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. 

Maternal COVID-19 infection and placental abnormality

Researchers from Northwestern University Feinberg School of Medicine say that women who have children at home may be at higher risk of severe coronavirus 2 infection (commonly known as COVID-19) in pregnancy. The finding, from a retrospective cohort study, persisted even after controlling for confounders.

American Journal of Obstetrics and Gynecology MFM

 the data reflect outcomes in women who delivered or intended to deliver at Northwestern Memorial Hospital between April 8, 2020 and May 31, 2020. The women were dichotomized by whether they had COVID-19 infection.

Of 1,418 women who met inclusion criteria, 7.1% (101) tested positive for COVID-19 and 76.2% (77) of whom had symptoms at diagnosis. Because some of the patients were recruited during a time interval where only women with symptoms were tested, this rate of severe symptoms cannot be extrapolated to the general pregnant population. 

Compared with women who had a negative test result for COVID-19, those who were positive were more likely to:

Identify as Black, African-American or Latin

Compared with women with no living children, those with living children had higher odds of testing positive for COVID-19, and the risk increased with the number of children: 1 child, odds ratio (OR) 2.5; 95% confidence interval (CI) 1.5 to 4.0; 2 living children, OR 2.1; 95% CI 1.0 to 4.1; 3 living children, OR 4.1; 95% CI 1.6 to 10.5; ≥ 4 living children, OR 7.0; 95% CI 2.8 to 17.7.

Having living children still was significantly associated with an increased risk of COVID-19 infection even after adjustment in multivariable analyses for maternal age, insurance, obesity, and pulmonary disease. 

The association was not substantively changed when the model included all other variables significantly associated with COVID-19 infection (adjusted OR, 2.298; 95% CI 1.11 to 4.74). There was no significant effect modification between race or ethnicity and number of living children with respect to COVID-19 infection.

The authors speculate that the “number of living children may reflect a higher household density, independent of children themselves being a vector. This may inhibit ability of pregnant women to follow social distancing and isolate children infected with SARS-CoV-2. Finally, residential segregation by race or ethnicity may also contribute to disparities in SARS-CoV-2 prevalence.”

Sakowicz A, Ayala AE, Ukeje CC, et al. Risk factors for severe acute respiratory syndrome coronavirus 2 infection in pregnant women.

Researchers from Northwestern University Feinberg School of Medicine say that women who have children at home may be at higher risk of severe COVID-19 in pregnancy. 

Having children at home and risk of COVID-19 in pregnancy

The first-of-its-kind analysis, done in a small sample of pregnant patients, shows that placenta-specific DNA increases prior to clinical development of gestational diabetes and that cell-free RNA (cfRNA) has a high positive predictive ability in detection of APOs.

 the results are from a study funded by the National Institute of Child Health and Human Development’s Human Placenta Project, a collaborative effort aimed at understanding the role of the placenta in health and disease. The study of cell-free DNA (cfDNA) methylation and transcriptomic signature prediction was led by researchers from UCLA.

For the analysis, the authors applied a method developed to deconvolute trace amounts of tumor DNA from the plasma background and extended it to extremely low-coverage sequencing data. 

They used the method, along with RNA sequencing, to test the hypothesis that cfDNA and cfRNA in maternal circulation may correlate with placental health and could be employed to differentiate between gestational disorders and normal, complication-free gestation.

DNA sequencing technique may help prenatally detect NIHF

The participants were women in their first trimester from February 2017 to 2019 who were enrolled in the PARENTS prospective cohort study, which is looking at mechanisms for and prediction of APOs. Of the 160 subjects in that study who have delivered, 61 had APOs.

The present placenta-specific DNA research included nine women with normal pregnancies, five with preeclampsia, three with gestational hypertension, and seven with gestational diabetes mellitus (GDM). 

GDM was defined as any degree of glucose intolerance initially recognized in pregnancy. Preeclampsia was defined as blood pressure ≥140/90 on two occasions at least 4 hours apart after 20 weeks’ gestation with a previously normal blood pressure and proteinuria of 300 mg for ≥24 hours.

Five different samples were taken from each subject at time points from 12 to 17 weeks, 18 to 22 weeks, 35 to 37 weeks, at delivery, and from cord blood. Plasma was also collected from seven women who served as controls.

The authors found that the placental fraction in GDM significantly increased compared with normal pregnancies in the first trimester and the trend persisted through the second and third trimesters, although it was not statistically significant. 

Early detection of a difference between pregnancies with GDM (mean 7.2%) and that were normal (mean 4%) based on the placental fraction, the researchers said, is of interest for future development of predictive biomarkers.

Non-placental tissue-of-origin, namely pancreatic cfDNA fraction, also was significantly increased only in the first trimester in subjects who went on to develop GDM. Pancreatic cfDNA also increased in the GDM cord blood, perhaps signaling future pancreatic dysregulation in the offspring.

The authors used cfRNA sequencing information from the first trimester to identify candidate biomarkers for detection of likelihood of developing APOs. 

A logistic regression model showed that upregulation of the genes 

 was associated with APOs as were upregulation of 

. The classifier had a positive predictive value of 0.91 for APOs, 0.86 for preeclampsia alone, and 0.64 for GDM.

Taking these results together, the researchers “presented cfDNA methylation signatures and transcriptomic signatures early in gestation that collectively could potentially assist in the prediction of subsequent development of APOs, prior to emergence of characteristic clinical features.” 

Their findings, the authors said, point to a need for a larger multicenter clinical trial and suggest that “these non-invasive approaches may be used effectively early in gestation.”

Del Vecchio G, Li Q, Li W, et al. Cell-free DNA methylation and transcriptomic signature prediction of pregnancies with adverse outcomes. 

. Published online: 13 Oct 2020 doi: 10.1080/15592294.2020.1816774

New research suggests that placental DNA may have potential as a biomarker for adverse pregnancy outcomes (APOs). 