Publications by authors named "Sindhu K Srinivas"

143 Publications

Examining Ultrasound Diagnostic Performance Improvement with Utilization of Maternal-Fetal Medicine Tele-Interpretation.

Am J Obstet Gynecol MFM 2021 May 3:100389. Epub 2021 May 3.

Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Background: Telemedicine can extend essential health services to under-resourced settings and improve level and quality of obstetric care. Specifically, evaluation and management of fetal anomalies often requires perinatal subspecialists, rendering prenatal diagnosis essential, and may benefit from telemedicine platforms to improve access to care.

Objective: This study examines the impact of a maternal-fetal medicine (MFM) tele-ultrasound program on diagnostic accuracy of fetal anomalies when deployed within practices where ultrasounds are otherwise interpreted by general obstetricians or family medicine physicians.

Study Design: This is a cross-sectional study of all patients receiving care at eleven private obstetric practices and imaging centers who had an obstetric ultrasound performed from January 1, 2020 - July 6, 2020. All ultrasounds were performed by sonographers remotely trained under a standardized protocol and interpreted by MFM physicians via telemedicine. Ultrasound characteristics and interpretation were extracted from ultrasound reports. Prior to introduction of tele-MFM, all ultrasounds were reviewed by general obstetricians and family medicine physicians with reliance predominantly on the sonographer's impression. The primary outcome was potential missed diagnosis of a fetal anomaly, defined as an ultrasound designated as normal by the sonographer but diagnosed with an anomaly via tele-MFM. These serve as a proxy measure of anomaly diagnoses that would likely be missed without MFM supervision. Characteristics of potential missed diagnoses were compared by type of scan and fetal organ system in univariable analysis. A survey was also conducted of sonographers and in-person obstetric providers to assess perceptions of MFM ultrasound interpretation via telemedicine.

Results: In total, 6,403 ultrasounds were evaluated, 310 of which had a diagnosis of a fetal anomaly by an MFM physician (4.8%). 43 of the anomalies were diagnosed on anatomic survey (13.9%) and 89 were cardiac anomalies (28.7%). The overall rate of potential missed diagnoses was 34.5% and varied significantly by type of ultrasound [anatomy scans versus other first, second, and third trimester ultrasounds] (p < 0.01). There were significant differences in the rate of potential missed diagnoses by organ system, with the highest rate for cardiac anomalies (p< 0.01).

Conclusions: MFM expertise refines diagnostic performance of antenatal ultrasound throughout pregnancy. This has implications for improving quality of antenatal care by ensuring appropriate referrals and site of delivery, particularly for cardiac anomalies.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100389DOI Listing
May 2021

Foreword: Smart Technology in Obstetrical Care.

Clin Obstet Gynecol 2021 06;64(2):331-332

University of Pennsylvania Perelman School of Medicine, Philadephia, Pennsylvania.

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http://dx.doi.org/10.1097/GRF.0000000000000612DOI Listing
June 2021

Comparison of Maternal and Neonatal Subspecialty Care Provision by Hospital.

Am J Perinatol 2021 Apr 20. Epub 2021 Apr 20.

Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.

Objective:  The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care.

Study Design:  This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated.

Results:  The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR 34.3-87.7 miles).

Conclusion:  Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.

Key Points: · High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present..
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http://dx.doi.org/10.1055/s-0041-1727223DOI Listing
April 2021

Identifying the effective components of a standardized labor induction protocol: secondary analysis of a randomized, controlled trial.

J Matern Fetal Neonatal Med 2021 Apr 13:1-7. Epub 2021 Apr 13.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Objective: Standardized labor induction protocols utilizing evidence-based active management practices are associated with improved obstetric outcomes. However, these protocols are complex and include multiple components. We aimed to identify which of the individual components of an evidence-based labor induction protocol are most associated with reduced rates of cesarean delivery, maternal morbidity, and neonatal morbidity.

Study Design: This is a secondary analysis of a randomized trial comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based standardized labor induction protocol. For each patient's induction, we assessed adherence to seven components of the protocol. Primary outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed the association of each protocol component with each outcome. Multivariable logistic regression determined independent predictors of each outcome.

Results: The 491 patients enrolled in the randomized trial were included in this analysis. For cesarean delivery, while adherence to four of the seven protocol components was associated with the outcome in bivariate analyses, only adherence to "cervical exams should be performed every 1-2 h in active labor" was associated with reduced cesarean rates when controlling for age, body mass index, and parity. For maternal morbidity, while adherence to "if misoprostol is utilized, it should not be continued beyond 6 doses or 24 h of use" was associated in bivariate analysis, it was no longer associated with the outcome in multivariable analysis. Finally, "cervical exams should be performed every 1-2 h in active labor" and "cervical exams should be performed every 2-4 h in latent labor" were associated with reduced neonatal morbidity both in bivariate analyses as well as when controlling for age, body mass index, and parity.

Conclusions: Within a standardized labor induction protocol, adherence to cervical exams every 1-2 h in active labor was associated with reduced cesarean rate, and adherence to cervical exams every 2-4 h in latent labor, as well as every 1-2 h in active labor is associated with reduced neonatal morbidity. Regular cervical examination during labor induction likely allows for intervention when cervical change is not made. This data warrants further investigation into the optimal frequency of cervical exams during labor induction. Furthermore, an understanding of which components of a complex, evidence-based labor induction protocol are most effective may be helpful for streamlining and education around this protocol as implementation occurs across diverse sites.
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http://dx.doi.org/10.1080/14767058.2021.1909561DOI Listing
April 2021

Society for Maternal-Fetal Medicine Special Statement: Maternal-fetal medicine subspecialist survey on abortion training and service provision.

Am J Obstet Gynecol 2021 Apr 10. Epub 2021 Apr 10.

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess attitudes of maternal-fetal medicine subspecialists about abortion services and available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to Associate and Regular members of the Society for Maternal-Fetal Medicine assessing their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses of survey responses were conducted. Of the 2,751 members contacted, 546 SMFM members who completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. Over 80% of respondents reported availability of abortion in their state, 70% reported availability in their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors in respondent's limiting their scope of abortion services or not performing abortion. In univariable analysis, exposure to formal family planning training programs, fewer years since residency completion, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were associated with abortion provision (all P < 0.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P = 0.20, adjusted odds ratio 1.34, 95% CI 0.85-2.10), whereas a favorable state policy environment and fewer years from residency retained their association. The results of this survey suggest factors at the individual, institution, and state level impact provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare.
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http://dx.doi.org/10.1016/j.ajog.2021.04.220DOI Listing
April 2021

The Fourth Trimester: 12 Weeks Is Not Enough.

Obstet Gynecol 2021 05;137(5):779-781

Dr. Mehta is from the Philadelphia Department of Public Health, Clinical Faculty, Department of OBGYN at the Pennsylvania Hospital/Penn Medicine, Philadelphia, Pennsylvania. Dr. Srinivas, is from the Department of Obstetrics and Gynecology at the University of Pennsylvania, Perelman School of Medicine, and the Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania; email:

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http://dx.doi.org/10.1097/AOG.0000000000004373DOI Listing
May 2021

Furosemide for Accelerated Recovery of Blood Pressure Postpartum in women with a hypertensive disorder of pregnancy: A Randomized Controlled Trial.

Hypertension 2021 05 8;77(5):1517-1524. Epub 2021 Feb 8.

From the Maternal and Child Health Research Center, Hospital of the University of Pennsylvania (J.L.P., A.H., S.K.S., M.A.E., L.D.L.), University of Pennsylvania Perelman School of Medicine, Philadelphia.

[Figure: see text].
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.120.16133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099047PMC
May 2021

Black-white disparities in maternal in-hospital mortality according to teaching and black-serving hospital status.

Am J Obstet Gynecol 2021 Jan 13. Epub 2021 Jan 13.

Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA; Departments of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.

Background: Maternal mortality is higher among black than white people in the United States. Whether black-white disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (black-serving vs nonblack-serving and teaching vs nonteaching) and whether overall maternal mortality differs across hospital types is not known.

Objective: The aims of this study were to determine whether risk-adjusted black-white disparities in maternal mortality during the delivery hospitalization vary by hospital types (this is analysis of disparities in mortality within hospital types) and compare risk-adjusted in-hospital maternal mortality among black-serving and nonblack-serving teaching and nonteaching hospitals regardless of race (this is an analysis of overall mortality across hospital types).

Study Design: We performed a population-based, retrospective cohort study of 5,679,044 deliveries among black (14.2%) and white patients (85.8%) in 3 states (California, Missouri, and Pennsylvania) from 1995 to 2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% black obstetrical patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed-to-expected ratios among black and white patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of black-white disparities in mortality attributable to delivering in black-serving hospitals using causal mediation analysis.

Results: There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than white patients (4.8 per 100,000) (relative risk, 2.38; 95% confidence interval, 1.89-2.98). Examination of black-white disparities revealed that after risk adjustment, black patients had significantly greater risk of death (adjusted relative risk, 1.44; 95% confidence interval, 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types revealed that among teaching hospitals, mortality was similar in black-serving and nonblack-serving hospitals. However, among nonteaching hospitals, mortality was significantly higher in black-serving vs nonblack-serving hospitals (adjusted relative risk, 1.47; 95% confidence interval, 1.15-1.87). Notably, 53% of black patients delivered in nonteaching, black-serving hospitals compared with just 19% of white patients. Among nonteaching hospitals, 47% of black-white disparities in maternal in-hospital mortality were attributable to delivering at black-serving hospitals.

Conclusion: Maternal in-hospital mortality during the delivery hospitalization among black patients is more than double that of white patients. Our data suggest this disparity is caused by excess mortality among black patients within each hospital type, in addition to excess mortality in nonteaching, black-serving hospitals where most black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at black-serving hospitals, overcoming barriers to accessing high-quality care among black patients, and eventually desegregation of healthcare.
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http://dx.doi.org/10.1016/j.ajog.2021.01.004DOI Listing
January 2021

Maternal and Perinatal Outcomes of Expectant Management of Full-Term, Low-Risk, Nulliparous Patients.

Obstet Gynecol 2021 02;137(2):250-257

Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, Northwestern University, Chicago, Illinois, University of Utah Health Sciences Center, Salt Lake City, Utah, Stanford University, Stanford, California, Columbia University, New York, New York, Brown University, Providence, Rhode Island, University of Texas Medical Branch, Galveston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, The Ohio State University, Columbus, Ohio, Metro Health Medical Center-Case Western Reserve University, Cleveland, Ohio, University of Texas Southwestern Medical Center, Dallas, Texas; University of Pennsylvania, Philadelphia, Pennsylvania, Duke University, Durham, North Carolina, University of Pittsburgh, Pittsburgh, Pennsylvania, Washington University in St. Louis, St. Louis, Missouri; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To compare risks of maternal and perinatal outcomes by completed week of gestation from 39 weeks in low-risk nulliparous patients undergoing expectant management.

Methods: We conducted a secondary analysis of a multicenter randomized trial of elective induction of labor at 39 weeks of gestation compared with expectant management in low-risk nulliparous patients. Participants with nonanomalous neonates, who were randomized to and underwent expectant management and attained 39 0/7 weeks of gestation, were included. Delivery gestation was categorized by completed week: 39 0/7-39 6/7 (39 weeks), 40 0/7-40 6/7 (40 weeks), and 41 0/7-42 2/7 (41-42 weeks) (none delivered after 42 2/7). The coprimary outcomes were cesarean delivery and a perinatal composite (death, respiratory support, 5-minute Apgar score 3 or less, hypoxic ischemic encephalopathy, seizure, sepsis, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, or hypotension requiring vasopressor support). Other outcomes included a maternal composite (blood transfusion, surgical intervention for postpartum hemorrhage, or intensive care unit admission), hypertensive disorders of pregnancy, peripartum infection, and neonatal intermediate or intensive care unit admission. For multivariable analysis, P<.0125 was considered to indicate statistical significance for the coprimary outcomes.

Results: Of 2,502 participants who underwent expectant management, 964 (38.5%) delivered at 39 weeks of gestation, 1,111 (44.4%) at 40 weeks, and 427 (17.1%) at 41-42 weeks. The prevalence of medically indicated delivery was 37.9% overall and increased from 23.8% at 39 weeks of gestation to 80.3% at 41-42 weeks. The frequency of cesarean delivery (17.3%, 22.0%, 37.5%; P<.001) and the perinatal composite (5.1%, 5.9%, 8.2%; P=.03) increased with 39, 40, and 41-42 weeks of gestation, respectively, and hypertensive disorders of pregnancy decreased (16.4%, 12.1%, 10.8%, P=.001). The adjusted relative risk, 95% CI (39 weeks as referent) was significant for cesarean delivery at 41-42 weeks of gestation (1.93, 1.61-2.32) and for hypertensive disorders of pregnancy at 40 weeks (0.71, 0.58-0.88) and 41-42 weeks (0.61, 0.45-0.82). None of the other outcomes were significant.

Conclusion: In expectantly managed low-risk nulliparous participants, the frequency of medically indicated induction of labor, and the risks of cesarean delivery but not the perinatal composite outcome, increased significantly from 39 to 42 weeks of gestation.
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http://dx.doi.org/10.1097/AOG.0000000000004230DOI Listing
February 2021

A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries.

Am J Obstet Gynecol MFM 2020 02 16;2(1):100070. Epub 2019 Nov 16.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Program Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes.

Objective: To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes.

Materials And Methods: This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ or Fisher exact test as appropriate.

Results: There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications.

Conclusion: Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100070DOI Listing
February 2020

A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes.

Am J Obstet Gynecol MFM 2020 08 5;2(3):100148. Epub 2020 Jun 5.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: There are marked disparities between black and nonblack women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. Although the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in nonobstetrical populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization.

Objective: In this study, we aimed to evaluate the effect of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal and neonatal morbidity.

Study Design: We performed a prospective cohort study of women undergoing an induction from 2013 to 2015. Full-term (≥37 weeks' gestation) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were included. We compared the cesarean delivery rate and maternal and neonatal morbidity between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and (2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race.

Results: A significant reduction in cesarean delivery rate in black women managed with the induction protocol was noted when compared with those in the observational group (25.7% vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women (34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction, and Bishop score at induction start. In addition, a significant reduction in neonatal morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%; P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for either race.

Conclusion: A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity in black women undergoing induction. Further studies should determine whether implementation of induction protocols in diverse settings could reduce national racial disparities in obstetrical outcomes.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100148DOI Listing
August 2020

Implementation Science is Imperative to the Optimization of Obstetric Care.

Am J Perinatol 2020 Dec 15. Epub 2020 Dec 15.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

In an effort aimed at improving outcomes, obstetric teams have enacted comprehensive care bundles and other clinical tools. Yet, these practices have had limited degrees of success on a national scale. Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization. This emerging field takes into account key stakeholders at the clinician, institution, and health policy levels. Implementation science evaluates how well an intervention is or can be delivered, to whom, in which context, and how it may be up-scaled and sustained. Other medical disciplines have embraced these concepts with success. The frameworks and theories of implementation science can and should be incorporated into both obstetric research and practice. By doing so, we can increase widespread and timely adoption of evidence and further our common goal of decreasing maternal morbidity and mortality. KEY POINTS: · Evidence-based practices have been implemented in obstetrics with variable success.. · Implementation science aims to bridge the divide between the development of evidence-based interventions and their real-world utilization.. · The methodologies of implementation science may be helpful to obstetric research and practice..
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http://dx.doi.org/10.1055/s-0040-1721728DOI Listing
December 2020

Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine.

JAMA Netw Open 2020 12 1;3(12):e2029043. Epub 2020 Dec 1.

Center for Emergency Care and Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Importance: The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone.

Objective: To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019.

Design, Setting, And Participants: A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list.

Exposures: State-level NAS incidence and county-level uninsured rates and rurality.

Main Outcomes And Measures: Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine.

Results: Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007).

Conclusions And Relevance: Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.29043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733157PMC
December 2020

Maternal Morbidity and Birth Satisfaction After Implementation of a Validated Calculator to Predict Cesarean Delivery During Labor Induction.

JAMA Netw Open 2020 11 2;3(11):e2025582. Epub 2020 Nov 2.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia.

Importance: A previously created and validated calculator provides an individualized cesarean delivery risk score for women undergoing labor induction. A higher predicted risk of cesarean delivery on the calculator has been associated with increased maternal and neonatal morbidity regardless of ultimate delivery mode. The effect of this calculator when implemented in clinical care has yet to be evaluated.

Objective: To determine whether implementation of a validated calculator that predicts the likelihood of cesarean delivery at the time of labor induction is associated with maternal morbidity and birth satisfaction.

Design, Setting, And Participants: This prospective cohort study used medical record review to compare the 1 year before calculator implementation (July 1, 2017, to June 30, 2018) with the 1 year after implementation (July 1, 2018, to June 30, 2019) at a US urban, university labor unit. Women admitted for labor induction with singleton gestation in cephalic presentation, intact membranes, and an unfavorable cervix were included. Data were analyzed from August 1, 2019, to September 13, 2020.

Exposures: Patient and clinician knowledge of the calculated cesarean delivery risk score based on the validated calculator.

Main Outcomes And Measures: The primary outcomes were (1) composite maternal morbidity defined by at least 1 of the following within 30 days of delivery: endometritis, postpartum hemorrhage (estimated or quantitative blood loss >1000 mL), blood transfusion, wound infection, venous thromboembolism, hysterectomy, intensive care unit admission, and readmission and (2) patient satisfaction assessed via Birth Satisfaction Scale-Revised (BSS-R) scores. Secondary outcomes included rate of cesarean delivery and neonatal morbidity.

Results: A total of 1610 women were included in the analysis (788 in the preimplementation and 822 in the postimplementation periods) with a median age of 29 (interquartile range [IQR], 24-34) years. There were no significant baseline differences between groups except fewer inductions at a gestational age of 40 weeks or later in the postimplementation period (256 [31.1%] vs 298 [37.8%]). Calculator implementation was associated with decreased maternal morbidity overall, even when adjusting for confounders (141 [17.9%] vs 95 [11.6%]; adjusted absolute risk difference [aARD], -6.3%; 95% CI, -9.7% to -2.8%). Although there was no difference in birth satisfaction overall, calculator implementation was associated with improvements on items pertaining to quality of care provision (median BSS-R score, 19 [IQR, 16-20] vs 19 [IQR, 17-20]; P = .006). Calculator implementation was also associated with a decrease in cesarean delivery rate (228 [28.9%] vs 167 [20.3%]; aARD, -8.5% [95% CI, -12.6% to -4.5%]). There were no significant differences in neonatal morbidity.

Conclusions And Relevance: These findings suggest that implementation of a validated calculator to predict risk of cesarean delivery in clinical care is associated with reduced maternal morbidity. Implementation should occur broadly to determine whether calculator use improves national maternal outcomes.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.25582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666421PMC
November 2020

Telemedicine in Obstetrics.

Clin Perinatol 2020 12;47(4):743-757

Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2nd Floor Silverstein Building, Philadelphia, PA 19146, USA. Electronic address:

Telemedicine is an important modality of care delivery in the twenty-first century and has many applications for the obstetric population. Existing research has shown the clinical efficacy and improved patient satisfaction of many telemedicine platforms in obstetrics. Telemedicine has the potential to reduce racial and geographic disparities in pregnancy care, but more research is necessary to inform best practices. Developing cost-effective telemedicine programs and establishing health care policy that standardizes insurance reimbursement are some of the most important steps toward scaling up telemedicine offerings for obstetric patients in the United States.
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http://dx.doi.org/10.1016/j.clp.2020.08.007DOI Listing
December 2020

Studying social media language changes associated with pregnancy status, trimester, and parity from medical records.

Womens Health (Lond) 2020 Jan-Dec;16:1745506520949392

Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, USA.

We sought to evaluate whether there was variability in language used on social media across different time points of pregnancy (before, during, and after pregnancy, as well as by trimester and parity). Consenting patients shared access to their individual Facebook posts and electronic medical records. Random forest models trained on Facebook posts could differentiate first trimester of pregnancy from 3 months before pregnancy (F1 score = .63) and from a random 3-month time period (F1 score = .64). Posts during pregnancy were more likely to include themes about family (β = .22), food craving (β = .14), and date/times (β = .13), while posts 3 months prior to pregnancy included themes about social life (β = .30), sleep (β = .31), and curse words (β = .27), and 3 months post-pregnancy included themes of gratitude (β = .17), health appointments (β = .21), and religiosity (β = .18). Users who were pregnant for the first time were more likely to post about lack of sleep (β = .15), activities of daily living (β = .09), and communication (β = .08) compared with those who were pregnant after having a child who posted about others' birthdays (β = .16) and life events (.12). A better understanding about social media timelines can provide insight into lifestyle choices that are specific to pregnancy.
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http://dx.doi.org/10.1177/1745506520949392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549071PMC
October 2020

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care.

Healthc (Amst) 2020 Dec 28;8(4):100456. Epub 2020 Aug 28.

Department of Obstetrics and Gynecology, Boston University School of Medicine, 850 Harrison Avenue, 5th Floor, Boston, MA 02118, USA; Department of Obstetrics and Gynecology, Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Science Center, 533 Bolivar Street, 5th Floor, New Orleans, LA, 70112, USA. Electronic address:

Background: Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes.

Methods: We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features.

Results: We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage.

Conclusions: Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions.

Implications: Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100456DOI Listing
December 2020

Successful implementation of text-based blood pressure monitoring for postpartum hypertension.

Pregnancy Hypertens 2020 Oct 10;22:156-159. Epub 2020 Sep 10.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center University of Pennsylvania Perelman School of Medicine, 421 Curie Boulevard, 1353 Biomedical Research Bldg. II/III, Philadelphia, PA 19104, USA. Electronic address:

Objectives: A clinical trial showed postpartum text-based blood pressure (BP) monitoring is effective in meeting clinical guidelines and reduces racial disparities in postpartum hypertension care. Our objective was to compare clinical outcomes to those from a clinical trial after implementation of the program in a second hospital within our hospital system.

Study Design: Comparison of women randomized to text-based BP monitoring in a clinical trial compared to an implementation cohort clinically enrolled in text-based BP monitoring. BP outcomes and postpartum visit were compared in bivariate and multivariable analyses.

Main Outcome Measures: BP ascertainment was defined as at least 1 BP texted during the 10 days of monitoring. American College of Obstetricians and Gynecologists (ACOG) recommendation was defined as BP sent on postpartum day 3-4 and again day 7-10.

Results: The implementation cohort had 333 women compared to 103 in the trial cohort. The implementation cohort was older (p < 0.001), and more likely to be non-Black race (p < 0.001), married (<0.001), and have commercial insurance (<0.001). BP ascertainment (95.5% vs. 92.2%, adjusted OR 1.41, [95% CI 0.55, 3.58]) and proportion meeting ACOG recommendations (84.7% vs. 81.6%, adjusted OR 0.89 [95% CI 0.48, 1.64]) were similar between groups. There were no differences in BP ascertainment among Black and non-Black women in the trial or implementation cohort.

Conclusions: Text-based BP monitoring performed similarly in an implementation cohort compared to the trial participants. This program is scalable to manage postpartum hypertension and reduce racial disparities in postpartum care in women with hypertensive disorders of pregnancy.
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http://dx.doi.org/10.1016/j.preghy.2020.09.001DOI Listing
October 2020

COVID-19 Testing, Personal Protective Equipment, and Staffing Strategies Vary at Obstetrics Centers across the Country.

Am J Perinatol 2020 12 26;37(14):1482-1484. Epub 2020 Sep 26.

Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island.

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http://dx.doi.org/10.1055/s-0040-1718401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724575PMC
December 2020

Universal testing for severe acute respiratory syndrome coronavirus 2 in 2 Philadelphia hospitals: carrier prevalence and symptom development over 2 weeks.

Am J Obstet Gynecol MFM 2020 11 11;2(4):100226. Epub 2020 Sep 11.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Philadelphia, PA.

Background: The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 has challenged obstetrical care providers. Universal testing on labor and delivery units has been implemented by many hospitals to ensure patient and staff safety. Asymptomatic carrier rates are expected to vary based on geographic differences in disease prevalence, although differences within the same city have not been reported previously. In addition, clinical follow-up of women who had a negative result for severe acute respiratory syndrome coronavirus 2 during obstetrical hospitalization has not been included in any previous reports.

Objective: This study aimed to describe the prevalence of positive severe acute respiratory syndrome coronavirus 2 test results among asymptomatic pregnant women at 2 Philadelphia obstetrical hospitals, characterize the clinical course of those who had a positive result, and report symptom development among all women tested in the 2 weeks after hospitalization.

Study Design: This is an observational study of asymptomatic pregnant women who underwent severe acute respiratory syndrome coronavirus 2 testing at 2 academic health centers (Hospital of the University of Pennsylvania and Pennsylvania Hospital) in Philadelphia, Pennsylvania, between April 13, 2020, and April 26, 2020. All women tested were contacted via telephone for symptom follow-up at 1 and 2 weeks after discharge. Asymptomatic positive test rates are reported for the overall population and by hospital. The hospital and 2-week posthospital course are described for women who had a positive result for severe acute respiratory syndrome coronavirus 2. Posthospital symptom development among women who had a negative result for severe acute respiratory syndrome coronavirus 2 is also described.

Results: A total of 318 asymptomatic women underwent severe acute respiratory syndrome coronavirus 2 testing during this 2-week period; 8 women had a positive result. The overall asymptomatic test positive rate was 2.5%. The rate at Hospital of the University of Pennsylvania was 3.8% compared with 1.3% at Pennsylvania Hospital (=.283). Of note, 3 women (37.5%) who were initially asymptomatic developed mild symptoms in the 2 weeks after a positive test result. Repeat severe acute respiratory syndrome coronavirus 2 testing was performed in 14 of the 310 women (4.5%) who initially had a negative result; 2 women (0.6%) had a positive result on repeat testing. Moreover, 242 (78.1%) and 213 (68.7%) of the 310 women who had a negative result for severe acute respiratory syndrome coronavirus 2 at the time of the initial hospitalization were followed up via telephone at 1 and 2 weeks after admission, respectively. Viral symptoms, including fevers, chills, shortness of breath, or cough, were self-reported in 4.5% and 4.2% of these women at 1 and 2 weeks after discharge, respectively.

Conclusion: The asymptomatic positive severe acute respiratory syndrome coronavirus 2 test rate among an obstetrical population in Philadelphia differed between 2 hospitals and was lower than that described in other geographic regions. This supports the importance of institution-specific testing protocols. The development of symptomatic severe acute respiratory syndrome coronavirus 2 infection after hospitalization among women with initial negative test results is uncommon.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485442PMC
November 2020

Customized Probability of Vaginal Delivery With Induction of Labor and Expectant Management in Nulliparous Women at 39 Weeks of Gestation.

Obstet Gynecol 2020 10;136(4):698-705

Departments of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah, Northwestern University, Chicago, Illinois, University of Alabama at Birmingham, Birmingham, Alabama, Stanford University, Stanford, California, Columbia University, New York, New York, Brown University, Providence, Rhode Island, University of Texas Medical Branch, Galveston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, The Ohio State University, Columbus, Ohio, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, University of Texas Southwestern Medical Center, Dallas, Texas, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, University of Pennsylvania, Philadelphia, Pennsylvania, Duke University, Durham, North Carolina, University of Pittsburgh, Pittsburgh, Pennsylvania, and Washington University in St. Louis, St. Louis, Missouri; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To develop models to predict vaginal delivery in low-risk, nulliparous women contemplating elective induction of labor or expectant management at 39 weeks of gestation.

Methods: We conducted a secondary analysis of a randomized controlled trial of planned elective induction of labor at 39 weeks of gestation compared with expectant management for low-risk nulliparous women. Two groups were included for this analysis: 1) women who were randomized to the induction of labor group and underwent elective induction at 39 0/7-39 4/7 weeks of gestation and 2) women who were randomized to the expectant management group who experienced spontaneous labor or medically indicated delivery (including postterm). Multivariable logistic regression models were developed for each group using patient characteristics that would be available at the time of counseling. Model selection was based on k-fold cross-validation using backward elimination and variables that remained significant at P<.05 were retained. To compare estimated with observed rates, the elective induction of labor model was then applied to each woman in both groups to estimate individualized predicted probabilities of vaginal delivery with elective induction of labor.

Results: Of 6,106 women enrolled in the trial, 4,661 met criteria for this analysis. Vaginal delivery occurred in 80.6% of the 2,153 women in the elective induction of labor group and 77.2% of the 2,508 women in the expectant management group (P=.005). The final elective induction of labor model included age, height, weight, and modified Bishop score (area under the receiver operating characteristic curve [AUROC] 0.72, 95% CI 0.70-0.75). The same variables were included in the final expectant management model (AUROC 0.70, 95% CI 0.67-0.72). Across the range of predicted probability deciles derived from the elective induction of labor model, almost all women who underwent elective induction of labor at 39 weeks of gestation had a higher observed chance of vaginal delivery than expectant management.

Conclusion: Irrespective of the individual predicted chance of vaginal delivery from elective induction of labor at 39 weeks of gestation, vaginal delivery is generally more frequent if elective induction of labor is undertaken rather than expectant management. These data can be used to counsel nulliparous women regarding their "customized" chances of vaginal delivery as they choose between elective induction of labor or expectant management at 39 weeks of gestation.

Clinical Trial Registration: ClinicalTrials.gov, NCT01990612.
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http://dx.doi.org/10.1097/AOG.0000000000004046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899015PMC
October 2020

Elective Labor Induction at 39 Weeks of Gestation Compared With Expectant Management: Factors Associated With Adverse Outcomes in Low-Risk Nulliparous Women.

Obstet Gynecol 2020 10;136(4):692-697

Departments of Obstetrics and Gynecology, Stanford University, Stanford, California, Northwestern University, Chicago, Illinois, University of Alabama at Birmingham, Birmingham, Alabama, University of Utah Health Sciences Center, Salt Lake City, Utah, Columbia University, New York, New York, Brown University, Providence, Rhode Island, University of Texas Medical Branch, Galveston, Texas, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, The Ohio State University, Columbus, Ohio, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, University of Texas Southwestern Medical Center, Dallas, Texas, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, University of Pennsylvania, Philadelphia, Pennsylvania, Duke University, Durham, North Carolina, University of Pittsburgh, Pittsburgh, Pennsylvania, Washington University in St. Louis, St. Louis, Missouri; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland.

Objective: To evaluate characteristics associated with adverse outcomes in low-risk nulliparous women randomized to elective labor induction at 39 weeks of gestation or expectant management.

Methods: We conducted a secondary analysis of women randomized during the 38th week to induction at 39 weeks of gestation or expectant management. Deliveries before 39 weeks of gestation and those not adherent to study protocol or with fetal anomalies were excluded. A composite of adverse outcomes (perinatal death or severe neonatal complications), third- or fourth-degree lacerations, and postpartum hemorrhage were evaluated. Log binomial regression models estimated relative risks and 95% CIs for associations of outcomes with patient characteristics including randomly assigned treatment group. Interactions between patient characteristics and treatment group were tested.

Results: Of 6,096 women with outcome data, 5,007 (82.1%) met criteria for inclusion in this analysis. Frequency of the perinatal composite was 252 (5.0%), 166 (3.3%) for third- or fourth-degree perineal laceration, and 237 (4.7%) for postpartum hemorrhage. In multivariable analysis, intended labor induction at 39 weeks of gestation was associated with a reduced perinatal composite outcome (4.1% vs 6.0%; adjusted relative risk [aRR] 0.71; 95% CI 0.55-0.90), whereas increasing body mass index (BMI) was associated with an increased perinatal composite outcome (aRR 1.04/unit increase; 95% CI 1.02-1.05). Decreased risk of third- or fourth-degree perineal laceration was observed with increasing BMI (aRR 0.96/unit increase; 95% CI 0.93-0.98) and in Black women compared with White women (1.2% vs 3.9%; aRR 0.34; 95% CI 0.19-0.60). Increased risk of postpartum hemorrhage was observed in Hispanic women compared with White women (6.3% vs 4.0%; aRR 1.64; 95% CI 1.18-2.29). Patient characteristics associated with adverse outcomes were similar between treatment groups (P for interaction >.05).

Conclusion: Compared with expectant management, intended induction at 39 weeks of gestation was associated with reduced risk of adverse perinatal outcome. Patient characteristics associated with adverse outcomes were few and similar between groups.

Clinical Trial Registration: ClinicalTrials.gov, NCT01990612.
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http://dx.doi.org/10.1097/AOG.0000000000004055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529933PMC
October 2020

Compassionate use of remdesivir for treatment of severe coronavirus disease 2019 in pregnant women at a United States academic center.

Am J Obstet Gynecol MFM 2020 08 25;2(3):100164. Epub 2020 Jun 25.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajogmf.2020.100164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314679PMC
August 2020

Predictive index for 90-day postoperative outcomes following gynecologic surgery.

Am J Manag Care 2020 07;26(7):303-309

Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Silverstein Pavilion, 3400 Spruce St, 3rd Floor, Philadelphia, PA 19104. Email:

Objectives: Assessment of the potential of LACE+ index scores in patients undergoing gynecologic surgery to predict short-term undesirable outcomes.

Study Design: Retrospective study over a 2-year time period (2016-2018).

Methods: Coarsened exact matching was used to assess the predictive capacity of the LACE+ index among all gynecologic surgery cases over a 2-year period (2016-2018) at 1 health system (N = 12,225). Study subjects were matched on characteristics not assessed by LACE+, including race and duration of surgery. For comparison of outcomes, LACE+ score was divided into quartiles and otherwise matched populations were compared in reference to LACE+ quartile (Q): Q4 vs Q1, Q4 vs Q2, Q4 vs Q3.

Results: A total of 1715 patients were matched for Q1 to Q4, 1951 patients were matched for Q2 to Q4, and 1822 patients were matched for Q3 to Q4. Escalating LACE+ score significantly predicted increased readmission, reoperation, and emergency department (ED) visits from 30 to 90 postoperative days as well as readmission, reoperation, and ED visits from 0 to 90 postoperative days.

Conclusions: The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a gynecologic surgery population.
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http://dx.doi.org/10.37765/ajmc.2020.43760DOI Listing
July 2020

Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial.

Am J Obstet Gynecol 2021 01 9;224(1):84.e1-84.e7. Epub 2020 Jul 9.

Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Background: The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics.

Objective: We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia.

Study Design: We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05).

Results: A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes.

Conclusion: In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.
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http://dx.doi.org/10.1016/j.ajog.2020.07.007DOI Listing
January 2021

Detection of COVID-19 in a Vulvar Lesion.

Am J Perinatol 2020 09 2;37(11):1183-1184. Epub 2020 Jul 2.

Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

As new information about coronavirus disease 2019 (COVID-19) is rapidly discovered, clinicians are better equipped to make informed decisions for their patients. While current research suggests COVID-19 viral antigen is not found in vaginal secretions, its detectability in the female lower genital tract may have clinical implications for obstetric and gynecologic care for women. We present a case of a woman at 31 weeks' gestation with simultaneous upper respiratory symptoms and vulvovaginitis. She was found to have a vulvar lesion positive for severe acute respiratory syndrome-COVID by viral swab. This case shows that COVID-19 is detectable in the vulva. This may have implications for health care workers' exposure and personal protective equipment needs. While vertical transmission has largely not been reported, the presence of detectable virus in the female lower genital tract makes this a continued possibility and area of study. KEY POINTS: · COVID-19 is detectable in the female lower genital tract.. · The detection of COVID-19 in the vulva may have implications for personal protective equipment use.. · The detection of COVID-19 in vulvovaginal lesions makes vertical transmission a continued possibility..
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http://dx.doi.org/10.1055/s-0040-1713665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7516389PMC
September 2020

Labor and Delivery Outcomes with the Sequential Use of Misoprostol Followed by Cervical Foley Catheter.

Am J Perinatol 2020 Jun 28. Epub 2020 Jun 28.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective:  Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol.

Study Design:  Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann-Whitney -tests compared continuous variables.

Results:  Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours,  < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26-3.44,  = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%,  = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%,  = 0.1) and maternal morbidity (15 vs. 8%,  = 0.08) in the misoprostol followed by Foley catheter group.

Conclusion:  In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling.

Key Points: · Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.. · Nulliparas and dilation <1 cm increases need for Foley after misoprostol.. · Complications were more common in women requiring Foley after misoprostol..
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http://dx.doi.org/10.1055/s-0040-1713818DOI Listing
June 2020

Community Obstetrical Units Less Likely than Academic Units to Have Universal COVID-19 Testing.

Am J Perinatol 2020 08 19;37(10):1074-1076. Epub 2020 May 19.

Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1055/s-0040-1712454DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416201PMC
August 2020

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Am J Obstet Gynecol MFM 2020 08 8;2(3):100134. Epub 2020 May 8.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited.

Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2.

Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported.

Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; =.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission.

Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205698PMC
August 2020

Care of critically ill pregnant patients with coronavirus disease 2019: a case series.

Am J Obstet Gynecol 2020 08 1;223(2):286-290. Epub 2020 May 1.

Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.ajog.2020.04.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252050PMC
August 2020