Publications by authors named "Dena Goffman"

84 Publications

Incident Reports of Naming Errors among Two Sets of Infant Twins.

Pediatr Qual Saf 2020 Nov-Dec;5(6):e356. Epub 2020 Oct 23.

Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, N.Y.

Newborns are at high risk for identification errors due to their inability to speak and indistinguishable features. To reduce this risk, The Joint Commission requires hospitals to use a distinct identification method for newborns. Most hospitals create medical records for newborns at birth using temporary naming conventions, resulting in patients with similar identifiers. Typically, multiple-birth infants are distinguished from their siblings by a single character (1, 2, or A, B), placing them at higher risk for identification errors, which can delay care and compromise patient safety.

Methods: We present 2 unrelated cases involving naming errors in sets of infant twins receiving care in a healthcare system using Joint Commission compliant distinct temporary naming convention.

Results: In the 2 cases, system failures contributed to naming errors in 2 sets of infant twins, which resulted in delayed care. In the first case, twins were inadvertently assigned the same temporary name. In the second case, an infant's blood specimen label did not include a single character, which distinguishes a multiple-birth infant from their sibling. Further safeguards are needed to reduce this risk. These cases illustrated the potential for misidentification related to newborn naming conventions during the registration process, especially between siblings of multiple-birth infants.

Conclusions: Further research is needed to determine strategies to prevent newborn identification errors. Potential strategies to reduce this risk and protect newborns include improving the design of newborn identifiers, systems-level interventions such as verification alerts, and improved registration processes.
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http://dx.doi.org/10.1097/pq9.0000000000000356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870170PMC
October 2020

Postpartum cardiac readmissions among women without a cardiac diagnosis at delivery.

J Matern Fetal Neonatal Med 2020 Dec 15:1-7. Epub 2020 Dec 15.

Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

Objective: To determine risk for cardiac readmissions among women without cardiac diagnoses present at delivery up to 9 months after delivery hospitalization discharge.

Methods: Delivery hospitalizations without cardiac diagnoses were identified from the 2010-2014 Nationwide Readmissions Database and linked with subsequent cardiac hospitalizations over the following 9 months. The temporality of new-onset cardiac hospitalizations was calculated for each 30-day interval from delivery discharge up to 9 months postpartum. Multivariable log-linear regression models were fit to identify risk factors for cardiac readmissions adjusting for patient, medical, and obstetrical factors with adjusted risk ratios as measures of effect (aRR).

Results: Among 4.4 million delivery hospitalizations without a cardiac diagnosis, readmission for a cardiac condition within 9 months occurred in 26.8 per 10,000 women. Almost half of readmissions (45.9%) occurred within the first 30 days after delivery discharge with subsequent hospitalizations broadly distributed over the remaining 8 months. Factors such as hypertensive diseases of pregnancy (aRR 2.19, 95% CI 2.09, 2.30), severe maternal morbidity at delivery (aRR 2.06, 95% CI 1.79, 2.37), chronic hypertension (aRR 2.52, 95% CI 2.31, 2.74), lupus (aRR 4.62, 95% CI 3.82, 5.60), and venous thromboembolism during delivery (aRR 3.72, 95% CI 2.75, 5.02) were all associated with increased risk for 9-month postpartum cardiac admissions as were Medicaid (aRR 1.57, 95% CI 1.51, 1.64) and Medicare insurance (aRR 3.06, 95% CI 2.70, 3.46) compared to commercial insurance and maternal ages 35-39 and 40-54 years (aRR 1.24, 95% CI 1.17, 1.32, aRR 1.74, 95% CI 1.60, 1.90, respectively) compared to maternal age 25-29 years.

Conclusions: Among women without a cardiac diagnosis at delivery, multiple medical factors and obstetrical complications are associated with development of new cardiac disease requiring readmission in the postpartum period. Given that pregnancy complications and comorbidities may be associated with intermediate-term health outcomes, these findings support the importance of continued health care access after six weeks postpartum.
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http://dx.doi.org/10.1080/14767058.2020.1863368DOI Listing
December 2020

Evaluation and Diagnostic Testing.

Clin Obstet Gynecol 2020 12;63(4):828-835

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York.

The evaluation of cardiovascular disease in pregnancy is challenging due to overlaps between cardiac and normal pregnancy symptomatology, as well as concerns about the potential impact, if any, of imaging studies on fetal development. We discuss here an approach to the evaluation of the pregnant cardiac patient and review the safety and utility of available diagnostic tests, including labs, electrocardiogram, echocardiography, stress testing, computed tomography, magnetic resonance imaging, and cardiac catheterization. Importantly, the majority of standard imaging studies can be safely performed in pregnancy, and a high index of suspicion must be maintained when evaluating pregnant patients, especially those with preexisting cardiovascular disease.
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http://dx.doi.org/10.1097/GRF.0000000000000566DOI Listing
December 2020

Infection prevention and control for labor and delivery, well baby nurseries, and neonatal intensive care units.

Semin Perinatol 2020 11 12;44(7):151320. Epub 2020 Oct 12.

Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, United States.

During the early months of the COVID-19 pandemic, infection prevention and control (IP&C) for women in labor and mothers and newborns during delivery and receiving post-partum care was quite challenging for staff, patients, and support persons due to a relative lack of evidence-based practices, high rates of community transmission, and shortages of personal protective equipment (PPE). We present our IP&C policies and procedures for the obstetrical population developed from mid-March to mid-May 2020 when New York City served as the epicenter of the pandemic in the U.S. For patients, we describe screening for COVID-19, testing for SARS-CoV-2, and clearing patients from COVID-19 precautions. For staff, we address self-monitoring for symptoms, PPE in different clinical scenarios, and reducing staff exposures to SARS-CoV-2. For visitors/support persons, we address limiting them in labor and delivery, the postpartum units, and the NICU to promote staff and patient safety. We describe management of SARS-CoV-2-positive mothers and their newborns in both the well-baby nursery and in the neonatal ICU. Notably, in the well-baby nursery we do not separate SARS-CoV-2-positive mothers from their newborns, but emphasize maternal mask use and social distancing by placing newborns in isolates and asking mothers to remain 6 feet away unless feeding or changing their newborn. We also encourage direct breastfeeding and do not advocate early bathing. Newborns of SARS-CoV-2-positive mothers are considered persons under investigation (PUIs) until 14 days of life, the duration of the incubation period for SARS-CoV-2. We share two models of community-based care for PUI neonates. Finally, we provide our strategies for enhancing communication and education during the early months of the pandemic.
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http://dx.doi.org/10.1016/j.semperi.2020.151320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550181PMC
November 2020

Outcomes of Neonates Born to Mothers With Severe Acute Respiratory Syndrome Coronavirus 2 Infection at a Large Medical Center in New York City.

JAMA Pediatr 2021 02;175(2):157-167

NewYork-Presbyterian Hospital, New York, New York.

Importance: Limited data on vertical and perinatal transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and health outcomes of neonates born to mothers with symptomatic or asymptomatic coronavirus disease 2019 (COVID-19) are available. Studies are needed to inform evidence-based infection prevention and control (IP&C) policies.

Objective: To describe the outcomes of neonates born to mothers with perinatal SARS-CoV-2 infection and the IP&C practices associated with these outcomes.

Design, Setting, And Participants: This retrospective cohort analysis reviewed the medical records for maternal and newborn data for all 101 neonates born to 100 mothers positive for or with suspected SARS-CoV-2 infection from March 13 to April 24, 2020. Testing for SARS-CoV-2 was performed using Cobas (Roche Diagnostics) or Xpert Xpress (Cepheid) assays. Newborns were admitted to well-baby nurseries (WBNs) (82 infants) and neonatal intensive care units (NICUs) (19 infants) in 2 affiliate hospitals at a large academic medical center in New York, New York. Newborns from the WBNs roomed-in with their mothers, who were required to wear masks. Direct breastfeeding after appropriate hygiene was encouraged.

Exposures: Perinatal exposure to maternal asymptomatic/mild vs severe/critical COVID-19.

Main Outcomes And Measures: The primary outcome was newborn SARS-CoV-2 testing results. Maternal COVID-19 status was classified as asymptomatic/mildly symptomatic vs severe/critical. Newborn characteristics and clinical courses were compared across maternal COVID-19 severity.

Results: In total, 141 tests were obtained from 101 newborns (54 girls [53.5%]) on 0 to 25 days of life (DOL-0 to DOL-25) (median, DOL-1; interquartile range [IQR], DOL-1 to DOL-3). Two newborns had indeterminate test results, indicative of low viral load (2.0%; 95% CI, 0.2%-7.0%); 1 newborn never underwent retesting but remained well on follow-up, and the other had negative results on retesting. Maternal severe/critical COVID-19 was associated with newborns born approximately 1 week earlier (median gestational age, 37.9 [IQR, 37.1-38.4] vs 39.1 [IQR, 38.3-40.2] weeks; P = .02) and at increased risk of requiring phototherapy (3 of 10 [30.0%] vs 6 of 91 [7.0%]; P = .04) compared with newborns of mothers with asymptomatic/mild COVID-19. Fifty-five newborns were followed up in a new COVID-19 Newborn Follow-up Clinic at DOL-3 to DOL-10 and remained well. Twenty of these newborns plus 3 newborns followed up elsewhere had 32 nonroutine encounters documented at DOL-3 to DOL-25, and none had evidence of SARS-CoV-2 infection, including 6 with negative retesting results.

Conclusions And Relevance: No clinical evidence of vertical transmission was identified in 101 newborns of mothers positive for or with suspected SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices.
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http://dx.doi.org/10.1001/jamapediatrics.2020.4298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551222PMC
February 2021

Implementation outcomes of policy and programme innovations to prevent obstetric haemorrhage in low- and middle-income countries: a systematic review.

Health Policy Plan 2020 Nov;35(9):1208-1227

Global Health Program, New York University School of Global Public Health, 14 East 4th St, RM300A, New York, NY 10003, USA.

Globally, obstetric haemorrhage (OH) remains the leading cause of maternal mortality. Much of the associated mortality is ascribed to challenges surrounding deployment of innovations rather than lack of availability. In low- and middle-income countries (LMICs), where the burden is highest, there is a growing interest in implementation research as a means to bridge the 'know-do' gap between proven interventions and their reliable implementation at scale. In this systematic review, we identified and synthesized qualitative and quantitative data across the implementation outcomes of OH prevention innovations in LMICs using a taxonomy developed by Proctor et al. We also identified service outcomes for the included innovations, as well as implementation strategies and implementation facilitators and barriers. Eligible studies were empirical, focused on the implementation of OH prevention programmes or policies and occurred in an LMIC. Eight databases were searched. Two authors independently assessed studies for selection and extracted data; the first author resolved discrepancies. Narrative synthesis was used to analyse and interpret the findings. Studies were predominantly focused in Africa and on primary prevention. Interventions included prophylactic use of uterotonics (n = 7), clinical provider skills training (n = 4) and provision of clinical guidelines (n = 1); some (n = 3) were also part of a multi-component quality improvement bundle. Various barriers were reported, including challenges among intervention beneficiaries, providers and within the health system; however, studies reported the development and testing of practical implementation solutions. These included training and monitoring of implementers, community and stakeholder engagement and guidance by external mentors. Some studies linked successful delivery to implementation outcomes, most commonly adoption and acceptability, but also feasibility, penetration and sustainability. Findings suggest that innovations to prevent OH can be acceptable, appropriate and feasible in LMIC settings; however, more research is needed to better evaluate these and other under-reported implementation outcomes.
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http://dx.doi.org/10.1093/heapol/czaa074DOI Listing
November 2020

Introduction.

Semin Perinatol 2020 11 31;44(7):151289. Epub 2020 Aug 31.

Department of Obstetrics and Gynecology, Columbia University, Irving Medical Center, New York, NY 10032, U.S.A.

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http://dx.doi.org/10.1016/j.semperi.2020.151289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458066PMC
November 2020

Reductions in commuting mobility correlate with geographic differences in SARS-CoV-2 prevalence in New York City.

Nat Commun 2020 09 16;11(1):4674. Epub 2020 Sep 16.

Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

SARS-CoV-2-related mortality and hospitalizations differ substantially between New York City neighborhoods. Mitigation efforts require knowing the extent to which these disparities reflect differences in prevalence and understanding the associated drivers. Here, we report the prevalence of SARS-CoV-2 in New York City boroughs inferred using tests administered to 1,746 pregnant women hospitalized for delivery between March 22nd and May 3rd, 2020. We also assess the relationship between prevalence and commuting-style movements into and out of each borough. Prevalence ranged from 11.3% (95% credible interval [8.9%, 13.9%]) in Manhattan to 26.0% (15.3%, 38.9%) in South Queens, with an estimated city-wide prevalence of 15.6% (13.9%, 17.4%). Prevalence was lowest in boroughs with the greatest reductions in morning movements out of and evening movements into the borough (Pearson R = -0.88 [-0.52, -0.99]). Widespread testing is needed to further specify disparities in prevalence and assess the risk of future outbreaks.
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http://dx.doi.org/10.1038/s41467-020-18271-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494926PMC
September 2020

Healing Our Own: A Randomized Trial to Assess Benefits of Peer Support.

J Patient Saf 2020 Sep 8. Epub 2020 Sep 8.

From the Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.

Objectives: This study aimed to develop and evaluate a structured peer support program to address the needs of providers involved in obstetric adverse outcomes.

Methods: In this pilot randomized controlled trial, participants were providers who experienced an obstetric-related adverse outcome. Providers were randomly assigned to routine support (no further follow-up) or enhanced support (follow-up with a trained peer supporter). Participants completed surveys at baseline, 3 months, and 6 months. The primary outcome was the use of resources and the perception of their helpfulness. Secondary outcomes were the effect on the recovery stages and the duration of use of peer support.

Results: Fifty participants were enrolled and randomly assigned 1:1 to each group; 42 completed the program (enhanced, 23; routine, 19). The 2 groups were not significantly different with respect to event type, demographics, or baseline stage; in both groups, most participants started at the stage 6 thriving path. Most participants required less than 3 months of support: 65.2% did not need follow-up after the first contact, and 91.3% did not need follow-up after the second contact. Participants who transitioned from an early stage of recovery (stages 1-3) to the stage 6 thriving path reported that they most often sought support from peers (P = 0.02) and departmental leadership (P = 0.07). Those in the enhanced support group were significantly more likely to consider departmental leadership as one of the most helpful resources (P = 0.02).

Conclusions: For supporting health care providers involved in adverse outcomes, structured peer support is a practicable intervention that can be initiated with limited resources.
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http://dx.doi.org/10.1097/PTS.0000000000000771DOI Listing
September 2020

Introduction.

Semin Perinatol 2020 Oct 23;44(6):151290. Epub 2020 Jul 23.

Department of Obstetrics and Gynecology, Columbia University, Irving Medical Center, New York, New York, 10032, USA.

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http://dx.doi.org/10.1016/j.semperi.2020.151290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376352PMC
October 2020

Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage.

Obstet Gynecol 2020 11;136(5):882-891

NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; The Ohio State University, Columbus, Ohio; University of Utah Health, Salt Lake City, Utah; the University of Pittsburgh Medical Center-Magee Women's Hospital, Pittsburgh, Pennsylvania; NewYork-Presbyterian/Queens, Flushing, New York; the University of Alabama, UAB Center for Women's Reproductive Health, Birmingham, Alabama; MetroHealth Medical Center, Cleveland, Ohio; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; the University of Texas Medical Branch at Galveston, Galveston, Texas; the University of Virginia, Charlottesville, Virginia; MedStar Washington Hospital Center, Washington, DC; Geisinger Medical Center, Danville, Pennsylvania; Massachusetts General Hospital, Boston, Massachusetts; the Cleveland Clinic, Cleveland, Ohio; Oregon Health & Science University, Portland, Oregon; Alydia Health, Menlo Park, California; McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Northwestern University/Northwestern Memorial Hospital, Chicago, Illinois; and the Indiana University School of Medicine, Indianapolis, Indiana.

Objective: To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment.

Methods: A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device.

Results: Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88-98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0-5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1-3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%).

Conclusion: Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality.

Funding Source: Alydia Health, Inc.

Clinical Trial Registration: ClinicalTrials.gov, NCT02883673.
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http://dx.doi.org/10.1097/AOG.0000000000004138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575019PMC
November 2020

Obstetric simulation for a pandemic.

Semin Perinatol 2020 10 23;44(6):151294. Epub 2020 Jul 23.

Department of Obstetrics and Gynecology, Baylor College of Medicine, CHRISTUS Health, San Antonio, TX, USA. Electronic address:

Objective: In the middle of the COVID-19 pandemic, guidelines and recommendations are rapidly evolving. Providers strive to provide safe high-quality care for their patients in the already high-risk specialty of Obstetrics while also considering the risk that this virus adds to their patients and themselves. From other pandemics, evidence exists that simulation is the most effective way to prepare teams, build understanding and confidence, and increase patient and provider safety.

Finding: Practicing in-situ multidisciplinary simulations in the hospital setting has illustrated key opportunities for improvement that should be considered when caring for a patient with possible COVID-19.

Conclusion: In the current COVID-19 pandemic, simulating obstetrical patient care from presentation to the hospital triage through postpartum care can prepare teams for even the most complicated patients while increasing their ability to protect themselves and their patients.
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http://dx.doi.org/10.1016/j.semperi.2020.151294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376342PMC
October 2020

The Response to a Pandemic at Columbia University Irving Medical Center's Department of Obstetrics and Gynecology.

Semin Perinatol 2020 10 23;44(6):151291. Epub 2020 Jul 23.

Columbia University Irving Medical Center, Department of Obstetrics & Gynecology USA; Division of Maternal Fetal Medicine USA.

The rapid evolution of the COVID-19 pandemic in New York City during the spring of 2020 challenged the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center to rely on its core values to respond effectively. In particular, five core values, "5 C's," were engaged: Communication; Collaboration; Continuity; Community; and Culture. Beginning on March 11, 2020, the Department of Ob/Gyn used these values to navigate an unprecedented public health crisis, continuing to deliver care to the women and families of New York City, to protecting and supporting its team, and to sharing its lessons learned with the national and international women's health community.
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http://dx.doi.org/10.1016/j.semperi.2020.151291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432709PMC
October 2020

Building an obstetric intensive care unit during the COVID-19 pandemic at a tertiary hospital and selected maternal-fetal and delivery considerations.

Semin Perinatol 2020 11 24;44(7):151298. Epub 2020 Jul 24.

Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY, United States. Electronic address:

During the novel Coronavirus Disease 2019 pandemic, New York City became an international epicenter for this highly infectious respiratory virus. In anticipation of the unfortunate reality of community spread and high disease burden, the Anesthesia and Obstetrics and Gynecology departments at NewYork-Presbyterian / Columbia University Irving Medical Center, an academic hospital system in Manhattan, created an Obstetric Intensive Care Unit on Labor and Delivery to defray volume from the hospital's preexisting intensive care units. Its purpose was threefold: (1) to accommodate the anticipated influx of critically ill pregnant and postpartum patients due to novel coronavirus, (2) to care for critically ill obstetric patients who would previously have been transferred to a non-obstetric intensive care unit, and (3) to continue caring for our usual census of pregnant and postpartum patients, who are novel Coronavirus negative and require a higher level of care. In this chapter, we share key operational details for the conversion of a non-intensive care space into an obstetric intensive care unit, with an emphasis on the infrastructure, personnel and workflow, as well as the goals for maternal and fetal monitoring.
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http://dx.doi.org/10.1016/j.semperi.2020.151298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378468PMC
November 2020

Neonates With Complex Cardiac Malformation and Congenital Diaphragmatic Hernia Born to SARS-CoV-2 Positive Women-A Single Center Experience.

World J Pediatr Congenit Heart Surg 2020 11 27;11(6):697-703. Epub 2020 Aug 27.

Department of Pediatrics, New York-Presbyterian/Morgan Stanley Children's Hospital, 21611Columbia University Irving Medical Center, New York, NY, USA.

Background: Our understanding of the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pregnancies and perinatal outcomes is limited. The clinical course of neonates born to women who acquired coronavirus disease 2019 (COVID-19) during their pregnancy has been previously described. However, the course of neonates born with complex congenital malformations during the COVID-19 pandemic is not known.

Methods: We report a case series of seven neonates with congenital heart and lung malformations born to women who tested positive for SARS-CoV-2 during their pregnancy at a single academic medical center in New York City.

Results: Six infants had congenital heart disease and one was diagnosed with congenital diaphragmatic hernia. In all seven infants, the clinical course was as expected for the congenital lesion. None of the seven exhibited symptoms generally associated with COVID-19. None of the infants in our case series tested positive by nasopharyngeal test for SARS-CoV-2 at 24 hours of life and at multiple points during their hospital course.

Conclusions: In this case series, maternal infection with SARS-CoV-2 during pregnancy did not result in adverse outcomes in neonates with complex heart or lung malformations. Neither vertical nor horizontal transmission of SARS-CoV-2 was noted.
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http://dx.doi.org/10.1177/2150135120950256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653328PMC
November 2020

Use of a cesarean delivery checklist in an African maternity ward to improve management and reduce length of hospital stay.

Int J Gynaecol Obstet 2021 Feb 21;152(2):236-241. Epub 2020 Sep 21.

Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.

Objective: To create, implement, and evaluate the effectiveness of a cesarean delivery checklist on maternal and neonatal outcomes in a rural African hospital.

Methods: Based on input from local authorities, WHO's Safe Surgical Checklist was modified for cesarean delivery and adapted for use in low-resource settings. Retrospective chart review between April and August 2013 in Kibogora Hospital, Nyamasheke, Rwanda, included the first 100 women undergoing cesarean after checklist implementation and the last 100 women undergoing cesarean before implementation. Checklist utilization was determined and degree of completeness assessed. Outcomes were compared between patients for whom the checklist was utilized and patients for whom the checklist was not utilized, in both pre and post-implementation groups.

Results: Checklist utilization rate was 83.0% (83/100). Checklist utilization was associated with significant increases in documentation of estimated blood loss (91.6% [76/83] vs 0.9% [1/117], P<0.001) and antibiotic administration before incision (96.4% [80/83] vs 30.8% [36/117], P<0.001). It was also associated with decreased rates of hospitalization longer than the standard 4 days (19.3% [16/83] vs 70.1% [82/117], P<0.001).

Conclusion: Implementation of a cesarean delivery checklist via a culturally specific and resource-specific strategy resulted in high utilization rates and improved performance in key best practices by healthcare providers.
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http://dx.doi.org/10.1002/ijgo.13355DOI Listing
February 2021

From the trenches: inpatient management of coronavirus disease 2019 in pregnancy.

Am J Obstet Gynecol MFM 2020 08 15;2(3):100154. Epub 2020 Jun 15.

Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, The Bronx, NY.

The novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 has become a pandemic. It has quickly swept across the globe, leaving many clinicians to care for infected patients with limited information about the disease and best practices for care. Our goal is to share our experiences of caring for pregnant and postpartum women with novel coronavirus disease 2019 in New York, which is the coronavirus disease 2019 epicenter in the United States, and review current guidelines. We offer a guide, focusing on inpatient management, including testing policies, admission criteria, medical management, care for the decompensating patient, and practical tips for inpatient antepartum service management.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294275PMC
August 2020

Consolidation of obstetric services in a public health emergency.

Semin Perinatol 2020 11 22;44(7):151281. Epub 2020 Jul 22.

Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, United States.

Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.
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http://dx.doi.org/10.1016/j.semperi.2020.151281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374143PMC
November 2020

Influence of Race and Ethnicity on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Rates and Clinical Outcomes in Pregnancy.

Obstet Gynecol 2020 11;136(5):1040-1043

Division of Maternal-Fetal Medicine and the Division of Gynecological Oncology, Department of Obstetrics and Gynecology, and the Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, and the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.

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http://dx.doi.org/10.1097/AOG.0000000000004088DOI Listing
November 2020

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data.

J Matern Fetal Neonatal Med 2020 Jun 29:1-7. Epub 2020 Jun 29.

Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.

Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62-69%) with a 91% PPV (89-94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15-32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10-22%). Sensitivity for ARF was 33% (95% CI 26-41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52-73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76-86% versus 56%, 95% CI 51-60%,  < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36-58% versus Hospital B 63%, 95% CI 58-67% versus Hospital C 80%, 95% CI 74-86%,  < .01). Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.
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http://dx.doi.org/10.1080/14767058.2020.1783229DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770034PMC
June 2020

Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers.

Obstet Gynecol 2020 08;136(2):273-282

Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, the Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, the Department of Obstetrics and Gynecology, NYU Langone Health & NYU Grossman School of Medicine, New York, the Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, and the Department of Obstetrics and Gynecology, NYC Health and Hospitals-Elmhurst, Elmhurst, New York.

Objective: To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020.

Methods: We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020.

Results: Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%).

Conclusion: During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.
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http://dx.doi.org/10.1097/AOG.0000000000004025DOI Listing
August 2020

Wrong-Patient Ordering Errors in Peripartum Mother-Newborn Pairs: A Unique Patient-Safety Challenge in Obstetrics.

Obstet Gynecol 2020 07;136(1):161-166

Department of Obstetrics & Gynecology and the Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, and the Department of Quality and Patient Safety, NewYork-Presbyterian Hospital, New York, New York.

Because maternal morbidity and mortality remain persistent challenges to the U.S. health care system, efforts to improve inpatient patient safety are critical. One important aspect of ensuring patient safety is reducing medical errors. However, obstetrics presents a uniquely challenging environment for safe ordering practices. When mother-newborn pairs are admitted in the postpartum setting with nearly identical names in the medical record (for example, Jane Doe and Janegirl Doe), there is a potential for wrong-patient medication ordering errors. This can lead to harm from the wrong patient receiving a medication or diagnostic test, especially a newborn receiving an adult dose of medication, as well as delaying treatment for the appropriate patient. We describe two clinical scenarios of wrong-patient ordering errors between mother-newborn pairs. The first involves an intravenous labetalol order that was placed for a postpartum patient but was released from the automated dispensing cabinet under the newborn's name. The medication was administered correctly, but an automatic order for labetalol was generated in the neonate's chart. Another scenario involves a woman presenting in labor with acute psychotic symptoms. The psychiatry service placed a note and orders for antipsychotic medications in the neonate's chart. These orders were cancelled shortly thereafter and replaced for the mother. These scenarios illustrate this specific patient-safety concern inherent in the treatment of mother-newborn pairs and highlight that perinatal units should evaluate threats to patient safety embedded in the unique mother-newborn relationship and develop strategies to reduce risk.
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http://dx.doi.org/10.1097/AOG.0000000000003872DOI Listing
July 2020

Coronavirus disease 2019 in pregnancy: early lessons.

Am J Obstet Gynecol MFM 2020 05 27;2(2):100111. Epub 2020 Mar 27.

Department of Obstetrics and Gynecology, New York-Presbyterian Hospital, New York, New York.

The worldwide incidence of coronavirus disease 2019 (COVID-19) infection is rapidly increasing, but there exists limited information on coronavirus disease 2019 in pregnancy. Here, we present our experience with 7 confirmed cases of coronavirus disease 2019 in pregnancy presenting to a single large New York City tertiary care hospital. Of the 7 patients, 5 presented with symptoms of coronavirus disease 2019, including cough, myalgias, fevers, chest pain, and headache. Of the 7 patients, 4 were admitted to the hospital, including 2 who required supportive care with intravenous hydration. Of note, the other 2 admitted patients who were asymptomatic on admission to the hospital, presenting instead for obstetrically indicated labor inductions, became symptomatic after delivery, each requiring intensive care unit admission.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271091PMC
May 2020

A Survey of Labor and Delivery Practices in New York City during the COVID-19 Pandemic.

Am J Perinatol 2020 08 9;37(10):975-981. Epub 2020 Jun 9.

Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.

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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http://dx.doi.org/10.1055/s-0040-1713120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416196PMC
August 2020

Telehealth Uptake into Prenatal Care and Provider Attitudes during the COVID-19 Pandemic in New York City: A Quantitative and Qualitative Analysis.

Am J Perinatol 2020 08 9;37(10):1005-1014. Epub 2020 Jun 9.

Department of Obstetrics and Gynecology, NewYork Presbyterian/Columbia University Irving Medical Center, Columbia University, New York, New York.

Objective: This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition.

Study Design: Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth.

Results: During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth ( = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients.

Conclusion: Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required.

Key Points: · Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..
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http://dx.doi.org/10.1055/s-0040-1712939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416212PMC
August 2020

Symptoms and Critical Illness Among Obstetric Patients With Coronavirus Disease 2019 (COVID-19) Infection.

Obstet Gynecol 2020 08;136(2):291-299

Department of Obstetrics and Gynecology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York.

Objective: To characterize symptoms and disease severity among pregnant women with coronavirus disease 2019 (COVID-19) infection, along with laboratory findings, imaging, and clinical outcomes.

Methods: Pregnant women with COVID-19 infection were identified at two affiliated hospitals in New York City from March 13 to April 19, 2020, for this case series study. Women were diagnosed with COVID-19 infection based on either universal testing on admission or testing because of COVID-19-related symptoms. Disease was classified as either 1) asymptomatic or mild or 2) moderate or severe based on dyspnea, tachypnea, or hypoxia. Clinical and demographic risk factors for moderate or severe disease were analyzed and calculated as odds ratios (ORs) with 95% CIs. Laboratory findings and associated symptoms were compared between those with mild or asymptomatic and moderate or severe disease. The clinical courses and associated complications of women hospitalized with moderate and severe disease are described.

Results: Of 158 pregnant women with COVID-19 infection, 124 (78%) had mild or asymptomatic disease and 34 (22%) had moderate or severe disease. Of 15 hospitalized women with moderate or severe disease, 10 received respiratory support with supplemental oxygen and one required intubation. Women with moderate or severe disease had a higher likelihood of having an underlying medical comorbidity (50% vs 27%, OR 2.76, 95% CI 1.26-6.02). Asthma was more common among those with moderate or severe disease (24% vs 8%, OR 3.51, 95% CI 1.26-9.75). Women with moderate or severe disease were significantly more likely to have leukopenia and elevated aspartate transaminase and ferritin. Women with moderate or severe disease were at significantly higher risk for cough and chest pain and pressure. Nine women received ICU or step-down-level care, including four for 9 days or longer. Two women underwent preterm delivery because their clinical status deteriorated.

Conclusion: One in five pregnant women who contracted COVID-19 infection developed moderate or severe disease, including a small proportion with prolonged critical illness who received ICU or step-down-level care.
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http://dx.doi.org/10.1097/AOG.0000000000003996DOI Listing
August 2020

A National Survey on the Use of Temporary Naming Conventions for Newborns: 5-Year Follow-up.

Clin Pediatr (Phila) 2020 09 19;59(9-10):925-928. Epub 2020 May 19.

Columbia University Irving Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1177/0009922820922534DOI Listing
September 2020

Telehealth for High-Risk Pregnancies in the Setting of the COVID-19 Pandemic.

Am J Perinatol 2020 06 12;37(8):800-808. Epub 2020 May 12.

Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York.

As New York City became an international epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic, telehealth was rapidly integrated into prenatal care at Columbia University Irving Medical Center, an academic hospital system in Manhattan. Goals of implementation were to consolidate in-person prenatal screening, surveillance, and examinations into fewer in-person visits while maintaining patient access to ongoing antenatal care and subspecialty consultations via telehealth virtual visits. The rationale for this change was to minimize patient travel and thus risk for COVID-19 exposure. Because a large portion of obstetric patients had underlying medical or fetal conditions placing them at increased risk for adverse outcomes, prenatal care telehealth regimens were tailored for increased surveillance and/or counseling. Based on the incorporation of telehealth into prenatal care for high-risk patients, specific recommendations are made for the following conditions, clinical scenarios, and services: (1) hypertensive disorders of pregnancy including preeclampsia, gestational hypertension, and chronic hypertension; (2) pregestational and gestational diabetes mellitus; (3) maternal cardiovascular disease; (4) maternal neurologic conditions; (5) history of preterm birth and poor obstetrical history including prior stillbirth; (6) fetal conditions such as intrauterine growth restriction, congenital anomalies, and multiple gestations including monochorionic placentation; (7) genetic counseling; (8) mental health services; (9) obstetric anesthesia consultations; and (10) postpartum care. While telehealth virtual visits do not fully replace in-person encounters during prenatal care, they do offer a means of reducing potential patient and provider exposure to COVID-19 while providing consolidated in-person testing and services. KEY POINTS: · Telehealth for prenatal care is feasible.. · Telehealth may reduce coronavirus exposure during prenatal care.. · Telehealth should be tailored for high risk prenatal patients..
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http://dx.doi.org/10.1055/s-0040-1712121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356069PMC
June 2020