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DeBolt CA, Rao MG, Limaye MA, London V, Sagaram D, Roman AS, Minkoff H, Bernstein PS, Overbey JR, Kaplowitz E, Meislin R, Toner LE, Khander A, Bigelow CA, Stone J. Grand Multiparity and Obstetric Outcomes in a Contemporary Cohort: The Role of Increasing Parity. Am J Perinatol 2024; 41:815-825. [PMID: 38057090 DOI: 10.1055/a-2223-6093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Evidence is inconsistent regarding grand multiparity and its association with adverse obstetric outcomes. Few large American cohorts of grand multiparas have been studied. We assessed if increasing parity among grand multiparas is associated with increased odds of adverse perinatal outcomes. STUDY DESIGN Multicenter retrospective cohort of patients with parity ≥ 5 who delivered a singleton gestation in New York City from 2011 to 2019. Outcomes included postpartum hemorrhage, preterm delivery, hypertensive disorders of pregnancy, shoulder dystocia, birth weight > 4,000 and <2,500 g, and neonatal intensive care unit (NICU) admission. Parity was analyzed continuously, and multivariate analysis determined if increasing parity and other obstetric variables were associated with each adverse outcome. RESULTS There were 2,496 patients who met inclusion criteria. Increasing parity among grand multiparas was not associated with any of the prespecified adverse outcomes. Odds of postpartum hemorrhage increased with history (adjusted odds ratio [aOR]: 2.65, 95% confidence interval [1.83, 3.84]) and current cesarean delivery (aOR: 4.59 [3.40, 6.18]). Preterm delivery was associated with history (aOR: 12.36 [8.70-17.58]) and non-White race (aOR: 1.90 [1.27, 2.84]). Odds of shoulder dystocia increased with history (aOR: 5.89 [3.22, 10.79]) and birth weight > 4,000 g (aOR: 9.94 [6.32, 15.65]). Birth weight > 4,000 g was associated with maternal obesity (aOR: 2.92 [2.22, 3.84]). Birth weight < 2,500 g was associated with advanced maternal age (aOR: 1.69 [1.15, 2.48]), chronic hypertension (aOR: 2.45 [1.32, 4.53]), and non-White race (aOR: 2.47 [1.66, 3.68]). Odds of hypertensive disorders of pregnancy increased with advanced maternal age (aOR: 1.79 [1.25, 2.56]), history (aOR: 10.09 [6.77-15.04]), and non-White race (aOR: 2.79 [1.95, 4.00]). NICU admission was associated with advanced maternal age (aOR: 1.47 [1.06, 2.02]) and non-White race (aOR: 2.57 [1.84, 3.58]). CONCLUSION Among grand multiparous patients, the risk factor for adverse maternal, obstetric, and neonatal outcomes appears to be occurrence of those adverse events in a prior pregnancy and not increasing parity itself. KEY POINTS · Increasing parity is not associated with adverse obstetric outcomes among grand multiparas.. · Prior adverse pregnancy outcome is a risk factor for the outcome among grand multiparas.. · Advanced maternal age is associated with adverse obstetric outcomes among grand multiparas..
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Affiliation(s)
- Chelsea A DeBolt
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Manasa G Rao
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Meghana A Limaye
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York
| | - Viktoriya London
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Deepika Sagaram
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York
| | - Peter S Bernstein
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Jessica R Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York
| | - Elianna Kaplowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York
| | - Rachel Meislin
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lorraine E Toner
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amrin Khander
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine A Bigelow
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanne Stone
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
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Oyelese Y, Javinani A, Gudanowski B, Krispin E, Rebarber A, Akolekar R, Catanzarite V, D'Souza R, Bronsteen R, Odibo A, Scheier MA, Hasegawa J, Jauniaux E, Lees C, Srinivasan D, Daly-Jones E, Duncombe G, Melcer Y, Maymon R, Silver R, Prefumo F, Tachibana D, Henrich W, Cincotta R, Shainker SA, Ranzini AC, Roman AS, Chmait R, Hernandez-Andrade EA, Rolnik DL, Sepulveda W, Shamshirsaz AA. Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus. Am J Obstet Gynecol 2024:S0002-9378(24)00442-3. [PMID: 38494071 DOI: 10.1016/j.ajog.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/01/2024] [Accepted: 03/09/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.
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Affiliation(s)
- Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
| | - Ali Javinani
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Brittany Gudanowski
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Eyal Krispin
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Andrei Rebarber
- Division of Maternal Fetal Medicine, Mount Sinai West, New York, NY; Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY; Carnegie Imaging for Women, PLLC, New York, NY
| | - Ranjit Akolekar
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Gillingham, United Kingdom; Institute of Medical Sciences, Canterbury Christ Church University, Chatham, United Kingdom
| | - Val Catanzarite
- Maternal-Fetal Medicine, Rady Children's Specialists of San Diego, San Diego, CA
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Richard Bronsteen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Anthony Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | | | - Junichi Hasegawa
- Department of Perinatal Development Pathophysiology, St. Marianna University Graduate School of Medicine, Kawasaki, Japan
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Christoph Lees
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Institute of Reproductive and Developmental Biology, Imperial College London, London, United Kingdom; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Deepa Srinivasan
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elizabeth Daly-Jones
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gregory Duncombe
- Department of Obstetrics and Gynaecology, Logan Hospital, Metro South Health, Meadowbrook, Australia
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Silver
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Federico Prefumo
- Obstetrics and Gynaecology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Wolfgang Henrich
- Department of Obstetrics, Campus Virchow-Klinikum, Campus Charité Mitte, Universitätsmedizin Berlin, Berlin, Germany; Department of Obstetrics, Charité - University Medical Center, Berlin, Germany
| | - Robert Cincotta
- Department of Maternal Fetal Medicine, Mater Mothers' Hospital, South Brisbane, Australia
| | - Scott A Shainker
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Angela C Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MetroHealth System, Case Western Reserve University, Cleveland, OH
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY
| | - Ramen Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Edgar A Hernandez-Andrade
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Waldo Sepulveda
- Fetal Imaging Unit, FETALMED Maternal-Fetal Diagnostic Center, Santiago, Chile
| | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
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Laspro M, Brydges HT, Verzella AN, Schechter J, Alcon A, Roman AS, Flores RL. Association of Commonly Prescribed Antepartum Medications and Incidence of Orofacial Clefting. Cleft Palate Craniofac J 2024:10556656241237679. [PMID: 38449319 DOI: 10.1177/10556656241237679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Pharmacologic agents are often used in the antepartum period, however, studies on their effect on fetal development are limited. Thus, this study aims to examine the effect of commonly prescribed antepartum medications on the development of orofacial clefting. METHODS Utilizing EPIC Cosmos deidentified data from approximately 180 US institutions was queried. Patients born between January 1, 2013, to January 1, 2023, were included. Eight OC cohorts were identified. Gestational medication use was identified by medications prescribed, provider-administered, or reported use by mothers. Medications used in at least 1 in 10,000 pregnancies were included in this analysis. RESULTS A total of 12 098 newborns with available maternal pharmacologic data were born with any type of orofacial clefting. Prevalence for all oral clefts, any cleft palate, and any cleft lip were 20.56, 18.10, and 10.60 per 10 000 individuals, respectively. Notable significant exposures include most anticonvulsants, such as lamotrigine (OR1.33, CI 1.10-1.62), and topiramate (OR1.35, CI 1.13-1.62), as well as nearly all SSRIs/SNRIs, including fluoxetine (OR1.34, CI 1.19-1.51), sertraline (OR1.25, CI 1.16-1.34), and citalopram (OR1.28, CI 1.11-1.47). Corticosteroids were also correlated including dexamethasone (OR1.19, CI 1.12-1.27), and betamethasone (OR1.64, CI 1.55-1.73), as were antibiotics, including amoxicillin (OR1.22, CI 1.14-1.30), doxycycline (OR1.29, CI 1.10-1.52), and nitrofuran derivatives (OR1.10, CI 1.03-1.17). CONCLUSION New associations between commonly prescribed antepartum medications and orofacial clefting were found. These findings should be confirmed as causality is not assessed in this report. Practitioners should be aware of the potential increased risk associated with these medications.
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Affiliation(s)
- Matteo Laspro
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Hilliard T Brydges
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Alexandra N Verzella
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Jill Schechter
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Andre Alcon
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
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Janssen MK, Levine LD, Bromley B, Chasen ST, Russo ML, Roman AS, Limaye MA, Ranzini AC, Clifford CM, Biggio JR, Subramanian A, Seasely A, Patil AS, Weed S, Page JM, Nicholas S, Idler J, Rao R, Crowder A, Shree R, McLennan G, Dugoff L. Clinical implications of crown-rump length discordance at 11 to 14 weeks in dichorionic twins. Am J Obstet Gynecol 2024; 230:83.e1-83.e11. [PMID: 37487855 DOI: 10.1016/j.ajog.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Crown-rump length discordance, defined as ≥10% discordance, has been investigated as an early sonographic marker of subsequent growth abnormalities and is associated with an increased risk of fetal loss in twin pregnancies. Previous studies have not investigated the prevalence of fetal aneuploidy or structural anomalies in twins with discordance or the independent association of crown-rump length discordance with adverse perinatal outcomes. Moreover, data are limited on cell-free DNA screening for aneuploidy in dichorionic twins with discordance. OBJECTIVE This study aimed to evaluate whether crown-rump length discordance in dichorionic twins between 11 and 14 weeks of gestation is associated with a higher risk of aneuploidy, structural anomalies, or adverse perinatal outcomes and to assess the performance of cell-free DNA screening in dichorionic twin pregnancies with crown-rump length discordance. STUDY DESIGN This was a secondary analysis of a multicenter retrospective cohort study that evaluated the performance of cell-free DNA screening for the common trisomies in twin pregnancies from December 2011 to February 2020. For this secondary analysis, we included live dichorionic pregnancies with crown-rump length measurements between 11 and 14 weeks of gestation. First, we compared twin pregnancies with discordant crown-rump lengths with twin pregnancies with concordant crown-rump lengths and analyzed the prevalence of aneuploidy and fetal structural anomalies in either twin. Second, we compared the prevalence of a composite adverse perinatal outcome, which included preterm birth at <34 weeks of gestation, hypertensive disorders of pregnancy, stillbirth or miscarriage, small-for-gestational-age birthweight, and birthweight discordance. Moreover, we assessed the performance of cell-free DNA screening in pregnancies with and without crown-rump length discordance. Outcomes were compared with multivariable regression to adjust for confounders. RESULTS Of 987 dichorionic twins, 142 (14%) had crown-rump length discordance. The prevalence of aneuploidy was higher in twins with crown-rump length discordance than in twins with concordance (9.9% vs 3.9%, respectively; adjusted relative risk, 2.7; 95% confidence interval, 1.4-4.9). Similarly, structural anomalies (adjusted relative risk, 2.5; 95% confidence interval, 1.4-4.4]) and composite adverse perinatal outcomes (adjusted relative risk, 1.2; 95% confidence interval, 1.04-1.3) were significantly higher in twins with discordance. A stratified analysis demonstrated that even without other ultrasound markers, there were increased risks of aneuploidy (adjusted relative risk, 3.5; 95% confidence interval, 1.5-8.4) and structural anomalies (adjusted relative risk, 2.7; 95% confidence interval, 1.5-4.8) in twins with CRL discordance. Cell-free DNA screening had high negative predictive values for trisomy 21, trisomy 18, and trisomy 13, regardless of crown-rump length discordance, with 1 false-negative for trisomy 21 in a twin pregnancy with discordance. CONCLUSION Crown-rump length discordance in dichorionic twins is associated with an increased risk of aneuploidy, structural anomalies, and adverse perinatal outcomes, even without other sonographic abnormalities. Cell-free DNA screening demonstrated high sensitivity and negative predictive values irrespective of crown-rump length discordance; however, 1 false-negative result illustrated that there is a role for diagnostic testing. These data may prove useful in identifying twin pregnancies that may benefit from increased screening and surveillance and are not ascertained by other early sonographic markers.
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Affiliation(s)
- Matthew K Janssen
- Maternal-Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Lisa D Levine
- Maternal-Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bryann Bromley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston MA
| | - Stephen T Chasen
- Department of Obstetrics and Gynecology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY
| | - Melissa L Russo
- Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Meghana A Limaye
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Angela C Ranzini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH
| | - Caitlin M Clifford
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Joseph R Biggio
- Women's Service Line, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Ochsner Health, New Orleans, LA
| | - Akila Subramanian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Angela Seasely
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Avinash S Patil
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ
| | - Samantha Weed
- Franciscan Maternal-Fetal Medicine Associates, Tacoma, WA
| | - Jessica M Page
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, UT
| | - Sara Nicholas
- Axia Women's Health Main Line Perinatal Associates, Wynnewood, PA
| | - Jay Idler
- Allegheny Health Network, Drexel University College of Medicine, Pittsburgh, PA
| | - Rashmi Rao
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Lorraine Dugoff
- Maternal-Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Trostle ME, Grossman TB, Penfield CA, Phoon CKL, Raabe VN, Sloane MF, Roman AS. A Pregnant Adolescent with COVID-19 and Multisystem Inflammatory Syndrome in Children. AJP Rep 2024; 14:e66-e68. [PMID: 38370327 PMCID: PMC10874691 DOI: 10.1055/s-0044-1779032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/22/2023] [Indexed: 02/20/2024] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C), a new condition related to coronavirus disease 2019 (COVID-19) in the pediatric population, was recognized by physicians in the United Kingdom in April 2020. Given those up to the age of 21 years can be affected, pregnant adolescents and young adults are susceptible. However, there is scant information on how MIS-C may affect pregnancy and whether the presentation differs in the pregnant population. We report a case of a pregnant adolescent with COVID-19 and MIS-C with a favorable outcome. This case highlights the considerations in managing a critically ill pregnant patient with a novel illness and the importance of a multidisciplinary team in coordinating care.
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Affiliation(s)
- Megan E. Trostle
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
| | - Tracy B. Grossman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
| | - Christina A. Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
| | - Colin K. L. Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone Medical Center, New York, New York
| | - Vanessa N. Raabe
- Division of Pediatric Infectious Diseases, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine and NYU Langone Vaccine Center, New York, New York
| | - Mark F. Sloane
- Division of Pulmonary and Critical Care Medicine, NYU Langone Medical Center, New York, New York
| | - Ashley S. Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York, New York
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Martin K, Norton ME, MacPherson C, Demko Z, Egbert M, Haeri S, Malone F, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Strong N, Silver R, Vohra N, Hyett J, Kao C, Hakonarson H, Jacobson B, Dar P. Impact of high-risk prenatal screening results for 22q11.2 deletion syndrome on obstetric and neonatal management: Secondary analysis from the SMART study. Prenat Diagn 2023; 43:1574-1580. [PMID: 38066724 DOI: 10.1002/pd.6483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE One goal of prenatal genetic screening is to optimize perinatal care and improve infant outcomes. We sought to determine whether high-risk cfDNA screening for 22q11.2 deletion syndrome (22q11.2DS) affected prenatal or neonatal management. METHODS This was a secondary analysis from the SMART study. Patients with high-risk cfDNA results for 22q11.2DS were compared with the low-risk cohort for pregnancy characteristics and obstetrical management. To assess differences in neonatal care, we compared high-risk neonates without prenatal genetic confirmation with a 1:1 matched low-risk cohort. RESULTS Of 18,020 eligible participants enrolled between 2015 and 2019, 38 (0.21%) were high-risk and 17,982 (99.79%) were low-risk for 22q11.2DS by cfDNA screening. High-risk participants had more prenatal diagnostic testing (55.3%; 21/38 vs. 2.0%; 352/17,982, p < 0.001) and fetal echocardiography (76.9%; 10/13 vs. 19.6%; 10/51, p < 0.001). High-risk newborns without prenatal diagnostic testing had higher rates of neonatal genetic testing (46.2%; 6/13 vs. 0%; 0/51, P < 0.001), echocardiography (30.8%; 4/13 vs. 4.0%; 2/50, p = 0.013), evaluation of calcium levels (46.2%; 6/13 vs. 4.1%; 2/49, P < 0.001) and lymphocyte count (53.8%; 7/13 vs. 15.7%; 8/51, p = 0.008). CONCLUSIONS High-risk screening results for 22q11.2DS were associated with higher rates of prenatal and neonatal diagnostic genetic testing and other 22q11.2DS-specific evaluations. However, these interventions were not universally performed, and >50% of high-risk infants were discharged without genetic testing, representing possible missed opportunities to improve outcomes for affected individuals.
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Affiliation(s)
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Cora MacPherson
- The Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | | | | | | | - Fergal Malone
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia Presbyterian Medical Center, New York, New York, USA
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, New York University Langone, New York, New York, USA
| | - Asma Khalil
- Department of Obstetrics and Gynecology, St. George's Hospital, University of London, London, UK
| | - Revital Faro
- Department of Obstetrics and Gynecology, St. Peter's University Hospital, New Brunswick, New Jersy, USA
| | - Rajeevi Madankumar
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Noel Strong
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Nidhi Vohra
- Department of Obstetrics and Gynecology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jon Hyett
- Department of Obstetrics and Gynecology, Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia
| | - Charlly Kao
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bo Jacobson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Perelman AD, Trostle ME, Pecoriello J, Quinn GP, Roman AS, Penfield CA. Acceptance of Routine Vaccines in Pregnancy during the COVID-19 Pandemic. Am J Perinatol 2023. [PMID: 37816391 DOI: 10.1055/a-2188-8511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE This study aimed to evaluate the rates of vaccination against infectious diseases (Tetanus, Diphtheria, and Pertussis [Tdap] and influenza) in pregnancy during the coronavirus disease 2019 (COVID-19) pandemic compared to contemporary historical controls. STUDY DESIGN This was a retrospective cohort study comparing rates of Tdap and influenza vaccination in pregnant people who received care at NYU Langone Health and delivered from September 1, 2020, to January 31, 2021 ("COVID cohort") to the same period the prior year ("2019 cohort"). Demographic information, trimester of initiation of prenatal care, insurance status, and medical comorbidities were evaluated. Outcomes were analyzed using chi-square, Fisher's exact test, and multivariable logistic regression, with significance of p < 0.05. RESULTS In total, 1,713 pregnant people were included. Compared to historical controls, the COVID cohort differed in age, race, timing of initiation of prenatal care, insurance status, and medical comorbidities. After adjusting for these covariates, pregnant people were significantly more likely to accept influenza vaccine in the COVID cohort (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.27-2.29) and had similar Tdap acceptance (aOR 1.5, 95% CI 0.99-2.17). However, this trend was not observed for the entire obstetric population; public insurance status and medical comorbidities were associated with lower vaccine rates during the pandemic. For those who had public insurance, rates of influenza vaccination decreased from 83% in 2019 to 40% during COVID (aOR 0.16, 95% CI 0.10-0.24) and for Tdap rates decreased from 93 to 54% (aOR 0.13, 95% CI 0.08-0.21). CONCLUSION During the COVID-19 pandemic era, pregnant people at large were more likely to accept the influenza vaccine. However, this trend did not apply to Tdap, and high-risk groups with public insurance and medical comorbidities. This study highlights potential disparities in vaccination rates, which need to be accounted for when evaluating national vaccine trends. These data support increased efforts in vaccine counseling for high-risk populations. KEY POINTS · Antenatal flu vaccination increased during the pandemic.. · Antenatal Tdap vaccination was unchanged during the pandemic.. · High-risk pregnant patients had decreased vaccine uptake.. · High-risk subgroups were not included in overarching vaccination trends..
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Affiliation(s)
- Allison D Perelman
- Department of Obstetrics & Gynecology, NYU Langone Health, New York, New York
| | - Megan E Trostle
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, NYU Langone Health, New York, New York
| | - Jillian Pecoriello
- Department of Obstetrics & Gynecology, NYU Langone Health, New York, New York
| | - Gwendolyn P Quinn
- Department of Obstetrics & Gynecology, NYU Langone Health, New York, New York
| | - Ashley S Roman
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, NYU Langone Health, New York, New York
| | - Christina A Penfield
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, NYU Langone Health, New York, New York
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Peterson JA, Szeto L, Wodoslawsky S, Futterman ID, Silverstein JS, Fiorentino DG, Li D, Al-Kouatly HB, Simpson LL, Roman AS, Strong NK. Genetic counseling practices among outpatient obstetric providers in the Northeast. Am J Obstet Gynecol MFM 2023; 5:101150. [PMID: 37683764 DOI: 10.1016/j.ajogmf.2023.101150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND The American College of Obstetricians and Gynecologists recommends all pregnant people be offered genetic screening and diagnostic testing regardless of risk factors. Previous studies have demonstrated disparities in referrals for genetic testing by race outside of pregnancy, but limited data exist regarding genetic counseling practices during pregnancy. OBJECTIVE This study aimed to describe how patient, provider, and practice demographics influence the offering of diagnostic prenatal genetic testing by outpatient prenatal care providers. STUDY DESIGN This was a multicenter anonymous survey study conducted between October 2021 and March 2022. Outpatient prenatal care providers, including family medicine and obstetrics attendings, residents, maternal-fetal medicine fellows, nurse practitioners, physician assistants, and midwives, were surveyed about their genetic counseling practices and practice demographics. The primary outcome was the proportion of respondents who answered "yes, all patients" to the survey question "Do you offer diagnostic genetic testing to all patients?" The secondary outcomes included the association between patient and practice demographics and offering diagnostic testing. Diagnostic testing was defined as chorionic villus sampling or amniocentesis. Screening genetic tests were defined as sequential screen, quadruple screen, cell-free DNA screening, or "other." The chi-square test or Fisher exact test was used as appropriate. For the outcome answers of diagnostic testing, logistic regression was performed to assess the association between the answer of diagnostic genetic testing and the current training level of providers, race and ethnicity, and insurance status variables. Multivariable analysis was performed to adjust for confounders. RESULTS A total of 635 outpatient prenatal care providers across 7 sites were sent the survey. Overall, 419 providers responded for a total response rate of 66%. Of the providers who responded, most were attendings (44.9%), followed by residents (37.5%). Providers indicated the race, insurance status, and primary language of their patient population. Screening genetic testing was offered by 98% of providers. Per provider report, 37% offered diagnostic testing to all patients, 18% did not offer it at all, and 44% only offered it if certain patient factors were present. Moreover, 54.8% of attendings reported universally offering diagnostic testing. On univariable analysis, residents were less likely to offer diagnostic testing than attendings (odds ratio, 0.18; 95% confidence interval, 0.11-0.30). Providers who serve non-Hispanic Black, Hispanic Black, and other Hispanic patients were less likely to report offering diagnostic testing than other patient populations. Providers who served non-Hispanic Whites were more likely to offer diagnostic testing (odds ratio, 2.26; 95% confidence interval, 1.51-3.39). Patient populations who were primarily privately insured were more likely to be offered diagnostic testing compared with primarily publicly insured patients (odds ratio, 6.25; 95% confidence interval, 3.60-10.85). Providers who served a primarily English-speaking population were more likely to offer diagnostic genetic testing than other patient populations (odds ratio, 0.43; 95% confidence interval, 0.26-0.69). On multivariable analysis, the factors that remained significantly associated with offering diagnostic testing included level of training (resident odds ratio, 0.33; 95% confidence interval, 0.17-0.62; P=.0006; advanced practice provider odds ratio, 0.34; 95% confidence interval, 0.15-0.82; P=.02), having at least one-third of the patient population identify as "other Hispanic" (odds ratio, 0.42; 95% confidence interval, 0.23-0.77; P=.005), and having private insurance instead of public insurance (primarily private insured odds ratio, 2.84; 95% confidence interval, 1.20-6.74; P=.02). CONCLUSION Although offering genetic screening and diagnostic testing to all patients is recommended, no provider group universally offers diagnostic testing. Providers who serve populations from a racial and ethnic minority, those with public insurance, and those whose primary language is not English are less likely to report universally offering diagnostic genetic testing.
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Affiliation(s)
- Jessica A Peterson
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Drs Peterson and Szeto, Ms Li, and Dr Strong).
| | - Libby Szeto
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Drs Peterson and Szeto, Ms Li, and Dr Strong)
| | - Sascha Wodoslawsky
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (Ms Wodoslawsky)
| | - Itamar D Futterman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Dr Futterman)
| | - Jenna S Silverstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY (Drs Silverstein and Roman)
| | - Desiree G Fiorentino
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY (Dr Fiorentino)
| | - Ditian Li
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Drs Peterson and Szeto, Ms Li, and Dr Strong)
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (Dr Al-Kouatly)
| | - Lynn L Simpson
- Columbia University Irving Medical Center, New York, NY (Dr Simpson)
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY (Drs Silverstein and Roman)
| | - Noel K Strong
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Drs Peterson and Szeto, Ms Li, and Dr Strong)
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9
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Griffin MM, Mehta-Lee SS, Penfield CA, Roman AS. Comparing outcomes of fetal growth restriction defined by estimated fetal weight versus isolated abdominal circumference. Arch Gynecol Obstet 2023:10.1007/s00404-023-07241-z. [PMID: 37891409 DOI: 10.1007/s00404-023-07241-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/17/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE The objective of this study was to compare maternal and neonatal outcomes when the diagnosis of FGR was based on isolated abdominal circumference < 10th percentile for gestational age (GA) (iAC group) versus overall estimated fetal weight < 10th percentile (EFW group). METHODS This was a retrospective cohort study of singleton gestations who underwent growth ultrasounds and delivered at a single health system from 1/1/19-9/4/20. The study group was comprised of patients with AC < 10th percentile and EFW ≥ than the 10th percentile (iAC group). The control group included patients with overall EFW < 10th percentile (EFW group). Outcomes evaluated included GA at delivery, mode of delivery, fetal and neonatal outcomes. Data was analyzed using Mann Whitney U, X2, and Fisher exact tests with significance defined as p < 0.05. RESULTS 635 women met the inclusion criteria, 259 women in the iAC group and 376 women in the EFW group. The iAC group was noted to have a later GA at diagnosis and delivery. iAC was associated with lower rates of preterm birth (PTB), NICU admission, SGA at delivery and umbilical artery cord gas < 7.0. CONCLUSION Using iAC as a definition of FGR increased the number of FGR cases by 1.69-fold over EFW criteria alone. However, obstetrical and neonatal outcomes for the iAC group appear to be significantly better than those in the EFW group, with low rates of PTB, NICU admission, and umbilical artery cord gas < 7.0.
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Affiliation(s)
- Myah M Griffin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, 550 First Ave., NBV 9N2, New York, NY, 10016, USA.
| | - Shilpi S Mehta-Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, 550 First Ave., NBV 9N2, New York, NY, 10016, USA
| | - Christina A Penfield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, 550 First Ave., NBV 9N2, New York, NY, 10016, USA
| | - Ashley S Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, 550 First Ave., NBV 9N2, New York, NY, 10016, USA
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10
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Griffin MM, Avtushka V, Venkatesh P, Aquino J, Roman AS. Reticulocyte hemoglobin trend in pregnancy. Am J Obstet Gynecol 2023; 229:471-472. [PMID: 37419168 DOI: 10.1016/j.ajog.2023.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/24/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Affiliation(s)
- Myah M Griffin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 1st Ave., NBV 9N2, New York, NY 10016.
| | - Valeryia Avtushka
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 1st Ave., NBV 9N2, New York, NY 10016
| | - Pooja Venkatesh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 1st Ave., NBV 9N2, New York, NY 10016
| | - Jennifer Aquino
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 1st Ave., NBV 9N2, New York, NY 10016
| | - Ashley S Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 1st Ave., NBV 9N2, New York, NY 10016
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11
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Dugoff L, Koelper NC, Chasen ST, Russo ML, Roman AS, Limaye MA, Ranzini AC, Clifford CM, Biggio JR, Subramaniam A, Seasely A, Patil AS, Weed S, Page JM, Nicholas S, Idler J, Rao RR, Crowder A, Shree R, McLennan G, Bromley B. Cell-free DNA screening for trisomy 21 in twin pregnancy: a large multicenter cohort study. Am J Obstet Gynecol 2023; 229:435.e1-435.e7. [PMID: 37030426 DOI: 10.1016/j.ajog.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Analysis of cell-free DNA from maternal blood provides effective screening for trisomy 21 in singleton pregnancies. Data on cell-free DNA screening in twin gestations are promising although limited. In previous twin studies, cell-free DNA screening was primarily performed in the second trimester and many studies did not report chorionicity. OBJECTIVE This study aimed to evaluate the screening performance of cell-free DNA for trisomy 21 in twin pregnancies in a large, diverse cohort. A secondary aim was to evaluate screening performance for trisomy 18 and trisomy 13. STUDY DESIGN This was a retrospective cohort study of twin pregnancies from 17 centers for which cell-free DNA screening was performed from December 2011 to February 2020 by one laboratory using massively parallel sequencing technology. Medical record review was conducted for all newborns and data on the birth outcome, the presence of any congenital abnormalities, phenotypic appearance at birth, and any chromosomal testing that was undertaken in the antenatal or postnatal period were extracted. Cases with a possible fetal chromosomal abnormality with no genetic test results were reviewed by a committee of maternal-fetal medicine geneticists. Cases with a vanishing twin and inadequate follow-up information were excluded. A minimum of 35 confirmed cases of trisomy 21 was required to capture a sensitivity of at least 90% with a prevalence of at least 1.9% with 80% power. Test characteristics were calculated for each outcome. RESULTS A total of 1764 samples were sent for twin cell-free DNA screening. Of those, 78 cases with a vanishing twin and 239 cases with inadequate follow-up were excluded, leaving a total of 1447 cases for inclusion in the analysis. The median maternal age was 35 years and the median gestational age at cell-free DNA testing was 12.3 weeks. In total, 81% of the twins were dichorionic. The median fetal fraction was 12.4%. Trisomy 21 was detected in 41 of 42 pregnancies, yielding a detection rate of 97.6% (95% confidence interval, 83.8-99.7). There was 1 false negative and no false positive cases. Trisomy 21 was detected in 38 out of 39 dichorionic twin pregnancies, yielding a detection rate of 97.4% (95% confidence interval, 82.6-99.7). Trisomy 18 was detected in 10 of the 10 affected pregnancies. There was 1 false positive case. Trisomy 13 was detected in 4 of the 5 cases, yielding a detection rate of 80% (95% confidence interval, 11.1-99.2). There was one false negative and no false positive cases. The nonreportable rate was low at 3.9 %. CONCLUSION Cell-free DNA testing is effective in screening for trisomy 21 in twin gestations from the first trimester of pregnancy. Detection of trisomy 21 was high in dichorionic and monochorionic twins, and the nonreportable result rates were low. This study included high numbers of cases of trisomy 18 and 13 when compared with the current literature. Although screening for these conditions in twins seems to be promising, the numbers were too small to make definitive conclusions regarding the screening efficacy for these conditions. It is possible that cell-free DNA testing performance may differ among laboratories and vary with screening methodologies.
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Affiliation(s)
- Lorraine Dugoff
- Division of Reproductive Genetics, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stephen T Chasen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NewYork Presbyterian-Weill Cornell Medical Center, New York, NY
| | - Melissa L Russo
- Division of Maternal-Fetal Medicine, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Meghana A Limaye
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Angela C Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH
| | - Caitlin M Clifford
- Division of Maternal-Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Joseph R Biggio
- Section of Maternal Fetal Medicine, Women's Service Line, Department of Obstetrics and Gynecology, Ochsner Health, New Orleans, LA
| | - Akila Subramaniam
- Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Angela Seasely
- Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Avinash S Patil
- Department of Obstetrics and Gynecology, The University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Samantha Weed
- Franciscan Maternal-Fetal Medicine Associates, Tacoma, WA
| | - Jessica M Page
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Healthcare and Intermountain Healthcare, Salt Lake City, UT
| | - Sara Nicholas
- Axia Women's Health Main Line Perinatal Associates, Wynnewood, PA
| | - Jay Idler
- Allegheny Health Network, Drexel University College of Medicine, Pittsburgh, PA
| | - Rashmi R Rao
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Bryann Bromley
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
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Norton ME, MacPherson C, Demko Z, Egbert M, Malone F, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Strong N, Haeri S, Silver R, Vohra N, Hyett J, Martin K, Rabinowitz M, Jacobsson B, Dar P. Obstetrical, perinatal, and genetic outcomes associated with nonreportable prenatal cell-free DNA screening results. Am J Obstet Gynecol 2023; 229:300.e1-300.e9. [PMID: 36965866 DOI: 10.1016/j.ajog.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/20/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND The clinical implications of nonreportable cell-free DNA screening results are uncertain, but such results may indicate poor placental implantation in some cases and be associated with adverse obstetrical and perinatal outcomes. OBJECTIVE This study aimed to assess the outcomes of pregnancies with nonreportable cell-free DNA screening in a cohort of patients with complete genetic and obstetrical outcomes. STUDY DESIGN This was a prespecified secondary analysis of a multicenter prospective observational study of prenatal cell-free DNA screening for fetal aneuploidy and 22q11.2 deletion syndrome. Participants who underwent cell-free DNA screening from April 2015 through January 2019 were offered participation. Obstetrical outcomes and neonatal genetic testing results were collected from 21 primary-care and referral centers in the United States, Europe, and Australia. The primary outcome was risk for adverse obstetrical and perinatal outcomes (aneuploidy, preterm birth at <28, <34, and <37 weeks' gestation, preeclampsia, small for gestational age or birthweight <10th percentile for gestational week, and a composite outcome that included preterm birth at <37 weeks, preeclampsia, small for gestational age, and stillbirth at >20 weeks) after nonreportable cell-free DNA screening because of low fetal fraction or other causes. Multivariable analyses were performed, adjusting for variables known to be associated with obstetrical and perinatal outcomes, nonreportable results, or fetal fraction. RESULTS In total, 25,199 pregnant individuals were screened, and 20,194 were enrolled. Genetic confirmation was missing in 1165 (5.8%), 1085 (5.4%) were lost to follow-up, and 93 (0.5%) withdrew; the final study cohort included 17,851 (88.4%) participants who had cell-free DNA, fetal or newborn genetic confirmatory testing, and obstetrical and perinatal outcomes collected. Results were nonreportable in 602 (3.4%) participants. A sample was redrawn and testing attempted again in 427; in 112 (26.2%) participants, results were again nonreportable. Nonreportable results were associated with higher body mass index, chronic hypertension, later gestational age, lower fetal fraction, and Black race. Trisomy 13, 18, or 21 was confirmed in 1.6% with nonreportable tests vs 0.7% with reported results (P=.013). Rates of preterm birth at <28, 34, and 37 weeks, preeclampsia, and the composite outcome were higher among participants with nonreportable results, and further increased among those with a second nonreportable test, whereas the rate of small for gestational age infants was not increased. After adjustment for confounders, the adjusted odds ratios were 2.2 (95% confidence interval, 1.1-4.4) and 2.6 (95% confidence interval, 0.6-10.8) for aneuploidy, and 1.5 (95% confidence interval, 1.2-1.8) and 2.1 (95% confidence interval, 1.4-3.2) for the composite outcome after a first and second nonreportable test, respectively. Of the patients with nonreportable tests, 94.9% had a live birth, as opposed to 98.8% of those with reported test results (adjusted odds ratio for livebirth, 0.20 [95% confidence interval, 0.13-0.30]). CONCLUSION Patients with nonreportable cell-free DNA results are at increased risk for a number of adverse outcomes, including aneuploidy, preeclampsia, and preterm birth. They should be offered diagnostic genetic testing, and clinicians should be aware of the increased risk of pregnancy complications.
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Affiliation(s)
- Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA.
| | - Cora MacPherson
- Biostatistics Center, George Washington University, Washington, DC
| | | | | | - Fergal Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia Presbyterian Medical Center, New York, NY
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Asma Khalil
- Department of Obstetrics and Gynaecology, St George's Hospital, University of London, London, United Kingdom
| | - Revital Faro
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, NJ
| | - Rajeevi Madankumar
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, Hyde Park, NY
| | - Noel Strong
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sina Haeri
- Austin Maternal-Fetal Medicine, Austin, TX
| | - Robert Silver
- Department of Obstetrics and Gynecology, The University of Utah, Salt Lake City, UT
| | - Nidhi Vohra
- Department of Obstetrics and Gynecology, North Shore University Hospital, Manhasset, NY
| | - Jon Hyett
- Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital and Western Sydney University, Sydney, Australia
| | | | | | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
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13
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Martin K, Dar P, MacPherson C, Egbert M, Demko Z, Parmar S, Hashimoto K, Haeri S, Malone F, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Strong N, Silver RM, Vohra N, Hyett J, Rabinowitz M, Kao C, Hakonarson H, Jacobsson B, Norton ME. Performance of prenatal cfDNA screening for sex chromosomes. Genet Med 2023:100879. [PMID: 37154148 DOI: 10.1016/j.gim.2023.100879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/29/2023] [Accepted: 04/30/2023] [Indexed: 05/10/2023] Open
Abstract
PURPOSE To assess the performance of cell-free DNA (cfDNA) screening to detect sex chromosome aneuploidies (SCA) in an unselected obstetrical population with genetic confirmation. METHODS This was a planned secondary analysis of the multicenter, prospective SMART study. Patients receiving cfDNA results for autosomal aneuploidies and who had confirmatory genetic results for the relevant sex chromosomal aneuploidies were included. Screening performance for SCAs, including monosomy X (MX) and the sex chromosome trisomies (SCTs; 47,XXX; 47,XXY; 47,XYY) was determined. Fetal sex concordance between cfDNA and genetic screening was also evaluated in euploid pregnancies. RESULTS 17,538 cases met inclusion criteria. Performance of cfDNA for MX, SCTs and fetal sex was determined in 17,297, 10,333 and 14,486 pregnancies, respectively. Sensitivity, specificity, and PPV of cfDNA were 83.3%, 99.9%, and 22.7% for MX, and 70.4%, 99.9%, and 82.6% for the combined SCTs. The accuracy of fetal sex prediction by cfDNA was 100%. CONCLUSION Screening performance of cfDNA for SCAs is comparable to that reported in other studies. The PPV for the SCTs was similar to the autosomal trisomies, while the PPV for MX was substantially lower. No discordance in fetal sex was observed between cfDNA and postnatal genetic screening in euploid pregnancies. These data will assist interpretation and counseling for cfDNA results for sex chromosomes.
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Affiliation(s)
| | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Cora MacPherson
- The Biostatistics Center, George Washington University, Washington, DC, USA
| | | | | | | | | | | | - Fergal Malone
- Rotunda Hospital, Royal College of Surgeons in Ireland, Department of Obstetrics and Gynecology, Dublin, Ireland
| | - Ronald J Wapner
- Columbia Presbyterian Medical Center, Department of Obstetrics and Gynecology, New York, NY, 10032, USA
| | - Ashley S Roman
- New York University Langone, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Asma Khalil
- St. George's Hospital, University of London, Department of Obstetrics and Gynecology, London, SW17 0RE, United Kingdom
| | - Revital Faro
- St. Peter's University Hospital, Department of Obstetrics and Gynecology, New Brunswick, NJ, USA
| | - Rajeevi Madankumar
- Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Obstetrics and Gynecology, New Hyde Park, NY, USA
| | - Noel Strong
- Icahn School of Medicine at Mount Sinai, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Robert M Silver
- University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT 84112, USA
| | - Nidhi Vohra
- North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Obstetrics and Gynecology, Manhasset, NY, USA
| | - Jon Hyett
- Western Sydney University, Department of Obstetrics and Gynaecology, Liverpool NSW 2170, Australia
| | | | - Charlly Kao
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA.
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14
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Griffin M, Avtushka V, Venkatesh P, Aquino J, Roman AS. Risk Factors for First Trimester Iron Deficiency. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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15
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Adelman SM, Charifson M, Brubaker SG, Roman AS, Kahn LG, Mehta-Lee S. The longitudinal impact of the COVID-19 pandemic on births in a single NYC health-care system. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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16
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Griffin M, Avtushka V, Venkatesh P, Aquino J, Roman AS. Reticulocyte Hemoglobin Trend in Pregnancy. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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17
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Griffin M, Liu W, Hoskins IA, Fenyö D, Roman AS. Prediction of Shoulder Dystocia Utilizing Machine Learning. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Hawks RJM, Ades V, Roman AS, Penfield CA, Goddard B. COVID-19 transmissibility during labor and vaginal delivery. Am J Obstet Gynecol MFM 2023; 5:100770. [PMID: 36240987 PMCID: PMC9554218 DOI: 10.1016/j.ajogmf.2022.100770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/29/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Rebecca J Mahn Hawks
- Jacobi Medical Center, Department of Obstetrics and Gynecology, Bronx, New York.
| | - Veronica Ades
- Jacobi Medical Center, Department of Obstetrics and Gynecology, Bronx, New York
| | - Ashley S Roman
- NYU Langone Health, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York NY
| | - Christina A Penfield
- NYU Langone Health, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York NY
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Mitchell SJ, Ngo G, Maurel KA, Hasegawa J, Arakaki T, Melcer Y, Maymon R, Vendittelli F, Shamshirsaz AA, Erfani H, Shainker SA, Saad AF, Treadwell MC, Roman AS, Stone JL, Rolnik DL. Timing of birth and adverse pregnancy outcomes in cases of prenatally diagnosed vasa previa: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 227:173-181.e24. [PMID: 35283090 DOI: 10.1016/j.ajog.2022.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa. DATA SOURCES Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022. STUDY ELIGIBILITY CRITERIA The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth. METHODS Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions. RESULTS The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation. CONCLUSION Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.
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Ungar SP, Solomon S, Stachel A, Demarco K, Roman AS, Lighter J. Impact of Prenatal SARS-CoV-2 Infection on Infant Emergency Department Visits and Hospitalization. Clin Pediatr (Phila) 2022; 61:206-211. [PMID: 34903074 DOI: 10.1177/00099228211065898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To better understand the impact of prenatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on infants, this study sought to compare the risk of hospital visits and of postnatal SARS-CoV-2 infection between infants born to mothers with and without prenatal SARS-CoV-2 infection. In this retrospective observational cohort study of 6871 mothers and their infants, overall rates of emergency department (ED) visits and hospital admissions in the first 90 days of life were similar for infants born to mothers with and without prenatal SARS-CoV-2 infection. Infants born to negative mothers were more likely than infants of positive mothers to be hospitalized after ED visit (relative risk: 3.76; 95% confidence interval: 1.27-11.13, P = .003). Five infants tested positive; all were born to negative mothers, suggesting that maternal prenatal SARS-CoV-2 infection may protect infants from postnatal infection. The lower acuity ED visits for infants born to mothers with prenatal SARS-CoV-2 infection may reflect a heightened level of concern among these mothers.
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21
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Dar P, Jacobsson B, MacPherson C, Egbert M, Malone F, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Edwards L, Haeri S, Silver R, Vohra N, Hyett J, Clunie G, Demko Z, Martin K, Rabinowitz M, Flood K, Carlsson Y, Doulaveris G, Malone C, Hallingstrom M, Klugman S, Clifton R, Kao C, Hakonarson H, Norton ME. Cell-free DNA screening for trisomies 21, 18, and 13 in pregnancies at low and high risk for aneuploidy with genetic confirmation. Am J Obstet Gynecol 2022; 227:259.e1-259.e14. [PMID: 35085538 DOI: 10.1016/j.ajog.2022.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cell-free DNA noninvasive prenatal screening for trisomies 21, 18, and 13 has been rapidly adopted into clinical practice. However, previous studies are limited by a lack of follow-up genetic testing to confirm the outcomes and accurately assess test performance, particularly in women at a low risk for aneuploidy. OBJECTIVE To measure and compare the performance of cell-free DNA screening for trisomies 21, 18, and 13 between women at a low and high risk for aneuploidy in a large, prospective cohort with genetic confirmation of results STUDY DESIGN: This was a multicenter prospective observational study at 21 centers in 6 countries. Women who had single-nucleotide-polymorphism-based cell-free DNA screening for trisomies 21, 18, and 13 were enrolled. Genetic confirmation was obtained from prenatal or newborn DNA samples. The test performance and test failure (no-call) rates were assessed for the cohort, and women with low and high previous risks for aneuploidy were compared. An updated cell-free DNA algorithm blinded to the pregnancy outcome was also assessed. RESULTS A total of 20,194 women were enrolled at a median gestational age of 12.6 weeks (interquartile range, 11.6-13.9). The genetic outcomes were confirmed in 17,851 cases (88.4%): 13,043 (73.1%) low-risk and 4808 (26.9%) high-risk cases for aneuploidy. Overall, 133 trisomies were diagnosed (100 trisomy 21; 18 trisomy 18; 15 trisomy 13). The cell-free DNA screen positive rate was lower in the low-risk vs the high-risk group (0.27% vs 2.2%; P<.0001). The sensitivity and specificity were similar between the groups. The positive predictive value for the low- and high-risk groups was 85.7% vs 97.5%; P=.058 for trisomy 21; 50.0% vs 81.3%; P=.283 for trisomy 18; and 62.5% vs 83.3; P=.58 for trisomy 13, respectively. Overall, 602 (3.4%) patients had no-call result after the first draw and 287 (1.61%) after including cases with a second draw. The trisomy rate was higher in the 287 cases with no-call results than patients with a result on a first draw (2.8% vs 0.7%; P=.001). The updated algorithm showed similar sensitivity and specificity to the study algorithm with a lower no-call rate. CONCLUSION In women at a low risk for aneuploidy, single-nucleotide-polymorphism-based cell-free DNA has high sensitivity and specificity, positive predictive value of 85.7% for trisomy 21 and 74.3% for the 3 common trisomies. Patients who receive a no-call result are at an increased risk of aneuploidy and require additional investigation.
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Affiliation(s)
- Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cora MacPherson
- The Biostatistics Center, George Washington University, Washington, DC
| | | | - Fergal Malone
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY
| | - Asma Khalil
- Department of Obstetrics and Gynecology, St George's Hospital, University of London, London, United Kingdom
| | - Revital Faro
- Department of Obstetrics and Gynecology, St. Peter's University Hospital, New Brunswick, NJ
| | - Rajeevi Madankumar
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, Hyde Park, NY
| | | | - Sina Haeri
- Austin Maternal-Fetal Medicine, Austin, TX
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Nidhi Vohra
- Department of Obstetrics and Gynecology, North Shore University Hospital, Manhasset, NY
| | - Jon Hyett
- Department of Obstetrics and Gynecology, Royal Prince Alfred Hospital, University of Sydney, Camperdown, Australia
| | - Garfield Clunie
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | - Karen Flood
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Georgios Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ciara Malone
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maria Hallingstrom
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susan Klugman
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Rebecca Clifton
- The Biostatistics Center, George Washington University, Washington, DC
| | - Charlly Kao
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
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Dar P, Jacobsson B, Clifton R, Egbert M, Malone F, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Edwards L, Strong N, Haeri S, Silver R, Vohra N, Hyett J, Demko Z, Martin K, Rabinowitz M, Flood K, Carlsson Y, Doulaveris G, Daly S, Hallingström M, MacPherson C, Kao C, Hakonarson H, Norton ME. Cell-free DNA screening for prenatal detection of 22q11.2 deletion syndrome. Am J Obstet Gynecol 2022; 227:79.e1-79.e11. [PMID: 35033576 DOI: 10.1016/j.ajog.2022.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Historically, prenatal screening has focused primarily on the detection of fetal aneuploidies. Cell-free DNA now enables noninvasive screening for subchromosomal copy number variants, including 22q11.2 deletion syndrome (or DiGeorge syndrome), which is the most common microdeletion and a leading cause of congenital heart defects and neurodevelopmental delay. Although smaller studies have demonstrated the feasibility of screening for 22q11.2 deletion syndrome, large cohort studies with confirmatory postnatal testing to assess test performance have not been reported. OBJECTIVE This study aimed to assess the performance of single-nucleotide polymorphism-based, prenatal cell-free DNA screening for detection of 22q11.2 deletion syndrome. STUDY DESIGN Patients who underwent single-nucleotide polymorphism-based prenatal cell-free DNA screening for 22q11.2 deletion syndrome were prospectively enrolled at 21 centers in 6 countries. Prenatal or newborn DNA samples were requested in all cases for genetic confirmation using chromosomal microarrays. The primary outcome was sensitivity, specificity, positive predictive value, and negative predictive value of cell-free DNA screening for the detection of all deletions, including the classical deletion and nested deletions that are ≥500 kb, in the 22q11.2 low-copy repeat A-D region. Secondary outcomes included the prevalence of 22q11.2 deletion syndrome and performance of an updated cell-free DNA algorithm that was evaluated with blinding to the pregnancy outcome. RESULTS Of the 20,887 women enrolled, a genetic outcome was available for 18,289 (87.6%). A total of 12 22q11.2 deletion syndrome cases were confirmed in the cohort, including 5 (41.7%) nested deletions, yielding a prevalence of 1 in 1524. In the total cohort, cell-free DNA screening identified 17,976 (98.3%) cases as low risk for 22q11.2 deletion syndrome and 38 (0.2%) cases as high risk; 275 (1.5%) cases were nonreportable. Overall, 9 of 12 cases of 22q11.2 were detected, yielding a sensitivity of 75.0% (95% confidence interval, 42.8-94.5); specificity of 99.84% (95% confidence interval, 99.77-99.89); positive predictive value of 23.7% (95% confidence interval, 11.44-40.24), and negative predictive value of 99.98% (95% confidence interval, 99.95-100). None of the cases with a nonreportable result was diagnosed with 22q11.2 deletion syndrome. The updated algorithm detected 10 of 12 cases (83.3%; 95% confidence interval, 51.6-97.9) with a lower false positive rate (0.05% vs 0.16%; P<.001) and a positive predictive value of 52.6% (10/19; 95% confidence interval, 28.9-75.6). CONCLUSION Noninvasive cell-free DNA prenatal screening for 22q11.2 deletion syndrome can detect most affected cases, including smaller nested deletions, with a low false positive rate.
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Affiliation(s)
- Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY.
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rebecca Clifton
- The Biostatistics Center, George Washington University, Rockville, MD
| | | | - Fergal Malone
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, New York University Langone, New York, NY
| | - Asma Khalil
- Department of Obstetrics and Gynaecology, St George's Hospital, University of London, London, United Kingdom
| | - Revital Faro
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, NJ
| | - Rajeevi Madankumar
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | | | - Noel Strong
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sina Haeri
- Austin Maternal-Fetal Medicine, Austin, TX
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Nidhi Vohra
- Department of Obstetrics and Gynecology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Jon Hyett
- Department of Obstetrics and Gynecology, Royal Prince Alfred Hospital, University of Sydney, Camperdown, New South Wales, Australia
| | | | | | | | - Karen Flood
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Georgios Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Sean Daly
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maria Hallingström
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cora MacPherson
- The Biostatistics Center, George Washington University, Rockville, MD
| | - Charlly Kao
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Perelman A, Trostle ME, Pecoriello J, Roman AS, Penfield CA. Acceptance of vaccines during pregnancy during the COVID-19 pandemic. Am J Obstet Gynecol 2022. [PMCID: PMC8696628 DOI: 10.1016/j.ajog.2021.11.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Dar P, MacPherson C, Jacobsson B, Egbert M, Malone FD, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Edwards L, Strong N, Haeri S, Silver RM, Vohra N, Hyett J, Clifton R, Kao C, Martin K, Demko Z, Norton ME. cfDNA prenatal screening for Cri-Du-Chat, Prader-Willi/Angelman and 1p36del syndromes in 10,971 pregnancies with genetic confirmation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Trostle ME, Griffin M, Patberg E, Kidd J, Chen Z, Ruggles K, Roman AS, Keefe DL, Chervenak J, Mehta-Lee SS, Heo H, Brubaker SG. The cervicovaginal microbiome at time of cerclage. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Dugoff L, Koelper NC, Chasen ST, Russo ML, Roman AS, Limaye MA, Ranzini A, Clifford C, Biggio JR, Long M, Subramaniam A, Seasely A, Patil A, Weed S, Page J, Nicholas S, Idler J, Rao R, Crowder A, Shree RS, McLennan G, Bromley B. Cell-free DNA screening for trisomy 21 in twin pregnancy: a large multicenter cohort study. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Trostle ME, Black M, Avtushka V, Brubaker SG, Roman AS. The association of Group B Streptococcus colonization with cerclage and suture material. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Perelman A, Marty L, Hirschberg CI, Pass AR, Quinn G, Roman AS, Penfield CA. Progression of hypertensive disorders of pregnancy during induction of labor at term. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Dugoff L, Koelper NC, Chasen ST, Russo ML, Roman AS, Limaye MA, Ranzini A, Clifford C, Biggio JR, Subramaniam A, Seasely AR, Patil A, Weed S, Page J, Nicholas S, Talbot C, Rao R, Crowder A, Shree RS, McLennan G, Bromley B. Factors that affect cell-free DNA fetal fraction in twin gestations. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Griffin M, Dennis A, Roman AS. Latency Period to Delivery Among Growth Restricted Fetuses with Abnormal Umbilical Artery Dopplers. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Trostle ME, Penfield CA, Roman AS. Adjustment of the spontaneous abortion rate following COVID-19 vaccination. Am J Obstet Gynecol MFM 2021; 4:100511. [PMID: 34656732 PMCID: PMC8516146 DOI: 10.1016/j.ajogmf.2021.100511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Megan E Trostle
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 First Ave., NBV 9N2, New York, NY 10016.
| | - Christina A Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 First Ave., NBV 9N2, New York, NY 10016
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, 550 First Ave., NBV 9N2, New York, NY 10016
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Affiliation(s)
- Ashley S Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, New York
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Meyer JA, Roman AS, Limaye M, Grossman TB, Flaifel A, Vaz MJ, Thomas KM, Penfield CA. Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia. J Matern Fetal Neonatal Med 2021; 35:8412-8418. [PMID: 34542385 DOI: 10.1080/14767058.2021.1977791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS This is an observational study of 61 pregnant women with confirmed SARS-CoV-2 infection who delivered and had a placental histological evaluation at NYU Langone Health between March 19, 2020 and June 30, 2020. Primary outcomes were the prevalence of placental histopathologic features and their association with maternal-fetal comorbidities and severity of COVID-19 related hypoxia. Analysis was performed using Fisher's exact test and t-test with p < 0.05 considered significant. RESULTS Sixty-one placentas were included in the study cohort, 71% from pregnancies complicated by at least one maternal-fetal comorbidity. Twenty-five percent of placentas were small for gestational age and 77% exhibited at least one feature of maternal vascular malperfusion. None of the histopathologic features in the examined placentas were associated with the presence of any specific maternal-fetal comorbidity. Thirteen percent of the cohort required maternal respiratory support for COVID-19 related hypoxia. Villous trophoblast necrosis was associated with maternal supplemental oxygen requirement (67 vs. 33%, p = 0.04) and intubation (67 vs. 33%, p = 0.01). CONCLUSION In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.
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Affiliation(s)
- Jessica A Meyer
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Meghana Limaye
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Tracy B Grossman
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY, USA
| | - Abdallah Flaifel
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Michelle J Vaz
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Kristen M Thomas
- Department of Pathology, NYU Grossman School of Medicine, New York, NY, USA
| | - Christina A Penfield
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, NY, USA
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Limaye MA, Roman AS, Trostle ME, Venkatesh P, Lantigua Martinez M, Brubaker SG, Chervenak J, Wei LS, Sahani P, Grossman TB, Meyer JA, Penfield CA. Predictors of severe and critical disease in pregnant women with SARS-CoV-2. J Matern Fetal Neonatal Med 2021; 35:7536-7540. [PMID: 34470122 PMCID: PMC8425435 DOI: 10.1080/14767058.2021.1951216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND/OBJECTIVE SARS-CoV-2 continues to spread widely in the US and worldwide. Pregnant women are more likely to develop severe or critical illness than their non-pregnant counterparts. Known risk factors for severe and critical disease outside of pregnancy, such as asthma, diabetes, and obesity have not been well-studied in pregnancy. We aimed to determine which clinical and pregnancy-related factors were associated with severe and critical COVID illness in pregnancy. STUDY DESIGN This was a retrospective cohort study of women with confirmed intrauterine pregnancy and positive nasopharyngeal swab for SARS-CoV-2 who presented to an academic medical center in New York City from 1 March 2020 to 1 July 2020. Severe and critical COVID-19 disease was defined by World Health Organization criteria. Women with severe/critical disease were compared to women with asymptomatic/mild disease. Continuous variables were compared with Mann-Whitney or t-test and categorical variables were compared using chi-square and Fisher's exact. Statistical significance was set at p < .05. Multivariable logistic regression was performed including variables that were significantly different between groups. RESULTS Two hundred and thirty-three patients were included, 186 (79.8%) with asymptomatic/mild disease and 47 (20.2%) with severe/critical disease. Women with asymptomatic/mild disease were compared to those with severe/critical disease. Women with severe/critical disease were more likely to have a history of current or former smoking (19.6 vs. 5.4%, p = .004), COVID-19 diagnosis in the 2nd trimester (42.6 vs. 11.8%, p = .001), and asthma or other respiratory condition (21.3 vs. 7.0%, p = .01). Women with severe/critical disease were more likely to have cesarean delivery (35.5 vs. 15.6%, p < .01) and preterm delivery <37 weeks (25.8 vs. 3.8%, p < .01). After adjustment, history of smoking remained significantly predictive of severe/critical disease [aOR 3.84 (95% CI, 1.25-11.82)]. CONCLUSION Pregnant women with a history of smoking, asthma, or other respiratory condition, and COVID-19 diagnosis in the second trimester of pregnancy were more likely to develop severe/critical disease. These findings may be useful in counseling women on their individual risk of developing the severe or critical disease in pregnancy and may help determine which women are good candidates for vaccination during pregnancy.
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Affiliation(s)
- Meghana A Limaye
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Ashley S Roman
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Megan E Trostle
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Pooja Venkatesh
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Meralis Lantigua Martinez
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sara G Brubaker
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Judith Chervenak
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Lili S Wei
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Parita Sahani
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Tracy B Grossman
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Jessica A Meyer
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Christina A Penfield
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
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DeBolt CA, Bianco A, Limaye MA, Silverstein J, Penfield CA, Roman AS, Rosenberg HM, Ferrara L, Lambert C, Khoury R, Bernstein PS, Burd J, Berghella V, Kaplowitz E, Overbey JR, Stone J. Pregnant women with severe or critical coronavirus disease 2019 have increased composite morbidity compared with nonpregnant matched controls. Am J Obstet Gynecol 2021; 224:510.e1-510.e12. [PMID: 33221292 PMCID: PMC7677036 DOI: 10.1016/j.ajog.2020.11.022] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 01/08/2023]
Abstract
Background In March 2020, as community spread of severe acute respiratory syndrome coronavirus 2 became increasingly prevalent, pregnant women seemed to be equally susceptible to developing coronavirus disease 2019. Although the disease course usually appears mild, severe and critical cases of coronavirus disease 2019 seem to lead to substantial morbidity, including intensive care unit admission with prolonged hospital stay, intubation, mechanical ventilation, and even death. Although there are recent reports regarding the impact of coronavirus disease 2019 on pregnancy, there is a lack of information regarding the severity of coronavirus disease 2019 in pregnant vs nonpregnant women. Objective We aimed to describe the outcomes of severe and critical cases of coronavirus disease 2019 in pregnant vs nonpregnant, reproductive-aged women. Study Design This is a multicenter, retrospective, case-control study of women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection hospitalized with severe or critical coronavirus disease 2019 in 4 academic medical centers in New York City and 1 in Philadelphia between March 12, 2020, and May 5, 2020. The cases consisted of pregnant women admitted specifically for severe or critical coronavirus disease 2019 and not for obstetrical indications. The controls consisted of reproductive-aged, nonpregnant women admitted for severe or critical coronavirus disease 2019. The primary outcome was a composite morbidity that includes the following: death, a need for intubation, extracorporeal membrane oxygenation, noninvasive positive pressure ventilation, or a need for high-flow nasal cannula O2 supplementation. The secondary outcomes included intensive care unit admission, length of stay, a need for discharge to long-term acute care facilities, and discharge with a home O2 requirement. Results A total of 38 pregnant women with severe acute respiratory syndrome coronavirus 2 polymerase chain reaction-confirmed infections were admitted to 5 institutions specifically for coronavirus disease 2019, 29 (76.3%) meeting the criteria for severe disease status and 9 (23.7%) meeting the criteria for critical disease status. The mean age and body mass index were markedly higher in the nonpregnant control group. The nonpregnant cohort also had an increased frequency of preexisting medical comorbidities, including diabetes, hypertension, and coronary artery disease. The pregnant women were more likely to experience the primary outcome when compared with the nonpregnant control group (34.2% vs 14.9%; P=.03; adjusted odds ratio, 4.6; 95% confidence interval, 1.2–18.2). The pregnant patients experienced higher rates of intensive care unit admission (39.5% vs 17.0%; P<.01; adjusted odds ratio, 5.2; 95% confidence interval, 1.5–17.5). Among the pregnant women who underwent delivery, 72.7% occurred through cesarean delivery and the mean gestational age at delivery was 33.8±5.5 weeks in patients with severe disease status and 35±3.5 weeks in patients with critical coronavirus disease 2019 status. Conclusion Pregnant women with severe and critical coronavirus disease 2019 are at an increased risk for certain morbidities when compared with nonpregnant controls. Despite the higher comorbidities of diabetes and hypertension in the nonpregnant controls, the pregnant cases were at an increased risk for composite morbidity, intubation, mechanical ventilation, and intensive care unit admission. These findings suggest that pregnancy may be associated with a worse outcome in women with severe and critical cases of coronavirus disease 2019. Our study suggests that similar to other viral infections such as severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, pregnant women may be at risk for greater morbidity and disease severity.
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Meyer JA, Limaye M, Roman AS, Caron J, Ricklan SJ, Sutter M, Brubaker SG, Mehta-Lee SS. 916 The association between preterm birth and ultrasound visualization of the cervical gland area. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hirschberg CI, Pass AR, Roman AS, Penfield CA. 562 Delivery outcomes in women with hypertensive disorders of pregnancy: comparing induction versus immediate cesarean delivery. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kidd J, Akerman M, Vertichio R, Cassidy M, Roman AS, Vintzileos A, Heo H. 229 EMR clinical decision support tools improve compliance with venous thromboembolism risk assessment in obstetrical patients. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Limaye MA, Lantigua-Martinez M, Trostle ME, Penfield CA, Conroy EM, Roman AS, Mehta-Lee SS. Differential Uptake of Telehealth for Prenatal Care in a Large New York City Academic Obstetrical Practice during the COVID-19 Pandemic. Am J Perinatol 2021; 38:304-306. [PMID: 33302308 DOI: 10.1055/s-0040-1721510] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic in New York City, telehealth was rapidly implemented for obstetric patients. Though telehealth for prenatal care is safe and effective, significant concerns exist regarding equity in access among low-income populations. We performed a retrospective cohort study evaluating utilization of telehealth for prenatal care in a large academic practice in New York City, comparing women with public and private insurance. We found that patients with public insurance were less likely to have at least one telehealth visit than women with private insurance (60.9 vs. 87.3%, p < 0.001). After stratifying by borough, this difference remained significant in Brooklyn, one of the boroughs hardest hit by the pandemic. As COVID-19 continues to spread around the country, obstetric providers must work to ensure that all patients, particularly those with public insurance, have equal access to telehealth. KEY POINTS: · Telehealth for prenatal care is frequently utilized during the COVID-19 pandemic.. · Significant concerns exist regarding equity in access among lower-income populations.. · Women with public insurance in New York City were less likely to access telehealth for prenatal care..
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Affiliation(s)
- Meghana A Limaye
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Meralis Lantigua-Martinez
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Megan E Trostle
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Christina A Penfield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Erin M Conroy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Ashley S Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
| | - Shilpi S Mehta-Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, New York City, New York
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Verma S, Bradshaw C, Auyeung NSF, Lumba R, Farkas JS, Sweeney NB, Wachtel EV, Bailey SM, Noor A, Kunjumon B, Cicalese E, Hate R, Lighter JL, Alessi S, Schweizer WE, Hanna N, Roman AS, Dreyer B, Mally PV. Outcomes of Maternal-Newborn Dyads After Maternal SARS-CoV-2. Pediatrics 2020; 146:peds.2020-005637. [PMID: 32737153 DOI: 10.1542/peds.2020-005637] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Infection with a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global pandemic. There are limited data describing the impact of SARS-CoV-2 infection on pregnant mothers and their newborns. The objective of this study is to describe characteristics and outcomes of maternal-newborn dyads with confirmed maternal SARS-CoV-2. METHODS This was a multicenter, observational, descriptive cohort study with data collection from charts of maternal-newborn dyads who delivered at 4 major New York City metropolitan area hospitals between March 1 and May 10, 2020, with maternal SARS-CoV-2 infection. RESULTS There were a total of 149 mothers with SARS-CoV-2 infection and 149 newborns analyzed (3 sets of twins; 3 stillbirths). Forty percent of these mothers were asymptomatic. Approximately 15% of symptomatic mothers required some form of respiratory support, and 8% required intubation. Eighteen newborns (12%) were admitted to the ICU. Fifteen (10%) were born preterm, and 5 (3%) required mechanical ventilation. Symptomatic mothers had more premature deliveries (16% vs 3%, P = .02), and their newborns were more likely to require intensive care (19% vs 2%, P = .001) than asymptomatic mothers. One newborn tested positive for SARS-CoV-2, which was considered a case of horizontal postnatal transmission. CONCLUSIONS Although there was no distinct evidence of vertical transmission from mothers with SARS-CoV-2 to their newborns, we did observe perinatal morbidities among both mothers and newborns. Symptomatic mothers were more likely to experience premature delivery and their newborns to require intensive care.
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Affiliation(s)
- Sourabh Verma
- Departments of Pediatrics and .,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Chanda Bradshaw
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | | | | | - Jonathan S Farkas
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Nicole B Sweeney
- Department of Pediatrics, New York University Long Island School of Medicine, New York University, New York, New York; and
| | - Elena V Wachtel
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Sean M Bailey
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Asif Noor
- Department of Pediatrics, New York University Long Island School of Medicine, New York University, New York, New York; and
| | | | - Erin Cicalese
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | | | - Jennifer L Lighter
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | | | | | - Nazeeh Hanna
- Department of Pediatrics, New York University Long Island School of Medicine, New York University, New York, New York; and
| | - Ashley S Roman
- Division of Maternal Fetal Medicine, New York University Grossman School of Medicine, New York, New York
| | - Benard Dreyer
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
| | - Pradeep V Mally
- Departments of Pediatrics and.,Department of Pediatrics, Bellevue Hospital Center, New York, New York
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Affiliation(s)
- Christina A Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, 150 E 32 St., NYU Langone Health, New York, NY 10016
| | - Jennifer Lighter
- Division of Pediatric Infectious Diseases, Department of Infection Prevention and Control and Pediatrics, NYU Langone Health, New York, NY
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY
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Westcott JM, Simpson S, Chasen S, Vieira L, Stone J, Doulaveris G, Dar P, Bernstein PS, Atallah F, Dolin CD, Roman AS. Prenatally diagnosed vasa previa: association with adverse obstetrical and neonatal outcomes. Am J Obstet Gynecol MFM 2020; 2:100206. [PMID: 33345921 DOI: 10.1016/j.ajogmf.2020.100206] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Vasa previa represents a rare prenatal finding with potentially life-threatening risk to the fetus. OBJECTIVE This study aimed to describe the natural history of prenatally diagnosed vasa previa and evaluate the association between antenatally diagnosed vasa previa and adverse obstetrical and neonatal outcomes. STUDY DESIGN This was a multicenter descriptive and retrospective study of patients diagnosed prenatally with vasa previa on transvaginal ultrasound in the New York City Maternal-Fetal Medicine Research Consortium centers between 2012 and 2018. Outcomes evaluated included persistence of vasa previa at the time of delivery, gestational age at delivery, indications for unplanned unscheduled delivery, and neonatal course. RESULTS A total of 165 pregnancies with vasa previa were included, of which 16 were twin gestations. Forty-three cases (26.1%) were noted to resolve on subsequent ultrasound. Of the remaining 122 cases with persistent vasa previa, 46 (37.7%) required unscheduled delivery. Twin gestations were nearly 3 times as likely to require unscheduled delivery as singleton gestations (73.3% vs 25.2%; P<.001). Most infants (70%) were admitted to the neonatal intensive care unit. There was 1 neonatal death (0.9%) because of complications related to prematurity. CONCLUSION Despite the low neonatal mortality rate with prenatal detection of vasa previa, one-third of patients required unscheduled delivery, and more than half of neonates experienced complications related to prematurity.
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Affiliation(s)
| | | | | | | | - Joanne Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Peer Dar
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Peter S Bernstein
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | | | - Cara D Dolin
- New York University Langone Health, New York, NY
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Peña JA, Bianco AT, Simpson LL, Bernstein PS, Roman AS, Goffman D, Schweizer WE, Overbey J, Stone JL. A Survey of Labor and Delivery Practices in New York City during the COVID-19 Pandemic. Am J Perinatol 2020; 37:975-981. [PMID: 32516817 PMCID: PMC7416196 DOI: 10.1055/s-0040-1713120] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 01/08/2023]
Abstract
Recently, a novel coronavirus, precisely severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), that causes the disease novel coronavirus disease 2019 (COVID-19) has been declared a worldwide pandemic. Over a million cases have been confirmed in the United States. As of May 5, 2020, New York State has had over 300,000 cases and 24,000 deaths with more than half of the cases and deaths occurring in New York City (NYC). Little is known, however, of how this virus impacts pregnancy. Given this lack of data and the risk for severe disease in this relatively immunocompromised population, further understanding of the obstetrical management of COVID-19, as well as hospital level preparation for its control, is crucial. Guidance has come from expert opinion, professional societies and public health agencies, but to date, there is no report on how obstetrical practices have adapted these recommendations to their local situations. We therefore developed an internet-based survey to elucidate the practices put into place to guide the care of obstetrical patients during the COVID-19 pandemic. We surveyed obstetrical leaders in four academic medical centers in NYC who were implementing and testing protocols at the height of the pandemic. We found that all sites made changes to their practices, and that there appeared to be agreement with screening and testing for COVID-19, as well as labor and delivery protocols, for SARS-CoV-2-positive patients. We found less consensus with respect to inpatient antepartum fetal surveillance. We hope that this experience is useful to other centers as they formulate their plans to face this pandemic. KEY POINTS: · Practices changed to accommodate public health needs.. · Most practices are screened for novel COVID-19 on admission.. · Fetal testing in COVID-19 patients varied..
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Affiliation(s)
- Juan A. Peña
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Angela T. Bianco
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lynn L. Simpson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York
| | - Peter S. Bernstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Ashley S. Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York
| | - William E. Schweizer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York
| | - Jessica Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanne L. Stone
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
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Doulaveris G, Ryken K, Papathomas D, Estrada Trejo F, Fazzari MJ, Rotenberg O, Stone J, Roman AS, Dar P. Early prediction of placenta accreta spectrum in women with prior cesarean delivery using transvaginal ultrasound at 11 to 14 weeks. Am J Obstet Gynecol MFM 2020; 2:100183. [PMID: 33345909 DOI: 10.1016/j.ajogmf.2020.100183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is a growing body of evidence that sonographic signs of placenta accreta spectrum can be observed in the first trimester of pregnancy. The most significant marker is placental location next to or in the scar niche in women with a prior cesarean delivery. OBJECTIVE This study aimed to assess the performance of transvaginal ultrasound in the early prediction of placenta accreta spectrum in women with a prior cesarean delivery. STUDY DESIGN This was a retrospective cohort of women with a history of cesarean delivery who had transvaginal ultrasound at 11 to 14 weeks' gestation between September 2016 and May 2018. Ultrasound reports were reviewed and graded for suspicion of placenta accreta spectrum as follows: Grade 0 (no suspicion) if the placenta is not next to the scar; Grade 1 (intermediate suspicion) if the placenta is next or on the scar; Grade 2 (high suspicion) if the placenta was inside the scar niche. In addition, all images were reviewed and graded by trained specialists blinded to the outcome. The primary outcome was a histologic diagnosis of placenta accreta spectrum. Sensitivity, specificity, positive predictive value, and negative predictive value of first-trimester transvaginal ultrasound to detect placenta accreta spectrum were assessed. RESULTS In this study, 467 patients were included, and 8 (1.7%) had placenta accreta spectrum at delivery. Using the original report, 442 patients (94.6%) were Grade 0, 20 (4.3%) Grade 1, and 5 (1.1%) Grade 2. The revised grading had 456 patients (97.6%) with Grade 0, 5 (1.1%) with Grade 1, and 6 (1.3%) with Grade 2. Patients with Grade 2 yielded a sensitivity of 62.5% (95% confidence interval, 24.5-91.5), specificity of 100% (95% confidence interval, 99.2-100.0), positive predictive value of 100% (95% confidence interval, 97.0-100.0), and negative predictive value of 99.4% (95% confidence interval, 98.4-99.7). Any sonographic suspicion of placenta accreta spectrum (Grade 1 or Grade 2) had a sensitivity of 75% (95% confidence interval, 34.9-96.8), specificity of 95.9% (95% confidence interval, 93.6-97.5), positive predictive value of 24% (95% confidence interval, 14.8-36.4), and negative predictive value of 99.6% (95% confidence interval, 98.5-99.9). The blinded image review yielded a better specificity (99.1% vs 95.9%; P=.001) and a positive predictive value (63.6% vs 24%; P=.02) with similar sensitivity (87.5% vs 75%; P=.52) and negative predictive value (99.8% vs 99.6%; P=.55). CONCLUSION Transvaginal ultrasound between 11 and 14 weeks' gestation in women a with prior cesarean delivery can identify at least 3 of 4 cases of placenta accreta spectrum. A finding of placental implantation within the scar niche has high positive predictive value for placenta accreta spectrum. Prospective studies are needed to assess routine screening for placenta accreta spectrum at 11 to 14 weeks' gestation in women with a prior cesarean delivery.
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Affiliation(s)
- Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Katherine Ryken
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Daphne Papathomas
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Fatima Estrada Trejo
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Melissa J Fazzari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Ohad Rotenberg
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Joanne Stone
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Pierce-Williams RA, Burd J, Felder L, Khoury R, Bernstein PS, Avila K, Penfield CA, Roman AS, DeBolt CA, Stone JL, Bianco A, Kern-Goldberger AR, Hirshberg A, Srinivas SK, Jayakumaran JS, Brandt JS, Anastasio H, Birsner M, O’Brien DS, Sedev HM, Dolin CD, Schnettler WT, Suhag A, Ahluwalia S, Navathe RS, Khalifeh A, Anderson K, Berghella V. Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study. Am J Obstet Gynecol MFM 2020; 2:100134. [PMID: 32391519 PMCID: PMC7205698 DOI: 10.1016/j.ajogmf.2020.100134] [Citation(s) in RCA: 223] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
Background The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.
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Affiliation(s)
- Rebecca A.M. Pierce-Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Julia Burd
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Laura Felder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Rasha Khoury
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Peter S. Bernstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Karina Avila
- Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, NY
| | - Christina A. Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, NY
| | - Ashley S. Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, NY
| | - Chelsea A. DeBolt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY
| | - Joanne L. Stone
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY
| | - Angela Bianco
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine, Mount Sinai, New York, NY
| | - Adina R. Kern-Goldberger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adi Hirshberg
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sindhu K. Srinivas
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jenani S. Jayakumaran
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Justin S. Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Hannah Anastasio
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke’s University Health Network, Bethlehem, PA
| | - Meredith Birsner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Luke’s University Health Network, Bethlehem, PA
| | - Devon S. O’Brien
- Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, NJ
| | - Harish M. Sedev
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cara D. Dolin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William T. Schnettler
- Division of Maternal-Fetal Medicine, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Anju Suhag
- Division of Maternal-Fetal Medicine, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Shabani Ahluwalia
- Department of Obstetrics and Gynecology, Crozer Chester Medical Center, Chester, PA
| | - Reshama S. Navathe
- Department of Obstetrics and Gynecology, Crozer Chester Medical Center, Chester, PA
| | - Adeeb Khalifeh
- Department of Obstetrics and Gynecology, Einstein Healthcare Network, Philadelphia, PA
| | - Kathryn Anderson
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Corresponding author: Vincenzo Berghella, MD.
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Silverstein JS, Limaye MA, Brubaker SG, Roman AS, Bautista J, Chervenak J, Ratner AJ, Sommer PM, Roselli NM, Gibson CD, Ellenberg D, Penfield CA. Acute Respiratory Decompensation Requiring Intubation in Pregnant Women with SARS-CoV-2 (COVID-19). AJP Rep 2020; 10:e169-e175. [PMID: 32509416 PMCID: PMC7272216 DOI: 10.1055/s-0040-1712925] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/24/2022] Open
Abstract
There is a current paucity of information about the obstetric and perinatal outcomes of pregnant novel coronavirus disease 2019 (COVID-19) patients in North America. Data from China suggest that pregnant women with COVID-19 have favorable maternal and neonatal outcomes, with rare cases of critical illness or respiratory compromise. However, we report two cases of pregnant women diagnosed with COVID-19 in the late preterm period admitted to tertiary care hospitals in New York City for respiratory indications. After presenting with mild symptoms, both quickly developed worsening respiratory distress requiring intubation, and both delivered preterm via caesarean delivery. These cases highlight the potential for rapid respiratory decompensation in pregnant COVID-19 patients and the maternal-fetal considerations in managing these cases.
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Affiliation(s)
- Jenna S. Silverstein
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Meghana A. Limaye
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Sara G. Brubaker
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Ashley S. Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Judita Bautista
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Judith Chervenak
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Adam J. Ratner
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Hassenfeld Children's Hospital at New York University Langone Medical Center, New York, New York
| | - Philip M. Sommer
- Department of Anesthesiology and Critical Care Medicine, New York University Langone Medical Center, New York, New York
| | - Nicole M. Roselli
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
| | - Charlisa D. Gibson
- Division of Pulmonary and Critical Care, Department of Internal Medicine, New York University Langone Medical Center, New York, New York
| | - David Ellenberg
- Division of Pulmonary and Critical Care, Department of Internal Medicine, New York University Langone Medical Center, New York, New York
| | - Christina A. Penfield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Bellevue Hospital Center, New York, New York
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Roman AS, Chasen ST, Westcott J, Vieira L, Dolin C, Doulaveris G, Atallah F, Simpson S, Dar P, Bernstein P, Stone J. 306: Prenatally diagnosed vasa previa: natural history and the association with adverse neonatal outcomes. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Westcott JM, Yaghoubian Y, Williams MR, Roman AS, Hughes F, Rosner M. Prophylactic percutaneous left ventricular assist device in pregnancy. Obstet Med 2018; 12:151-152. [PMID: 31523273 DOI: 10.1177/1753495x18777346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pregnancy-associated cardiomyopathy can present earlier in gestation than traditionally defined peripartum cardiomyopathy. Management and optimal delivery timing for these patients are not well defined. We present the case of a 30-year-old primigravid at 26 weeks who presented with new onset ventricular tachycardia, biventricular cardiac failure, and severe mitral regurgitation. She was medically stabilized for two weeks prior to delivery with modest improvement in her condition. Due to concern for life-threatening cardiac failure and pulmonary edema at the time of delivery, a percutaneous left ventricular assist device was inserted immediately prior to cesarean delivery. She remained on mechanical circulatory support for 36 h. We discuss considerations regarding use of a percutaneous left ventricular assist device as a novel therapy to support the hemodynamic changes following delivery in parturients with decompensated heart failure.
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Affiliation(s)
- Jill M Westcott
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, USA
| | - Yasaman Yaghoubian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, USA
| | - Mathew R Williams
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY, USA
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, USA
| | - Francine Hughes
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, USA
| | - Mara Rosner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY, USA
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Rosner JY, Gutierrez M, Dziadosz M, Bennett TA, Dolin C, Pham A, Herbst A, Lee S, Roman AS. Prehypertension in early versus late pregnancy. J Matern Fetal Neonatal Med 2017; 32:188-192. [DOI: 10.1080/14767058.2017.1374363] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jonathan Y. Rosner
- Division of Maternal Fetal Medicine, Department of OBGYN and Women’s Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Megan Gutierrez
- Department of OBGYN, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Margaret Dziadosz
- Department of OBGYN, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Terri-Ann Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
| | - Cara Dolin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
| | - Amelie Pham
- Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Science, Washington, DC, USA
| | - Allyson Herbst
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
| | - Ashley S. Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
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Rosner JY, Gutierrez M, Dziadosz M, Pham A, Bennett TA, Dolin C, Herbst A, Lee S, Roman AS. Prehypertension in Early Pregnancy: What is the Significance? Am J Perinatol 2017; 34:117-122. [PMID: 27322669 DOI: 10.1055/s-0036-1584542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective Hypertensive disorders play a significant role in maternal morbidity and mortality. There is limited data on prehypertension (pre-HTN) during the first half of pregnancy. We sought to examine the risk of adverse pregnancy outcomes in patients with prehypertension in early pregnancy (<20 weeks' gestational age). Study Design A retrospective cohort study of 377 patients between 2013 and 2014. Patients were divided based on the highest blood pressure in early pregnancy, as defined per the JNC-7 criteria. There were 261 control patients (69.2%), 95 (25.2%) pre-HTN patients, and 21 (5.6%) chronic hypertension (CHTN) patients. The groups were compared using X2, Fisher's Exact, Student t-test, and Mann-Whitney U test with p < 0.05 used as significance. Results Patients with pre-HTN delivered earlier (38.8 ± 1.9 weeks vs 39.3 ± 1.7 weeks), had more pregnancy related hypertension (odds ratio [OR], 4.62; confidence interval [CI], 2.30-9.25; p < 0.01) and composite maternal adverse outcomes (OR, 2. 10; 95% CI, 1.30-3.41; p < 0.01), NICU admission (OR, 2.21; 95% CI, 1.14-4.26; p = 0.02), neonatal sepsis (OR, 6.12; 95% CI, 2.23-16.82; p < 0.01), and composite neonatal adverse outcomes (OR, 2.05; 95% CI, 1.20-3.49; p < 0.01). Conclusion Although women with pre-HTN are currently classified as normal in obstetrics, they are more similar to women with CHTN. Pre-HTN in the first half of pregnancy increases the likelihood of adverse outcomes.
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Affiliation(s)
- Jonathan Y Rosner
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York
| | - Megan Gutierrez
- Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, New Jersey
| | - Margaret Dziadosz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Amelie Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Terri-Ann Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Cara Dolin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Allyson Herbst
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Sarah Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
| | - Ashley S Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Medical Center, New York
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