Amniocentesis to diagnose congenital cytomegalovirus infection following maternal primary infection

BACKGROUND

Congenital cytomegalovirus infection following maternal primary cytomegalovirus infection affects approximately 0.4% of newborns in the United States but may be hard to diagnose prenatally.

OBJECTIVE

To evaluate the current sensitivity and specificity of amniocentesis in detecting congenital cytomegalovirus infection.

STUDY DESIGN

Secondary analysis of a multicenter randomized placebo-controlled trial designed to evaluate whether cytomegalovirus hyperimmune globulin reduces congenital cytomegalovirus infection in neonates of individuals diagnosed with primary cytomegalovirus infection before 24 weeks of gestation. At randomization, subjects had no clinical evidence of fetal infection. Eligible subjects were randomized to monthly infusions of cytomegalovirus hyperimmune globulin or placebo until delivery. Although not required by the trial protocol, amniocentesis following randomization was permitted. The fetuses and neonates were tested for the presence of cytomegalovirus at delivery. Comparisons were made between those with and without amniocentesis and between those with cytomegalovirus-positive and negative results, using chi-square or Fisher exact test for categorical variables and the Wilcoxon rank sum test or t test for continuous variables. A P value of <.05 was considered significant.

RESULTS

From 2012 to 2018, 397 subjects were included, of whom 55 (14%) underwent amniocentesis. Cytomegalovirus results were available for 53 fetuses and neonates. Fourteen amniocenteses were positive (25%). Gestational age at amniocentesis was similar between those with and without cytomegalovirus present, as was the interval between maternal diagnosis and amniocentesis. The prevalence of fetal or neonatal infection was 26% (14/53). The neonates of all 12 subjects with a positive amniocentesis and available results had cytomegalovirus infection confirmed at delivery, as did 2 neonates from the group of 41 subjects with a negative amniocentesis, with a sensitivity of 86% (95% confidence interval, 57-98), specificity of 100% (95% confidence interval, 91-100), positive predictive value of 100% (95% confidence interval, 74-100), and negative predictive value of 95% (95% confidence interval, 83-99). Amniocentesis-positive pregnancies were delivered at an earlier gestational age (37.4 vs 39.6 weeks; P<.001) and had lower birthweights (2583±749 vs 3428±608 g, P=.004) than amniocentesis-negative pregnancies.

CONCLUSION

Amniocentesis results are an accurate predictor of congenital cytomegalovirus infection.

Association Between Low- Dose Aspirin and Development of Gestational Diabetes: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the association between the use of low-dose aspirin for preeclampsia prophylaxis and risks of gestational diabetes (primary outcome), neonatal hypoglycemia, macrosomia, large for gestational age, birth trauma, and shoulder dystocia (secondary outcomes).

DATA SOURCES

We searched Ovid MEDLINE, Embase, CINAHL, and Cochrane/CENTRAL for studies published between January 1, 1989, and April 24, 2021.

STUDY SELECTION

Randomized controlled trials (RCTs) or cohort studies of any size conducted in any setting were included.

DATA EXTRACTION AND SYNTHESIS

We assessed risk of bias using the Cochrane Risk of Bias tool 2.0 (for RCTs) and the Newcastle-Ottawa Scale (for cohort studies). We meta-analyzed relative risks (RRs) using random-effects models.

CONCLUSIONS

Our search retrieved 4441 records, of which 9 studies (6 RCTs with 1932 patients and 3 cohort studies with 313 837 patients) met inclusion criteria. We rated only 4 of the 6 RCTs and 1 of the 3 cohort studies at low risk of bias. Low-dose aspirin in pregnancy for preeclampsia prophylaxis was not associated with a greater risk of gestational diabetes (RR 1.18; 95% confidence interval 0.80-1.74). No studies reported data for the secondary outcomes. In summary, the use of low-dose aspirin does not appear associated with risk of gestational diabetes. The poor quality and small number of studies limit the interpretation of these results.

Association of Body Mass Index With the Use of Health Care Resources in Low-Risk Nulliparous Pregnancies After 39 Weeks of Gestation

OBJECTIVE

To compare health care medical resource utilization in low-risk nulliparous pregnancies according to body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) categories.

METHODS

This is a secondary analysis of a multicenter randomized controlled trial of induction of labor between 39 0/7 39 and 4/7 weeks of gestation compared with expectant management in low-risk nulliparous pregnant people, defined as those without standard obstetric indications for delivery at 39 weeks. Body mass index at randomization was categorized into four groups (lower than 25, 25-29, 30-39, and 40 or higher). The primary outcome of this analysis was time spent in the labor and delivery department from admission to delivery. Secondary outcomes included length of stay (LOS) postdelivery, total hospital LOS, and antepartum, intrapartum, and postpartum resource utilization, which were defined a priori. Multivariable generalized linear modeling and logistic regressions were performed, and 99% CIs were calculated.

RESULTS

A total of 6,058 pregnant people were included in the analysis; 640 (10.6%) had BMIs of lower than 25, 2,222 (36.7%) had BMIs between 25 and 29, 2,577 (42.5%) had BMIs of 30-39, and 619 (10.2%) had BMIs of 40 or higher. Time spent in the labor and delivery department increased from 15.1±9.2 hours for people with BMIs of lower than 25 to 23.5±13.6 hours for people with BMIs of 40 or higher, and every 5-unit increase in BMI was associated with an average 9.8% increase in time spent in the labor and delivery department (adjusted estimate per 5-unit increase in BMI 1.10, 99% CI 1.08-1.11). Increasing BMI was not associated with an increase in antepartum resource utilization, except for blood tests and urinalysis. However, increasing BMI was associated with higher odds of intrapartum resource utilization, longer total hospital LOS, and postpartum resource utilization. For example, every 5-unit increase in BMI was associated with an increase of 26.1% in the odds of antibiotic administration, 57.6% in placement of intrauterine pressure catheter, 5.1% in total inpatient LOS, 31.0 in postpartum emergency department visit, and 23.9% in postpartum hospital admission.

CONCLUSION

Among low-risk nulliparous people, higher BMI was associated with longer time from admission to delivery, total hospital LOS, and more frequent utilization of intrapartum and postpartum resources.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01990612.

Stress, anxiety and depression levels in pregnancy: outpatient versus inpatient

OBJECTIVE

To compare stress, anxiety and depression levels among 3 groups of pregnant women: 1) low-risk outpatient (LRO), 2) high-risk outpatient (HRO), and 3) inpatient (IP).

METHODS

This was a cross-sectional study using validated instruments. Inclusion criteria were pregnancies 23-37 weeks and maternal age > 18 years. The primary outcome was mean/median scores of Perceived Stress Scale (PSS), State Trait Anxiety Inventory (STAI), and Edinburgh Depression Scale (EDS). Secondary outcome was rate of abnormal scores.

RESULTS

Among 190 women approached, 180 (95%) participated, with 60 (33%) in each group. Mean PSS scores (range 0-40) significantly increased from LRO (12.0, standard deviation [SD] 7.8) to HRO (14.7, SD 7.9) to IP (15.6, SD 8.2); p = .04. Mean STAI scores (range 20-80) also significantly increased from LRO (32.0, SD 11.1) to HRO (35.8, SD 11.9) to IP (40.9, SD 13.1); p < .01. Abnormal anxiety (STAI ≥ 40) was present in 40% of women and significantly higher among IP compared to LRO (56% vs 25%; RR 2.24, 95% CI 1.36-3.67; aRR 2.24, 95% CI 1.34-3.74).

CONCLUSION

Stress and anxiety scores significantly differ in LRO, HRO, and IP women. While depression screening is common postpartum, screening for stress, anxiety and depression prenatally may be beneficial.

Association between route of delivery and maternal adverse outcomes in pregnancies complicated by preterm birth

INTRODUCTION

To determine the impact of route of delivery on maternal outcomes among individuals who deliver preterm (before 37 weeks).

MATERIALS AND METHODS

This was a population-based retrospective cohort study using the U.S. vital statistics datasets on Period Linked Birth-Infant Death Data from 2014 to 2018. The study population was restricted to live births from women with non-anomalous singletons who delivered at 24-36 weeks of gestation. The main explanatory variable for this study was route of delivery, which was categorized as: (i) vaginal delivery, (ii) cesarean delivery with labor, and (iii) cesarean delivery without labor. The primary outcome was composite maternal adverse outcome, which encompassed any of the following: admission to the intensive care unit, maternal blood transfusion, uterine rupture, or unplanned hysterectomy. The results were presented as adjusted relative risk (aRR) with 95% confidence interval (CI).

RESULTS

Over the study period 1,440,510 live births met the inclusion criteria, and the overall composite maternal adverse outcome was 14.38 per 1,000 live births. After multivariable adjustment, compared to women who underwent a vaginal delivery, the risk of composite maternal adverse outcome was higher in women who had a cesarean delivery with labor (aRR 3.70; 95% CI 3.52-3.90) and those who had a cesarean delivery without labor (aRR 4.79; 95% CI 4.59-4.98).

CONCLUSION

With preterm birth, cesarean delivery without labor has higher rate of composite maternal morbidity than cesarean during labor or vaginal delivery.

Remdesivir use in pregnancy during the SARS-CoV-2 pandemic

OBJECTIVE

To ascertain the composite maternal and neonatal outcomes in pregnant individuals with moderate, severe, or critical coronavirus disease 2019 (COVID-19) treated with remdesivir.

MATERIALS AND METHODS

This is a secondary analysis of the COVID in Pregnancy Registry in Houston, Texas. Women were included if they met the criteria of moderate, severe or critical COVID-19 illness. Composite adverse maternal outcome was defined as any of the following outcomes: placental abruption, pregnancy-related hypertension, chorioamnionitis, stroke, delivery with estimated blood loss >1000 mL, diagnosis of pulmonary embolism or deep venous thromboembolism, or maternal death. Composite adverse neonatal outcome was defined as any of the following: Apgar score ≤3 at 5 min, arterial cord pH <7.0, positive SAR-CoV-2 test, intraventricular hemorrhage, periventricular leukomalacia, stillbirth, or neonatal death. Comparative analyses between participants receiving remdesivir versus those not exposed were performed.

RESULTS

A total of 994 patients were diagnosed with COVID-19 infection. Of these, 95 (9.6%) met criteria for moderate, severe, or critical disease. Forty-one percent of these patients (n = 39) received remdesivir. Baseline demographic characteristics were not different between groups. No patients reported an allergic reaction with the administration of remdesivir; however, 16.7% of the patients had the medication discontinued due to transaminitis. Patients receiving the drug were more likely to have a longer illness duration on admission, more likely to require oxygen support on arrival and have a longer hospital stay.

CONCLUSIONS

Remdesivir appears to be safe, well tolerated within our cohort with no cases of recorded adverse reaction.

Semiquantitative Assessment of Amniotic Fluid Among Individuals With and Without Diabetes Mellitus

OBJECTIVE

To compare the rate and severity of abnormal amniotic fluid volumes (oligohydramnios or polyhydramnios), as well as the distribution of amniotic fluid levels, in pregnancies with and without diabetes.

METHODS

We performed a retrospective cohort study of singleton nonanomalous pregnancies receiving an ultrasound examination (USE) in the third trimester. Pregnancies were categorized into those with and without diabetes and subcategorized by diabetes type. The primary outcomes were oligohydramnios or polyhydramnios. Polyhydramnios was also examined by severity. The association between maternal diabetes status and oligohydramnios or polyhydramnios was assessed using logistic regression. In addition, we computed gestational age-specific amniotic fluid index (AFI) and deepest vertical pocket (DVP) centiles for pregnancies with and without diabetes.

RESULTS

There were 60,226 USEs from 26,651 pregnancies that met inclusion criteria. There were 3992 (15.0%) pregnancies with diabetes and 22,659 (85.0%) without diabetes. Using AFI, the rate of polyhydramnios was 10.5 versus 3.8% (odds ratio [OR] 2.95; 95% confidence interval [CI] 2.62-3.32) for pregnancies with versus without diabetes, respectively; using DVP, the rate of polyhydramnios was 13.9 versus 5.4% (OR 2.84; 95% CI 2.56-3.15). Rates of oligohydramnios were also increased in pregnancies with diabetes (3.3 versus 2.6%; OR 1.26; 95% CI 1.04-1.52). The AFI and DVP were significantly higher in the cohort with diabetes between 28 and 36 weeks.

CONCLUSION

Within our study population, pregnancies with diabetes had increased rates of oligohydramnios and polyhydramnios as well as increased gestational age-specific amniotic fluid volumes between 28 and 36 weeks. A higher prevalence of polyhydramnios was observed using DVP as compared to AFI; nevertheless, associations were similar using either method.

Planned versus Unplanned Delivery for Placenta Accreta Spectrum

OBJECTIVE

Women with placenta accreta spectrum (PAS) having an unplanned delivery may have worse outcome compared with women with a planned delivery. The primary objective of this study was to compare severe maternal morbidity among women with PAS who had a planned scheduled delivery versus an unplanned delivery. Secondary objective was to compare neonatal outcomes.

STUDY DESIGN

Retrospective cohort study at two tertiary centers (January 2009 to June 2019) of all women who underwent a hysterectomy with a histologic proven PAS. Primary outcome was severe maternal morbidity which defined as any of the following: transfusion of ≥4 RBC units or ureter/bowel injury. Neonatal outcome was a composite neonatal morbidity defined as any of the following: Apgar score's < 5 at 5 minutes, mechanical ventilation, or respiratory distress syndrome. Maternal demographic, clinical, and sonographic characteristics were compared between the two groups (planned vs. unplanned). Descriptive statistics were used as appropriate, and a statistical significance was established if p-value was < 0.05.

RESULTS

Of 109 women who underwent cesarean hysterectomy for PAS, 41 (37.6%) had an unplanned delivery. There was no significant difference in the number of previous cesarean deliveries or ultrasound findings between the two groups. Women with an unplanned delivery were more likely to bleed during pregnancy than those that had a planned delivery (p = 0.04). Women with unplanned delivery had lower gestational age at delivery (30.3 vs. 33.8 weeks, p = 0.001) had a 75% higher rate of the primary outcome (63 vs. 36%, p = 0.007) and had a higher rate of intensive care unit admissions (39 vs. 17.7%, p = 0.01) compared with women with a planned delivery. The neonatal morbidity did not differ between the two groups.

CONCLUSION

Since unplanned cesarean hysterectomy among women with PAS occurs in 40% and is associated with significantly higher morbidity, interventions are needed to mitigate the rate of adverse outcomes.

KEY POINTS

· Only 60% of women with PAS reached planned delivery at 34 weeks.. · PAS unplanned delivery is associated with high morbidity.. · Some women with PAS may need a scheduled earlier delivery..

Daily meditation program for anxiety in individuals admitted to the antepartum unit: a multicenter randomized controlled trial (MEDITATE)

BACKGROUND

Inpatient antepartum women have higher levels of anxiety than outpatient. Former randomized trials using mindful meditation programs to decrease maternal anxiety have conflicting results; some studies showed a considerable decrease in anxiety levels, whereas others showed no difference. A paucity of trials exist using mindful meditation for maternal anxiety in the inpatient antepartum population; most studies focus on the outpatient clinic population. Because of inpatient acuity and anxiety factors, we conducted a randomized trial to target this population.

OBJECTIVE

This study aimed to compare anxiety levels on day 4 of either routine care or routine care plus a twice-daily application-based mindful meditation program in women admitted to the antepartum unit.

STUDY DESIGN

In a multisite randomized trial (ClinicalTrials.gov Identifier: NCT03737279), women admitted to the antepartum units were randomized to either routine care plus educational pamphlets (control arm) or routine care plus a twice-daily application-based mindful meditation program (intervention arm). The inclusion criteria were age of at least 18 years, gestational age of at least 23 weeks, planned inpatient care for >3 days from randomization, and care by our university physician team. The primary outcome was maternal state anxiety level (measured using the validated State-Trait Anxiety Inventory) on day 4 (randomization being day 1). The secondary outcomes included stress (measured using the Perceived Stress Scale) and depression (measured using the Edinburgh Depression Scale) on day 4, latency period from randomization to delivery, patient experience, number of meditation sessions, and total meditation time. A total of 56 women were needed for 90% power to detect a decrease in the primary outcome by 30% in the intervention group, compared with the control group. All women were observed using an intention-to-treat analysis. We compared the continuous variables using the Wilcoxon rank-sum test or t test and the categorical variables using the chi-squared test or the Fisher exact test.

RESULTS

From March 4, 2019, to December 20, 2019, 412 women were screened for eligibility, 77 women (18.7%) were found eligible, and 56 women (72.7%) were randomized with 28 women in each group. Of note, 96.4% of women completed at least 1 meditation session, and 39.3% of women completed all meditation sessions. The mean score of the anxiety level using the State-Trait Anxiety Inventory on day 4 was not significantly different (P=.24) between the control group (42.0±10.8) and meditation group (37.5±13.1). A decreased anxiety score from day 1 to day 4 was seen in both the control group and meditation group (-4.7 vs -9.4, respectively; P=.12). The rate of abnormal State-Trait Anxiety Inventory scores on day 4 was not significantly different between the control group and meditation group (62% vs 45%, respectively; P=.28). When asked about the experience with the research trial, 88.8% of women in the control group and 89.5% of women in the meditation group reported a positive experience.

CONCLUSION

Compared with the control group, a twice-daily application-based mindful meditation program for women admitted to the antepartum unit did not considerably decrease the anxiety score on day 4. However, >88% of women in both groups had a positive experience with the nonpharmacologic intervention.

The Association Between Number of Repeat Cesarean Deliveries and Adverse Outcomes among Low-Risk Pregnancies

OBJECTIVE

To investigate maternal and neonatal adverse outcomes among low-risk pregnancies delivered at ≥ 37 weeks by repeat cesarean deliveries (RCD).

METHODS

A population-based, retrospective-study using the U.S. vital statistics datasets (2014-2018) evaluating low-risk pregnancies with a non-anomalous singleton non-laboring RCD from 37 to 41 weeks. People with hypertensive disorders or diabetes were excluded. Primary outcome was composite maternal adverse outcome (CMAO). Secondary outcome was composite neonatal adverse outcome (CNAO). Multivariable Poisson regression models were used to estimate the association between number of RCD and outcomes (using adjusted relative risks [aRR] and 95% confidence interval [CI]).

RESULTS

Of the 19,623,195 live births, 1,747,610 (8.9%) met inclusion criteria and among them, 1,144,186 (65.5%) had 1 prior CD, 454,817 (26.0%) had 2 prior CD, 119,087 (6.8%) had 3 prior CD, and 29,520 (1.7%) had ≥4 prior CD. Compared with individuals with 1 prior CD, the risk of CMAO was higher in individuals with 2 (aRR=1.41, 95% CI= 1.34-1.48), 3 (1.96, 1.83-2.10), and ≥4 (2.98, 2.69-3.29) prior CD. An increased risk of CNAO was also found with an increasing number of RCD CONCLUSION: Among low-risk pregnancies undergoing RCD, increasing number of prior CD was associated with a higher risk of adverse outcomes.

Detection of Fetal Anomalies by Remotely Directed and Interpreted Ultrasound (Teleultrasound): A Randomized Noninferiority Trial

OBJECTIVE

To determine the accuracy and reliability of remotely directed and interpreted ultrasound (teleultrasound) as compared with standard in-person ultrasound for the detection of fetal anomalies, and to determine participants' satisfaction with teleultrasound.

STUDY DESIGN

This was a single-center, randomized (1:1) noninferiority study. Individuals referred to the maternal-fetal medicine (MFM) ultrasound clinic were randomized to standard in-person ultrasound and counseling or teleultrasound and telemedicine counseling. The primary outcome was major fetal anomaly detection rate (sensitivity). All ultrasounds were performed by registered diagnostic medical sonographers and interpretations were done by a group of five MFM physicians. After teleultrasound was completed, the teleultrasound patients filled out a satisfaction survey using a Likert scale. Newborn data were obtained from the newborn record and statewide birth defect databases.

RESULTS

Of 300 individuals randomized in each group, 294 were analyzed in the remotely interpreted teleultrasound group and 291 were analyzed in the in-person ultrasound group. The sensitivity of sonographic detection of 28 anomalies was 82.14% in the control group and of 20 anomalies in the telemedicine group, it was 85.0%. The observed difference in sensitivity was 0.0286, much smaller than the proposed noninferiority limit of 0.05. Specificity, negative predictive value, positive predictive value, and accuracy were more than 94% for both groups. Patient satisfaction was more than 95% on all measures, and there were no significant differences in patient satisfaction based on maternal characteristics.

CONCLUSION

Teleultrasound is not inferior to standard in-person ultrasound for the detection of fetal anomalies. Teleultrasound was uniformly well received by patients, regardless of demographics. These key findings support the continued expansion of telemedicine services.

KEY POINTS

· For detection of major anomalies, teleultrasound is comparable to standard ultrasound.. · Teleultrasound was well accepted by patients.. · Teleultrasound use should be expanded..