Perinatal Outcomes Associated With Institutional Changes Early in the COVID-19 Pandemic.

OBJECTIVE: Many institutions implemented policy changes to protect patients and clinicians during the COVID-19 pandemic. This study examines how institutional policy changes and patient behaviors affected perinatal outcomes. We hypothesized that obstetric practice changes occurred and that these changes affected perinatal outcomes. METHODS: We conducted a retrospective cohort study of singleton pregnancies delivered at a single institution with low incidence of COVID-19. Deliveries occurring from December 15, 2019 through March 14, 2020 were designated as the pre-COVID-19 group. Those occurring from March 15, 2020, through June 15, 2020, were designated the COVID-19 group. The primary outcome is a perinatal composite defined as delivery ≥ 41 weeks, hypertensive disorder of pregnancy at term, unplanned Cesarean delivery, term neonatal intensive care unit admission, 42-day maternal readmission, and 7-day neonatal readmission. Additional maternal, neonatal, and delivery composites also were analyzed, and we evaluated all individual outcomes secondarily. RESULTS: Of 2,268 deliveries, 1,210 occurred during the COVID-19 period. Four of the 1,210 (0.3%) were diagnosed with COVID-19. Women during the COVID-19 period were more likely to present in spontaneous labor and less likely to undergo induction. Maternal and neonatal length of stay was also shorter. There was no difference in the perinatal composite between the 2 groups (36.3% vs 36.7% [OR 1.05; 95% CI, 0.86-1.21]). There was a significant increase in deliveries occurring at or after 41 weeks (4.7% vs 6.9% [OR 1.83; 95% CI, 1.00-3.34]). There was no difference in maternal, neonatal, and delivery composites or the outcomes assessed individually. CONCLUSIONS: We demonstrated significant changes in clinical practice secondary to policy changes and patient behaviors during the COVID-19 pandemic. As an institution that globally adopted ARRIVE (A Randomized Trial of Induction Versus Expectant Management) practices, we noted fewer inductions, more women presenting in labor and more women delivering at or after 41 weeks. We also noted a shorter length of hospital stay for the mother-baby dyad. Overall, these changes in clinical practice did not affect perinatal outcomes.

Dose of aspirin to prevent preterm preeclampsia in women with moderate or high-risk factors: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of aspirin dose on the incidence of all gestational age preeclampsia and preterm preeclampsia. DATA SOURCES: Electronic databases (Cochrane, PubMed, Scopus, ClinicalTrials.gov and the Web of Science) were searched for articles published between January 1985 and March 2019 with no language restrictions. METHODS: We followed the PRIMSA guidelines and utilized Covidence software. Articles were screened by 2 independent reviewers, with discrepancies settled by an independent 3rd party. Study selection criteria were randomized trials comparing aspirin for prevention of all gestational age and preterm preeclampsia to placebo or no antiplatelet treatment in women aged 15-55 years with moderate or high-risk factors according to the list of risk factors from American College of Obstetricians and Gynecologists and United States Preventive Services Task Force guidelines. The quality of trials was assessed using the Cochrane risk of bias tool. The data were pooled using a random-effects meta-analysis comparing aspirin at doses of <81, 81, 100, and 150 mg. Pre-specified outcomes were all gestational age and preterm preeclampsia. RESULTS: Of 1,609 articles screened, 23 randomized trials, which included 32,370 women, fulfilled the inclusion criteria. In preterm preeclampsia, women assigned at random to 150 mg experienced a significant 62% reduction in risk of preterm preeclampsia (RR = 0.38; 95% CI: 0.20-0.72; P = 0.011). Aspirin doses <150 mg produced no significant reductions. The number needed to treat with 150 mg of aspirin was 39 (95% CI: 23-100). There was a maximum 30% reduction in risk of all gestational age preeclampsia at all aspirin doses. CONCLUSIONS: In this meta-analysis, based on indirect comparisons, aspirin at a dose greater than the current, recommended 81 mg was associated with the highest reduction in preterm preeclampsia. Our meta-analysis is limited due to the deficiency of homogeneous high evidence data available in the literature to date; however, it may be prudent for clinicians to consider that the optimal aspirin dose may be higher than the current guidelines advise. Future research to compare the efficacy aspirin doses greater than 81 mg is recommended. STUDY REGISTRATION: PROSPERO, CRD42019127951 (University of York, UK; http://www.crd.york.ac.uk/PROSPERO/).

Use of dexamethasone, remdesivir, convalescent plasma and prone positioning in the treatment of severe COVID-19 infection in pregnancy: A case report.

Severe infection with COVID-19 virus in pregnancy offers unique management challenges for the obstetrician and critical care specialist. We report the case of a woman at 26 weeks of gestation with acute respiratory distress syndrome secondary to COVID-19 infection treated with dexamethasone, remdesivir, convalescent plasma and mechanical ventilation. Cesarean delivery was performed at 29 weeks due to worsening maternal status. This case offers insight into the assessment and successful use of treatment strategies, including dexamethasone, remdesivir, convalescent plasma, early prone positioning, conservative fluid management, permissive hypoxia and low tidal volume parameters with ventilator support for pregnancies affected by severe COVID-19 infection.