OBJECTIVE:To examine the presentation, management, and outcomes of pregnancies complicated by diabetic ketoacidosis (DKA) in a contemporary obstetric population. METHODS:This is a case series of all admissions for DKA during pregnancy at a single Midwestern academic medical center over a 10-year period. Diabetic ketoacidosis was defined per the following diagnostic criteria: anion gap more than 12 mEq/L, pH less than 7.30 or bicarbonate less than 15 mEq/L, and elevated serum or urine ketones. Demographic information, clinical characteristics, and maternal and neonatal outcomes were assessed. Patient characteristics and clinical outcomes were compared between individuals with type 1 and those with type 2 diabetes mellitus. RESULTS:Between 2012 and 2021, there were 129 admissions for DKA in 103 pregnancies in 97 individuals. Most individuals (n=75, 77.3%) admitted for DKA during pregnancy had type 1 diabetes. The majority of admissions occurred in the third trimester (median gestational age 29 3/7 weeks). The most common precipitating factors were vomiting or gastrointestinal illness (38.0%), infection (25.6%), and insulin nonadherence (20.9%). Median glucose on admission was 252 mg/dL (interquartile range 181-343 mg/dL), and 21 patients (17.6%) were admitted with euglycemic DKA. Fifteen admissions (11.6%) were to the intensive care unit. Pregnancy loss was diagnosed during admission in six individuals (6.3%, 95% CI, 2.3-13.7%). Among pregnant individuals with at least one admission for DKA, the median gestational age at delivery was 34 6/7 weeks (interquartile range 33 2/7-36 3/7 weeks). Most neonates (85.7%, 95% CI, 76.8-92.2%) were admitted to the neonatal intensive care unit and required treatment for hypoglycemia. The cesarean delivery rate was 71.9%. Despite similar hemoglobin A 1C values before pregnancy and at admission, individuals with type 1 diabetes had higher serum glucose (median [interquartile range], 256 mg/dL [181-353 mg/dL] vs 216 mg/dL [136-258 mg/dL], P =.04) and higher serum ketones (3.78 mg/dL [2.13-5.50 mg/dL] vs 2.56 mg/dL [0.81-4.69 mg/dL] mg/dL, P =.03) on admission compared with those with type 2 diabetes. Individuals with type 2 diabetes required intravenous insulin therapy for a longer duration (55 hours [29.5-91.5 hours] vs 27 hours [19-38 hours], P =.004) and were hospitalized longer (5 days [4-9 days] vs 4 days [3-6 days], P =.004). CONCLUSION:Diabetic ketoacidosis occurred predominantly in pregnancies affected by type 1 diabetes. Individuals with type 1 diabetes presented with greater DKA severity but achieved clinical resolution more rapidly than those with type 2 diabetes. These results may provide a starting point for the development of interventions to decrease maternal and neonatal morbidity related to DKA in the modern obstetric population.

To address increases in severe maternal morbidity (SMM) and mortality, systematic improvements in the care of high-risk parturients at facility and population levels have been advocated. Part of this effort involves levels of maternal care which account for perinatal regionalization and risk-appropriate maternal care for high-risk patients. In 7/2019, the Ohio Department of Health's Maternity Licensure requirements established transfer of patients ≥37 weeks from Level 1 and ≥34 weeks from Level 2 to Level 3 or 4 perinatal centers for hypertensive disorders of peripartum with severe features (HDP-SF). Our analysis assessed changes following the statewide implementation. We retrospectively analyzed patients transferred from Level 1 and 2 centers to our Level 4 perinatal center from 1/2018 to 5/2021. Viable pregnancies >24 weeks with HDP-SF with evidence of liver injury (ALT/AST > 2x the upper limit of normal or ICD-10 code of liver failure) and renal injury (serum Cr >1.1 or ICD-10 code of renal failure) were included. Primary outcome measure included differences in intensive care unit (ICU) admission. Statistical significance was assessed by Chi-square and process control charts. Comparing the pre (n = 573) and post (n = 670) implementation of the statewide transfer policy, there was a significant increase in the rate of patients transferred with HDP-SF features based on liver (1.8% pre and 10.9% post, p< .01) and renal injury (4.4% pre and 8.6% post, p< .01) to our Level 4 facility. While statistically not significant, the rate of ICU transfer decreased 55% between pre- and post-implementation (2.0% pre and 0.9% post, p=.12) (Figure 1). The implementation of a statewide policy to transfer high-risk patients with HDP-SF from Level 1 and 2 hospitals to Level 4 perinatal centers resulted in identification of higher markers for SMM based on liver and/or renal injury. These statewide care arrangements may lead to earlier identification of SMM, resulting in more robust and appropriate services provided to these patients, ultimately leading to a reduction in ICU transfers.

Objective Peripartum cardiomyopathy (PPCM) affects 1:1,000 U.S. pregnancies, and while many recover from the disease, the risk of recurrence in subsequent pregnancy (SSP) is high. This study aims to evaluate the utility of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) to predict the risk of recurrence of PPCM in SSP. Study Design We retrospectively evaluated outcomes in women with a history of PPCM and SSP at a large-volume cardioobstetrics program (2008–2019). Results There were 18 women who had incident PPCM and pursued SSP. Of 24 pregnancies in these women, 8 (33%) were complicated by the development of recurrent PPCM. LVEF ≥ 52% or GLS ≤ −16 was associated with a low risk of recurrent PPCM. Conclusion Approximately one-third of women with PPCM developed recurrent PPCM in SSP. LVEF and GLS on prepregnancy echocardiography may predict the risk of recurrence. Additional studies evaluating risk for recurrence are required to better understand which women are the safest to consider SSP. Key Points

OBJECTIVE: To examine whether there are racial and ethnic differences in postoperative complications after nonobstetric surgery during pregnancy in the United States. METHODS: We conducted a secondary analysis of the prospective ACS NSQIP (American College of Surgeons National Surgical Quality Improvement) program from 2005 to 2012. We assessed pregnant women 18–50 years without prior surgery in the preceding 30 days who underwent a nonobstetric surgery. Race and ethnicity were categorized as non-Hispanic Black, Hispanic, and non-Hispanic White (reference). The primary outcome was a composite of 30-day major postoperative complications inclusive of cardiovascular, pulmonary, and infectious complications, reoperation, unplanned readmission, blood transfusion, and death. We used modified Poisson regression to estimate the relative risk of complications. RESULTS: Among 3,093 pregnant women, 18% were non-Hispanic Black, 20% Hispanic, and 62% non-Hispanic White. The most common surgeries were appendectomy (36%) and cholecystectomy (19%). Black women (18%) were more likely to be assigned American Society of Anesthesiologists (ASA) physical status class III or higher than their White (12%) or Hispanic (9%) peers. Non-Hispanic Black pregnant women had a higher risk of 30-day major postoperative complications compared with their White peers (9% vs 6%; adjusted relative risk [aRR] 1.41, 95% CI 1.11–1.99). This difference persisted when limiting the analysis to apparently healthy women (ASA class I or II) (7% vs 4%; aRR 1.64, 95% CI 1.08–2.50), those who underwent appendectomy (10% vs 3%; aRR 2.36, 95% CI 1.13–4.96), and when appendectomy and cholecystectomy were performed by laparoscopy (7% vs 3%; aRR 2.62, 95% CI 1.22–5.58). Hispanic pregnant women were not at an increased risk of complications compared with non-Hispanic pregnant White women. CONCLUSIONS: Pregnant non-Hispanic Black women were at higher risk of major postoperative complications after nonobstetric surgery compared with their White counterparts.

To determine whether non-Hispanic Black and Latina pregnant women were at higher risk of 30-day postoperative complications after non-obstetric surgery compared with non-Hispanic White pregnant women, and whether this risk persisted among apparently healthy pregnant women. Retrospective analysis of the National Surgical Quality Improvement program from 2005-2012. We included pregnant women 18-51 years without prior surgery in the preceding 30 days who underwent a non-obstetrical operation (i.e., no cesarean delivery, peripartum hysterectomy). Race and ethnicity were categorized as non-Hispanic Black, Latina, and non-Hispanic White (referent group). Those with other race or ethnicity were excluded from the analysis. The outcome was 30-day composite of major postoperative complications. We used modified Poisson regression. Because disparities in outcomes have been attributed to a higher burden of preoperative comorbidities among Black patients, differences in racial outcomes among healthy pregnant women defined as ASA physical status of 1 or 2 were also examined. Among 3,093 pregnant women, 18% were non-Hispanic Black, 20% Latina, and 62% non-Hispanic White. The most common surgical procedures were appendectomy (36%) and cholecystectomy (19%). The frequency of chronic comorbidities (ASA class >2) was higher in Black (18%) compared with Latina (9%) and White women (12%, all p<0.001) (Table 1). Black pregnant women had a higher risk of 30-day major postoperative complications compared with their White peers (9% vs. 6%: adjusted risk ratio, aRR: 1.64, 95% CI: 1.08-2.50 (Table 2). The increased risk of complications persisted among healthy Black pregnant women compared with their healthy White peers (7% vs. 4%; aRR: 1.64, 95% CI: 1.08-2.50). Latina women were not increased risk postoperative complications. Non-Hispanic Black pregnant women were at higher risk of postoperative complications following non-obstetric surgery. The Black-White racial disparity in risk of postoperative complications persisted among healthy pregnant women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Introduction: Experiences of racial discrimination in the medical setting are common among Black patients and may be linked to mistrust in medical recommendations and poorer clinical outcomes. However, little is known about the prevalence of experiences of racial mistreatment by healthcare workers among Black patients seeking addiction treatment, or how these experiences might influence Black patients' medical mistrust or expectations of care. Methods: Participants were 143 Black adults recruited consecutively from two university addiction treatment facilities in Columbus, Ohio. All participants completed validated surveys assessing perceptions of prior racial discrimination in the medical setting and group-based medical mistrust. Participants were also asked a series of questions about their expectations of care with regard to racial discrimination and addiction treatment. Descriptive analyses were used to characterize the sample with regard to demographics, perceived racial discrimination and medical mistrust. Kendall tau-b correlations assessed relationships between racial discrimination, mistrust and expectations of care. Results: Seventy-nine percent (n = 113) of participants reported prior experiences of racial discrimination during healthcare. Racial discrimination in the medical setting was associated with greater mistrust in the medical system and worse expectations regarding racial discrimination in addiction treatment including delays in care-seeking due to concern for discrimination, projected non-adherence and fears of discrimination-precipitated relapse. Conclusions: Black patients seeking addiction treatment commonly report experiencing racial discrimination by healthcare workers which may be associated with mistrust in the medical system and expectations of care. Strategies to eliminate and mitigate experiences of racial discrimination may improve addiction treatment receptivity and engagement.

Newborns with in-utero opioid exposure are most commonly evaluated for neonatal opioid withdrawal syndrome (NOWS) using the modified Finnegan neonatal abstinence scoring system (FNASS) to assess for withdrawal and guide pharmacologic intervention. While some studies suggest high variability related to the observer-rated scale, few studies have assessed the relationship between FNASS scores guiding pharmacologic treatment and infant race or ethnicity. We sought to investigate racial disparities in pharmacologic treatment for NOWS based on FNASS assessments. Retrospective cohort study of patients with opioid use disorder (OUD) who received co-located prenatal and addiction care from 2013 to 2020 at a large academic institution. Non-Hispanic Black (NHB) patients were matched to a group of non-Hispanic White (NHW) patients by gestational age and year of delivery. Race and ethnicity were based on mother reported data. The primary outcome was pharmacological treatment of newborns for NOWS. Secondary outcomes included differences in modified Finnegan neonatal abstinence scoring system (FNASS) composite scores. Multivariable analysis was conducted adjusting for >1 illicit substance on admission UDS. A total of 42 NHB mother-newborn dyads were compared to 42 matched NWH dyads. There were no significant differences in baseline demographics between the two groups, including SSRI use, gestational age at delivery, male infant or breastfeeding rates (Table 1). Infants born to NHB patients were less likely to receive pharmacological treatment for NOWS compared to those born to NHW patients (36% vs 57%, aOR 0.41, 95% CI 0.17-0.99) (Table 2). No significant differences in the occurrence or severity of NOWS based on incidence and frequency Finnegan scores ≥8 or length of stay >5 day. Despite no differences in severity of NOWS, infants born to NHB patients, and exposed to opioids in-utero, were less likely to receive pharmacologic treatment for withdrawal symptoms. Our findings provide initial evidence of racial disparities in the treatment of NHB newborns with NOWS.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Neonates exposed in-utero to opioids are commonly evaluated for neonatal opioid withdrawal syndrome (NOWS) using modified Finnegan Neonatal Abstinence Scoring System (FNASS). FNASS includes 21 different components of central nervous system, metabolic, vasomotor, respiratory, and GI disturbances. Consecutive cumulative scores ≥8 are suggestive for starting pharmacologic treatment. Our objective was to identify significant differences in FNASS scoring in neonates stratified by race. Retrospective cohort study of patients with opioid use disorder (OUD) who received co-located prenatal and addiction care from 2013 to 2020 at a large academic institution. Non-Hispanic Black (NHB) patients were matched to non-Hispanic White (NHW) patients by year and gestational age at delivery. Race and ethnicity were self-reported by the mother. The primary outcome was differences in individual scoring components. 42 NHB mother-newborn dyads were compared to 42 matched NWH dyads. There were no significant differences in baseline demographics between the groups. NHB newborns were significantly less likely than NHW to be scored for observed red, blotchy skin changes consistent with skin mottling (79% vs 100%, P<0.01). All NHB and NHW newborns were scored for mild tremors when disturbed and increased muscle tone; there were no significant scoring differences in the remaining FNASS components. NHB newborns were less likely to receive a FNASS ≥8 (69% vs. 81%, RR 0.85, CI 0.66-1.09) compared to NHW infants, and to receive pharmacological treatment for NOWS (76% vs. 98%, RR 0.78, CI 0.66-0.93) compared with NHW newborns. However, within this cohort of NHB newborns, receiving a score for mottling would have resulted in earlier and/or increased rates of pharmacologic treatment for NOWS in 36% (n=15) of patients. Infants born to NHB patients were less likely to receive score for skin mottling on modified FNASS. Lack of recognition of mottling maybe due to skin pigmentation differences and could potentially result in underscoring and delay of pharmacological treatment for NOWS.

To investigate racial and ethnic disparities in resource utilization after discharge from delivery hospitalization using a contemporary cohort. Secondary analysis of an RCT of induction of labor at 39 0/7-39 4/7 weeks compared with expectant management in low-risk nulliparous persons. The primary outcome is a composite of unplanned visits after discharge from delivery admission through eight weeks postpartum: unanticipated office, urgent care, or emergency department visits, or hospital admission. Utilization of resources was defined a priori in the parent trial. Race and ethnicity were self-reported as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and non-Hispanic Asian (NHA). Multivariable generalized linear modeling and modified Poisson regression were performed adjusting for relevant morbidities and significant covariates, with NHW as referent group. 5,951 persons (45% NHW, 28% Hispanic, 24% NHB, and 3% NHA) were included. NHB and Hispanic persons were more likely to be obese and to be diagnosed with hypertensive disorders. Hispanic persons were more likely to have intrapartum infection and postpartum hemorrhage compared with NHW (Table 1). Despite these differences, NHB and NHW had equivalent rates of the primary outcome (15% vs. 15%, aRR 0.97, 0.75-1.27). Moreover, despite a higher proportion of pre-discharge morbidities, Hispanic persons had a lower rate of the primary outcome (9.1% vs. 15%, aRR 0.64, 0.48-0.85), and were less likely to have any clinic visit, or to be readmitted compared with NHW. These discrepancies in resource utilization persisted despite controlling for insurance status, obesity, smoking, and ante-, intra-, and immediate postpartum morbidities (Table 2). Despite higher rates of morbidities noted prior to delivery admission discharge, Hispanic persons were less likely to present for unanticipated visits in the postpartum period and NHB persons no more likely. Further research is needed to evaluate varying utilization of postpartum resources and the association with the racial disparities in maternal morbidity and mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Accidental overdose is increasing among perinatal women in Ohio and now accounts for more than 40% of pregnancy-associated years of life lost in the state.

Maternal mortality and morbidity continue to rise in the United States. Despite these trends there are limited novel interventions to investigate and improve these metrics, partly due to research protocol limitations which restrict participation of pregnant women. Inclusion of pregnant women in research studies is integral to the process of obtaining important information regarding the safety and efficacy of therapeutics or interventions to improve maternal health and pregnancy outcomes. While significant changes in research practices have resulted in an increase of female participants, there remains a paucity of research trials directly targeting pregnant and lactating women. This article provides an overview of issues surrounding inclusion of pregnant or breastfeeding women in research studies, and includes historical perspectives, navigating concerns over safety profile, considerations for appropriate development, and future perspectives.

In response to the coronavirus disease 2019 (COVID-19) pandemic, and to control viral spread among patients and staff, delivery of healthcare rapidly adjusted by reducing in-person patient interactions.1Uscher-Pines L. Huskamp H.A. Mehrotra A. Treating patients with opioid use disorder in their homes: an emerging treatment model.JAMA. 2020; ([Epub ahead of print])Crossref PubMed Scopus (29) Google Scholar,2Aziz A. Zork N. Aubey J.J. et al.Telehealth for high-risk pregnancies in the setting of the COVID-19 pandemic.Am J Perinatol. 2020; 37: 800-808Crossref PubMed Scopus (166) Google Scholar Worldwide and for a variety of specialties, healthcare protocols were tailored to allow for expansion of telehealth services. For vulnerable populations, such as pregnant women with opioid use disorder (OUD), this shift in practice represented an abrupt transition and compounded the significant barriers to care that already exist for this population.3Dunlop A. Lokuge B. Masters D. et al.Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic.Harm Reduct J. 2020; 17: 26Crossref PubMed Scopus (196) Google Scholar,4Peahl A.F. Smith R.D. Moniz M.H. Prenatal care redesign: creating flexible maternity care models through virtual care.Am J Obstet Gynecol. 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (111) Google Scholar Here, we report our experience with implementation of telehealth services for a cohort of pregnant women with OUD. In our practice, maternal fetal medicine and addiction specialists care for pregnant women with OUD in a colocated office-based outpatient program. A major component of this program is weekly in-person psychotherapeutic/psychoeducational/supportive interventions group therapy. As part of our response to the COVID-19 pandemic, weekly group therapy services transitioned from in-person to virtual meetings between April 1, 2020 and May 26, 2020 to reduce potential COVID-19 exposure among patients and to comply with social distancing as recommended by the Centers for Disease Control and Prevention (CDC). Patients who received individual counseling sessions were also transitioned to virtual sessions. The group prenatal care model transitioned to individual care visits based on a department-developed algorithm for providing prenatal care during the COVID-19 pandemic, considering the patient's gestational age and acuity of additional medical complications. Visits to obtain urine drug screens (UDS) and prescriptions for medication-assisted therapy (MAT) remained in-person and were adjusted from weekly to biweekly visits on the basis of patient compliance history and availability. During the reopening phase (after May 27, 2020), a combined approach was adapted in which patients chose either in-person (limited to <10 patients per session in compliance with CDC recommendations for social distancing) or virtual group sessions. Patients attending group care visits in person received a temperature and symptom screen before arrival; visitors, including children, were not allowed to accompany the patient to any outpatient prenatal visit or ultrasound. For this study, patient data on group attendance, UDS results, emergency department (ED) and/or obstetrical triage visits, at-home assaults, overdoses, uptitration of MAT, and opiate craving scores were collected. The opiate craving score is based on a 10-point Likert craving score composed of 3 questions: (1) How much do you currently crave opiates? (2) In the past week, please rate how strong your desire to use opiates has been when something in the environment has reminded you of opiates. (3) Imagine yourself in the environment in which you previously used opiates. If you were in this environment today and if it were that time of day that you typically used opiates, what is the likelihood that you would use opiates today? The Impact of Event Scale-Revised (IES-R) was administered after resumption of in-person groups to assess distress because of the pandemic. Data were collected by obstetrical physicians providing care within the OUD pregnancy colocated clinic. After verification by the authors, these variables were then compared among 3 periods representing the immediate pre- and postperiods as well as the virtual group therapy–only period. To meet the inclusion criteria for this analysis, a patient should have enrolled in the obstetrical OUD treatment program with stable MAT dosing 4 weeks before the first case of COVID-19 in Ohio and continued prenatal care through virtual-only and combined in-person and virtual care periods. Postpartum participants, those entering care after the transition to virtual visits, or those demonstrating instability before the changes related to the pandemic were excluded from analysis. A total of 13 patients met inclusion criteria and were included in this study. Continuous variables were compared using repeated measures analysis of variance and categorical variables using Fisher exact or chi-square tests. The study was deemed exempt by the institutional review board. When compared with in-person sessions, attendance to group therapy sessions virtually was significantly lower by more than 3-fold (Figure A ). Common reasons cited for not attending virtual sessions were unavailability of technology, technological malfunction or poor digital literacy, unreliable internet connection, or inability to access virtual sessions in a location meeting appropriate per the Health Insurance Portability and Accountability Act regulations for patient privacy (such as for patients residing in shelters or other multiresident living situations). Although there was no significant difference in the number of positive UDS results between periods, the data are notable for a relapse and overdose in 1 previously stable patient in addition to a significant increase in the total number of patients requiring uptitration in MAT dosage because of intensified cravings during the period of virtual-only sessions. Furthermore, there was a notable trend toward higher ED and/or obstetrical triage visits, reported assaults, and craving scores (Table). Craving scores peaked for 6 (46%) patients during the virtual-only period (Figure B). Furthermore, 2 (15%) women reported IES-R scores of >34, which is concerning for COVID-19–specific distress.TableOutcomes for women with opioid use disorderNumber of participants (n=13)In-person (before virtual-only meetings)Virtual-onlyCombined (after virtual-only meetings)P valuePeriodFeb. 19–March 11April 1–May 26May 27–June 25Number of group therapy sessions offered over defined period485Percentage of group therapy sessions attended67±21.421±18.768±22.4<.001aStatistically significant (P<.05)Positive UDS tests for illicit substances9 (21)8 (13)2 (5).12ED or triage visitsbThe number of ED or triage visits, reported assaults, and uptitration of MAT dosage visits were only counted once per participant in each specific period.1 (8)4 (30)1 (8).17Reported assaultsbThe number of ED or triage visits, reported assaults, and uptitration of MAT dosage visits were only counted once per participant in each specific period.0 (0)2 (15)0 (0).08OverdosesbThe number of ED or triage visits, reported assaults, and uptitration of MAT dosage visits were only counted once per participant in each specific period.0 (0)1 (8)0 (0).39Uptitration of MAT dosage during defined periodbThe number of ED or triage visits, reported assaults, and uptitration of MAT dosage visits were only counted once per participant in each specific period.0 (0)5 (38)1 (8).02aStatistically significant (P<.05)Average number of craving questionnaires completed per participant2.8±0.83.2±1.23.4±0.9.47Total craving scores3.6 [3–5]4.3 [3–8.5]3.7 [3–5.5].15Data are presented as number (percentage), mean±standard deviation, or median [interquartile range], as applicable.ED, emergency department, MAT, medication-assisted therapy; UDS, urine drug screen.McKiever. Telehealth transition for OUD pregnancies during the COVID-19 pandemic. Am J Obstet Gynecol 2020.a Statistically significant (P<.05)b The number of ED or triage visits, reported assaults, and uptitration of MAT dosage visits were only counted once per participant in each specific period. Open table in a new tab Data are presented as number (percentage), mean±standard deviation, or median [interquartile range], as applicable. ED, emergency department, MAT, medication-assisted therapy; UDS, urine drug screen. McKiever. Telehealth transition for OUD pregnancies during the COVID-19 pandemic. Am J Obstet Gynecol 2020. To protect patients and staff and minimize exposure to COVID-19, care models shifted toward fewer in-person visits during the peak of the pandemic. Although this model has public health benefits, transitioning to primarily telehealth healthcare administration also has unintended consequences, and some patient subgroups may be at risk of harm. One example of an at-risk group is pregnant women with OUD. These patients frequently have social vulnerabilities, significant barriers to care,3Dunlop A. Lokuge B. Masters D. et al.Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic.Harm Reduct J. 2020; 17: 26Crossref PubMed Scopus (196) Google Scholar history of trauma, and psychiatric illnesses that are exacerbated in times of uncertainty such as during the COVID-19 pandemic. Compounding the general atmosphere of uncertainty and anxiety because of the pandemic, the shift toward telehealth removed the consistency of care and support provided during in-person group visits. Although changes associated with the pandemic, including social distancing measures, closure of conveniences, and food and work insecurity largely affected the population as a whole, these changes compounded an already vulnerable population working to overcome addiction. Patients within this population are often limited in their social support groups, are frequently isolated from family, and have limited abilities to set up contingencies for childcare and work-related changes. Our study suggests that the switch from in-person to virtual-only group visits compounded change within this population and led to decreased attendance of therapy sessions and uptitration of MAT secondary to cravings. The small sample size is a limitation of this study; however, it is strengthened by its longitudinal design. As we continue to navigate care through the continually evolving pandemic and as healthcare moves into a paradigm where telehealth has a more permanent place, we need to consider the impact of that transition on our most vulnerable populations.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which has developed into a global pandemic with vast social, economic, and health consequences. High transmissibility in asymptomatic individuals makes controlling viral spread difficult and poses unprecedented challenges to healthcare systems. At the onset of the pandemic in the United States, 19% of reportable cases were healthcare workers (HCWs) with the majority reporting exposure within the workplace.1CDC COVID-19 Response TeamCharacteristics of health care personnel with COVID-19—United States, February 12-April 9, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 477-481Crossref PubMed Scopus (563) Google Scholar Although hospital protocols have morphed with increasing available data, there continues to be a variation in screening, testing, and personal protective equipment (PPE) use across the country. Obstetrical units are an underestimated hotspot in the pandemic, owing to an asymptomatic population, high patient turnover, integrated workstations, and frequent emergencies requiring response from multiple disciplines and expedient transfer to onsite surgical suites. These factors underscore current advocacy from professional obstetrical and anesthesia societies for universal PPE in obstetrical units and the use of N95 masks during vaginal deliveries of infected patients because of suspected aerosolization during this procedure.2American College of Obstetricians and GynecologistsACOG urges action on testing and PPE for labor and delivery. 2020.https://www.acog.org/en/News/News%20Articles/2020/04/ACOG%20Urges%20Action%20on%20Testing%20and%20PPE%20for%20Labor%20and%20DeliveryDate accessed: May 3, 2020Google Scholar,3Society for MFM and Society for Obstetric and Anesthesia and PerinatologyLabor and delivery COVID-19 considerations. 2020.https://s3.amazonaws.com/cdn.smfm.org/media/2327/SMFM-SOAP_COVID_LD_Considerations_-_revision_4-14-20_-_changes_highlighted.pdfDate accessed: May 3, 2020Google Scholar Therefore, we investigated the exposure and seroconversion to SARS-CoV-2 among obstetrical HCWs in a tertiary care center. This prospective cohort study investigated SARS-CoV-2 antibody levels in obstetrical HCWs at a tertiary hospital with approximately 5500 deliveries per year. The study included HCWs employed in the inpatient obstetrical unit. Written consent was obtained, and blood samples were obtained at 2 time points 4 weeks apart, with baseline collection beginning March 25, 2020, and follow-up on April 23, 2020. Data regarding the demographics, symptoms, previous nasopharyngeal polymerase chain reaction (PCR) results for SARS-CoV-2, and the timing of high-risk exposures were collected through a voluntary written survey. Immunoglobulin M (IgM) and Immunoglobulin G (IgG) levels in the serum were measured from whole blood samples of all study participants at the 2 time points using a validated SARS-CoV-2 enzyme-linked immunosorbent assay (ELISA) per manufacture's protocol (Novel Coronavirus COVID-19 IgG ELISA Kit; Epitope Diagnostics Inc, San Diego, CA).4Epitope Diagnostics, Inc. COVID-19, Diagnostic immunoassay solutions for coronavirus detection. 2020.https://eaglebio.com/wp-content/uploads/data-pdf/EagleBio-COVID-19-ELISA-Assay-04.15.20.pdfDate accessed: May 18, 2020Google Scholar The optical density ratio for positive IgM was >0.201 (negative cutoff value of <0.179) and positive IgG was >0.439 (negative cutoff value of <0.359). The minimal detectable concentration for IgM and IgG was 5 IU/mL. The inter- and intra-assay coefficients of variation were <15% and <20%, respectively. Participants were considered to have seroconverted if they had a positive result for IgM or IgG. Specimen collection began in accordance with institutional biorepository (Institutional Review Board [IRB] study #2013H0404), and specimen and data analysis continued with additional institutional approval (IRB study #2020H0133). Of note, an outbreak of SARS-CoV-2 among obstetrical HCWs in our inpatient unit occurred between baseline and follow-up blood collection, with the first positive case on March 26, 2020. Mandatory employee temperature and symptom screening began on March 27, 2020, and universal masking was enforced on April 1, 2020. A total of 110 obstetrical HCWs completed the survey and blood collection at the 2 time points. All participants were female with a median age of 34 years (interquartile range, 28.8–45.0) and predominantly white (86%). Most participants were registered nurses (68.2%), followed by obstetrical and anesthesia physicians (24.5%). At the time of the follow-up collection, 90 participants (82%) reported exposure to SARS-CoV-2; 66 (60%) reported 1 or more COVID-19 symptoms; 52 (47%) had nasopharyngeal PCR testing, of which 15 (29%) received a positive result for the virus (Figure and Supplemental Table). At baseline, 3 (2.7%) of the participants had positive antibodies, whereas 22 (20%) had positive antibodies at the time of the follow-up collection. A total of 14 (93%) of the participants who received a positive result for SARS-CoV-2 by nasopharyngeal PCR seroconverted. Notably, 3 (8.1%) participants who received a negative result for nasopharyngeal PCR had positive antibodies. An additional 2 participants had positive IgM and IgG antibodies on baseline sample and an IgG that persisted at 4 weeks; both were asymptomatic and did not undergo nasopharyngeal PCR testing. Furthermore, 3 participants without any nasopharyngeal PCR testing seroconverted to IgM only at 4 weeks. In total, 5 participants (4.5%) who reported being asymptomatic seroconverted at either of the 2 time points (Figure and Supplemental Figure). Reported symptoms in this cohort varied from headache (77.3%) as the most common to chest pain (18.2%) as the least. However, the most predictive symptoms for any positive SARS-CoV-2 test result (PCR or antibody) were loss of taste and loss of smell, both independently with a positive predictive value, sensitivity, and specificity of 87.5%, 60.9%, and 97.7%, respectively. Limited data are available on antibody testing for SARS-CoV-2 and our study presents seroconversion rates in high-risk HCWs after a contained outbreak within our unit. About 20% of our participants received a positive result for SARS-CoV-2 antibodies, and all but 1 participant that received a positive result for COVID-19 based on PCR had evidence of seroconversion (93%). Of further interest, antibody testing was positive in 3 participants who received negative PCR test results and 5 participants who reported no symptoms at all. In addition, our study evaluated a broad range of associated symptoms and found a loss of taste and smell to be the most predictive, which is a finding similar to other published reports.5Tostmann A. Bradley J. Bousema T. et al.Strong associations and moderate predictive value of early symptoms for SARS-CoV-2 test positivity among healthcare workers, the Netherlands, March 2020.Euro Surveill. 2020; 25: 2000508Crossref Scopus (166) Google Scholar

INTRODUCTION: To compare neonatal characteristics among neonates born to women with opioid use disorder (OUD) on buprenorphine/naloxone medication assisted therapy (MAT) receiving traditional prenatal care (TPNC) or multidisciplinary OUD group (MOG) prenatal care. METHODS: A retrospective cohort analysis was performed of dyads treated with OUD on MAT who received TPNC or MOG prenatal care. MOG prenatal care is a comprehensive approach comprising of prenatal care and group counselling, social work, psychiatry, psychotherapy, mindfulness-integrated cognitive behavior therapy, pregnancy and OUD educational topics (breastfeeding, postpartum blues/depression, contraception, hepatitis C and Narcan administration). RESULTS: From July 2017 to June 2019, we identified 177 mother-infant dyads; 102 received TPNC and 75 received MOG prenatal care. Continuous data were analyzed for normality using the Shapiro-Wilk test. Student's t-test or Mann-Whitney U test were also employed. Categorical data analyzed with chi-square. Neonates born to mothers receiving MOG prenatal care were significantly less likely to require NICU admission (25.3% vs 41.2%, P=.048). Among neonates requiring NAS treatment, those born to mothers in MOG care had a significantly reduced duration of treatment (6 days vs 9 days, P=.001). Neonates born to mothers receiving MOG care were less likely to be treated for NAS, had a lower peak NAS score, higher birthweight and were less likely to be born prematurely; although these differences did not achieve statistical significance. CONCLUSION: Neonates born to mothers receiving MOG care were less likely to require NICU admission and had a shorter duration of NAS treatment.

INTRODUCTION: To evaluate accuracy of last menstrual period (LMP) in pregnancy dating at time of presentation for prenatal care. METHODS: An IRB-approved retrospective study of all women presenting in 2016 for pregnancy confirmation was performed. All women received a sonogram to confirm gestation. Dating was based on American College of Obstetricians and Gynecologists guidelines. Charts were reviewed for utilization of genetic screening and scheduled delivery. Logistic regression models assessed the association between estimated due date (EDD) changes and patient characteristics. RESULTS: Of 1,724 individuals presenting for pregnancy confirmation, 1,376 patients sought care in the first trimester with known LMP. Of these, 23.5% had their EDD changed based on ultrasound. When changed, 43.9% were at less than 9 weeks' gestation. 21.2% who underwent first trimester screening would have missed the opportunity for screening during the 13th week if EDD was not changed. Of the 41.6% who underwent medically indicated or elective scheduled delivery, 41.1% would have been scheduled too early if their EDD were not changed. Obese (OR 1.98, 95% CI 1.39-2.84) and underweight (OR 2.96, 95% CI 1.29-6.77) women were most likely to require alteration of EDD. There was a trend towards EDD modification with increasing gravidity and biphasic oral contraceptive use. CONCLUSION: Nearly 1 in 4 women presenting for prenatal care in the first trimester with known LMP required adjustment of their EDD based on first trimester ultrasound. The characteristic most significantly associated with EDD adjustment was BMI. First trimester ultrasound is vital as it affects timing of genetic screening and scheduled delivery.

While congenital Zika infection may lead to significant fetal neurologic abnormalities, little is known about the postnatal consequences of Zika exposure to apparently asymptomatic fetuses. Our aim was to examine the postnatal outcomes of infants exposed to maternal Zika infection during pregnancy. This is an ongoing prospective, observational cohort study from a large-scale, county hospital-based prenatal Zika screening program in a southern border state. All women reporting travel to an at-risk region during pregnancy were screened with serum Zika IgM or PCR as appropriate. Infants born to women with laboratory evidence of Zika infection during pregnancy underwent laboratory and comprehensive neurologic evaluation at birth, and were surveyed for developmental milestones and head circumference (HC) measurements at local pediatric clinics. HC measurements were compared using Z-scores to sex-specific reference standards from the World Health Organization (WHO) using a mixed effects repeated measures model. Among 26,789 women screened between March 2016 and July 2017, a total of 55 women with laboratory evidence of probable or confirmed Zika virus infection delivered neurologically intact infants at our hospital. One (1.8%) asymptomatic infant had serologic evidence of probable congenital flavivirus infection. No significant intracranial abnormalities were identified on prenatal or postnatal head imaging (n=55). All infants had normal hearing screens prior to hospital discharge (n=55), and those with dilated eye exams were unremarkable (n=29, 52%). Among 31 female and 24 male infants, there were no significant deviations in available head circumference Z-scores from respective WHO population means over 210 days of life (Figure). Developmental milestones were achieved for infants available for follow-up through 2 months (n=29/52) and 6 months (n=13/41) of life. Asymptomatic infants born to women with probable or confirmed Zika virus infection during pregnancy do not have significant head circumference deviations from population expectations through at least 6 months of life, and no adverse developmental outcomes have been identified in assessed infants to date. These data could be used to support future CDC guidance on evaluation of asymptomatic Zika-exposed infants.

The objective of this study is to determine whether evaluation of maternal cardiac status with using routine echocardiography in patients with risk factors for cardiac dysfunction such as hypertension, diabetes or obesity is useful in detecting subclinical disease. Patients seen from January 2013-January 2014 were scheduled for routine maternal echocardiography and electrocardiogram using standard clinical protocol. Data were collected including the patient's indication for echocardiography, maternal BMI, and maternal race. Data were analyzed using the ANOVA and T-test where appropriate. During the time period, 116 women were evaluated by using both modalities. 20 of the 116 women had abnormal echocardiograms (17%). None of the patients with an abnormal echocardiogram had an abnormal electrocardiogram. 11 of the 20 were noted to have significant end-diastolic dysfunction. (11%). The remaining 9 patients had moderate to severe valvular disease. Ejection fraction was normal. A BMI of greater than 40 in conjunction with diabetes or chronic hypertension was associated with the greatest risk for end-diastolic dysfunction, p=<0.05. Routine maternal echocardiography is a useful tool in evaluating patients at risk for cardiovascular disease.