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Objective: To review obstetric personnel absences at a hospital during the initial peak of coronavirus disease 2019 (COVID-19) infection risk in New York City from March 25 to April 21, 2020., Study Design: This retrospective study evaluated absences at Morgan Stanley Children's Hospital. Clinical absences for (1) Columbia University ultrasonographers, (2) inpatient nurses, (3) labor and delivery operating room (OR) technicians, (4) inpatient obstetric nurse assistants, and (5) attending physicians providing inpatient obstetric services were analyzed. Causes of absences were analyzed and classified as illness, vacation and holidays, leave, and other causes. Categorical variables were compared with the chi-square test or Fisher's exact test., Results: For nurses, absences accounted for 1,052 nursing workdays in 2020 (17.2% of all workdays) compared with 670 (11.1%) workdays in 2019 ( p  < 0.01). Significant differentials in days absent in 2020 compared with 2019 were present for (1) postpartum nurses (21.9% compared with 12.9%, p  < 0.01), (2) labor and delivery nurses (14.8% compared with 10.6%, p  < 0.01), and (3) antepartum nurses (10.2% compared with 7.4%, p  = 0.03). Evaluating nursing assistants, 24.3% of workdays were missed in 2020 compared with 17.4% in 2019 ( p  < 0.01). For ultrasonographers, there were 146 absences (25.2% of workdays) in 2020 compared with 96 absences (16.0% of workdays) in 2019 ( p  < 0.01). The proportion of workdays missed by OR technicians was 22.6% in 2020 and 18.3% in 2019 ( p  = 0.25). Evaluating attending physician absences, a total of 78 workdays were missed due to documented COVID-19 infection. Evaluating the causes of absences, illness increased significantly between 2019 and 2020 for nursing assistants (42.6 vs. 57.4%, p  = 0.02), OR technicians (17.1 vs. 55.9%, p  < 0.01), and nurses (15.5 vs. 33.7%, p  < 0.01)., Conclusion: COVID-19 outbreak surge planning represents a major operational issue for medical specialties such as critical care due to increased clinical volume. Findings from this analysis suggest it is prudent to devise backup staffing plans., Key Points: · 1) COVID-19 outbreak surge planning represents a major operational issue for obstetrics.. · 2) Inpatient obstetric volume cannot be reduced.. · 3) Staffing contingencies plans for nurses, sonographers, and physicians may be required.., Competing Interests: M.E.D. has had a leadership role in ACOG II's Safe Motherhood Initiative which has received unrestricted funding from Merck for Mothers. C.G.-B. disclosed receiving an unrestricted research grant paid to the institution by SMFM/AMAG and research funding from NICHD and NHLBI. She also served on a local advisory board for Sera Prognostics. R.M. disclosed receiving honorarium for writing a chapter on TRAP sequence for UpToDate. The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Objective: This study was aimed to review 4 weeks of universal novel coronavirus disease 2019 (COVID-19) screening among delivery hospitalizations, at two hospitals in March and April 2020 in New York City, to compare outcomes between patients based on COVID-19 status and to determine whether demographic risk factors and symptoms predicted screening positive for COVID-19., Study Design: This retrospective cohort study evaluated all patients admitted for delivery from March 22 to April 18, 2020, at two New York City hospitals. Obstetrical and neonatal outcomes were collected. The relationship between COVID-19 and demographic, clinical, and maternal and neonatal outcome data was evaluated. Demographic data included the number of COVID-19 cases ascertained by ZIP code of residence. Adjusted logistic regression models were performed to determine predictability of demographic risk factors for COVID-19., Results: Of 454 women delivered, 79 (17%) had COVID-19. Of those, 27.9% ( n  = 22) had symptoms such as cough (13.9%), fever (10.1%), chest pain (5.1%), and myalgia (5.1%). While women with COVID-19 were more likely to live in the ZIP codes quartile with the most cases (47 vs. 41%) and less likely to live in the ZIP code quartile with the fewest cases (6 vs. 14%), these comparisons were not statistically significant ( p  = 0.18). Women with COVID-19 were less likely to have a vaginal delivery (55.2 vs. 51.9%, p  = 0.04) and had a significantly longer postpartum length of stay with cesarean (2.00 vs. 2.67days, p  < 0.01). COVID-19 was associated with higher risk for diagnoses of chorioamnionitis and pneumonia and fevers without a focal diagnosis. In adjusted analyses, including demographic factors, logistic regression demonstrated a c-statistic of 0.71 (95% confidence interval [CI]: 0.69, 0.80)., Conclusion: COVID-19 symptoms were present in a minority of COVID-19-positive women admitted for delivery. Significant differences in obstetrical outcomes were found. While demographic risk factors demonstrated acceptable discrimination, risk prediction does not capture a significant portion of COVID-19-positive patients., Key Points: · COVID-19 symptoms were present in a minority of COVID-19-positive women admitted.. · COVID-19 symptomatology did not appear to differ before or after the apex of infection in New York.. · Demographic risk factors are unlikely to capture a significant portion of COVID-19-positive patients.., Competing Interests: M.D. has had a leadership role in American College of Obstetrics and Gynecology (ACOG) II's Safe Motherhood Initiative which has received unrestricted funding from Merck for Mothers. C.G.-B. disclosed receiving money paid to her institution from Society for Maternal Fetal Medicine (SMFM)/AMAG Pharmaceuticals. She also received funding from Sera Prognostics and various funds for medicolegal work. She also disclosed receiving National Institute of Health (NIH) grants. R.M. disclosed receiving honorarium for writing a chapter on twin reversed arterial perfusion syndrome sequence for UpToDate. He received funds for medicolegal consulting (cases entirely unrelated to the topic of this study). The other authors did not report any potential conflicts of interest., (Thieme. All rights reserved.)

Objective: To characterize symptoms and disease severity among pregnant women with coronavirus disease 2019 (COVID-19) infection, along with laboratory findings, imaging, and clinical outcomes., Methods: Pregnant women with COVID-19 infection were identified at two affiliated hospitals in New York City from March 13 to April 19, 2020, for this case series study. Women were diagnosed with COVID-19 infection based on either universal testing on admission or testing because of COVID-19-related symptoms. Disease was classified as either 1) asymptomatic or mild or 2) moderate or severe based on dyspnea, tachypnea, or hypoxia. Clinical and demographic risk factors for moderate or severe disease were analyzed and calculated as odds ratios (ORs) with 95% CIs. Laboratory findings and associated symptoms were compared between those with mild or asymptomatic and moderate or severe disease. The clinical courses and associated complications of women hospitalized with moderate and severe disease are described., Results: Of 158 pregnant women with COVID-19 infection, 124 (78%) had mild or asymptomatic disease and 34 (22%) had moderate or severe disease. Of 15 hospitalized women with moderate or severe disease, 10 received respiratory support with supplemental oxygen and one required intubation. Women with moderate or severe disease had a higher likelihood of having an underlying medical comorbidity (50% vs 27%, OR 2.76, 95% CI 1.26-6.02). Asthma was more common among those with moderate or severe disease (24% vs 8%, OR 3.51, 95% CI 1.26-9.75). Women with moderate or severe disease were significantly more likely to have leukopenia and elevated aspartate transaminase and ferritin. Women with moderate or severe disease were at significantly higher risk for cough and chest pain and pressure. Nine women received ICU or step-down-level care, including four for 9 days or longer. Two women underwent preterm delivery because their clinical status deteriorated., Conclusion: One in five pregnant women who contracted COVID-19 infection developed moderate or severe disease, including a small proportion with prolonged critical illness who received ICU or step-down-level care.

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.., Competing Interests: M.E.D. has had a leadership role in the American College of Obstetricians and Gynecologists II's Safe Motherhood Initiative which has received unrestricted funding from Merck for Mothers. The other authors did not report any potential conflicts of interest., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease)., (© 2020 Elsevier Inc. All rights reserved.)

Maternal morbidity and mortality have gained major attention recently, spurred on by rising domestic rates even as maternal mortality decreases in Europe. A major driver of morbidity and mortality among delivering women is postpartum hemorrhage (PPH). PPH is currently phenotyped using the subjective measure of 'Estimated blood loss' (EBL), which has been shown to be unreliable for tracking quality. Here we present a framework for phenotyping PPH into multiple severity levels, using a combination of data-driven techniques and expert-derived clinical indicators. We validate the framework by predicting large drops in hematocrit and quantitative blood loss, finding that the framework performs better in predicting coded PPH than a hematocrit-based predictor or predictors based on other metrics such as blood transfusions, and does better in predicting quantitative blood loss, a gold standard metric for blood loss that we have for a subset of patients, than any predictor we could build using hematocrit drops alone. In all, we present a principled framework that can be used to phenotype PPH in hospitals using readily available EHR data, and that will perform with more granularity and accuracy than existing methods., (©2019 AMIA - All rights reserved.)

Objectives To identify risk factors associated with urban postpartum emergency department utilization. Methods This case-control study included 100 matched pairs of postpartum women who had delivered at a large, integrated urban medical system in Bronx, New York, in 2012-2013, with the cases having had an emergency department visit within 42 days of delivery. The cases, identified utilizing administrative and billing data, were matched 1:1 with controls by labor unit, delivery mode and date, excluding nonviable pregnancies. The controls did not have a known postpartum emergency department visit. Variables were abstracted from administrative data and chart review, and included demographics, antenatal/intrapartum/postpartum complications and neonatal intensive care unit admission. Factors associated with puerperal emergency department use were identified via univariate and multivariable analyses. Results Following conditional logistic regression, primiparity [54% vs. 32%, aOR 5.91, 95% CI 2.34-14.91], public insurance [70% vs. 56%, aOR 4.22, 95% CI 1.60-11.12], weekend delivery [30% vs. 26%, aOR 7.61, 95% CI 1.15-52.43] and delivery-related complications [47% vs. 28%, aOR 2.95, 95% CI 1.16-7.51] were associated with an increased risk of postpartum emergency department use, while women of younger ages (17-24 years old) were less likely to have postpartum emergency department use [aOR 0.23, 95% CI 0.07-0.74]. Univariate analysis of individual events within the composite variables showed an association between gestational hypertension/pre-eclampsia and postpartum emergency department use [28% vs. 13% OR 2.60, 95% CI 1.26-5.39]. Psychiatric history, social instability, preterm delivery/neonatal intensive care unit admission, pre-existing medical/antepartum conditions and prolonged postpartum stay were not associated. Conclusions for Practice Delivery-related complications, delivery timing, and certain sociodemographic factors are identifiable risk factors for increased postpartum emergency department utilization. These may be targeted for development of interventions improving puerperal care and potentially preventing emergency department visits, which are costly to the health system and disruptive to the lives of women and their families.