OBJECTIVE: To characterize clinical management of deliveries resulting in neonatal hypoxic ischemic encephalopathy. DESIGN: Retrospective case series SETTING: Three academic referral medical centers in the United States POPULATION: All neonates ≥35 weeks’ gestation with HIE based on cord blood pH<7.0, base deficit of ≥12.0mmol/L, along with relevant radiological, laboratory, and clinical findings. METHODS: Clinical management was characterized based on whether (i)delivery occurred within 120 minutes of presentation, (ii)delivery occurred due to a sentinel event such as cord prolapse or uterine rupture, and (iii)the fetal heart rate tracing(FHR) demonstrated variability, accelerations, or both upon presentation and in the half hour before delivery. MAIN OUTCOME MEASURES: Relationship of mode of delivery to FHR tracing characteristics at delivery. Obstetric outcomes, labour course and management were analysed. RESULTS: Of 144,904 deliveries, 102 maternal-newborn dyads met criteria. Of these, 19 delivered within 120 of minutes of presentation and four further women experienced a sentinel event. Of the remaining 79, 66(84%) had a FHR tracing on presentation that demonstrated variability, accelerations or both. Of these 66 cases, 27 had a fetal heart tracing that demonstrated variability, accelerations or both in the 30 minutes preceding delivery. CONCLUSION: Approximately two-thirds of cases of HIE occurred in cases where the FHR tracing initially demonstrated variability, accelerations, or both, without a sentinel event and without a condition requiring delivery within 120 minutes of presentation. Of these >40% had variability, accelerations, or both in the half hour before delivery. This suggests additional insights are required to prevent some cases of HIE.

Objective To evaluate relationships between cycle threshold values and COVID-19 presentations and clinical courses in women presenting for childbirth. Cycle threshold values from polymerase chain reaction (PCR) testing are inversely proportional to viral burden and may be important predictors of disease state and infectivity risk. Design Retrospective cohort study Setting Three Yale-New Haven Health Hospitals between 4/2/2020-5/14/2020 Population Women presenting for childbirth who underwent SARS-CoV-2 PCR testing Methods Electronic health records were reviewed for socio-demographics, medical comorbidities, pregnancy and postpartum course, and COVID-19 symptoms and exposures. Records of SARS-CoV-2 positive women were reviewed for symptom onset, duration, and relation to test timing, disease course, and neonatal SARS-CoV-2 results. Main Outcome Measures SARS-CoV-2 real-time PCR cycle threshold values from positive tests were compared between asymptomatic and symptomatic women and in relation to disease severity. In women with symptomatic COVID-19, cycle threshold values were evaluated as a function of time since symptom onset. Results 1,210 women gave birth during the study period with 84 (6.9%) positive for SARS-CoV-2. Higher cycle threshold values were seen in asymptomatic SARS-CoV-2 positive patients (8/38 (21.1%) of asymptomatic women had cycle threshold <30 compared to 22/32 (68.0%) of symptomatic women, p<0.0001). In symptomatic women, values increased as time from symptom onset increased. Conclusion This study demonstrates higher cycle threshold values in asymptomatic patients and symptomatic patients tested remote from symptom onset, signifying older infections and detection of lower levels of viral RNA. Assessment of standardized cycle threshold values may help to understand disease characteristics and progression.