preoperative COVID-19 laboratory screening, 7.7% of cases were diagnosed preoperatively compared to 65.2% after institution of screening (P = 0.0008). The perioperative mortality rate was 16.7% in those with COVID-19 compared to 1.4% in COVID-19 negative subjects aRR = 9.29; 95% confidence interval (CI), 5.68-15.21. Serious complications were identified in 58.3% of COVID-19 subjects versus 6.0% of controls (aRR = 7.02; 95%CI, 4.96-9.92). Cardiac arrest, sepsis/shock, respiratory failure, pneumonia, acute respiratory distress syndrome, and acute kidney injury were more common in those with COVID-19. The intensive care unit admission rate was 36.1% in those with COVID-19 compared to 16.4% of controls (aRR = 1.34; 95%CI, 0.86-2.09).
COVID-19 is associated with an increased risk for serious perioperative morbidity and mortality. A substantial number of patients with COVID-19 are not identified until after surgery.
Venous thromboembolism represents a persistent proportionate cause of maternal mortality in the United States accounting for 9% to 10% of maternal deaths. Given that overall maternal mortality rose ...>40% since the late 1990s, it is likely that absolute venous thromboembolism mortality risk increased as well. This persistent risk may be secondary to increases in broad population-based risk factors for venous thromboembolism such as obesity and cesarean delivery. Widespread adoption of perioperative cesarean mechanical thromboprophylaxis is associated with reduced risk for venous thromboembolism events but has not been sufficient to reduce mortality. Experts agree that improved clinical care is required to reduce risk as it is unlikely that trends in venous thromboembolism risk factors will reverse course anytime soon. Experts further agree that improving prophylaxis and prevention may provide the largest benefit. However, how to best improve prophylaxis is highly controversial with both experts and guidelines in disagreement. In the United Kingdom, mortality risk decreased substantially following the 2004 recommendations for broader heparin prophylaxis without evidence of increased mortality risk from hemorrhage. A key clinical question in the United States is whether heparin prophylaxis should be expanded to patients hospitalized for cesarean delivery or an antepartum indication. Some experts, including us, support expanded heparin prophylaxis. Evidence supporting heparin prophylaxis includes (1) demonstration of safety and efficacy in the United Kingdom, (2) that mechanical prophylaxis—the primary alternative to heparin—has major limitations outside the immediate perioperative setting, and (3) that hospitalized cesarean and antepartum patients are at high relative risk of events. Experts against broader heparin prophylaxis cite concerns related to safety, efficacy, and cost. This expert review focused on whether heparin prophylaxis should be routinely used during antepartum hospitalizations and after cesarean delivery. First, we review the differences in major society guidelines. Second, we review arguments for and against broader heparin prophylaxis. Third, we discuss what future research may be most likely to further inform best practices. Fourth, we review practical clinical considerations with heparin prophylaxis, including access to neuraxial anesthesia. Given the best available data, we concluded that expanding heparin prophylaxis represents a modest intervention with the potential to meaningfully reduce venous thromboembolism mortality.
Cardio-obstetrics refers to a team-based approach to maternal care that includes multidisciplinary collaboration among maternal fetal medicine, cardiology, and others.
This study sought to describe ...clinical characteristics, maternal and fetal outcomes, and cardiovascular readmissions in a cohort of pregnant women with underlying cardiovascular disease (CVD) followed by a cardio-obstetrics team.
We identified patients evaluated by our cardio-obstetrics team from January 1, 2010, through December 31, 2019, at a quaternary care hospital in New York City. Information was collected regarding demographics, comorbidities, underlying CVD, medications, maternal and fetal outcomes, and cardiovascular readmissions. Each patient was assigned a Cardiac Disease in Pregnancy (CARPREG) II score based on her clinical characteristics and underlying CVD.
During the study period, 306 pregnant women (median age 29 years, 52.9% Hispanic or Latino) with CVD were seen. Most women (74.2%) were insured through Medicaid. The most common forms of CVD included arrhythmia (n = 88, 28.8%), congenital heart disease (n = 72, 23.5%), and cardiomyopathy (n = 72, 23.5%). The median CARPREG II score was 3; 130 patients (42.5%) had a CARPREG II score ≥4. Gestational diabetes occurred in 11.4%, gestational hypertension in 9.5%, and preeclampsia in 12.1% of women. Intensive care unit admission was required for 27 patients (8.8%) during delivery. Median gestational age for delivery was 38 weeks (interquartile range: 37 to 39). Live birth occurred in 98% of pregnancies. One maternal death occurred within a year of delivery in a woman with Eisenmenger syndrome. Following delivery, 30-day readmission rate was 2% and the rate of readmission from 30 to 90 days postpartum was 4.6%. Median follow-up was 2.6 years.
In a population of primarily Medicaid-insured pregnant women managed by a cardio-obstetrics team, maternal outcomes were encouraging and readmission rates following delivery were low. Prospective studies are needed to evaluate the impact of cardio-obstetric models of care on maternal outcomes.
Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform ...clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition.
Maternal age and risk for adverse outcomes Sheen, Jean-Ju; Wright, Jason D.; Goffman, Dena ...
American journal of obstetrics and gynecology,
October 2018, 2018-10-00, 20181001, Letnik:
219, Številka:
4
Journal Article
Recenzirano
The objective of this study was to characterize the risk for severe maternal morbidity and other pregnancy complications by maternal age during delivery hospitalizations.
This retrospective cohort ...analysis used the Perspective database to characterize the risk for adverse maternal outcomes from 2006 to 2015 based on maternal age. Women were divided into 7 categories based on maternal age: 15–17, 18–24, 25–29, 30–34, 35–39, 40–44, and 45–54 years of age. The primary outcome of this study was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Secondary outcomes included (1) overall comorbid risk; (2) risk for pregnancy complications such as postpartum hemorrhage, gestational diabetes, preeclampsia, and cesarean delivery; and (3) risk for individual severe morbidity diagnoses such as stroke, embolism, eclampsia, and hysterectomy. Adjusted models were fitted to assess factors associated with severe morbidity with adjusted risk ratios (aRRs) and 95% confidence intervals (CI) as measures of effect. Population weights were applied to create national estimates.
Of 36,944,292 deliveries included, 2.5% occurred among women aged 15–17 years (n = 921,236), 29.1% to women aged 18–24 years (n = 10,732,715), 28.6% to women aged 25–29 years (n = 10,564,850), 24.9% to women aged 30–34 years (n = 9,213,227), 12.1% to women aged 35–39 years (n = 4,479,236), 2.6% to women aged 40–44 years (n = 974,289), and 0.2% to women aged 45–54 years (n = 58,739). In unadjusted analyses, severe morbidity was more than 3 times higher (risk ratio RR, 3.33, 95% confidence interval CI, 3.03–3.66) for women 45-54 years compared with women 25–29 years. Women aged 40–44, 35–39, and 15–17 years were also at increased risk (RR, 1.83, 95% CI, 1.77–1.89; RR, 1.36, 95% CI, 1.33–1.39; RR, 1.39, 95% CI, 1.34–1.45, respectively). In the adjusted model, the 45–54 year old group was associated with the highest relative risk (aRR, 3.46, 95% CI, 3.15–3.80) followed by the 40–44 year old group (aRR 1.90, 95% CI, 1.84–1.97), the 35–39 year old group (aRR, 1.43, 95% CI, 1.40–1.47), and the 15–17 year old group (aRR, 1.20, 95% CI, 1.15–1.24). Cesarean delivery, preeclampsia, postpartum hemorrhage, and gestational diabetes were most common among women aged 45–54 years, as were thrombosis and hysterectomy.
While differential risk was noted across maternal age categories, women aged 45 years old and older were at highest risk for a broad range of adverse outcomes during delivery hospitalizations.
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