AJP Reports最新文献

Objective  Non-Hispanic black and Hispanic women experience significantly higher adverse maternal and neonatal outcomes compared with non-Hispanic white women. The purpose of this study is to explore whether disparities in obstetric outcomes exist by race among women who are college-educated. Study Design  This is a retrospective cohort study from a multicenter observational cohort of women undergoing cesarean delivery. Women were defined as "college-educated" if they reported completion of a 4-year college degree. Race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, Asian, Native American, or unknown. The primary outcome was a composite of maternal morbidity, and a composite of neonatal morbidity was evaluated as a secondary outcome. A multivariable logistic regression model was then utilized to assess associations of race with the primary and secondary outcomes. Results  A total of 2,540 women were included in the study. After adjusting for potential confounding variables, maternal morbidity was found to be significantly higher for college-educated non-Hispanic black women compared with non-Hispanic white women (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.12-2.80). The incidence of neonatal morbidity was significantly higher for non-Hispanic black (OR 1.91, 95% CI 1.31-2.79) and Hispanic (OR 3.34, 95% CI 2.23-5.01) women. Conclusion  In this cohort, the odds of cesarean-related maternal and neonatal morbidities were significantly higher for college-educated non-Hispanic black women, compared with their non-Hispanic white counterparts. This demonstrates that even among women with higher level education, racial and ethnic disparities persist in obstetric outcomes.

Objective  To assess and correlate sleep quality and depressed mood symptoms in the late pregnancy and early postpartum periods. Study Design  In a prospective pilot observational study, participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Edinburgh Postnatal Depression Scale (EPDS) questionnaires at delivery, 1, and 2 months postpartum. Pearson's correlation coefficients and PROC MIXED function estimated overall correlation for repeated measures. Results  Twenty-six women were enrolled with a mean gestational age at delivery of 38.4 (± 2.4) weeks. Sleep quality and mood data were available at the three time points for 24, 16, and 11 participants, respectively. Poor sleep scores were noted by 75.0, 87.5, and 72.7% of women at the three time points. An elevated EPDS score of 10 or higher was claimed by 20.8, 12.5, and 18.2% of women, respectively. Higher PSQI scores were positively associated with higher EPDS scores overall ( r  = 0.71, p  < 0.001) and at each of the individual time points ( r  = 0.79, p  < 0.0001; r  = 0.52, p  = 0.04; and r  = 0.70, p  = 0.016, respectively). None of the women reporting good sleep quality had elevated EPDS scores. Conclusion  Poor sleep is commonly reported around delivery, and at 1 and 2 months postpartum, and there is an association between poor sleep and depression symptoms.

Background  Common maternal medical comorbidities such as hypertensive disorders, diabetes, tobacco use, and extremes of maternal age, body mass index, and gestational weight gain are known individually to influence the rate of cesarean delivery. Numerous studies have estimated the risk of individual conditions on cesarean delivery. Objective  To examine the risk for primary cesarean delivery in women with multiple maternal medical comorbidities to determine the cumulative risk they pose on mode of delivery. Study Design  In this population-based retrospective cohort study, we analyzed data from Ohio live birth records from 2006 to 2015 to estimate the influence of individual and combinations of maternal comorbidities on rates of singleton primary cesarean delivery. The exposures were individual and combinations of maternal medical conditions (chronic hypertension [CHTN], gestational hypertension, pregestational diabetes, gestational diabetes, tobacco use, advanced maternal age, and maternal obesity) and outcomes were rates and adjusted relative risk (aRR) of primary cesarean delivery. Results  There were 1,463,506 live births in Ohio during the study period, of which 882,423 (60.3%) had one or more maternal medical condition, and of those 243,112 (27.6%) had primary cesarean delivery. The range of rates and aRR range of primary cesarean delivery were 13.9 to 29.3% (aRR 0.78-1.68) in singleton pregnancies with a single medical condition, and this increased to 21.9 to 48.6% (aRR 1.34-3.87) in pregnancies complicated by multiple medical comorbidities. The highest risk for primary cesarean occurred in advanced maternal age, obese women with pregestational diabetes, and CHTN. Conclusion  A greater number of maternal medical comorbidities during pregnancy is associated with increasing cumulative risk of primary cesarean delivery. These data may be useful in counseling patients on risk of cesarean during pregnancy.

Rocky Mountain spotted fever (RMSF) is a common tick-borne disease and can have variable presentation with potentially fatal outcomes when untreated. We describe an atypical presentation of RMSF in the third trimester. A 37-year-old multiparous woman at 31 ^0/7 weeks' gestation presented normotensive with headaches and fever but no rash or significant tick exposure. She was initially treated for atypical hemolysis, elevated liver enzymes, and low platelet count syndrome but further decompensated, requiring intensive care unit transfer, intubation, and emergent delivery. Doxycycline administration was associated with marked improvement with no significant sequalae to mother or infant. Later convalescent serologies were positive for RMSF. RMSF is a clinically challenging diagnosis in pregnancy. Given significant morbidity and mortality associated with delayed treatment, high suspicion in endemic areas is needed, and prompt antibiotic use with doxycycline should be administered.

Objective  The four initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected pregnant women presenting at term gestation to our institution presented with transaminitis. Three of the four were diagnosed with intrahepatic cholestasis of pregnancy (IHCP). Growing evidence exists of an associated transaminitis in nonpregnant SARS-CoV-2 patients. However, there are limited data of hepatic involvement of SARS-CoV-2 in pregnancy, and no previous studies have assessed the association with IHCP in patients with coronavirus disease 2019 (COVID-19). Study Design  This was a retrospective, single-center case series of four consecutive pregnant women with a positive result for SARS-CoV-2 presenting with transaminitis in third trimester. Results  The clinical courses of four pregnant women with COVID-19 and transaminitis, three of four of whom were diagnosed with IHCP, are described. Testing for SARS-CoV-2 was done through a reverse transcription polymerase chain reaction test of a nasopharyngeal swab. Conclusion  As we await larger studies ascertaining the incidence of IHCP in SARS-CoV-2, this prevalence highlights the importance of diagnosing IHCP among women with COVID-19 as a potential etiology of transaminitis, as IHCP risks may be ameliorated with earlier delivery. Moreover, delineating a hepatobiliary association in pregnancy may provide further information about the mechanism of liver impairment in SARS-CoV-2 in all patients.

Due to the potential for severe maternal morbidity and even mortality, pregnancy-associated spontaneous coronary artery dissection (P-SCAD) often presents as a clinical conundrum. While current recommendations encourage coronary interventions when medically indicated even during pregnancy, the hesitation still understandably exists. Meanwhile, given the rarity of the condition, the guidelines for management are still based on expert consensus. We present a case of P-SCAD in a 38-year-old woman with initial presentation at 28 weeks' gestation and recurrence at 9 days postpartum. A unique complication of this case is its transcontinental nature: the initial event occurred while the patient was on vacation across the country from her home. Questions arose not only with regard to her immediate management and care but also when she would be able to travel and how her complex care would be continued cross-country. This case raised important questions regarding the antepartum management of acute coronary syndrome (ACS). It also highlights the importance of multidisciplinary care, especially with a cardio-obstetrics team, in the management of P-SCAD and emphasizes the role for universal screening for cardiac diseases in pregnancy.

Neuroendocrine small cell cervical carcinoma is an aggressive cancer which accounts for approximately 1 to 3% of all cervical neoplasms. Therapy must be altered in pregnancy to optimize maternal-fetal outcomes. A 39-year-old woman presented for a routine prenatal visit and was noted to have a grossly abnormal cervix. Cervical biopsies confirmed small cell carcinoma. At 19 weeks' gestation, chemotherapy was initiated. The patient delivered at 34 weeks' gestation to initiate radiation therapy. Six months later, she was diagnosed with metastatic disease and died from cancer complications. In pregnancy, treatment modalities for small cell cervical carcinoma are based on the patient's gestational age at diagnosis. While aggressive early treatment is preferred, platinum-based chemotherapy can be initiated in the second trimester and radiation therapy delayed until delivery. Small cell cervical carcinoma complicating pregnancy requires aggressive treatment. Chemotherapy in the second trimester with planned delayed radiation therapy, may optimize fetal outcomes.

In massive pulmonary embolism (PE), anticoagulation and thrombolytics may increase the risk of retroperitoneal bleeding following vascular cannulation for extracorporeal hemodynamic support resulting in abdominal compartment syndrome (ACS). A 27-year-old women at 33 weeks of gestation presented with acute chest pain and shortness of breath. Massive PE was diagnosed. Intravenous unfractionated heparin was started together with catheter-directed tissue plasminogen activator (tPA) infusion and mechanical thrombectomy. During the procedure, cardiac arrest developed. Cardiopulmonary resuscitation, intravenous tPA, and urgent perimortem cesarean delivery were performed. After return of spontaneous circulation, profound right ventricular failure required venoarterial membrane oxygenation. Six hours afterward, ACS secondary to retroperitoneal bleeding developed, requiring surgical intervention. ACS may result from retroperitoneal bleeding following cannulation for extracorporeal hemodynamic support.

Cornelia de Lange's syndrome (CDLS) is a multisystem genetic syndrome characterized by well-defined physical, intellectual, and behavioral characteristics. The diagnosis of CDLS is typically done clinically after birth; however, recent studies have demonstrated the ability to use prenatal ultrasound and whole-exome sequencing to diagnose CDLS prenatally. Here we present a prenatal case in which multiple fetal anomalies were identified on ultrasound at 20 weeks of gestation. Use of whole-exome sequencing allowed for successful diagnosis of CDLS in this fetus prenatally.

We describe a pregnant patient with severe compulsive water ingestion and vomiting that lead to metabolic alkalosis and preterm delivery. A 21-year-old patient was hospitalized multiple times throughout pregnancy for symptoms initially thought to be related to hyperemesis gravidarum. Overtime, it became apparent that the patient induced vomiting by rapidly drinking large volumes of water. At 32 weeks' gestation, rapid ingestion of water caused 3 days of vomiting with findings of hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and compensatory respiratory acidosis. Fetal monitoring showed minimal variability and recurrent decelerations; subsequent biophysical profile score of 2/10 prompted urgent cesarean section. A male newborn was delivered and cord blood gases reflected neonatal metabolic alkalosis and electrolyte imbalances identical to those of the mother. Compensatory hypoventilation in both mother and fetus were treated with assisted ventilation. With saline administration and repletion of electrolytes, metabolic alkalosis resolved for both patients within days. Metabolic alkalosis was transplacentally acquired by the fetus. This case demonstrates the development of metabolic alkalosis in a pregnant woman caused by vomiting severe enough to prompt preterm delivery for nonreassuring fetal status. It also demonstrates fetal dependence on both placenta and mother to maintain physiologic acid-base and electrolyte balance.