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Massage is systematic touch and manipulation of the soft tissues of the body that is increasingly being used as an adjunctive therapy for stress relief and to promote relaxation and wellbeing during pregnancy and as an alternative to pharmacologic or invasive forms of analgesia during labor. Literature to support the use of massage in pregnancy and labor is limited; however, evidence to support its use has been increasing over the past 30 years. Massage has been shown to be valuable to pregnant women with anxiety, depression, leg, and back pain, and has shown significant benefit in perception of pain during labor.

Introduction: Adverse pregnancy outcomes (APOs) are risk enhancing factors for future cardiovascular (CV) disease. Our study aims to understand the clinical, sociodemographic and neighborhood factors of patients who suffered APOs in our health system. Methods: We performed a retrospective analysis of 66,136 single-gestation pregnancies from 7 hospitals in the Northwell Health System between March 2018 and June 2020. Pregnancies with known APO status were included in final analysis (n=64,804). Data extracted from EHR included demographics, parity, insurance, hospital of delivery, medical history, and APO outcomes: pre-term birth (PTB), stillbirth (SB), small for gestational age (SGA) and low birth weight (LBW). Median neighborhood household income, percent unemployed, and household size (extracted from census data based on zip code) were used to represent the mean demographics of those living within certain geographic regions. Results: In our study population, the average ±SD age was 31.4 ±5.4 years; 46.9% were white, 12.4% were black, 12.4% were Asian and 52.3% were overweight or obese. The composite incidence of SB, SGA and LBW was 13.8% while incidence of PTB was 7.2%. Being single or having public health insurance had an increased odds of overall APOs, OR 1.4 (95%CI 1.3-1.4) and OR 1.3 (95%CI 1.2-1.3), respectively. Median neighborhood household income was significantly associated with odds of APOs, with lower income categories having increased odds of APOs and odds of PTB compared to higher income categories. Those with a hypertensive disorder (HTN) (during or pre-pregnancy) had increased odds of having an APO compared to those without, OR 2.2 (95%CI 2.1-2.4). Those with HTN, glucose intolerance or obesity (pre-pregnancy BMI ≥ 40) during or pre-pregnancy had increased odds of a PTB compared to those without any of these conditions, OR 3.6 (95%CI 3.4 - 3.9), OR 1.7(95%CI 1.6-1.9) and OR 1.9 (95%CI 1.7-2.2), respectively. Conclusions: CV risk factors, sociodemographic and neighborhood characteristics are likely associated with APOs. These potential relationships may provide useful information for CV prevention in pregnancy. Future research is needed to further elucidate these associations.

Objective Coronavirus disease 2019 (COVID-19) is associated with cardiac injury1-3 and bradycardia4 in the non-pregnant population. The incidence of these complications in pregnancy is unknown. The objective of this study was to determine the rate of abnormal serum cardiac biomarkers or bradycardia among pregnant and immediately postpartum women admitted for treatment of severe or critical COVID-19 in a large integrated health system in New York. Study Design This is a retrospective review of all pregnant and immediately postpartum women hospitalized for COVID-19 at 7 hospitals within Northwell Health, the largest academic health system in New York state, from March 1 to April 30, 2020. Women who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction (PCR) assay and who met the National Institute of Health (NIH) criteria for severe or critical illness5 were included. Women with a positive PCR test who were admitted for a reason other than treatment of COVID-19 (eg, labor) were excluded. The Northwell Health Institutional Review Board approved the study as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent. Clinical records were manually reviewed. Data collected included demographics, medical comorbidities, pregnancy characteristics, laboratory and imaging results, medications administered, and clinical outcomes. Laboratory and imaging studies were ordered at the discretion of the attending physician. The primary outcomes evaluated were elevated cardiac troponins (I, T, or high sensitivity), elevated brain natriuretic peptide (BNP), bradycardia (defined as < 60 beats per minute, bpm), and maternal heart rate (HR) nadir. Descriptive statistics were used to characterize the data. Results A total of 31 women met inclusion criteria; 20 (65%) had cardiac biomarkers measured during hospitalization (Table). Cardiac troponins and BNP were elevated in 22% (n=4/18) and 30% (n=3/10) of these patients, respectively. Four patients had transthoracic echocardiograms performed and all were reported as normal. No patients had preexisting cardiovascular disease or hypertension. Two maternal mortalities in this cohort were previously reported;6 both patients had elevated cardiac troponins and one also had an elevated BNP. The nadir HR ranged from 30-92 bpm and bradycardia occurred in one-third of patients (n=10/31). Half of women with elevated troponin and three-fourths of women with elevated BNP had an episode of bradycardia recorded during their hospital course. Conclusion Myocardial injury as demonstrated by abnormal cardiac biomarkers and bradycardia may be common among pregnant women with severe or critical COVID-19. In this study, one-fifth of patients who had troponin levels measured were found to have elevations (one-eighth of the overall study population). Among patients who had brain natriuretic peptide levels measured, 30% were elevated (10% of the overall study population). One third of women had bradycardia. This study is limited by a small sample size. Laboratory testing and imaging was not uniform due to the retrospective nature of the study. Sampling bias was unavoidable because the decision to measure cardiac markers or perform imaging studies was made by the patient’s care team, based on clinical presentation rather than a formal protocol. Few studies have evaluated the risk of cardiac injury or arrhythmia among pregnant women with COVID-19. It is also unknown whether there are long-term sequelae that affect maternal health or future pregnancy outcomes. This is an important area of focus for future research.

Background Transthoracic point-of-care ultrasonography of the lungs has become a standard technique in critical care medicine for the evaluation of patients with respiratory signs or symptoms but has not been well studied in pregnancy. Objective To compare lung ultrasound patterns in third-trimester gravidas with and without preeclampsia and assess interobserver agreement between 3 obstetrical providers and a physician expert in critical care lung ultrasound. Study Design This is a prospective observational study of 262 women with singleton pregnancies between 32 0/7 and 41 6/7 weeks’ gestation. Lung ultrasound examinations were performed and interpreted by a team of obstetrical care providers and then interpreted by an expert in point-of-care lung ultrasound. The number of B-lines in each of the 4 lung fields, indicating the accumulation of fluid in the interstitial space and the alveoli, was evaluated. The primary outcome was a positive study for pulmonary interstitial edema, defined as an ultrasound study with 3 or more B-lines in 2 or more bilateral lung fields. The secondary outcome was a lung ultrasound study with 1 or 2 B-lines in 1 or more lung fields or 3 B-lines in 1 lung field. Interobserver agreement in lung ultrasound interpretation between obstetrical care providers and an expert in critical care point-of-care ultrasonography of the lung was assessed. Results Among healthy gravidas, no subject had a lung ultrasound examination positive for pulmonary interstitial edema. Notably, 2 patients with preeclampsia had positive lung ultrasound studies, and both had respiratory symptoms or signs of pulmonary edema. One or 2 B-lines or 3 B-lines in 1 lung field were identified in 11.4% of healthy gravidas and 18.6% of patients with preeclampsia. There was no difference in lung ultrasound patterns between healthy gravidas and those with preeclampsia. The obstetrical care providers and the lung ultrasound expert had a high proportion of agreement regarding the interpretation of negative lung ultrasound examinations. The 2 patients with clinical signs of pulmonary edema were judged to have positive studies by both the obstetrical team and the expert; however, the obstetrical team classified more studies as positive. Conclusion Lung ultrasound patterns in women with preeclampsia without respiratory symptoms or clinical signs of pulmonary edema are similar to the lung ultrasound patterns of healthy gravidas. Point-of-care lung ultrasound can be used to evaluate third-trimester gravidas with preeclampsia and respiratory complaints or signs concerning for pulmonary edema. Formal training is important before the widespread adoption of point-of-care lung ultrasound by obstetrical healthcare providers.

Objective: To identify maternal and peripartum characteristics in twin gestations that are associated with postpartum hemorrhage (PPH) in which one or more units of packed red blood cells (PRBCs) w...

Background In a normal pregnancy, cervical collagen fibers remain organized in predictable patterns throughout most of the gestation. Cervical remodeling reflects a rearrangement of collagen fibers in which they become increasingly disordered and contribute to the pathogenesis of spontaneous preterm birth. Quantitative ultrasound analysis of cervical tissue echotexture may have the capacity to identify microstructural changes before the onset of cervical shortening. Objective The primary objective of this study was to examine the utility of a novel quantitative sonographic marker, the cervical heterogeneity index (HI), which reflects the relative organization of cervical collagen fibers. Also, we aimed to determine an optimal HI cut-point to predict spontaneous preterm birth. Study Design This retrospective cohort study employed a novel image-processing technique on transvaginal ultrasound images of the cervix in gestations between 14 and 28 completed weeks. The transvaginal sonography images were analyzed in MATLAB (MathWorks, Natick, MA) using a custom image-processing technique that assessed the relative heterogeneity of the cervical tissue. Results A total of 151 subjects were included in the study. The mean HI in subjects who delivered preterm and at term was 8.28 ± 3.73 and 12.35 ± 5.80, respectively (p Conclusion Quantitative ultrasound measurement of the cervical HI is a promising, noninvasive tool for early prediction of spontaneous preterm birth.

(A leading cause of several nontransmissible chronic medical conditions and of disability-adjusted life years globally, overweight and obesity have reached pandemic proportions. Their worldwide trend is compounded by the existence of marked social, ethnic, and environmental disparities and by an incomplete understanding of the most helpful and effective interventions that could control or reverse the course of the pandemic. To a great extent, these challenges stem from the contribution of many individual, socioeconomic, nutritional, and environmental factors that determine the risk of obesity and overweight and shape the disparities. This chapter provides a glimpse into a few of these factors; there are many more, and some of them were perhaps not even identified yet. If we contemplate these factors as a group, one of their most salient features is their diversity. Racism and discrimination, social capital, food environments, social networks, access to recreational facilities, and exposure to obesogens are the topics that historically belonged to distinct disciplines yet are now merging into an intricate and dynamic interdisciplinary and cross-disciplinary network of acute medical, public health, and economic relevance. Adding to the present impact of the pandemic, emerging evidence points toward the potential of some of the contributing factors to exert transgenerational effects, indicating that in all likelihood, we have only witnessed the tip of the iceberg for what is increasingly being recognized as one of the biggest medical and public health challenges of our time.

Due to the increase in the chronic kidney disease and transplant population, contraception counseling is essential in preventing unplanned pregnancies during the pre- and post-transplant period. Unintended pregnancy can have devastating effects on both mother and fetus. The physician must work with the patient to find the best method of contraception, taking into account patient preference as well as medical comorbidities. The LNG-IUS is an ideal option for the CKD and transplant patient as it is a first-line method, will help decrease monthly blood loss, and is easily reversible. In addition to the IUD, the ENG-implant is a good progestin-only method due to its high efficacy and ease of use. Individual bleeding patterns may vary but can be treated. Combined hormonal methods may be appropriate on a case-by-case basis, but have higher failure rates. If pregnancy occurs and termination is desired, the decision for an inpatient versus outpatient procedure will depend on the individual’s clinical status. Consultation with a family planning specialist is advised. Most women will not be candidates for medical termination.

Babesiosis, caused predominantly by Babesia microti, is an emerging health risk in the Northeastern and Midwestern United States. We present a case of a pregnant woman with history of splenectomy diagnosed with babesiosis at 23 5/7 weeks of gestational age refractory to antimicrobial therapy. She underwent the first reported red blood cell exchange transfusion for babesiosis in pregnancy, at 24 4/7 weeks of gestational age, which resulted in resolution of parasitemia. She had a full term, uncomplicated cesarean delivery. Exchange transfusion is potentially a safe treatment option for severe babesiosis infection in pregnancy and should be considered when other methods are poorly tolerated or ineffective.

OBJECTIVES To determine whether a novel, noninvasive quantitative ultrasound (US) technique can detect differences in proximal and distal cervical tissue echogenicity in women with and without a shortened cervical length (CL). METHODS We conducted a retrospective case-control study of singleton pregnancies at 16 to 26 weeks' gestation in which a transvaginal US examination was performed to measure CL from 2013 to 2015. Initial CLs in cases and controls were less than 2.5 cm and 2.5 cm or greater, respectively. For each US image, a region of interest was selected in the proximal and distal cervical stroma, in both the anterior and posterior cervical lips. The Floyd-Steinberg dithering algorithm transformed grayscale pixels in each region of interest into a binary map. A histogram tabulated the number of black and white pixels, allowing determination of the percent echogenicity. The difference in the percent echogenicity was calculated by subtracting the distal cervical echogenicity (average of anterior and posterior lips) from the proximal cervical echogenicity (average of anterior and posterior lips). RESULTS Ultrasound images from 177 women were analyzed. There was a difference in the percent echogenicity (P

Spontaneous spinal epidural abscess (SEA) is a rare infection of the central nervous system. We report a case of a 25-year-old G3 P0020 at 36 weeks of gestational age with history of intravenous drug abuse presenting with acute-onset and severe back pain. Despite antibiotic therapy, pain worsened and she developed lower extremity weakness. Magnetic resonance imaging (MRI) revealed an SEA, and cesarean delivery was performed secondary to increasing weakness, followed by laminectomy (T9-12) and decompression of epidural abscess. Postoperative course was complicated by a psoas muscle abscess and persistent SEA refractory to antibiotic therapy, requiring surgical reexploration and extended treatment with antibiotics. She was discharged home in stable condition and neonate did well with no resulting sequelae. Spinal epidural and psoas abscesses are rare and diagnosis is often delayed. Prompt recognition and treatment are necessary to prevent catastrophic neurologic consequences, and the diagnosis should be considered in pregnant patients presenting with back pain, especially in those with risk factors.

Uterine myomas are the most common pelvic tumors in women, diagnosed in approximately 12%-25% of reproductive age women. Most women with symptomatic myomas are between 20 to 40 years, which are prime reproductive years. Surgical myomectomy is performed secondary to infertility as it can significantly improve fecundity. Myomectomy has become increasingly prevalent secondary to minimally invasive techniques, which allow for reduction of blood loss and postoperative pain, decreased hospital stay, and recovery time.

INTRODUCTION:To determine whether there was a cerclage height threshold associated with spontaneous preterm birth in patients with physical exam indicated cerclage (PEIC).METHODS:We performed a retrospective multicenter cohort study of women with a PEIC. Functional cervical length and the cerclage h