Health Care Workers' Attitudes Toward Patients With COVID-19

BACKGROUND

Early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, before the routine availability and/or use of personal protective equipment, health care workers were understandably concerned. Our aim was to explore health care workers' attitudes toward patients infected with SARS-CoV-2 at the time of the nation's first surge in 2 highly affected hospitals in New York.

METHODS

We performed a cross-sectional, self-administered survey study of health care workers. The survey consisted of 17 multiple-choice questions including demographic information, ethics, and willingness to care for patients with SARS-CoV-2 infection. Subgroup analyses were performed using the Fisher exact test.

RESULTS

Of 340 health care workers approached, 338 (99.4%) consented to the survey; 163 (48.7%) were registered nurses and 160 (48.3%) lived with children. While 326 (97.3%) workers were concerned about putting their family/coworkers at risk of infection after caring for a patient with SARS-CoV-2, only 30 (8.9%) were unwilling to treat a patient with SARS-CoV-2 infection. Registered nurses were more likely than other health care workers to think it was ethical to refuse care for SARS-CoV-2-infected patients, worried more often about contracting infection, and felt that SARS-CoV-2 added to their stress level (P = .009, P = .018, P < .001, respectively). A similar contrast was seen when comparing workers who live with children with those who did not.

CONCLUSIONS

Levels of stress and concern were extremely high. In spite of that, the overwhelming majority of workers were willing to treat patients with SARS-CoV-2 infection. Registered nurses and health care workers who live with children were more likely to think it is ethical to refuse care for SARS-CoV-2-infected patients.

Histologic and Immunohistochemical Evaluation of 65 Placentas From Women With Polymerase Chain Reaction-Proven Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection

CONTEXT.—

Coronavirus disease 2019 (COVID-19) has been shown to have effects outside of the respiratory system. Placental pathology in the setting of maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains a topic of great interest because earlier studies have shown mixed results.

OBJECTIVE.—

To ascertain whether maternal SARS-CoV-2 infection is associated with any specific placental histopathology, and to evaluate the virus's propensity for direct placental involvement.

DESIGN.—

Placentas from 65 women with polymerase chain reaction-proven SARS-CoV-2 infection underwent histologic evaluation using Amsterdam consensus group criteria and terminology. Another 85 placentas from women without SARS-CoV-2 constituted the negative control group. A total of 64 of the placentas from the SARS-CoV-2-positive group underwent immunohistochemical staining for SARS-CoV-2 nucleocapsid protein.

RESULTS.—

Pathologic findings were divided into maternal vascular malperfusion, fetal vascular malperfusion, chronic inflammatory lesions, amniotic fluid infection sequence, increased perivillous fibrin, intervillous thrombi, increased subchorionic fibrin, meconium-laden macrophages (M-LMs) within fetal membranes, and chorangiosis. There was no statistically significant difference in prevalence of any specific placental histopathology between the SARS-CoV-2-positive and SARS-CoV-2-negative groups. There was no immunohistochemical evidence of SARS-CoV-2 virus in any of the 64 placentas that underwent staining for viral nucleocapsid protein.

CONCLUSIONS.—

Our study results and a literature review suggest that there is no characteristic histopathology in most placentas from women with SARS-CoV-2 infection. Likewise, direct placental involvement by SARS-CoV-2 is a rare event.

The Relationship between Status at Presentation and Outcomes among Pregnant Women with COVID-19

OBJECTIVE

This study was aimed to compare maternal and pregnancy outcomes of symptomatic and asymptomatic pregnant women with novel coronavirus disease 2019 (COVID-19).

STUDY DESIGN

This is a retrospective cohort study of pregnant women with COVID-19. Pregnant women were divided into two groups based on status at admission, symptomatic or asymptomatic. All testing was done by nasopharyngeal swab using polymerase chain reaction (PCR) for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Initially, nasopharyngeal testing was performed only on women with a positive screen (symptoms or exposure) but subsequently, testing was universally performed on all women admitted to labor and delivery. Chi-square and Wilcoxon's rank-sum tests were used to compare outcomes between groups.

RESULTS

Eighty-one patients were tested because of a positive screen (symptoms [n = 60] or exposure only [n = 21]) and 75 patients were universally tested (all asymptomatic). In total, there were 46 symptomatic women and 22 asymptomatic women (tested based on exposure only [n = 12] or as part of universal screening [n = 10]) with confirmed COVID-19. Of symptomatic women (n = 46), 27.3% had preterm delivery and 26.1% needed respiratory support while none of the asymptomatic women (n = 22) had preterm delivery or need of respiratory support (p = 0.007 and 0.01, respectively).

CONCLUSION

Pregnant women who presented with COVID19-related symptoms and subsequently tested positive for COVID-19 have a higher rate of preterm delivery and need for respiratory support than asymptomatic pregnant women. It is important to be particularly rigorous in caring for COVID-19 infected pregnant women who present with symptoms.

KEY POINTS

· Respiratory support is often needed for women who present with symptoms.. · Low rate of severe disease in women who present without symptoms.. · There were no neonatal infections on day 0 of life..

Caring for Pregnant Patients with COVID-19: Practical Tips Getting from Policy to Practice

Novel coronavirus disease 2019 (COVID-19) is a pandemic with most American cases in New York. As an institution residing in a high-prevalence zip code, with over 8,000 births annually, we have cared for over 80 COVID-19-infected pregnant women, and have encountered many challenges in applying new national standards for care. In this article, we review how to change outpatient and inpatient practices, develop, and disseminate new hospital protocols, and we highlight the psychosocial challenges for pregnant patients and their providers. KEY POINTS: · Novel coronavirus disease 2019 (COVID-19) information rapidly changes.. · Multidisciplinary communication is key.. · This study addresses psychosocial challenges..

Carcinoembryonic antigen as a biomarker for meconium-stained amniotic fluid

OBJECTIVE

To assess whether elevated carcinoembryonic antigen (CEA) concentration in amniotic fluid can indicate meconium-stained amniotic fluid (MSAF).

METHODS

In a prospective cohort study, women with a term singleton pregnancy who were in labor but had intact membranes were recruited at a center in Israel over a 5-month period in 2013. Only women who subsequently underwent artificial rupture of membranes following a clear medical indication were included. Samples of amniotic fluid, urine, and serum were collected. Amniotic fluid was examined by sight and classified as clear, MSAF, or undetermined. CEA concentration in the samples was measured.

RESULTS

Among 81 participants, 45 had clear amniotic fluid, 28 had MSAF, and eight had undetermined amniotic fluid. Mean CEA concentration was more than 10 times higher in MSAF (2658 μg/L, standard error 250) than in clear amniotic fluid (238 μg/L, standard error 29; P<0.001). Receiver operating characteristic curve analysis demonstrated a sensitivity of 96% and a specificity of 100% for distinguishing MSAF from clear amniotic fluid at a CEA cutoff of 799.2 μg/L. CEA concentrations in urine and serum were all within the normal range (≤5 μg/L), irrespective of amniotic fluid status.

CONCLUSION

High CEA concentrations in amniotic fluid can assist in the diagnosis of MSAF. These findings could provide the basis for a bedside test to detect MSAF following rupture of membranes.

Methicillin-Resistant Staphylococcus aureus Necrotizing Pneumonia Arising From an Infected Episiotomy Site

BACKGROUND

We report a case of methicillin-resistant Staphylococcus aureus (MRSA) sepsis and pneumonia in a postpartum patient.

CASE

A 21-year-old gravida 1 para 1 presented on postpartum day 9 with persistent elevated fever, dyspnea, cellulitis of the upper extremities, and an infected episiotomy site. Computed tomography of the chest revealed multiple widely distributed nodules and bilateral infiltrates with central cavitations. Sputum, blood, urine, and episiotomy site cultures grew MRSA, subsequently demonstrated by molecular fingerprinting and antibiotic susceptibility to be community acquired. A magnetic resonance imaging of the pelvis demonstrated pelvic thrombophlebitis.

CONCLUSION

Community-acquired MRSA is an emerging problem, which may present as skin and soft tissue infections or sepsis. Seeding from an infected episiotomy site seems to be a potential route of systemic infection. The use of empirical treatment with beta-lactam agents may fail. Appropriate cultures should be obtained and if MRSA is diagnosed, vancomycin should be employed.

Determinants of women's choice of obstetrician/gynecologist

INTRODUCTION

There has been a reported increase in women's desires to have female medical providers. It is unclear if this finding extends to obstetrician/gynecologists or how important gender is relative to other factors in choosing a provider. This study seeks to address these issues.

METHODS AND MATERIALS

In community locations in Brooklyn, New York, 537 women completed a questionnaire regarding demographics, gender of their current provider, and whether they considered age, gender, experience, location, or cost to be the most important factor in choosing an obstetrician/gynecologist. They rated their current experience and the importance of gender using a 10-point Likert scale.

RESULTS

Overall, 61% of participants preferred a female provider. The proportion did not vary with gender of the interviewer or participants' age. A female provider was preferred by 56% of Protestants, 58% of Catholics, and 58% of Jews and by 74% of Hindus and 89% of Muslims (p = 0.02). Regardless of whether a woman preferred a male or a female provider, 38% of participants felt strongly (7-10 on Likert scale) that gender was important. There was no difference in satisfaction with current provider between women who preferred a male or female provider. Gender was as important in choosing an obstetrician as experience or cost. Almost as many women with a female provider indicated a preference for a male (46%) as women with a male provider who preferred a female provider (54%).

CONCLUSIONS

A slight majority of these women, particularly those who are Hindu or Moslem or currently use a female, prefer female providers. Only a minority of these women feel strongly about their preference, and women with male providers are as satisfied as are women with female providers. Gender of provider was about as important as a physician's experience in choice of clinician.

The relationship between pregnancy and sexual risk taking

OBJECTIVES

We attempted to determine whether risks of acquiring sexually transmitted diseases differ between pregnant and nonpregnant women.

STUDY DESIGN

Women attending clinics in Brooklyn (332 pregnant and 1069 nonpregnant) were interviewed and tested for Trichomonas vaginalis and Chlamydia trachomatis. Independent-sample t tests were conducted via SPSSX (SPSS Inc., Chicago) to assess differences in risk behavior across pregnancy status.

RESULTS

In the pregnant sample 17.2% had positive test results for chlamydia and 23.4% had T vaginalis. In the nonpregnant women the rates were 10.9% and 17.7%, respectively (p<0.01). Pregnant respondents used condoms less consistently than nonpregnant women (p<0.01). Although nonpregnant women reported a higher frequency of sexual activity and more sexual partners in the previous month, the strength of those relationships was weak.

CONCLUSION

We have found that pregnancy does not represent a time of reduced sexual risks. The differences in self-reported risk, with the exception of consistency of condom use, all showed very weak indexes of strength. Providers of obstetric services should incorporate "safer sex" messages into routine prenatal care.

Changes in perinatal cocaine use in an inner-city hospital, 1988 to 1992

Temporal trends in perinatal drug use among parturients at an inner-city hospital were assessed in a cohort study of 1300 parturients in 1991 through 1992 and 1111 parturients in 1988 through 1989. Toxicology results were coupled to data sheets containing demographic and obstetrical information. A decrease was noted between 1988 and 1992 in the prevalence of cocaine metabolites, independent of the utilization of prenatal services. An increase in marijuana use and no change in opiate use were seen. When adjusted for ethnicity and receipt of care, a 50% decline in the odds ratio (OR) of cocaine use was noted between 1988 and 1992 (OR = 0.55; 95% confidence interval = 0.39, 0.79).

The impact of prenatal exposure to cocaine on newborn costs and length of stay

OBJECTIVE

Our intention is to determine newborn costs and lengths of stay attributable to prenatal exposure to cocaine and other illicit drugs.

DATA SOURCES AND STUDY SETTING

All parturients who delivered at a large municipal hospital in New York City between November 18, 1991 and April 11, 1992.

STUDY DESIGN

A cross-sectional analysis used multivariate, loglinear regressions to analyze differences in costs and length of stay between infants exposed and unexposed prenatally to cocaine and other illicit drugs, adjusting for maternal race, age, prenatal care, tobacco, parity, type of delivery, birth weight, prematurity, and newborn infection.

DATA COLLECTION/EXTRACTION METHODS

Urine specimens, with linked obstetric sheets and discharge abstracts, provided information on exposure, prenatal behaviors, costs, length of stay, and discharge disposition.

PRINCIPAL FINDINGS

Infants exposed to cocaine or some other illicit drug stay approximately seven days longer at a cost of $7,731 more than infants unexposed. Approximately 60 percent of these costs are indirect, the result of adverse birth outcomes and newborn infection. Hospital screening as recorded on discharge abstracts substantially underestimates prevalence at delivery, but overestimates its impact on costs.

The effect of recent cocaine use on the progress of labor

OBJECTIVE

This study was undertaken to determine whether peripartum cocaine use shortens labor.

STUDY DESIGN

A total of 1220 gravidas delivering at an urban county hospital (November 1991 through April 1992) had urine specimens sent for toxicology studies. Cervical dilatation on admission and time intervals during the course of labor were recorded. Analysis of covariance and exact tests for multiple contingency tables were used to compare duration of labor by cocaine use after we adjusted for other factors.

RESULTS

Compared with nonusers, women who had positive test results for cocaine were older, were of greater parity, and were admitted to the hospital at greater cervical dilatation (4.63 cm vs 3.96 cm, p < 0.05). The duration of labor from admission to birth was also shorter (336 vs 565 minutes, p < 0.001). After we controlled for type of delivery, parity, birth weight, and prenatal care, there was no significant difference in labor duration in any stage.

CONCLUSIONS

There is no difference in duration of any stage of labor related to cocaine use after patients' obstetric characteristics are controlled for.

Predictors of cocaine use in pregnancy

Several hundred thousand infants are exposed to cocaine in utero every year in the United States. In an attempt to provide services for women abusing drugs, various programs have been proposed for prenatal drug testing. This study was conducted to assess the sensitivity, specificity, and predictive values of screening programs based on a variety of clinical and historical factors. Between October 1988 and March 1989, 1111 parturients who delivered at an inner-city hospital had urine samples and data collected. The urine, linked by code number to the data, which contained no identifiers, was tested anonymously for illicit drugs. We then assessed the associations of a variety of historical and clinical variables with positive toxicologies. An acknowledged history of drug use or a combination of no prenatal care and cigarette use provided the most valid prediction of cocaine use, with a 59.8% sensitivity, 97.5% specificity, 70% positive predictive value, and 94.9% negative predictive value for positive urine toxicologic examinations. The addition of clinical data such as low birth weight did not improve predictive values significantly. Although the use of easily available historical data allowed correct identification of 60% of parturients who used cocaine, no combination of factors could detect all users. If it is considered beneficial to identify all users at a given point, then urine toxicology screening would be more appropriate than sole reliance on patient history.

A cohort study of the impact of perinatal drug use on prematurity in an inner-city population

Perinatal illicit drug use was determined by anonymously testing the urine of 1111 inner-city parturients. Fourteen percent tested positive, 11.5% for cocaine. As determined by self-report or by positive test results, 17% used drugs. Twenty-eight percent of low birthweights and 20% of premature births in this group were attributable to drug use. Risk of prematurity was reduced by a factor of 2 to 3 with adequate prenatal care. These data suggest an enormous potential for improving perinatal health.

The biologic and social consequences of perinatal cocaine use in an inner-city population: results of an anonymous cross-sectional study

Cocaine use among pregnant women and reports of its adverse perinatal consequences have increased substantially over the past 10 years. However, most researchers have studied patients registered at drug treatment centers or have relied on voluntary participation by patients, either of which introduces the possibility of selection bias. To determine the frequency and consequences of prenatal cocaine use among an unselected inner-city obstetric population, we collected urine samples from parturient women at a municipal hospital and anonymously tested these specimens for metabolites of cocaine, marijuana, opiates, and methadone. Urine specimens, with linked obstetric data sheets, were available from a study population of 1111 patients, and pediatric data sheets were available for 846 mother-infant pairs. Cocaine metabolites were found in 11.5% of the urine samples collected, whereas metabolites of marijuana, opiates, and methadone, respectively, were present in 1.1%, 1.2%, and 0.3% of the specimens. Cocaine users were more likely than nonusers to have had no prenatal care (51% vs 8.8%; p less than 0.0001), to be American-born rather than Caribbean-born (71% vs 33%; p less than 0.001), and to have a higher parity (1.83 vs 1.14; p less than 0.0001). Infants of cocaine users had a lower mean gestational age (-0.93 weeks; p less than 0.01), a lower mean birth weight (2560 +/- 788 vs 3151 +/- 699 gm; p less than 0.001), and an increased probability of having an Apgar score of less than 7 at 5 minutes (12.5% vs 3.2%; p less than 0.0001). Multiple linear regression analysis that isolated confounding variables such as the presence or absence of prenatal care, maternal age and parity, and the use of cigarettes and alcohol did not substantially affect the differences described above. The effect of cigarette smoking on reducing fetal size was cumulative. In conclusion, cocaine is the most commonly used illicit drug among parturients in this community and is strongly associated with underutilization of prenatal care services. Infants of cocaine users are more likely to be preterm and depressed at birth and to have a low birth weight. Cocaine use, through the above-noted effects, increases the need for prenatal care while simultaneously decreasing the likelihood that it will be obtained.

The relationship of cocaine use to syphilis and human immunodeficiency virus infections among inner city parturient women

To study the relationship of cocaine use to syphilis and human immunodeficiency virus infections a blinded urine and serum survey was performed among parturient women at an inner city hospital. Discarded urine samples of 1206 parturient women were saved and given code numbers that were also assigned to data sheets containing nonidentifying information, including prenatal care status and syphilis serologic results. In the latter part of the study blood remaining after syphilis serologic tests were performed (n = 480) were tested for human immunodeficiency virus antibodies. Overall 12.9% of urine samples had cocaine derivatives, 1.4% opiates, 1.5% marijuana, 0.0% benzodiazepine, and 0.3% methadone. The prevalence of positive rapid plasma reagin tests was 18.7% among patients with positive urine toxicologic tests for cocaine and 2.41% for patients with negative urine tests (odds ratio = 9.3, 95% confidence interval 5.2 to 16.5, p less than 0.001). Fluorescent treponemal antibodies were also significantly more frequent among patients with positive urine samples. Four of 53 (7.6%) patients with positive urine toxicologic screens were human immunodeficiency virus antibody positive compared with six of 427 (1.4%) women with negative screens (odds ratio = 5.7, 95% confidence interval = 1.4 to 21.5, p = 0.019). Cocaine patients with positive cocaine screens and with syphilis or human immunodeficiency virus had prenatal care in 6 of 21 (28.6%) and 0 of 4 (0%) cases, respectively, while patients with negative cocaine screens and syphilis or human immunodeficiency virus had prenatal care in 13 of 18 (72.2%) and 5 of 6 (83.3%) cases, respectively (p = 0.010 and p = 0.048). Cocaine use appears to be associated with both the acquisition of human immunodeficiency virus and syphilis and the failure of infected individuals to utilize prenatal services.

Serosurvey of human immunodeficiency virus infection in parturients. Implications for human immunodeficiency virus testing programs of pregnant women

Although perinatal transmission of the human immunodeficiency virus (HIV) is well documented, seroprevalence rates of HIV in populations of women of reproductive age have not yet been reported. To determine the seroprevalence of HIV in childbearing women from a population with a high incidence of acquired immunodeficiency syndrome, cord blood samples were collected from 602 infants delivered at an inner-city municipal hospital in New York. Demographic and HIV risk factor information was also collected from mothers of these infants. Twelve (2%) of 602 samples (95% confidence interval, 1% to 4%) were positive for HIV on enzyme-linked immunosorbent assay and Western blot analysis. In interviews, seven of 12 seropositive women had risk factors as defined by the Centers for Disease Control, Atlanta; the remaining five seropositive women had no self-identified risk factors. The HIV seroprevalence rate in our hospital (2.0%) is several times higher than that of many other diseases for which screening is already routine. This serosurvey indicates that HIV infection of inner-city parturients is a significant problem that warrants broadly implemented health strategies. Furthermore, the data also suggest that if risk factor information elicited by physicians is used to initiate HIV antibody counseling and testing of pregnant women, a significant number of seropositive parturients is missed. In areas with significant seroprevalence rates of HIV infection, a broader counseling and testing program may be needed.