Lasix for the prevention of de novo postpartum hypertension: A randomized placebo-controlled trial (LAPP Trial)

BACKGROUND

Birthing people with de novo postpartum hypertensive disorders remain among the highest risk for severe maternal morbidity. Randomized controlled trials demonstrate a benefit to oral loop-diuretics in decreasing postpartum hypertensive morbidity in patients with an antenatal diagnosis of preeclampsia. It is not known whether this same therapy benefits patients at risk for new-onset postpartum hypertension OBJECTIVE: To evaluate whether oral furosemide can reduce risk for de novo postpartum hypertension (dnPPHTN) among high-risk birthing people by reducing post-delivery blood pressure.

STUDY DESIGN

From October 2021 to April 2022, we conducted a randomized triple-masked placebo-controlled clinical trial of individuals at high risk for dnPPHTN at a single university-based tertiary care medical center. A total of 82 postpartum patients with no antenatal diagnosis of chronic hypertension or a hypertensive disorder of pregnancy who were at high-risk for the development of dnPPHTN based on a pre-specified risk factor algorithm were enrolled after childbirth. The participants were randomly assigned in a 1:1 ratio to a five-day course of oral furosemide 20 mg daily or identical-appearing placebo starting within eight hours of delivery. Participants were followed for 6 weeks postpartum using Bluetooth-enabled remote blood pressure monitoring and electronic surveys. The primary outcome was the difference in mean arterial pressure (MAP) averaged over the 24 hours prior to discharge or the 24 hours prior to antihypertensive therapy initiation. The study was powered to detect a 5 mmHg difference in mean MAP (standard deviation 6.4 mmHg) with 90% power at an alpha of 0.05, requiring a sample size of 41 per group. Secondary outcomes included the rate of dnPPHTN, readmission data, other measures of hypertensive and maternal morbidity, breastfeeding data, and drug-related neonatal outcomes.

RESULTS

The primary outcome was assessed in 80 of the 82 participants. Baseline characteristics were similar between groups. There was no significant difference in mean MAP 24 hours prior to discharge (or antihypertensive initiation) in the furosemide group (88.9 ± 7.4 mmHg) compared to the placebo group (86.8 ± 7.1 mmHg; absolute difference 2.1 mmHg, 95% CI -1.2 to 5.3). Of the 79 participants for whom secondary outcomes were assessed, 10% (n=8) developed dnPPHTN and 9% (n=7) were initiated on antihypertensive therapy. Rates were not significantly different between groups.

CONCLUSIONS

De novo postpartum hypertension is a common phenomenon among at-risk patients, warranting close monitoring for severe hypertension and other maternal morbidity. There is insufficient evidence to suggest that furosemide reduces mean MAP in the 24 hours prior to discharge from the delivery hospitalization (or antihypertensive medication initiation) compared to placebo.

Adverse Outcomes during Postpartum Readmissions after Deliveries Complicated by Hypertensive Disorders of Pregnancy

OBJECTIVE

This study aimed to characterize risk for postpartum complications based on specific hypertensive diagnosis at delivery.

STUDY DESIGN

This retrospective cohort study used the 2010 to 2014 Nationwide Readmissions Database to identify 60-day postpartum readmissions. Delivery hospitalizations were categorized based on hypertensive diagnoses as follows: (1) preeclampsia with severe features, (2) superimposed preeclampsia, (3) chronic hypertension, (4) preeclampsia without severe features, (5) gestational hypertension, or (6) no hypertensive diagnosis. Risks for 60-day readmission was determined based on hypertensive diagnosis at delivery. The following adverse outcomes during readmissions were analyzed: (1) stroke, (2) pulmonary edema and heart failure, (3) eclampsia, and (4) severe maternal morbidity (SMM). We fit multivariable log-linear regression models to assess the magnitude of association between hypertensive diagnoses at delivery and risks for readmission and associated complications with adjusted risk ratios (aRR) as measures of effect.

RESULTS

From 2010 to 2014, 15.7 million estimated delivery hospitalizations were included in the analysis. Overall risk for 60-day postpartum readmission was the highest among women with superimposed preeclampsia (6.6%), followed by preeclampsia with severe features (5.2%), chronic hypertension (4.0%), preeclampsia without severe features (3.9%), gestational hypertension (2.9%), and women without a hypertensive diagnosis (1.5%). In adjusted analyses for pulmonary edema and heart failure as the outcome, risks were the highest for preeclampsia with severe features (aRR = 7.82, 95% confidence interval [CI]: 6.03, 10.14), superimposed preeclampsia (aRR = 8.21, 95% CI: 5.79, 11.63), and preeclampsia without severe features (aRR = 8.87, 95% CI: 7.06, 11.15). In the adjusted model for stroke, risks were similarly highest for these three hypertensive diagnoses. Evaluating risks for SMM during postpartum readmission, chronic hypertension and superimposed preeclampsia were associated with the highest risks.

CONCLUSION

Chronic hypertension was associated with increased risk for a broad range of adverse postpartum outcomes. Risk estimates associated with chronic hypertension with and without superimposed preeclampsia were similar to preeclampsia with severe features for several outcomes.

KEY POINTS

· Chronic hypertension was associated with increased risk for a broad range of adverse outcomes.. · Close postpartum follow-up is required if hypertension is present at delivery.. · The majority of readmissions occurred within 10 days after delivery hospitalization discharge..

Health Care Disparities in the COVID-19 Pandemic in the United States: A Focus on Obstetrics

The influence of social determinants of health on disease dynamics and outcomes has become increasingly clear, making them a prime target of investigation and mitigation efforts. The obstetric population is uniquely positioned to provide insight into the health inequities exacerbated by the coronavirus disease 2019 pandemic given their susceptibility to infectious disease morbidity and frequent interactions with the health care system, which provide opportunities for ascertainment of disease incidence and severity. This review summarizes the data on disparities identified in the US obstetric population during the coronavirus disease 2019 pandemic as they relate to race and ethnicity, built environment, insurance status, language, and immigration status.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

No clinical evidence of vertical transmission was identified in 101 newborns of mothers positive for or with suspected SARS-CoV-2 infection, despite most newborns rooming-in and direct breastfeeding practices.

Advances in Management for Preterm Fetuses at Risk of Delivery

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.

A review of newborn outcomes during the COVID-19 pandemic

As the COVID-19 pandemic continues to spread worldwide, it is crucial that we determine populations that are at-risk and develop appropriate clinical care policies to protect them. While several respiratory illnesses are known to seriously impact pregnant women and newborns, preliminary data on the novel SARS-CoV-2 Coronavirus suggest that these groups are no more at-risk than the general population. Here, we review the available literature on newborns born to infected mothers and show that newborns of mothers with positive/suspected SARS-CoV-2 infection rarely acquire the disease or show adverse clinical outcomes. With this evidence in mind, it appears that strict postnatal care policies, including separating mothers and newborns, discouraging breastfeeding, and performing early bathing, may be more likely to adversely impact newborns than they are to reduce the low risk of maternal transmission of SARS-CoV-2 or the even lower risk of severe COVID-19 disease in otherwise healthy newborns.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

· Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..

Associations Between Built Environment, Neighborhood Socioeconomic Status, and SARS-CoV-2 Infection Among Pregnant Women in New York City

This cross-sectional study investigates associations of residential building characteristics and markers of neighborhood socioeconomic status (SES) with screen-detected SARS-CoV-2 prevalence among pregnant women delivering in 2 New York City hospitals.

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

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

Optimal Obstetric Management for Women with Diabetes: the Benefits and Costs of Fetal Surveillance

PURPOSE OF REVIEW

To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes.

RECENT FINDINGS

Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes. The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.