Italian adolescents after the pandemic in the Istituto Superiore di Sanita - the National Institute of Health in Italy - snapshot: first results from the HBSC 2022 surveillance

The international multicentre study HBSC (Health Behaviour in Schoolaged Children) conducted since 1983 in collaboration with the World Health Organization, has been adopted in our country as the national adolescent health surveillance system since 2017. The main aim is to describe and understand health-related behaviour in 11-, 13- and 15-year-olds in approximately 50 countries between Europe and North America. The study investigated different aspects, such as nutrition, risk behaviors, school and family life and social media use. In addition, the latest survey involved 17-year-old adolescents and included a section on the impact of the COVID-19 pandemic.

COVID-19 in pregnancy may significantly affect fetal growth

Objective. Whilst most cases of COVID-19 in pregnancy evolve uneventfully, some others have a poor outcome, such as preterm birth and HDP. The effect of COVID-19 on fetal growth still has to be addressed and appears controversial. Our study aims to focus on fetal growth velocity across the trimesters in pregnancy affected with COVID-19. Materials and Methods. This is a multicentric prospective observational study on data from COVID-19 pregnancies referred to the centers of Careggi University Hospital and S. Stefano Hospital in Prato from 2020 to 2022, included in the local branch of ItOSS surveillance. Fetal growth was evaluated across the three trimesters of pregnancy by abdominal circumference (AC) and expected fetal weight (EFW). Both AC, and EFW plus birthweight were used to calculate growth velocity (Vannuccini et al., 2017). Results. Data from a cohort of 211 cases was collected. The majority (80%) of COVID-19 cases occurred in the third trimester. Of note, the percentage of gestational diabetes (12.3%) and preterm births (7.1%) was comparable to the general population. Mean birthweight was 3259 +/- 509 g. The percentage of cesarean sections was acceptable (13.7%). Concerning the velocity of growth, AC decreased from the second to third trimester to reach values < 10th centile in 24% of cases and < 5th percentile in 17% of cases, even in presence of 2% of hypertensive disorders (HDP). Fetal growth restriction according to Gordjin et al. (2015) was antenatally identified in 4.7% of cases. Fetal growth > 95th centile occurred in 5.7% of cases. At birth, the cumulative percentage of small for gestational age newborns defined as birth weight < 2500 g resulted 5.2%. A significant percentage of newborns required NICU assistance (7.8%). Conclusions. Regardless of the association and prevalence of preterm birth, SGA and HDP in pregnant women, fetal growth appears to be affected by COVID-19 with a higher incidence of impaired growth velocity compared to the general population.

Third level care experience during SARS-CoV-2 pandemic

Objective. As the SARS-CoV-2 Pandemic has widely changed pregnancy experience and assessment, the inpatient and outpatient services have had to be re-organized. Since March 2020, Careggi University Hospital (CUH) has provided a dedicated COVID-pathway: spaces for women with unknown swab status and a COVID-19 ward delivery room. The aim of this study is to analyze the inpatient and outpatient COVID-19 related activities in CUH. Materials and Methods. We prospectively collected data from consecutive COVID-19 pregnancies referred from 2020 to 2022, included in the local branch of the ItOSS surveillance. All patients experienced COVID-19 in pregnancy at various stages of severity and gestational ages. Results. From March 2020 to June 2022, 165 COVID-19 deliveries occurred (169 newborns), while 16 pregnant positive women were admitted without delivering. A single emergency C-section (CS) was performed because of Sars-CoV-2 related ARDS, 15 women experienced serious maternal morbidity and 5 needed ECMO. A single maternal death occurred four months after delivery (C-section). Considering ECMO supported cases during pregnancy or postpartum, the first one tested positive for COVID-19 during the second trimester. She developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a CS at term was performed following obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation and experienced a precipitous vaginal delivery at 31 weeks+6 days of gestation while on ECMO. She was discharged 1 month later in good general conditions. The third patient was an obese (BMI 38) 43-year-old woman who had performed an IVF with embryo donation;she tested positive at 38 weeks+2 days of gestation. A CS was performed because of the worsening of her condition. After the delivery she was admitted in ICU and she underwent ECMO. She died 143 days after the CS by sepsis and multiple organ failure (MOF). For all these pregnancies neonatal outcomes were positive. No perinatal death occurred and only one baby tested positive for SARS-CoV-2 infection at nasal swab sampling (case 3). The anesthesiology team performed neuroassial analgesia intrapartum in all the positive women who needed/requested it. Monoclonal Antibodies (mAbs) have been widely used to treat mild to moderate COVID-19 outpatients (NIH and RCOG recommendations) at risk for developing severe disease. Regarding this specifical therapy, an essential role in the management of the pregnant outpatient was played by the Infectious Disease Department. All patients above 28 weeks requiring hospitalization received LMWH prophylaxis, which was administrated under 28 weeks only in presence of additional risk factors (obesity, IVF, etc.). All new mothers received a ten days LMWH prophylaxis. On the outpatient side, we performed 22 teleconsultations, 43 obstetric ultrasounds (including I trimester screening), 90 obstetric checks with clinical evaluation and home therapy management, 32 fetal monitoring and 47 naso-pharingeal swabs. Conclusions. At Careggi Hospital Maternal Department an extensive re-organization of inpatient and outpatient services has been performed in order to guarantee good practice and management of all pregnant women during the SARS-CoV-2 pandemic. This was only possible thanks to a wide multidisciplinary group which enhanced every professional.

Placental Dysmaturity within a Large Cohort of SARS-CoV-2-Positive Pregnant Women

Background. From 25 February 2020 to 30 June 2021, experienced perinatal pathologists examined 975 placentas, macroscopically and microscopically, of SARS-CoV-2- positive mothers enrolled in a national prospective study, adopting the Amsterdam Consensus Statement protocol. The main results included the absence of specific pathological findings for SARS- CoV-2 infections, even though a high proportion of placentas showed signs of inflammation, including chorioamnionitis, funisitis, villitis, chronic histiocytic intervillositis, and fibrin deposition. In this further analysis, we focused our attention on placental maturity in SARS-CoV-2 infection as, according to recent literature, this feature has scarcely been considered. Method(s): All the maternal and placental data were collected by an online database system. Placental maturation was evaluated in 975 placentas from SARS-CoV-2 positive pregnant women according to the onset of maternal infection. Gestational age (GA) at the time of infection included placentas less than 14 weeks up to 41, but pathological analyses were carried out at delivery, in the third trimester. Parenchymal maturation was classified as follows: consistent with GA, immature, dysmature (also known as delayed villous maturation), and hypermature (or accelerated villous maturation). Incidence of maternal diabetes was also calculated as may affect placental maturation. Result(s): Among 975 placentas, 29 cases were missing (data not inserted by pathologists). On the whole, placental maturation was consistent with GA in 686 cases, immature in 77, hypermature in 48, and dysmature in 135. According to the gestational age at which SARS-CoV-2 infection was diagnosed, the results were as follows: - < 14 weeks: 27 placentas consistent with GA, 2 immature, 4 hypermature, 5 dysmature - 14-27 weeks: 95 placentas consistent with GA, 10 immature, 6 hypermature, 22 dysmature - >=28 weeks: 559 placentas consistent with GA, 65 immature, 38 hypermature, 107 dysmature Incidence of maternal diabetes was quite low in any kind of placental maturation, as reported below: - Immature: 1 / 77 (1.3%) - Consistent with GA: 8/686 (1.2%) - Hypermature: 2/48 (4.2%) - Dysmature: 4/135 (3%) Conclusion(s): In our population, 260/975 cases (26.7%) presented abnormal placental maturation, and among them, about a half (135/260), showed dysmaturity. According to maternal GA at onset of infection, anomalous development was mainly diagnosed after 28 weeks. Incidence of maternal diabetes was very low and unlikely correlated with the histological findings. If SARS-CoV-2 infection plays a role in determining placental abnormal maturation, or instead, if this anomaly may be a permissive feature to the virus, has yet to be investigated.

Coronavirus and birth in Italy: results of a national population-based cohort study

Introduction: The study was implemented to provide guidance to decision-makers and clinicians by describing hospital care offered to women who gave birth with confirmed SARS-CoV-2 infection. Materials and methods: National population-based prospective cohort study involving all women with confirmed SARS-CoV-2 infection who gave birth between February 25 and April 22, 2020 in any Italian hospital.

SARS-CoV-2 infection among hospitalised pregnant women and impact of different viral strains on COVID-19 severity in Italy: a national prospective population-based cohort study.

OBJECTIVE: The primary aim of this article was to describe SARS-CoV-2 infection among pregnant women during the wild-type and Alpha-variant periods in Italy. The secondary aim was to compare the impact of the virus variants on the severity of maternal and perinatal outcomes. DESIGN: National population-based prospective cohort study. SETTING: A total of 315 Italian maternity hospitals. SAMPLE: A cohort of 3306 women with SARS-CoV-2 infection confirmed within 7 days of hospital admission. METHODS: Cases were prospectively reported by trained clinicians for each participating maternity unit. Data were described by univariate and multivariate analyses. MAIN OUTCOME MEASURES: COVID-19 pneumonia, ventilatory support, intensive care unit (ICU) admission, mode of delivery, preterm birth, stillbirth, and maternal and neonatal mortality. RESULTS: We found that 64.3% of the cohort was asymptomatic, 12.8% developed COVID-19 pneumonia and 3.3% required ventilatory support and/or ICU admission. Maternal age of 30-34 years (OR 1.43, 95% CI 1.09-1.87) and ≥35 years (OR 1.62, 95% CI 1.23-2.13), citizenship of countries with high migration pressure (OR 1.75, 95% CI 1.36-2.25), previous comorbidities (OR 1.49, 95% CI 1.13-1.98) and obesity (OR 1.72, 95% CI 1.29-2.27) were all associated with a higher occurrence of pneumonia. The preterm birth rate was 11.1%. In comparison with the pre-pandemic period, stillbirths and maternal and neonatal deaths remained stable. The need for ventilatory support and/or ICU admission among women with pneumonia increased during the Alpha-variant period compared with the wild-type period (OR 3.24, 95% CI 1.99-5.28). CONCLUSIONS: Our results are consistent with a low risk of severe COVID-19 disease among pregnant women and with rare adverse perinatal outcomes. During the Alpha-variant period there was a significant increase of severe COVID-19 illness. Further research is needed to describe the impact of different SARS-CoV-2 viral strains on maternal and perinatal outcomes.

SARS-CoV-2 pandemic and pregnancy: the Italian obstetric surveillance system contribution during the first wave in Italy

Introduction: Since the beginning of the pandemic, the Italian Obstetric Surveillance System (ItOSS) coordinated research activities to support health professionals and decision makers. The aim of this paper is to describe the results of the populationbased prospective study on SARS-CoV-2 infection among pregnant women during the first pandemic wave. Materials and methods: From the end of February 2020, ItOSS launched a prospective population-based cohort study enrolling all SARSCoV- 2 pregnant women admitted to any Italian hospital. Anamnestic and clinical information was collected in a structured form and entered in a web-based secure system by trained clinicians of any maternity unit.

Fetal growth in covid pregnancy: Better than expected?

INTRODUCTION The COVID pandemic has widely affected the pregnancy experience, being a novel risk factor for maternalfetal morbidity/mortality, preterm birth and, as recently hypothesized, preeclampsia. The aim of our study was to investigate the impact of COVID in pregnancy on fetal growth. METHODS Data from ultrasound reports of 73 consecutive pregnancies enrolled in the local ItOSS surveillance on COVID and pregnancy were analyzed. All patients had experienced COVID in pregnancy at various stages of severity. Eight cases were excluded as they did not fit the aim of the study. Fetal abdominal circumference (AC) in 2nd and 3rd trimester were compared for each case, and then with the neonatal birthweight, in order to clarify the possible presence of growth defects/accelerations. RESULTS No case of AC <10° centile was reported neither in the 2nd nor in the 3rd trimester. Interestingly, the percentage of SGA at birth was 5.6%. The same percentage of neonates had pH <7.10 at birth. Only one case presented an AC drop >40 centiles. LGA neonates, with AC >90° centile, accounted for 22.5%, including 8.4% of cases that presented an acceleration of growth velocity from 2nd to 3rd trimester. During the 3rd trimester to birth interval, we observed 8.4% of decrease and 2.8% increase of growth velocity, respectively, in terms of percentiles of expected birthweight vs neonatal birthweight. CONCLUSIONS Data about fetal growth in COVID pregnancies are overall encouraging. No case of defined FGR was observed. Conversely, acceleration of growth from 2nd to 3rd trimester was higher than expected. This may be accountable on poor metabolic status due to the prolonged use of corticosteroids or on lack of regular glycemic screening/nutrition due to pandemic.

Childbirth Care among SARS-CoV-2 Positive Women in Italy

The new coronavirus emergency spread to Italy when little was known about the infection's impact on mothers and newborns. This study aims to describe the extent to which clinical practice has protected childbirth physiology and preserved the mother-child bond during the first wave of the pandemic in Italy. A national population-based prospective cohort study was performed enrolling women with confirmed SARS-CoV-2 infection admitted for childbirth to any Italian hospital from 25 February to 31 July 2020. All cases were prospectively notified, and information on peripartum care (mother-newborn separation, skin-to-skin contact, breastfeeding, and rooming-in) and maternal and perinatal outcomes were collected in a structured form and entered in a web-based secure system. The paper describes a cohort of 525 SARS-CoV-2 positive women who gave birth. At hospital admission, 44.8% of the cohort was asymptomatic. At delivery, 51.9% of the mothers had a birth support person in the delivery room;the average caesarean section rate of 33.7% remained stable compared to the national figure. On average, 39.0% of mothers were separated from their newborns at birth, 26.6% practised skin-to-skin, 72.1% roomed in with their babies, and 79.6% of the infants received their mother's milk. The infants separated and not separated from their SARS-CoV-2 positive mothers both had good outcomes. At the beginning of the pandemic, childbirth raised awareness and concern due to limited available evidence and led to "better safe than sorry" care choices. An improvement of the peripartum care indicators was observed over time.

Family Care Centres for health protection and promotion of individuals and communities: a reflection at the time of the Coronavirus

The context: among the community health services representing a resource to face the COVID-19 emergency, there are the Family Care Centres (FCCs). A national study coordinated by the Italian National Institute of Health (ISS) and funded by the Italian Ministry of Health, recently described their activities and needs, highlighting a large interregional variability in the number of centres and staff availability. Ante and post-natal care, cervical cancer screening and actions addressed at teenagers are the FCCs strategic activities. The CF in front of COVID-19: despite the need to limit the offer of care to the services that cannot be postponed during the lockdown, many FCCs have been exemplary in promptly reorganizing activities in the new context. The paper presents a selection of experiences carried out from March to June 2020 by some FCCs in different Italian Regions concerning FCCs strategic activities. Conclusions: the combined reading of some of the results of the ISS study and of the activities implemented during the COVID-19 pandemic offers a measure of the ability of the FCCs to respond to the needs of the community and to adapt to change. These services based on an innovative health model deserve enhancement and support.