a BELS-certified medical writer and editor, and an editorial consultant for 

Judith M. Orvos, ELS

Sarah Rae Easter, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, and Carolyn M. Zelop, MD, Director of Ultrasound, Fetal Echocardiography and Perinatal Research, The Valley Hospital, Ridgewood, NJ, and Clinical Professor of Ob/Gyn, NYU School of Medicine, New York, New York.

In this protocol, Easter and Zelop review the clinical presentation and diagnosis of peripartum cardiomyopathy, the pathogenesis of peripartum and other cardiomyopathies, and stabilization and treatment. Included is information on immediate management of peripartum cardiomyopathy, considerations for location and timing of delivery, perspective on chronic therapy and long-term follow-up, and pearls for the obstetric care provider.

Crackles or rales, systolic or diastolic murmur, or extra heart sounds such as an S3 or S4 should heighten concern for peripartum cardiomyopathy. Evaluation includes chest x-ray and an electrocardiogram. Abnormal results, or normal results on either plus an atypical history or physical exam, warrant further investigation.

The clinical presentation of peripartum cardiomyopathy is most often that of decompensated left-sided heart failure but right-sided dysfunction also can be present.

Common risk factors for peripartum cardiomyopathy are maternal age > 30 years, African descent, multiple gestation, and history of hypertension or preeclampsia.

Immediate management of peripartum cardiomyopathy is focused on optimization of preload, typically with diuretics, afterload reduction, and supportive care. Cardiac telemetry, continuous fetal monitoring, and close urine output monitoring with placement of a urethral catheter are warranted.

Delivery is recommended for patients with unstable peripartum cardiomyopathy but timing depends on the gestational age of the fetus. An attempted vaginal delivery is recommended for patients without an obstetric contraindication with consideration of cesarean delivery for causes of acute decompensated heart failure.

With medical therapy (i.e. beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretics) 50% to 80% of women with peripartum cardiomyopathy ultimately recover to an ejection fraction > 50% at 6 months. Those with a left ventricular ejection fracture < 50% should be advised against pregnancy. 

Watch an interview with Queenan and Spong here.

Articles

Snapshot: Protocol 18 - Peripartum Cardiomyopathy

Protocols for High-Risk Pregnancies, 7th Edition: Snapshot: Protocol 18 - Peripartum Cardiomyopathy

 George A. Macones, MD, Division of Maternal-Fetal Medicine, Dell Medical School-University of Texas at Austin and Robert B. Gherman, MD, Division of Maternal-Fetal Medicine, WellSpan Health System, York, PA.

 In this protocol, Macones and Gherman reviews the pathophysiology, diagnosis, and management of shoulder dystocia. Included are descriptions of extraordinary movements and a list of documentation suggested when a shoulder dystocia is encountered.

Protocols for High-Risk Pregnancies, 7th Edition

As the authors note, shoulder dystocia is unpredictable and reported incidence varies from 0.2% to 3.0%. Risk does increase with birth weight, but up to 60% of shoulder dystocias occur in infants weighing less than 4000 g and only 3.3% of births with weights greater than 4000 g involve this complication. Episiotomy alone will not release an impacted shoulder and cutting a generous episiotomy or proctoepisiotomy should be based on clinical circumstances.

Prior shoulder dystocia statistically increases risk of recurrence. However, there are no clinically useful positive predictive values for antenatal prediction of the condition.

No randomized clinical trials exist to guide management of shoulder dystocia. Fetal injury is possible with all maneuvers that have been described to relieve it.

Most shoulder dystocias can be relieved within several minutes. Permanent brain injury can occur with a delay as short as 3 to 4 minutes or as long as 15 to 20 minutes. The determining factor is the condition of the fetus at the time of the dystocia.

It is key for the mother to stop pushing when shoulder dystocia is encountered.

The first technique used to alleviate the condition is usually the McRoberts maneuver. Suprapubic pressure also can be applied in conjunction with or before it.

If those techniques fail, delivery of the posterior arm is recommended, followed (if necessary) by rotation of the posterior shoulder.

Fundal pressure should not be applied nor should rotation of the fetal head. Traction should be downward and axial, in alignment with the fetal cervico-thoracic spine.

“Rescue” techniques for shoulder dystocia include the Gaskin maneuver, axillary traction, and the Zavanelli maneuver. Abdominal rescue should rarely be used.

Read the complete chapter on shoulder dystocia from 

, edited by John T. Queenan, MD, Catherine Y. Spong, MD, and Charles J. Lockwood, MD, MHCM, 

Protocols for High-Risk Pregnancies: An Evidence-Based Approach, 7th Edition

Snapshot: Protocol 56 - Shoulder Dystocia

Protocols for High-Risk Pregnancies, 7th Edition: Shoulder Dystocia

A retrospective study by researchers from Cedars-Sinai Medical Center in Los Angeles of the impact of COVID-19-driven changes in Labor and Delivery (L&D) protocols shows that shortening lengths of stay (LOS) was safe for both mothers and their babies. The results reflect experience with both vaginal and cesarean deliveries early in the pandemic, in comparison with similar periods in 2018 and 2019.

Beginning in March 2020, in response to COVID-19, Cedars-Sinai modified its L&D practices to reduce risk of infection to patients and staff. Among the measures instituted were:

Permitting no visitors during the hospital stay for mothers admitted with or suspected to have COVID-19;

Allowing COVID-19-negative mothers to have only one support person during delivery and no visitors postpartum (after April 20, 2020, a single support person was allowed postpartum for COVID-19-negative mothers);

Advising COVID-19-positive mothers or those undergoing testing for it to be temporarily separated from their newborns after delivery; and

Recommending protective measures, such as isolette care in the room and gloving and masking during handling of the newborn, to COVID-19-positive mothers or those undergoing testing who did not want to be temporarily separated from their newborns after delivery.

During the period of study—January 1, 2020 to April 30, 2020—1,936 deliveries occurred: 1,016 before the changes were made and 920 after. Only two COVID-19 laboratory test-positive cases occurred during the study period, both of which were removed from the LOS analysis.

Postpartum LOS was significantly shorter after implementation of the COVID-19-driven measures. Of the patients treated post-implementation, 48.5% had a one-night stay after vaginal delivery, versus 24.9% in the preimplementation group (

 < .0001). Among those who delivered by cesarean, 40.9% had an LOS of two nights or less postimplementation, versus 11.8% preimplementation (

Reviewing newborn care, the authors found that 49.0% delivered vaginally were discharged home after one night in the post-implementation group versus 24.9% in the preimplementation group (

 < .0001). A similar trend was seen in association with cesarean delivery: 42.5% discharge rate after two nights or less in the post-implementation group vs 12.5% in the preimplementation group (

There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the two groups. Adjustment for month-to-month variation in length of postpartum hospitalization for mothers and newborns showed no significant differences in neonatal or maternal LOS between January to February and March to April in 2018 and 2019, regardless of mode of delivery.

The American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine

, the authors said that “the reasons for this reduction in postpartum length of stay are likely multifactorial but may be attributed partially to changes to our visitor policy…It is likely that the initial restrictions may have motivated patients and providers toward an earlier discharge.”

The researchers said their study “suggests that it is reassuring that these early discharges were not associated with an increased rate of readmissions or postpartum medical complications,” noting that “future studies are needed to determine what long-term effects the shorter stay might have on other outcomes such as maternal health, bonding, and ongoing breastfeeding.”

Greene NH, Kilpatrick SJ, Wong MS, et al. Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

The results of this retrospective study reflect experience with both vaginal and cesarean deliveries early in the pandemic, in comparison with similar periods in 2018 and 2019.

L&D discharge profiles in the wake of COVID-19

If their data are confirmed in future studies, say the authors, long-term neonatal follow-up may be warranted in such patients.

The American Journal of Obstetrics and Gynecology

 the report is from a cohort of women admitted for delivery at ≥37 weeks between March 31, 2020 and June 17, 2020. Placental histopathological findings from 77 women with COVID-19 who delivered a singleton at term were compared to a control group of 56 term patients without COVID-19.

On admission, all of the patients had been tested for COVID-19. None of the controls had obstetrics or medical complications. Multivariable logistic regression models were created for variables that were significant in univariable analyses. A subgroup analysis also was performed to compared women with asymptomatic COVID-19 infection to the controls.

Women with COVID-19 were significantly more likely to be younger (29.9 years vs 32.2 years, 

 = 0.01), and to deliver vaginally (74% vs 25%, 

Of the patients studied, 87% were asymptomatic. In the remainder, any symptoms were mild and included fever, cough, upper respiratory complaints, and shortness of breath. No testing for inflammatory markers or coagulation studies were performed because they were not indicated.

Univariable analyses showed that the placentas of the women with COVID-19 were more likely to have evidence of fetal vascular malperfusion (32.5% vs 3.6%, 

 < 0.0001) and villitis of unknown etiology (20.8% vs 7.1%, 

 = 0.030). These findings persisted in a subgroup comparison of women with asymptomatic COVID-19 versus controls.

Frequency of fetal vascular malperfusion abnormalities remained significantly higher in the COVID-19 group (odds ratio [OR] = 12.63, 95% confidence interval [CI] 2.40-66.40) in a multivariable model that adjusted for maternal age, race/ethnicity, mode of delivery, pre-eclampsia, fetal growth restriction, and oligohydramnios.

Frequency of villitis of unknown etiology was more than double in the placentas of women with COVID-19 versus the controls, but the difference was not statistically significant in a multivariable model (OR = 2.11, 95% CI 0.50-8.97).

All of the infants born to COVID-19-positive mothers tested negative for SARS-CoV-2 on polymerase chain reaction.

Despite the increased rate of placental abnormalities in the COVID-19-positive mothers, their infants had birthweights, rates of neonatal intensive care unit admission, and APGAR scores similar to that in infants of mothers in the control group. 

The authors hypothesized that “this suggests that the placenta may act as a defensive biological ‘filter,’ offering a degree of protection to the neonate, may modify its immune status or may actively produce factors that may protect the fetus in utero.” 

They underscored, however, that there may still be “injury” to the placenta, and noted that the possibility of adverse effects in the neonates points to a need for follow-up in these cases for long-term side effects.

Patberg ET, Adams T, Wek PR, et al. COVID-19 infection and placental histology in women delivering at term. 

. Published: October 19, 2020. doi: https://doi.org/10.1016/j.ajog.2020.10.020

Findings from a retrospective study by researchers from NYU suggest that women with COVID-19 in pregnancy have an increased risk of placental abnormalities, regardless of whether their infection is symptomatic. 

Judith M. Orvos, ELS

Articles

Protocols for High-Risk Pregnancies, 7th Edition: Snapshot: Protocol 18 - Peripartum Cardiomyopathy

Protocols for High-Risk Pregnancies, 7th Edition: Shoulder Dystocia

L&D discharge profiles in the wake of COVID-19

Maternal COVID-19 infection and placental abnormality