ABSTRACT
Background: Monash Health implemented a new telehealth-integrated antenatal care schedule in March 2020, in response to the COVID-19 pandemic. Given ever-increasing healthcare costs, new interventions must be evaluated to ensure value for money. Method(s): We conducted a retrospective comparative cost analysis from the health service and patient perspective. Women with a singleton pregnancy who received antenatal care and gave birth at Monash Health from 1 January 2018 to 22 March 2020 (pre-telehealth) and 20 April 2020 to 31 December 2021 (post-telehealth) were included. We generated propensity score matched pre- and post-telehealth cohorts, balancing baseline characteristics and comorbidities. We assigned costs for all episodes of care at Monash Health and calculated the average cost per birth in each cohort. Travel costs were estimated using the average travel distance and time. Result(s): Matched pre- and post-telehealth cohorts (both n = 13 534) were generated from the pre-telehealth ( n = 18 628) and post-telehealth ( n = 14 137) populations. We found an AU$122 increase per birth, for a total cost of AU$12 069 per birth post-telehealth. This was mainly driven by an AU$188 per birth increase in outpatient costs, associated with an extra half an appointment per birth, but offset by an AU$99 per birth decrease in patient travel costs. Differences in clinical outcomes are described in Table 1. Conclusion(s): Telehealth-integrated antenatal care enabled the health service to provide safe, ongoing care for more complex pregnancies during the pandemic for only a minimal cost increase. The results highlight the need for more research into obstetric telehealth, including more comprehensive valuations of benefits and costs to all stakeholders.
ABSTRACT
Background: Melbourne's 2020 pandemic lockdown was associated with an increase in stillbirths and a reduction in preterm births (PTB) among singleton pregnancies. Twin pregnancies may be particularly susceptible due to higher background risk. We aimed to compare the rates of adverse pregnancy outcomes in twin pregnancies exposed and unexposed to Melbourne's lockdown. Method(s): Multicentre retrospective cohort study of all twin pregnancies > 20 weeks birthing in all 12 public maternity hospitals in Melbourne. Multivariable log-binominal regressions were used to compare outcomes between a pre-pandemic control group ('unexposed') independently with two lockdown-exposed groups: exposure 1 from 22 March 2020 to 21 March 2021 (pre-vaccination era) and exposure 2 from 22 March 2021 to 27 March 2022 (vaccination era). Result(s): We included 2259 pregnancies. There were fewer PTBs < 37 weeks during exposure 1 compared with the pre-pandemic era (63.1% vs. 68.3%;adjusted risk-ratio (aRR) 0.95;95% confidence interval (CI) 0.88-0.98, P = 0.01). This lower rate was most prominent in iatrogenic PTB for suspected fetal compromise (13.4% vs. 20.3%;aRR 0.94 95% CI 0.90-0.99, P = 0.01). There were correspondingly fewer special care nursery admissions during exposure 1 (38.5% vs. 43.5%;aRR 0.91 95% CI 0.87-0.95, P < 0.001), but no changes in stillbirth (1.5% vs. 1.4%;aRR 1.00, 95% CI 0.99-1.01, P = 0.85). Compared with the pre-pandemic period, exposure 2 was associated with a trend to more PTB < 28 weeks and significantly higher neonatal intensive care unit admissions (25.0% vs. 19.6%;aRR 1.06 95% CI 1.03-1.10, P < 0.001). Conclusion(s): Melbourne's first lockdown-exposure period was associated with fewer preterm twin births for suspected fetal compromise, without any increase in stillbirth.
ABSTRACT
Background: COVID-19 is caused by SARS-CoV-2 and has is responsible for over 619 million infections and over 6.5 million deaths globally since identification in 2019. Infection during pregnancy is associated with increased adversity including increased risks of admission to intensive care, increased ventilatory support, preeclampsia, preterm birth and maternal death. Vaccination remains the best protection against severe disease. The majority of trials for novel or repurposed COVID-19 therapies including mRNA vaccinations have excluded pregnant or lactating women despite being an at-risk population. Broccoli sprout extract contains a naturally occurring phytonutrient sulforaphane which upregulates the Nrf2 transcription factor resulting in expression of antioxidant proteins, anti-inflammatory effects and has demonstrated anti-viral effects in-vitro . Severe COVID-19 results in excessive cytokine production resulting in a proinflammatory state with significant oxidative stress and multi-organ dysfunction with evidence of placental abnormalities in almost half of infected mothers. Method(s): CO-Sprout is a pilot, double blinded, placebo controlled randomised trial that is recruiting pregnant women ( n = 60) between 20 and 36 weeks completed gestation with COVID-19 diagnosed within 5 days. Participants are randomised to either broccoli sprout capsules (containing 21 mg sulforaphane) or identical placebo (microcrystalline cellulose) twice daily for 14 days. The primary outcome will be duration (days) of COVID-19 related symptoms and other exploratory outcomes including unplanned hospital admissions, birth outcomes, inflammatory markers, microbiome and placental changes. Patients are recruited through maternity departments at Monash Health and Jessie McPherson Private Hospital. Result(s): Trial in progress. Conclusion(s): Trial results to be published after trial completion.
ABSTRACT
Background: COVID-19 can cause placental histopathological changes through associated inflammatory responses, maternal hypoxia and hypoperfusion, with subsequent placental microvasculopathy and fetal hypoxia. We hypothesise that these placental changes will cause placental insufficiency, as reflected by histopathological abnormalities and fetal distress on a cardiotocography (CTG), that correlates with disease severity. Methods: During the Delta wave, Monash Medical Centre was the only referral centre for pregnant women with COVID-19 in Victoria, Australia. Three groups undergoing caesarean section prior to the onset of labour were identified: 13 women with severe COVID-19 requiring hospitalisation, 53 with asymptomatic/ mild illness and 10 with placental insufficiency without COVID-19. CTGs and placental histology were analysed for evidence of maternal and fetal hypoxia. Results: Placental histology was obtained in 12/13 of severe, 40/53 asymptomatic/mild and 8/8 cases of placental insufficiency without COVID-19. Histopathological abnormalities were associated with COVID-19 disease severity;severe (8/12, 67%) and asymptomatic/mild (24/40, 60%) compared with 100% (8/8) in the placental insufficiency group. Maternal vascular malperfusion was seen in 58%, 15% and 75% and inflammatory changes in 17%, 30% and 0%, respectively (Table 1). Abnormal CTGs reflecting fetal hypoxia were seen in 77% of severe COVID-19 cases and in 49% with asymptomatic/mild illness (Table 2). Conclusions: Both mild/asymptomatic and severe COVID-19 illness are associated with high rates of CTG and placental abnormalities. These changes are similar to those seen with other causes of placental insufficiency. Therefore, increased surveillance and delivery from >37 weeks should be considered in women with COVID-19 in pregnancy, regardless of disease severity. (Table Presented).
ABSTRACT
OBJECTIVE: To investigate the effect of restriction measures implemented to mitigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission during the coronavirus disease 2019 (COVID-19) pandemic on pregnancy duration and outcome. METHODS: A before-and-after study was conducted with cohort sampling in three maternity hospitals in Melbourne, Australia, including women who were pregnant when restriction measures were in place during the COVID-19 pandemic (estimated conception date between 1 November 2019 and 29 February 2020) and women who were pregnant before the restrictions (estimated conception date between 1 November 2018 and 28 February 2019). The primary outcome was delivery before 34 weeks' gestation or stillbirth. The main secondary outcome was a composite of adverse perinatal outcomes. Pregnancy outcomes were compared between women exposed to restriction measures and unexposed controls using the χ-square test and modified Poisson regression models, and duration of pregnancy was compared between the groups using survival analysis. RESULTS: In total, 3150 women who were exposed to restriction measures during pregnancy and 3175 unexposed controls were included. Preterm birth before 34 weeks or stillbirth occurred in 95 (3.0%) exposed pregnancies and in 130 (4.1%) controls (risk ratio (RR), 0.74 (95% CI, 0.57-0.96); P = 0.021). Preterm birth before 34 weeks occurred in 2.4% of women in the exposed group and in 3.4% of women in the control group (RR, 0.71 (95% CI, 0.53-0.95); P = 0.022), without evidence of an increase in the rate of stillbirth in the exposed group (0.7% vs 0.9%; RR, 0.83 (95% CI, 0.48-1.44); P = 0.515). Competing-risks regression analysis showed that the effect of the restriction measures on spontaneous preterm birth was stronger and started earlier (subdistribution hazard ratio (HR), 0.81 (95% CI, 0.64-1.03); P = 0.087) than the effect on medically indicated preterm birth (subdistribution HR, 0.89 (95% CI, 0.70-1.12); P = 0.305). The effect was stronger in women with a previous preterm birth (RR, 0.42 (95% CI, 0.21-0.82); P = 0.008) than in parous women without a previous preterm birth (RR, 0.93 (95% CI, 0.63-1.38); P = 0.714) (P for interaction = 0.044). Composite adverse perinatal outcome was less frequent in the exposed group than in controls (all women: 2.1% vs 2.9%; RR, 0.73 (95% CI, 0.54-0.99); P = 0.042); women with a previous preterm birth: 4.5% vs 8.4%; RR, 0.54 (95% CI, 0.25-1.18); P = 0.116). CONCLUSIONS: Restriction measures implemented to mitigate SARS-CoV-2 transmission during the COVID-19 pandemic were associated with a reduced rate of preterm birth before 34 weeks. This reduction was mainly due to a lower rate of spontaneous prematurity. The effect was more substantial in women with a previous preterm birth and was not associated with an increased stillbirth rate. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.