Frequency of positive antiphospholipid antibodies in pregnant women with SARS-CoV-2 infection and impact on pregnancy outcome: A single-center prospective study on 151 pregnancies.

Background: At the beginning of the SARS-CoV-2 pandemic, there was a lack of information about the infection's impact on pregnancy and capability to induce de novo autoantibodies. It soon became clear that thrombosis was a manifestation of COVID-19, therefore the possible contribution of de novo antiphospholipid antibodies (aPL) raised research interest. We aimed at screening SARS-CoV-2 positive pregnant patients for aPL. Methods: The study included consecutive pregnant women who were hospitalized in our Obstetric Department between March 2020 and July 2021 for either a symptomatic SARS-CoV-2 infection or for other reasons (obstetric complications, labour, delivery) and found positive at the admission nasopharyngeal swab. All these women underwent the search for aPL by means of Lupus Anticoagulant (LA), IgG/IgM anti-cardiolipin (aCL), IgG/IgM anti-beta2glycoprotein I (aB2GPI). Data about comorbidities, obstetric and neonatal complications were collected. Results: 151 women were included. Sixteen (11%) were positive for aPL, mostly at low titre. Pneumonia was diagnosed in 20 women (5 with positive aPL) and 5 required ICU admission (2 with positive aPL). Obstetric complications occurred in 10/16 (63%) aPL positive and in 36/135 (27%) negative patients. The occurrence of HELLP syndrome and preeclampsia was significantly associated with positive aPL (p=0,004). One case of maternal thrombosis occurred in an aPL negative woman. aPL positivity was checked after at least 12 weeks in 7/16 women (44%): 3 had become negative; 2 were still positive (1 IgG aB2GPI + IgG aCL; 1 IgM aB2GPI); 1 remained positive for IgG aCL but became negative for aB2GPI; 1 became negative for LA but displayed a new positivity for IgG aCL at high titre. Conclusions: The frequency of positive aPL in pregnant women with SARS-CoV-2 infection was low in our cohort and similar to the one described in the general obstetric population. aPL mostly presented as single positive, low titre, transient antibodies. The rate of obstetric complications was higher in aPL positive women as compared to negative ones, particularly hypertensive disorders. Causality cannot be excluded; however, other risk factors, including a full-blown picture of COVID-19, may have elicited the pathogenic potential of aPL and contributed themselves to the development of complications.

Obstetric Disorders and Critical Illness.

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

Changing Trends of Pregnancy Related Acute Kidney Injury - a Single Centre Prospective Observational Study from Southern India

Introduction: Pregnancy-related acute kidney injury (PR-AKI) in India is largely showing a declining trend due to improved and accessible obstetric care. Nevertheless, PR-AKI continues to cause significant maternal and fetal morbidity and mortality. This study was taken up with the intention to study the incidence and clinical spectrum of AKI in pregnancy in recent times and assess maternal and neonatal outcomes Methods: All pregnant women admitted in the Department of Obstetrics and Gynecology at St John's Medical College Hospital, Bengaluru between January 2018 to June 2020 were screened for AKI with the following criteria 1. Increase in serum creatinine to >0.8mg/dL and/or a sudden increase in serum creatinine by more than 50% when prior renal function was normal. 2. Oligo-anuria 3. Need for renal replacement therapy Women with preexisting CKD were excluded. Patient's clinical and laboratory details recorded. Dialysis support was provided if indicated. The clinical profile and renal outcome of the mother and fetal outcome was assessed at the time of discharge. Mothers' were also followed up at the end of 3 months of postpartum period. Recovery was categorized as Complete recovery- normal serum creatinine (<0.8 mg/dL) or a previously known baseline and no proteinuria /hypertension at the end of 3 months Partial recovery- renal function improved but serum creatinine did not return to normal range and patient was dialysis independent. No recovery- patient continued to require dialysis at the end of 3months. Result(s): Of the 2650 deliveries in the study period 42 women (Mean age 26.9 +/-3.6 years) were diagnosed AKI during pregnancy (1.58%). Baseline characteristics and outcomes are depicted in table 1. Majority of women (n=37) were referred from peripheral hospitals. Hypertension and decreased fetal movements were the common reasons for referral. Third trimester was the most common time of presentation (76.1%). Severe Preeclampsia and HELLP syndrome was the leading cause of AKI (59.5%).ATN secondary to obstetric complications, sepsis and hemolytic uremic syndrome were the other causes. One case each of cortical necrosis, acute fatty liver of pregnancy and COVID 19 associated AKI was seen. Mean duration of hospital stay was 12.1+/-6.9 days. More than one third patients' required ICU stay (35.7%).12 patients (28.5%) required renal replacement therapy. Of them, 3 were dialysis dependent at the end of 3 months and 4 had partial renal recovery. 3 patients expired during hospital stay. Fetal survival was 69.04%.13 babies' required NICU care (44.8%). Neonatal outcomes are summarized in table 2. Close to one third of the pregnancies with AKI were associated with intrauterine fetal demise (28.5%). Low birth weight and prematurity were the common reasons for NICU admission with mean NICU stay of 8.2 +/-2.3 days [Formula presented] [Formula presented] Conclusion(s): Severe preeclampsia was the most common cause of AKI in our study. PR-AKI continues to be a significant problem in the peripheries of developing countries where availability of health care facilities is meager, with late referral to tertiary care centers. One third of the patients required ICU stay & dialytic support. Women who required dialysis had poorer renal prognosis. There was 30% fetal loss seen in PR-AKI and also a higher incidence of low birth weight and prematurity. No conflict of interestCopyright © 2023

PREGNANCY AND PERINATAL OUTCOMES OF COVID-19 (SARS-COV-2).

This article presents current data on the impact of COVID-19 (SARS-CoV-2) on pregnancy and perinatal consequences. The working theories of the pathogenesis of obstetric and fetal complications due to infection during pregnancy, already proven to date, are considered. Symptoms of COVID-19 disease, the risk of their development, and frequency of severe disease in non-pregnant and pregnant women of reproductive age do not differ significantly. However, there are powerful studies that have shown that this infection in pregnant women leads to a high probability of a dramatically severe and fulminant course. Pregnant women with SARS-CoV-2 infection have an increased risk of preeclampsia, incl. severe, hemolysis, thrombocytopenia and increased levels of liver enzymes compared with pregnant women without infection. Women who have COVID-19 are twice as likely to have preterm rupture of the membranes and three times as likely to have a preterm birth compared to the not infected pregnant women. Vertical transmission of the virus from mother to fetus is likely, but data are insufficient to be certain. There is also insufficient evidence of an increased miscarriage rate and teratogenic effects of the COVID-19 virus. However, antenatal fetal death is statistically significantly more common in infected pregnant women than in uninfected pregnant women. Morphological and functional disorders in the chorion/placenta are the main pathogenetic factor in the development of preeclampsia, intrauterine growth retardation, antenatal fetal death and impaired state of the fetus and children born by women with COVID-19. Many studies report that mothers with confirmed COVID-19 infection has asymptomatic babies. At the same time, some studies indicate adverse complications in newborns from infected mothers. The most common neonatal disorders in babies from pregnant women with COVID-19 are tachypnea, hyperthermia, and gastrointestinal disorders, in particular vomiting and flatulence. Further research of the COVID-19 impact on pregnancy and perinatal outcomes is urgently needed.Copyright © 2022 Trylyst. All rights reserved.

HELLP syndrome and COVID-19: A minor revision of a possible new "COVID-19-linked HELLP-like syndrome".

To report the characteristics described in the literature on a possible new "COVID-19-linked HELLP-like syndrome" in pregnant women with COVID-19: its association with the severity; prevalence; clinical; laboratory; pathophysiological and therapeutic management differences from the classic HELLP syndrome and their impact on outcomes. Observational, cohort, case-control, case-series and case-report studies were included. Data were extracted independently by the authors of the study, to ensure accuracy, consistency and performed the quality assessment. The database search resulted in 77 references, of which two satisfied the eligibility criteria. In these 2 studies we found a possible "COVID-19-linked HELLP-like syndrome", associated with severe COVID-19. There is a high possibility of the existence of "COVID-19-linked HELLP-like syndrome" and its association with severe COVID-19 in pregnant women, with a prevalence of 28,6%. Some characteristics of "COVID-19-linked HELLP-like syndrome" and the classic HELLP syndrome are similar. Differential diagnosis indicated two different types of therapeutic management: conservative for "COVID-19-linked HELLP-like syndrome" and delivery for the HELLP syndrome. HELLP clinical management is mandatory for both.

Hypertensive disorders of pregnancy and severe acute respiratory syndrome coronavirus-2 infection.

OBJECTIVES: We aimed to determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is associated with an increased risk of hypertensive disorders of pregnancy (HDP). METHODS: A multicenter retrospective cohort study of all pregnant patients who had SARS-CoV-2 testing and delivered in a large health system between March 2020 and March 2021. Cases were stratified into two groups: patients who tested positive for SARS-CoV-2 during pregnancy vs. patients who tested negative. The primary outcome of HDP, defined as a composite of gestational hypertension, preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP Syndrome), and eclampsia by standard criteria, was compared between the two groups. Statistical analysis included multivariable logistic regression to adjust for potential confounders such as maternal demographics and comorbidities. Patient ZIP codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey. RESULTS: Of the 22,438 patients included, 1,653 (7.4%) tested positive for SARS-CoV-2 infection. Baseline demographics such as age, body mass index, race, ethnicity, insurance type, neighborhood-built environmental and socioeconomic status, nulliparity, and pregestational diabetes differed significantly between the two groups. SARS-CoV- 2 infection in pregnancy was not associated with an increased risk of HDP compared to those without infection (14.9 vs. 14.8%; aOR 1.06 95% CI 0.90-1.24). CONCLUSIONS: In this large cohort that included a universally-tested population with several socioeconomic indicators, SARS-CoV-2 infection in pregnancy was not associated with an increased risk of HDP.

Impact of a Pandemic on Women Diagnosed With Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a dilated form of cardiomyopathy that occurs during the last month of pregnancy or up to five months postpartum. Approximately 1,100 women develop PPCM in the United States each year. The aim of our study is to compare the incidence of PPCM prior to the start of the Coronavirus Disease 2019 (COVID) pandemic to afterwards and to determine the impact of COVID on hospitalized patients with PPCM. Method(s): This was a retrospective study of 2,286 patients with a diagnosis of PPCM who were admitted to a private hospital system across the United States between the year 2017 and year 2021. There was 1,790 patients in the pre-COVID cohort, and 496 patients in the COVID era cohort. Demographics of patients were collected, with t-test and chi square p-values utilization for statistical description. Result(s): The mean age of women was 32.13 years. In the COVID era cohort, the percentage of Hispanic patients was significantly higher than the pre-COVID era (16.84% vs. 12.34%, p=0.012). In the COVID era, patients were more likely to have preeclampsia (20.16% vs. 13.52%, p<0.001), HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (2.62% vs. 0.61%, p<0.001), respiratory failure (19.56% vs. 10.57%, p<0.001), and myocardial infarction (3.63% vs. 1.90%, p=0.022). There was no significant difference in troponin and d-dimer values between the two era cohorts. The average length of stay, percentage of patients admitted to the intensive care unit (ICU), and death did not significantly differ between the pre-COVID and COVID era cohorts. Conclusion(s): In our study, although there was no significant difference in length of stay, ICU admission, or death in the COVID era cohort, myocardial infarction, preeclampsia, HELLP syndrome, and respiratory failure were each more prevalent in women with PPCM during the COVID era. These findings might indicate suboptimal access to outpatient and inpatient medical care during the COVID pandemic, which could have led to these more serious diagnoses.

Rara Associacao De Anemia Hemolitica Microangiopatica E Adenocarcinoma Gastrico Avancado

Introducao: As sindromes de microangiopatia trombotica incluem causas primarias e secundarias: infeccao sistemica, hipertensao grave, sindrome HELLP e malignidades. A anemia hemolitica microangiopatica associada ao cancer (CA-MAHA) e uma complicacao rara e de alta letalidade caracterizada por anemia hemolitica nao imune e trombocitopenia. Raramente diagnostica-se doencas malignas a partir de um quadro de anemia hemolitica, apesar de o cancer estar muito associado a disturbios hematologicos. Descrevemos um caso de anemia hemolitica microangiopatica associada a adenocarcinoma gastrico em celulas de sinete metastatico. Relato de caso: Homem, 47 anos, admitido no Hospital das Clinicas de Marilia por tromboembolismo pulmonar (TEP), a principio associado a recente infeccao por COVID-19. Antecedentes: previamente higido;negava medicacoes continuas;referia lombalgia cronica, com uso excessivo de anti-inflamatorios;episodio de dispepsia em 2021, automedicado com melhora. Iniciada enoxaparina, evoluindo com equimoses espontaneas e trombocitopenia. Foi suspensa a medicacao sem melhora, seguindo com trombocitopenia progressiva e anemia hemolitica microangiopatica (HB 6,5;HT 20;esquizocitos em lamina;plaquetas 31000;DHL 1002;reticulocitos 17,10% e coombs direto negativo). Questionado purpura trombocitopenica trombotica (PLASMIC score 5), prescrita imunoglobulina e pulsoterapia com metilprednisolona, enquanto aguardava-se possibilidade de plasmaferese, porem foi refratario ao tratamento, sendo ainda tentado rituximabe. Ao longo da internacao, teve piora da dor lombar, com necessidade de doses crescentes de morfina. Ressonancia magnetica detectou alteracao de sinal da medular ossea em toda extensao de coluna cervical a sacral e bacia, sugerindo desordem mieloproliferativa/processo neoplasico. Mielograma afastava neoplasias hematologicas. Durante pulsoterapia, apresentou hemorragia digestiva alta e em endoscopia digestiva viu-se lesao de corpo gastrico semelhante a linite plastica. Biopsia revelou adenocarcinoma de celulas de sinete, sendo esta a causa da anemia hemolitica microangiopatica. Iniciado quimioterapia, porem evoluiu com rapida deterioracao clinica e obito. Discussao: CA-MAHA e uma rara complicacao mais associada a tumores em estagio avancado, atribuindo alta morbimortalidade. Relatados casos em neoplasia de mama, prostata, pulmao e estomago, sendo este o sitio mais relacionado. A fisiopatologia permanece incerta, com hipotese do desencadeamento da cascata de coagulacao pela mucina liberada pelos tumores e possivel associacao de mecanismos imunologicos. Em pacientes com cancer metastatico, costuma-se observar anemia, trombocitopenia e niveis sericos elevados de lactato e DHL. A investigacao diferencial inclui teste de coombs negativo e hemacias fragmentadas no esfregaco de sangue periferico. O diagnostico da malignidade subjacente e importante e quase sempre feito tardiamente e, mesmo com a quimioterapia, o prognostico e reservado. Sabe-se que a CA-MAHA e distinta da PTT, SHU e CIVD e, apesar de apresentacoes clinicas semelhantes, os tratamentos para PTT nao sao eficazes para essa entidade. Conclusao: O caso demonstra que, diante de uma anemia hemolitica microangiopatica, sobretudo se refrataria aos tratamentos e excluidas as causas mais provaveis, deve-se ter uma alta suspeicao para tumor solido, mesmo em pacientes jovens e com clinica pouco expressiva, visto a alta mortalidade associada. Copyright © 2022

[Severe lactic acidosis in a pregnant woman with partial HELLP syndrome and COVID-19]

The present report describes the case of a 23-year old pregnant woman who was in the 36.5th week of gestation of her second pregnancy. She was attended at the emergency room because of dry cough and progressive dyspnea, in association with headache and myalgia. The nasopharyngeal swab for SARS-CoV-2 polymerase chain reaction (PCR) was positive. Oxygen saturation and chest x-ray were normal. Laboratory tests showed elevated values of bilirubin, aminotransferases, alkaline phosphatase and lactic dehydrogenase, and mild thrombocytopenia. Shortly after being admitted she began with labor. Faced with the lack of progression, the termination of the pregnancy by cesarean section was decided. Arterial blood gases showed severe lactic acidosis. She never presented evidence of clinical signs of tissue hypoperfusion or sepsis that could explain it. The patient completed her postoperative period in the intensive care unit, undergoing supportive treatment. All laboratory parameters were normalized after 72 hours, evolving favorably from the clinical point of view. It was interpreted that she had a partial HELLP syndrome. Lactic acidosis is not a component of this syndrome. Nor can it be ascribed to a mild disease by SARS-Cov-2. It probably responded to a summation of causes, including hyperproduction of lactic acid during labor, as well as its reduced clearance because of liver dysfunction related to HELLP syndrome.

Maternal and foetal outcomes in pregnant women undergoing lower segment caesarean section during COVID-19 pandemic: a retrospective analysis

Background and Aims: Coronavirus disease 2019 (COVID-19) adds more challenges to the perioperative management of pregnant women. The aim of this study is to examine severity of COVID-19 disease and maternal and foetal outcome among COVID-19 positive pregnant women undergoing caesarean section. Methods: This retrospective observational study was conducted at a tertiary teaching hospital in Karnataka between 1stApril to 31st July 2021, during which 100 COVID-19 positive pregnant women with ASA physical class II, III and IV who have undergone lower segment emergency caesarean section were selected on the basis of simple random sampling method. Results: A total of 100 women who had undergone caesarean section under spinal anaesthesia with positive SARS-CoV-2 PCR tests were assessed. Mean age was 24.45± 4.3 years, eight women were having severe covid-19 infection and overall mortality rate was 5% (5/100) in women and 1 woman had HELPP syndrome and one met with PPH (post-partum haemorrhage). Seven (7%) COVID-19 pregnant women required intensive care in the perioperative period. Eight neonates required NICU admission and had APGAR score less than 7. Fifty-five (55%) women were asymptomatic. While the rate of pneumonia in symptomatic women was 3.6% (8/45), the pneumonia incidence among all SARS-CoV-2 PCR (+) pregnant women was 8% (8/100). Conclusion: In our study, 61% of patients had pulmonary involvement and the mortality rate was 8% among mothers and 1% in neonates.

FRESH FROZEN PLASMA AND THE PRACTICAL MANAGEMENT: A COMPREHENSIVE AUDIT INCLUDING A SYNOPSIS OF CHALLENGES

Background: There is universal concern about the inappropriate use of fresh frozen plasma (FFP). Earlier investigations have indicated that FFP may be associated with high rates of inappropriate transfusion, with some studies indicating rates of up to 50% non-compliance with established guidelines. The current British Committee for Standards in Haematology (BCSH) guidelines on the use of FFP aim to reinforce the message regarding avoidance of its inappropriate use. Aims: Audit the use of appropiate FFP in the context of the COVID pandemia. Methods: Retrospective analysis of requests for plasma transfusion in adults, in our institution, between January/2020 and January/2022, This audit was undertaken to determine current use of FFP and to see if any improvements in the use of this component in relation to recommended guidance. May be we use more FFP due to covid situation. The data was obtained by consulting the Integrated System of Blood Banks. Results: During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. During the study period, 98 units of FFP were used for 'acute' episodes including management of acute COVID complications. Only 67% of these transfusion episodes were deemed appropriate, based on the BSH criteria. This also means that 13 units of FFP may have been wasted. FFP is used by both medical and surgical specialties with general surgery, general medicine and neurosurgery being the main users. 159 requests for plasma were registered in the analyzed period. In most cases (98), the reason was hemorrhage due to multiple factor deficiencies, including liver disease, trauma, lung disease or a massive transfusion. Prophylactic/therapeutic replacement of congenital factor XI deficiency, associated with bleeding episodes, was indicated in 2 situations. In 1 case, the indication was treatment of HUS and 2 cases of HELLP syndrome. In 7 cases, there was an overlapping of indications. In 7 cases, plasma was administered in unforeseen situations, such as for the correction of laboratory abnormalities without clinical manifestations (4 cases) or for prophylaxis of invasive techniques without abnormal coagulation tests (2 cases). Summary/Conclusion: The proportion of inappropriate requests is similar between surgical and non-surgical specialties and also when broken down into individual departments, the number of inappropriate requests consistently outnumbers appropriate requests across all departments. FFP continues to be frequently used in the absence of bleeding and / or evidence of abnormal coagulation, thus highlights the need for concerted efforts in the education of clinicians who prescribe FFP. In the analysis of the indications for plasma prescription, it is concluded that in 17 % cases the indication was not complete adequately or justifable. 7% of cases given FFP had no record of post-transfusion coagulation data. Following this work, dissemination coupled with education was undertaken. The use of FFP for Warfarin reversal has correctly indicated (> 95%). it may suggest that an education programmes directed at specific aspects of practice do influence clinical behaviour over needs to be addressed.

SARS-CoV-2 placentitis as a cause of intrauterine death of a fetus in a patient with covid-19 infection and ongoing HELLP syndrome.

OBJECTIVE: We hereby present a case of intrauterine death of a fetus due to placental damage by placentitis caused by SARS-CoV-2 infection in ongoing covid-19 disease and HELLP syndrome. CASE REPORT: In this case report, we describe a patient who experienced intrauterine death of a fetus and the development of HELLP syndrome in ongoing covid-19 infection. Placentitis caused by SARS-CoV-2 infection was identified as the cause of intrauterine death of a fetus. After the end of pregnancy, a patient experienced an improvement in the symptoms of covid-19 and also a gradual improvement and adjustment of laboratory and coagulation parameters. CONCLUSION: SARS-CoV-2 infection in pregnancy can be complicated by the development of SARS-CoV-2 placenitis, which can cause intrauterine death of a fetus. Covid-19 infection can even have similar signs to HELLP syndrome and therefore careful monitoring of pregnant women with covid-19 is recommended.

Coagulation conundrum in obstetric anesthesia with COVID-19.

Coronavirus disease (COVID-19) pandemic is an unprecedented public health calamity that has caused an immense setback to maternal health services in developing countries. In addition to morbidity and mortality caused by COVID-19 disease in parturient directly, the indirect adverse impact of lockdown imposed during pandemic causing loss of follow-up of patients with coexisting illness is significant. There are no standard protocols to manage COVID-19 patients with comorbid medical illness, who are not optimized during antenatal visits. We report an interesting case of an antenatal patient with COVID-19, with prosthetic aortic valve on warfarin with elevated International Normalized Ratio (INR) and severe pre-eclampsia, posted for emergency cesarean section.

Maternal mortality in modern world

Aim: to analyze the causes and level of global maternal mortality (MM) according to the data published within the last 7 years. Materials and Methods. Search for publications in the PubMed/MEDLINE database was conducted according to the criteria: meta-analysis, free full-text, English, 2015-2021 period. The PICO principle (Patient/Problem, Intervention, Comparison, Outcome) and the keywords "maternal mortality causes", "maternal death causes", "maternal outcomes" were used. The search was finished on October 13, 2021 after retrieving 137 results. Results. The rate of MM and cause pattern has been changing during COVID-19 pandemic. The first weeks of the COVID-19 lockdown showed that in-hospital mortality among pregnant women increased from 0.13 up to 0.20 % (p = 0.01) and in MM the proportion of respiratory diseases elevated up to 32 % versus 5.6%. Certain geographic regions of the world showed that MM due to COVID-19 reached extremely high values extending 3399 per 100,000 live births as well as increased general MM rate. Heart and vascular diseases (pericarditis, myocardial infarction, thromboembolism) have a significant position among the causes of MM. The rate of MM due to cardiovascular disease was inversely related to the population income level. Cardiomyopathy is the cause of death in 4 % (95 % confidence interval (95 % CI) = 2-7) of mothers in developed countries and 14 % (95 % CI = 10-18) in developing countries. The mortality rate 6 weeks after delivery among women with pregnancy-related myocardial infarction was 5.03 % (95 % Cl = 3,78-6,27), whereas it associated with thromboembolism among women with a mechanical heart valve was related to the agent used to prevent thrombosis, ranging from 0.9 (95 % CI = 0.1-1.6) for vitamin K antagonists up to 3.4 (95 % CI = 0-7.7) for unfractionated heparin per 100 pregnancies with a mechanical heart valve. After 2000, the proportion of anesthesia among immediate MМ causes decreased from 3.5 % (95 % CI = 2.9-4.3) down to 2.4 % (95 % CI = 1.9-2.9) in low- and middle-income countries. High MM odds due to maladjusted pregnancy are still observed: OR (odds ratio) = 17 (95 % CI = 9.6-28.8) for hypertension, OR = 3.70 (95 % CI = 1.72-7.99) for HELLP syndrome with acute kidney injury. Severe obstetric complications cause MM in sub-Saharan Africa and South Asia: bleeding (OR = 28.8;95 % CI = 20.3-40.7), preeclampsia or eclampsia (OR = 9.13;95 % CI = 6.10-13.7), maternal infections in antenatal period (OR = 2.80;95 % CI = 1.63-4.80). About 67 % of pregnant women in such countries obtain no antenatal care (OR = 2.80;95% CI = 1.63-4.80), predominantly giving birth at home in sub-Saharan Africa. In Ethiopia, ММ results from obstructed home delivery resulting in maternal death in 17.27 %, where uterine rupture is cause of death in 7.75 % of women. Conclusion. The COVID-19 pandemic contributed a lot to MM. Diseases of the cardiovascular system markedly elevate the MM risk and long-term mortality after delivery. For countries with traditionally home births in the absence of medical care, a high MM remains due to complicated and protracted labor complicated by uterine rupture.

Microangiopathy during pregnancy HELLP/aHUS/TTP taking COVID-19 in pregnancy into account

The fact that leading laboratory symptoms of thrombocytopenia in combination with other signs of hemolysis and a resulting microangiopathy, which may be associated with further clinical and, in particular additional acute symptoms, also concerns obstetricians in terms of differential diagnostics during pregnancy and around birth. The complexity of the diseases and also the different forms of treatment, make it necessary for gynecologists to have a basic knowledge of internal diseases that can lead to hemolysis. The differential diagnoses must therefore be known as these lead to different treatment needs and long-term damage to the kidneys, for example, must be avoided. The differential diagnoses of thrombocytopenia are the starting point for further diagnostics. In combination with signs of hemolysis and changes in erythrocyte morphology (fragmentocytes), there are different causes for microangiopathy. Thrombotic thrombocytopenic purpura (TTP) can be the cause of such changes throughout pregnancy, but especially in the last trimester. In this case, additional gastrointestinal or neurological symptoms are often present. Pre-eclampsia, especially in HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome, can also lead to microangiopathy, usually with a corresponding increase in blood pressure and especially with a significant increase in liver transaminases, also typically combined in the last trimester. If corresponding changes occur after birth and these are associated with renal failure in addition to hemolysis, this can be an atypical hemolytic uremic syndrome (aHUS), which should be specifically treated with antibodies. In addition to the typical coagulation activation in the sense of thrombosis, the entire picture of a corresponding microangiopathy is also found in coronavirus disease 2019 (COVID-19), partly through corresponding activation of the coagulation system and partly through an intensification of the other microangiopathies. The differential diagnoses and possible treatment for all areas are outlined in the article.

Decision-making using Placental Growth Factor(PLGF) in Preeclampsia-Pilot study in Wales

Objective: PLGF point of care blood test is a NICE validated tool recommended between 20 and 34+6 weeks gestation to diagnose and predict early onset of preeclampsia. During the Covid pandemic, we pioneered and assessed the clinical utility of this point of care blood test in NHS Wales by doing a pilot study of 6 months at our district hospital with 2700 deliveries/annum. Design: Prospective study Method: Patients presenting at maternity day assessment unit with new onset hypertension, proteinuria or worsening chronic hypertension were selected. This simple point of care blood test with a turnaround time of 15 minutes was conducted by the triage midwife at the bedside. Patients were classified into red (<12 pg./ml), amber (≥12-< 100 pg./ml) and green (≥100 pg/ml) alert groups. We interpreted our results using the PARROT trial flowchart and clinical decisions were made based on the risk stratification and overall clinical picture. Results: Cases in the Red alert group and high blood pressure were admitted and to our surprise all 6 cases developed severe preeclampsia (3 of which developed HELLP) within the same week. They were delivered after stabilization of blood pressure and prophylactic steroids for the preterm fetus. The amber group was managed with increased outpatient surveillance until a maximum of 37 -38 weeks. Using the reported high negative predictive value of 97.5% in the green group (PARROT trial), we could reassure 64% of the green group patients to prolong the pregnancy without inpatient admission and continue antenatal care till term. Our cohort experience of 34 patients found that overall 68% of the cases were managed with outpatient surveillance. Conclusions: PLGF is now incorporated into our routine practice. The amber to green risk stratification helped in reducing unnecessary inpatient admissions and improved patient experience by alleviating maternal anxiety. There were no stillbirths and it prevented iatrogenic preterm deliveries by giving clinicians reassurance in their decisions. The Red alert group with PLGF <12 pg./ml, was highly suggestive of placental dysfunction needing early delivery. The Amber alert group (with the PLGF ≥12 and <100 pg/ml) may be cared with increased outpatient surveillance. Those patients in the Green alert group (with the PLGF ≥100 pg./ml) were reassured and cared for till term, if possible. The underlying caveats always being PLGF was always supplemented by a complete clinical evaluation to determine early prediction and management of pre-eclampsia.

Management of atypical Hemolytic-Uremic Syndrome in gravida with SARS-COVID-2 infection

Background. Coronavirus disease is a highly contagious infection that can be deadly and is caused by the severe acute respiratory syndrome SARS-CoV-2.The current literature indicates that pregnancy may worsen the course of COVID-19 infection compared to non pregnant women at the same age. Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated disorder, characterized by microangiopathic hemolysis, thrombocytopenia, and renal failure. Case presentation. A case of a gravida at 20 weeks of gestation with worsening clinical conditions due to aHUS, and SARS-COV-2 infection was managed. Continuous renal replacement therapies with transfusion of plasma was started. Diagnosis comprised atypical HELLP presentation with progressive reduction of PLT levels versus other thrombotic microangiopathy. Conclusions. The lack of anti-ADAMTS 13 antibodies allowed to make the diagnosis of Hemolytic-Uremic Syndrome (HUS). The patient started therapy with Eculizumab 900 mg that was administered one time every 7 days. The patient resumed spontaneous urination after one day of therapy. Renal failure persisted after 5 days with creatinine levels at 7.9 mg/dL and azotemia at 126 mg/dL. It is challenging to predict the impact of immune-mediated therapies on pregnant women. Furthermore, additional data about the immunomodulatory changes in COVID-19 patients during pregnancy may reveal pathophysiological events behind this deadly disease.

Messenger RNA covid-19 vaccines tozinameran (comirnaty°) and elasomeran (spikevax°) during pregnancy

Pregnant women who become infected with Sars-CoV-2 are at higher risk of developing severe forms of covid-19 and potentially fatal complications, especially towards the end of pregnancy. These complications are more common in women with at least one risk factor, such as diabetes or hypertension. The mRNA covid-19 vaccines are not live vaccines, and mRNA does not enter the cell nucleus. No particular effects on reproduction have been shown in animal studies with either tozinameran or elasomeran. No increase in the risk of spontaneous abortion, preterm birth or low birthweight following vaccination has emerged from the data available from several countries as of early December 2021. Very limited data are available on the risk of fetal disorders or malformations. A French report published in late December 2021 mentions that, as of early December, 12 babies had malformations and, in two of these cases, the timing made a causal link with the vaccine plausible. There is some evidence of a possible increased risk of uterine contractions and HELLP syndrome. In view of the consequences of covid-19 in pregnant women and the observed efficacy of the vaccines against the main variants prevalent in 2020 and 2021, the data available in early 2022 suggest that vaccination with tozinameran is useful for pregnant women, ideally between 10 weeks' and 20 weeks' gestation.

Post covid pregnancy related haemolytic Uraemic syndrome masquerading as HELLP syndrome-A twisted tale of gravid

Pregnancy associated atypical haemolytic uremic syndrome (p-aHUS) is an infrequent condition to be encountered during the puerperium period and is associated with microangiopathic haemolytic anaemia, thrombocytopenia as well as acute kidney injury. This syndrome is triggered by pregnancy in the women who are predisposed genetically leading to an unfortunate haemolytic disease which is associated with endothelial diffuse damage and consumption of the platelets. This is a dangerous condition which required prompt diagnosis as well as management. Diagnosing p-a HUS can be challenging for the treating clinicians as it may mimic other conditions like HELLP Syndrome during the pregnancy as well as postpartum period. Plasma exchange should be started within 24 hours of diagnosing the condition in order to prevent mortality. With the emergence of the corona virus pandemic, atypical SARS Covid -2 presentations during pregnancy have emerged, ranging from COVID-19-associated HELLP syndrome to intrauterine death. COVID-19 has been linked to an atypical haemolytic uremic syndrome, with COVID-19 causing ischemic acute tubular necrosis or thrombotic microangiopathy through a complex complement activation process. We are presenting a case of 28 year old female with nine months amenorrhea who presented with bilateral pedal oedema and oliguria since one week and had severe thrombocytopenia along with acute kidney injury following 28 days of contracting COVID-19. She was diagnosed as Post COVID-19 p-a HUS following diagnostic work up and was treated promptly with plasmapheresis leading to complete recovery.