Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study

BACKGROUND

Placenta accreta spectrum (PAS) is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in outcomes of patients with PAS.

OBJECTIVE

To investigate health inequities in maternal and neonatal outcomes of pregnancies with PAS.

STUDY DESIGN

This multicentered retrospective cohort study included patients with histopathological diagnosis of PAS at four regional perinatal centers between 1/1/2013 - 6/30/2022. Maternal race and/or ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. Primary outcome was a composite adverse maternal outcome: transfusion of 4+ units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury or mortality. Secondary outcomes were composite adverse neonatal outcome (APGAR < 7 at 1-minute, morbidity, or mortality), gestational age at PAS diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race/ethnicity with maternal and neonatal outcomes.

RESULTS

408 pregnancies with PAS were included. In 218 patients (53%), the diagnosis of PAS was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, BMI, income and parity, there was no difference in composite adverse maternal outcome among racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team and cesarean hysterectomy were similar between groups.

CONCLUSION

In our multicenter PAS cohort, race and/or ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis and planned multi-disciplinary care. We hypothesize that comparable incidence of individual risk factors for perinatal morbidity as well as geographic proximity reduce potential inequities that may exist in the larger population.

Thromboelastography versus Standard Coagulation Assays in Patients with Postpartum Hemorrhage

OBJECTIVE

 Thromboelastography (TEG), a point-of-care test that measures blood's dynamic viscoelastic properties, is routinely used to guide resuscitation in surgical specialties with high hemorrhage risk. Patients with ongoing postpartum hemorrhage (PPH) often develop coagulopathy and hypofibrinogenemia. Timely assessment of fibrinogen is crucial because cryoprecipitate for repletion requires thawing time prior to administration. TEG may provide rapid assessment of coagulopathy in ongoing hemorrhage but this has not been thoroughly studied. Our objective was to determine if TEG accurately reflects coagulopathy in ongoing PPH when compared with standard assays.

STUDY DESIGN

 This was a retrospective cohort study of people with ongoing PPH (quantified blood loss >1,000 mL), from January 1, 2016, to December 31, 2019. TEG variables and standard coagulation parameters were compared in patients who had both assays drawn simultaneously. As a secondary analysis, patients who had TEG were compared with those who did not. The Mann-Whitney, Fisher's exact, Kruskal-Wallis, Spearman's rho, and logistic regression tests were used for analysis. Significance was set at p < 0.05.

RESULTS

 A total of 680 patients were included, 69 of whom had TEG and coagulation parameters drawn simultaneously and were included in the primary analysis. The remainder were included in the secondary analysis. TEG variables and coagulation assays correlated significantly-prolonged R with increased PTT (rho 0.25, p = 0.04), prolonged K and decreased α angle with decreased fibrinogen (rho -0.61, p < 0.001; rho 0.24, p < 0.001), and decreased maximum amplitude with decreased platelets (rho 0.62, p < 0.001). Those who had thromboelastographic assays had higher blood loss and need for interventions to manage hemorrhage than those who did not.

CONCLUSION

 TEG correlated significantly with standard laboratory assays in ongoing PPH, including for patients with hypofibrinogenemia. Given the point-of-care nature and rapid turnaround time, TEG should be considered for timely hemorrhage evaluation and directed resuscitation of coagulopathy.

KEY POINTS

· TEG significantly correlates with standard laboratory measures of coagulopathy in postpartum hemorrhage, including in patients with hybofibrinogemia (fibrinogen <200).. · TEG is routinely used in nonobstetric hemorrhage, and should be considered in PPH.. · Due to the point-of-care nature, TEG may allow for rapid guided resuscitation, including fibrinogen..

Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia

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.

A modern measles outbreak: understanding maternal immunity and impact on postpartum vaccination uptake

BACKGROUND

In October 2018, a measles (rubeola) outbreak was identified in New York City and Rockland County, and a public health campaign and hospital policy changes were made to increase awareness of the importance of vaccination and increase vaccination rates.

OBJECTIVE

We describe the prevalence of rubeola immunity in pregnant women and the change in uptake of postpartum measles, mumps, and rubella vaccination before and during the measles outbreak.

STUDY DESIGN

A multipronged intervention was developed by the health system with the intent of raising awareness of the outbreak, identifying patients at risk of contracting measles during pregnancy, and limiting exposure of inpatients to the disease. This was a quality improvement study to assess the impact of the intervention and public health policy on the rates of documentation of rubeola immunity and rubeola vaccination rates in nonimmune women. Women who delivered at New York University Langone Health before the outbreak July 1, 2016 to July 1, 2017 were compared with women who delivered during the outbreak July 1, 2018 to July 1, 2019. The primary outcome was acceptance of measles, mumps, and rubella vaccination in nonimmune women during the postpartum period. Analysis was conducted using logistic regression and chi-square tests, and alpha was set at 0.05.

RESULTS

A total of 19,585 patients were analyzed; 9162 women delivered before the outbreak and 10,423 delivered during the outbreak. Of these, 2589 (13.2%) were documented as living in a high-risk zone improvement plan code, which were areas at the epicenter of the measles outbreak. Notably, 14,731 women (75.2%) were tested for rubeola immunity and 3270 of those tested (22.2%) were not immune. In the year of the outbreak, a higher proportion of women had rubeola immunity documented with serum titers than in the year before the outbreak (81% vs 69%; P<.001). Inpatient compliance with postpartum measles, mumps, and rubella administration was greater during the outbreak than before it (76% vs 59%; P<.001) for patients from both low-risk and high-risk zone improvement plan codes.

CONCLUSION

The New York City and Rockland County measles outbreak, together with the implementation of a health system-wide education program and a change in public health policy, led to an increase in the proportion of pregnant women being screened for rubeola immunity. It also led to an increase in uptake of the immediate postpartum measles, mumps, and rubella vaccine.

Factors Associated with Attempted External Cephalic Version for Fetal Malpresentation at Term

Objective  To assess differences in patient characteristics between women who did and did not undergo attempted external cephalic version (ECV) for fetal malpresentation at term. Study Design  This was a retrospective cohort study of women with a singleton gestation and noncephalic presentation at > 37.0 weeks between October 2014 and October 2015. We compared demographic and clinical characteristics of women who did and did not undergo attempted ECV and assessed the reasons that women did not attempt ECV. Results  Among 215 women, only 51 (24%) attempted ECV. There were no differences in age, race, insurance type, or body mass index between women who underwent attempted ECV and those who did not. Women who underwent ECV were significantly more likely to have had a prior vaginal delivery (69 vs. 36%, p  < 0.001). Seventy-six women (46%) declined ECV. Women who declined ECV were more likely to be nulliparous than those who accepted the procedure (66 vs. 29%, p  < 0.001). Among women who had ECV, the success rate was 55%. There were no adverse events after attempted ECV in this cohort. Conclusion  Among women with fetal malpresentation at term, those without a prior vaginal delivery were significantly less likely to undergo attempted ECV.

Induction, labor length and mode of delivery: the impact on preeclampsia-related adverse maternal outcomes

OBJECTIVE

The objectives were to evaluate whether induction, specifically prolonged labor, was associated with adverse maternal outcomes related to preeclampsia with severe features (PEC-S) and whether cesarean affected the rate.

STUDY DESIGN

This was a retrospective cohort study of women with PEC-S ⩾34 weeks who were diagnosed either before planned cesarean or before induction/latent labor. The primary outcome was a composite adverse maternal outcome related to PEC-S.

RESULTS

The final cohort comprised 193 women (n=172 with labor and n=21 with planned cesarean). The prevalence of the outcome was 15.5%. Women exposed to labor did not have a higher rate compared with planned cesarean (16.3% vs 9.5%, P=0.4). Adjusting for confounders, women with a cesarean after prolonged labor had a 10-fold higher adverse outcome risk compared with women with a planned cesarean (adjusted odds ratio (aOR) 9.7 (1.2 to 78.6), P=0.03) or with a vaginal delivery <24 h (aOR 9.7 (1.4 to 67.4), P=0.02).

CONCLUSION

Prolonged labor and cesarean in labor were both associated with an increase in our outcome.

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy

OBJECTIVE

The objective of this study is to evaluate a woman's risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy.

METHODS

A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed.

RESULTS

Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p = 0.004 and 0.005, respectively) and hypertension later in life (p = 0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p = 0.006 and 0.002, respectively).

CONCLUSIONS

Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.

The utility of ICD9-CM codes in identifying induction of labor

BACKGROUND

Data evaluating the accuracy of ICD9-CM codes in identifying inductions are limited. Our objective was to examine the test characteristics of ICD9-CM coding for induction of labor and to identify differences between those captured by coding and those not.

METHODS

We performed a retrospective cohort study of ICD9-CM codes in identifying charts of induced women at our institution from 2005 to 2009. Review of the medical record was the gold standard. Characteristics of the charts were compared using Mann-Whitney U tests and chi-square tests where appropriate.

RESULTS

A total of 3,263 women were included, 708 with ICD9-CM coding for induction (screen positive). A total of 422 women were randomly sampled from those not coded as induction (screen negative). The sensitivity of ICD9-CM coding for induction was 51.4%, specificity 98.8%, positive predictive value 96.6%, negative predictive value 74.7%. False negative charts (25%) were more likely to be women induced for premature rupture of membranes (40% versus 8%, p < 0.001) or with oxytocin (51% versus 33%, p < 0.001) when compared with screen positive charts.

CONCLUSIONS

It is reassuring that 97% of charts coded for induction by ICD9-CM codes are, in fact, patients that were induced. With this degree of accuracy, we can be confident that charts coded as induction are unlikely to be miscoded.

In vitro drug resistance in acute myeloid and chronic B-lymphocytic leukaemic blasts and in normal blood and marrow populations

The sensitivities of AML and BCLL blasts to daunorubicin have been determined, using an in vitro (MTT) assay of resistance, and compared with the sensitivities of normal haemopoietic populations and cells of the multidrug-resistant, T-lymphoid line CEM VLB100; The role of the drug-efflux pump, P-glycoprotein, was determined by adding the 'modifier' cyclosporin and by measuring numbers of P-glycoprotein positive cells by immunofluorescence. ID50s for 17 cases of de novo AML varied from 5 to 300 ng/ml giving a median of 105 ng/ml which was similar to the median of 11 normal marrow mononuclear cell preparations (80 ng/ml) but considerably less than the median ID50 of eight blood lymphocyte samples (3500 ng/ml). ID50s for five relapsed and two refractory AML samples ranged from 27 to 240 ng/ml, well within the de novo range: we had obtained presentation samples for two of these and, in both cases, ID50s were lower at relapse. ID50s, however, were raised in seven marrow mononuclear cell populations taken soon after remission induction (ID50 for remission MNC and normal MNC = 200 and 80 ng/ml, respectively); this may reflect either a property of regenerating populations, or an activation of cellular resistance mechanisms following chemotherapy. ID50s for 17 cases of BCLL ranged from 7 to 200 ng/ml with a median of 48 ng/ml which was significantly lower than the ID50 of AML blasts or of blood lymphocytes. Cyclosporin induced less than two-fold reductions in ID50s of blood lymphocytes, marrow mononuclear cells and de novo AML and BCLL blasts despite giving log reversals in resistance in the CEM VLB100 line. This reflected numbers of P-glycoprotein positive cells in our samples, which were high in CEM VLB100 but low in fresh normal or leukaemic cell suspensions. For both de novo AML and BCLL groups, however, the change in ID50, on addition of cyclosporin, was significant. These data imply a minor role for P-glycoprotein in drug resistance of leukaemic blasts. Nevertheless, there was a positive correlation between daunorubicin ID50s in de novo AML and time to remission which confirms that in vitro chemosensitivity assays can provide a useful measure of in vivo resistance.

Influence of fluoride containing toothpaste on serum and urine fluoride levels in children

This study was undertaken to investigate the effect of fluoridated toothpaste on serum and urine fluoride levels in two groups of children with supervised brushing. As part of the study dietary intakes of fluoride were calculated from a 24 hour diet record and eight samples of water from different families were also analysed for their fluoride content.

A clinical evaluation of glove washing and re-use in dental practice

This study has assessed the durability of four brands of latex gloves, Ansell Medical 'Medi-Grip', Regent 'Biogel D', Surgikos 'Microtouch' and the London Rubber Company 'Supreme', under conditions of repeated washing and re-use in a clinical dental setting. The microbiological effectiveness of 'Hibiscrub' as a decontaminating washing agent was examined simultaneously. Examination by an electrical test for micropunctures in 200 unused gloves of each brand revealed such defects in 6(3%) of Ansell 'Medi-Grip', 3(1.5%) of 'Biogel D', 14(7%) of Surgikos 'Microtouch' and 2(1%) of LRC 'Supreme' gloves. Following repeated clinical use, micropunctures were detected in 18% of Ansell 'Medi-Grip', 10% of 'Biogel D', 75% of Surgikos 'Microtouch' and 56% of LRC 'Supreme'. Microorganisms were isolated from the glove surfaces after 45% of the occasions on which the gloves were washed for 1 min in 'Hibiscrub' (ICI Dental). Eighty-five per cent of these isolates were environmental organisms, but oral streptococci were isolated from 8.4% of the pairs of gloves examined. The high rate of micropuncture development following repeated washing and re-use of latex gloves indicates that they cannot effectively perform their barrier function under such conditions. The microbiological data have also revealed the potential for cross-infection between patients through inadequate decontamination of glove surfaces. For operative dental surgery, the results suggest that heavier, surgical type gloves are to be preferred, and that multiple use of any glove type should be discouraged.