Clinical analysis of liver dysfunction in pregnant patients with mild SARS CoV-2 infection

Objective: The current study aimed to describe the clinical characteristics of mild SARS-CoV-2 infected pregnant women with abnormal liver function (ALF), explore the association between ALF with maternal and fetal outcomes. Method(s): This retrospective analysis included 87 pregnant patients with mild SARS-CoV-2 infection admitted and treated from December 1, 2022, to 31, 2022 in the department of Obestircs at Beijing Obstetrics and Gynecology Hospital. We evaluated patients for demographic and clinical features, laboratory parameters and pregnancy complications. Result(s): 27 Patients in this cohort had clinical presentations of ALF. Compared with the control group, the peripheral blood platelet (PLT), D-dimer quantitative determination (D-Dimer), lactate dehydrogenase (LDH), total protein (TP), albumin (ALB), indirect bilirubin (DBIL), gamma- glutamyltranspeptidase (GGT) and total bile acid (TBA) showed significantly differences (p<0.05). 12 cases (44.44%) complicated with pregnancy induced hypertension (PIH), 14 cases (51.85%) complicated with intrahepatic cholestasis of pregnancy (ICP), 2 cases (7.4%) complicated with acute fatty liver during pregnancy (AFLP) and 5 cases (14.81%) complicated with postpartum hemorrhage in patients with abnormal LFT were significantly higher than those in the control group (p<0.05). Compared with the control group, the incidence of premature delivery (22.22%) and fetal distress (37.04%) in the experiment group were significantly higher (p<0.05), and the incidence of neonatal asphyxia was not significantly different (p>0.05). Conclusion(s): Pregnant women are generally susceptible to mild SARS-CoV-2 and may induce ALF. ALF is associated with increased risk of mother and infant. The maternal and infant outcomes of those who terminated pregnancy in time are acceptable. Therefore, pregnant women with COVID-19 who received antiviral treatment should be closely monitored for evaluating liver function and relevant indicators. The long-term outcomes in the future are worth to further study.Copyright © 2023

GDM diagnosis criteria: Standard and Covid-19 criteria

Aim: Standard diagnosis of gestational diabetes (GDM) is based on the Oral Glucose Tolerance test (OGTT). During the Covid-19 outbreak, due to Covid restrictions, criteria were modified i.e Fasting Blood Glucose >=5.3 and/ or HbA1c >= 39 for diagnosis of GDM. After the lifting of the Covid restrictions, the standard criteria were reimplemented and on analyzing the data, it was highlighted that some of the patients could have tested negative for GDM based on Covid Criteria. Method(s): We analyzed the data of 43 patients based on standard criteria (OGTT and HbA1c) after Covid restrictions, with the following results. Result(s): 11/43(28%) patients who were diagnosed on the basis of standard criteria could have been missed based on Covid criteria. Out of 11 deliveries, 2 babies with weight above 4 kg. There were no admissions to NICU. One patient had postpartum hemorrhage with 670 mL of blood loss. Conclusion(s): This was a retrospective study in which we analyzed the data of 45 pregnant females diagnosed with GDM based on testing using the Covid criteria and compared this to 43 pregnant females who were diagnosed with GDM on the basis of OGTT based on GOLD standard NICE criteria. In addition, we also examined maternal and obstetric outcomes in both groups such as the mode of delivery, the baby's birth weight, the incidence of shoulder dystocia, mean blood loss (MBL), and NICU admission. We understand that Covid GDM diagnosis was a necessity of time. In this study, we want to learn what could have been missed with that diagnostic criteria. For future pandemics, we need to revise our diagnostic criteria to avoid the risk of underdiagnosing GDM and associated complications.

Management of Pregnant Woman in their Third Trimester with SARS-COV-2 Symptoms in the Rural Setting

Objective: Can a way forward be created to establish baseline criteria to better assist aeromedical transport crews with optimizing care and increasing the probability of survival of acutely distressed women in their third trimester of pregnancy with SARS-COV-2 symptoms? Information has been derived from a mixed methods research approach. Pregnant individuals with SARS-COV-2 are at increased risk of intensive care unit admission, mechanical ventilation, and death compared with both pregnant individuals without SARS-CoV-2 infection and nonpregnant adults with SARS-CoV-2 infection1. Hypertensive disorders of pregnancy affect up to 20% of pregnancies in the United States and are leading causes of serious obstetric morbidity1. The focus of this research included nearly 2,400 pregnant women infected with SARS-CoV-2 and found that those with moderate to severe infection were more likely to have a cesarean delivery, to deliver preterm, to die around the time of birth, or to experience serious illness from hypertensive disorders of pregnancy, postpartum hemorrhage, or from infection other than SARS-CoV-2. They were also more likely to lose the pregnancy or to have an infant die during the newborn period. Mild or asymptomatic infection was not associated with increased pregnancy risks. Method(s): We intend to develop an algorithm based on current guidelines to smooth the transition of care from prehospital to intrahospital. We will use the guidelines set forth by The American College of Obstetrics and Gynecology (ACOG). In addition, we will take an example of the policies and procedures from a prehospital care aeromedical flight service for inclusion in our proposed treatment recommendation(s). Result(s): We will then use the guidelines to make an all-encompassing protocol to guide the whole trip from onset of symptoms to in hospital care. We believe that a protocol that encompasses the whole of both systems, prehospital flight and in hospital, will help to streamline patient care tasks and reduce the probabilities of morbidity and mortality. Conclusion(s): The aeromedical community should seek out partnerships with the appropriate entities to provide invaluable information about a critical time of transitioning the patient from the point of access to the healthcare system to the appropriate definitive care facility. The aeromedical community has specialized paramedics, nurses, and physicians with knowledge and experience that cannot easily be quantified. These efforts could result in treatment modalities addressing acute management intra/inter hospital upon initial publication and equip air medical personnel with additional critical care education and knowledge to take back to their perceptive communities to enhance the probability of survival with pregnant women adversely affected by SARS-COV-2.Copyright © 2022

Strategies to meet blood demand for transfusions during the COVID-19 pandemic: lessons learnt from a large central hospital in Malawi

Background: The coronavirus disease-19 (COVID-19) pandemic affected blood banks globally. We sought to examine how COVID-19 affected blood supply and transfusion in our institution. Method(s): The study was conducted at the Queen Elizabeth Central Hospital (QECH) and the Malawi Blood Transfusion Service (MBTS) in Malawi. Data from April to November 2020, collected during the pandemic, were compared with data from the same time period in 2019 pre-COVID-19. Additionally, in-depth interviews with key personnel were conducted at both institutions. Statistical analysis was performed using Stata 15 and qualitative data were analyzed using Nvivo software. Result(s): There was a significant reduction in blood supplied to the QECH from 7,303 [2019] to 6,028 units [2020] (P<0.04). The highest reduction in blood supply was to the Adult Emergency & Trauma department (29%) while the lowest was in Obstetrics & Gynecology, and Pediatric departments (17% reduction each). This is despite that the transfusion services continued to conduct blood drives during the pandemic, and the hospital laboratory prioritized blood issuing for emergency indications. Conclusion(s): Blood supply has significantly reduced during COVID-19 pandemic in our centers. Developing plans for overcoming similar shortages in future pandemics is critical.Copyright © Annals of Blood. All rights reserved.

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.

Perinatal Outcome in Covid-19 Positive Patients at Obstetrics & Gynecological Unit

Aim: To determine the frequency of perinatal outcomes in COVID-19 positive patients at obstetric and gynecological unit. Material(s) and Method(s): An observational cross sectional study was conducted at Aziz Fatimah medical college, Obstetrics and Gynecology department from January 2021 to June 2021 on 100 pregnant COVID positive patients. Perinatal outcomes such as cesarean section, postpartum hemorrhage, preterm birth and NICU admissions were assessed. Data was presented as frequencies, percentages and Mean+/-SD. Result(s): Mean maternal age was 29.71+/-6.05 years. The mean gestational age was 36.47+/-3.83 weeks. Postpartum hemorrhage was seen in 11 (11%) patients, Preterm birth rate was 37 (37%), NICU admissions rate was 44 (44%) and 54 (54%) patients had cesarean section. Conclusion(s): Pregnant COVID 19 positive women are at great risk of having perinatal complication.Copyright © 2022 Lahore Medical And Dental College. All rights reserved.

Analysis of Causes of Maternal Death in East Java Province, Indonesia

BACKGROUND: The maternal mortality rate is an indicator that reflects the mother's health status, especially the risk of death for the mother during pregnancy and childbirth. Measles, Mumps, and Rubella (MMR) has a close relationship with efforts to increase human development. Therefore, efforts are needed to reduce MMR by identifying the factors that influence MMR. AIM: The aim of the study was to analyze the factors causing the incidence of Maternal Death in East Java Province. METHOD(S): The research design used in this research is a quantitative research using descriptive-analytical. The population of this research is districts/cities in East Java Province, with a sample of 38 districts/cities. The research period starts from August to September 2021. Data analysis using grouping and percentage of cases. RESULT(S): The results of the study found that cases of maternal death in East Java due to postpartum hemorrhage in 2021 were 131 cases. Cases due to hypertension as many as 115 cases. Cases due to infection as many as 25 cases. The incidence of maternal death due to abortion is 1 case. There were 13 cases of maternal death due to blood disorders. There were 6 cases of maternal death due to metabolic disorders - cases of maternal death due to Heart as many as 54 cases. Maternal deaths due to COVID-19 were 793 cases. CONCLUSION(S): Factors causing maternal death in East Java Province, namely, hypertension bleeding, infection, abortion, blood disorders, heart metabolic disorders, and COVID-19. The most influential factor in maternal mortality in 2021 is COVID-19.Copyright © 2023 Maharani Maharani, Sutrisno Sutrisno.

Are Viscoelastometric Assays of Old Generation Ready for Disposal? Comment on Volod et al. Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J. Clin. Med. 2022, 11, 860.

With the advent of new viscoelastometric hemostatic assay (VHA) devices, with ready-to-use cartridge reagents allowing for their use by people without special laboratory skills, the appreciation of the actual clinical value of VHAs in settings such as severe trauma, post-partum hemorrhage, cardiac surgery and liver transplantation still needs to be fully validated. While two of the newest versions remain based on a 'cup and pin' system (ROTEM® sigma, ClotPro®), two other new devices (TEG® 6s, Quantra®) rely on very different technologies: clotting blood is no longer in contact with the probe and challenged by oscillation of one of the components but explored with ultrasound exposure. A systematic literature search (including Sonoclot®) retrieved 20 observational studies (19 prospective). Most studies pointed to imperfect agreements, highlighting the non-interchangeability of devices. Only a few studies, often with a limited number of patients enrolled, used a clinical outcome. No study compared VHA results with conventional laboratory assays obtained through a rapid tests panel. Clinical evidence of the utility of the new VHAs largely remains to be proven through randomized clinical trials, with clinically relevant outcomes, and compared to rapid panel hemostasis testing. The availability of new, improved VHA devices provides an impetus and an opportunity to do so.

Postpartum Blood Loss in COVID-19 Patients-Propensity Score Matched Analysis.

The aim of this study was to compare the estimated blood loss and the frequency of obstetric hemorrhage among pregnant women with and without COVID-19 infection. The study was carried out in the Department of Obstetrics and Gynecology, at the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Poland. From 15 May 2020 to 26 April 2021, a total of 224 parturients with COVID-19 infection were admitted for labor. The control group consisted of 300 randomly recruited pre-pandemic deliveries that took place between 15 May 2019 and 26 April 2020 at the Department. The primary outcome was the presence of postpartum hemorrhage, defined as an estimated blood loss of ≥500 mL within 24 h after birth or the need to transfuse 2 or more units of packed red blood cells (pRBCs). Secondary outcomes were the difference between hemoglobin and hematocrit levels at 24 h postpartum, the number of pRBCs units transfused, and the need for transperitoneal drainage. After applying the propensity-score-matching procedure for postpartum bleeding risk factors, 325 eligible patients were included in the final analysis, divided into 203 COVID-19 positive and 122 COVID-19 negative prepandemic deliveries. SARS-CoV-2 infected patients were characterized by a longer activated partial thromboplastin time (APTT), a reduced prothrombin time (PT), and lower platelet count at initial presentation. COVID-19 deliveries were found to be associated with a higher frequency of postpartum hemorrhage, an increased estimated blood loss, the more frequent use of peritoneal drainage, and more pRBCs units transfused. During the pandemic, an increased risk of postpartum hemorrhage posed another threat to SARS-CoV-2 infected pregnant women. It is essential to be aware of this when approaching COVID-19 delivery and to implement efficient preventative methods.

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.

Peripartum Outcomes Following COVID-19 Vaccination in Late Pregnancy: Findings from a Population-Based Retrospective Cohort Study in Ontario, Canada

Objectives: Evaluate peripartum outcomes following COVID-19 vaccination during pregnancy. Methods: Ontario population-based retrospective cohort between December 14, 2020 and September 30, 2021 using linkage of provincial birth registry and COVID-19 immunization databases. Poisson regression was used to generate risk ratios (RR) and 95% confidence intervals (CI), adjusted for temporal, socio-demographic, and clinical factors using propensity scores. Obstetric (postpartum hemorrhage, chorioamnionitis, cesarean birth) and newborn (NICU admission and 5-minute Apgar<7) outcomes were compared for those who received ≥1 dose of COVID-19 vaccine during pregnancy with 2 unexposed groups—Group 1: individuals vaccinated postpartum, Group 2: never vaccinated. Results: Among 97 590 individuals, 22 660 (23%) received ≥1 dose of vaccine during pregnancy (64% received dose 1 in 3rd trimester). Compared with those vaccinated postpartum, we found no increased risks of postpartum hemorrhage (aRR 0.91, 95% CI 0.82–1.02);chorioamnionitis (aRR 0.92, 95% CI 0.70–1.21);or cesarean (aRR 0.92, 95% CI 0.89–0.95) following COVID-19 vaccination, nor any increased risk of NICU admission or 5-minute Apgar <7. All findings were similar when compared with individuals who did not receive COVID-19 vaccination at any point. We did not observe any difference according to vaccine product, number of doses received during pregnancy, or trimester of dose 1. Conclusions: As of late 2021, there is limited evidence from comparative studies in large populations on outcomes following COVID-19 vaccination during pregnancy. Our study of births up to September 30, 2021 did not identify any increased adverse peripartum outcomes associated with later pregnancy COVID-19 vaccination. Once more individuals vaccinated earlier in pregnancy deliver, we will report on other important obstetric and perinatal outcomes. Keywords: COVID-19 vaccine;pregnancy;epidemiology

A review of high dependency unit admissions in a busy maternity hospital

Introduction: Due to the COVID-19 pandemic, critical care demands on our health service have come into focus. In our stand-alone maternity hospital, patients requiring more than single organ support must be transferred to a general adult hospital for critical care, however those requiring single organ support or increased levels of monitoring are cared for in our high dependency unit. This is best practice for our patients but must be staffed appropriately.We sought to quantify our burden of HDU admissions, and to ascertain our reasons for admission. Methods: We retrospectively examined our critical care admissions over a four-month period from July 2021 to October 2021. We separated our analysis into two groups- those admitted for obstetric reasons or those admitted for non-obstetric reasons (i.e. gynaecology patients). Results: Over the four months we examined there were 2642 births, including 832 caesarean sections. In that time, 33 women were admitted to our HDU for obstetric reasons, and six women were admitted for reasons related to a gynaecology procedure. Among our obstetric patients, preeclampsia was the most common reason for admission (48%), and postpartum haemorrhage was the second most common (39%). Sepsis was the most common reason for admission amongst our gynaecology patients. Discussion: The HSE guidelines for critically ill women in obstetrics in 2014 recognised that quantifying high dependency care needs for obstetric patients is challenging, as most are managed within their local maternity HDUs and are not included in national data [1]. The overriding principle in the care of sick postpartum women is to keep the woman and her baby together, if possible, to maximise bonding and ease psychological trauma [2]. Therefore, it is important that these patients are kept in their maternity hospital as far as is safe for them. We hope that by auditing our hospital’s critical care needs, we can ensure it is staffed appropriately, and more importantly that our staff receive the appropriate training in the management of the most common critical care issues.

Room of Knowledge (RoK): An initiative to encourage ad-hoc multi-disciplinary practical teaching

Objective: Clinical skill development is an essential part of speciality training in Obstetrics and Gynaecology. The COVID-19 pandemic has profoundly affected this with the move to remote learning, social distancing rules, increased workload, staff shortages and re-deployment. In order to improve access to clinical skills training it is imperative that we utilise the time spent in clinical settings such as labour ward and theatres to maximise training opportunities and skill development. Design: Qualitative study. Method: A pre-implementation online survey was carried out to analyse clinical skill training opportunities available to obstetric trainees and midwives on labour ward. In accordance with survey results, a trolley was assembled with the required equipment and easy to follow guides for carrying out several practical procedures and management of key emergency scenarios. The initial procedures and scenarios covered included;management of labour and delivery, post-partum haemorrhage, suturing and intrauterine device insertion. A log of the trolley's usage is being maintained and a follow up survey will be carried out in 3 months. Results: As per the initial survey, 90% of the respondents said that they were involved in ad hoc teaching only once a month or less. More than 80% trainees reported that they found impromptu teaching using models and aids on labour ward very useful and more than 95% said that they would attend such training if available. The most common procedures and/or skills identified as areas that should be covered included suturing, fetal scalp electrode attachment, breech vaginal birth and instrumental delivery. This project has significantly boosted the clinical teaching in our unit. The initial response from the log records revealed regular use on daily basis by trainee doctors as well as midwives. Operative vaginal delivery is the most utilised procedure to date. The first follow up survey will be conducted in April to assess the impact and analyse the scope for further expansion to include other aspects such as CTG training. Conclusion: The presence of the trolley along with materials and aids has helped create a learning environment on the labour ward with more frequent impromptu training even during busy shifts. It has instilled great enthusiasm amongst the trainees as well as trainers as evident from the verbal feedback and log records. A follow up survey and its statistical analysis will be carried out to substantiate our conclusion.

Emergency Peripartum Hysterectomy in a Tertiary Care Centre of North India during COVID-19 Pandemic: A Retrospective Study

Introduction: The pandemic of Coronavirus Disease 2019 (COVID-19) had a significant impact on obstetric surgeries. Obstetric surgical procedures during the COVID-19 pandemic affect individuals who are suspected or proven to be high-risk endeavors. Aim: To evaluate the demographic characteristics, indications, intraoperative and postoperative complications, and foetomaternal outcomes in the women who had an Emergency Peripartum Hysterectomy (EPH) during the first and second waves of the COVID-19 at a tertiary care centre in North India. Materials and Methods: This was a retrospective cohort study, conducted in the Department of Obstetrics and Gynaecology at a tertiary care centre in Uttar Pradesh, India, including women who underwent EPH operated from March 2020 to May 2021 in terms of demographic characteristics, indications, intraoperative and postoperative complications, and foetomaternal outcomes. Information about their self-reported health issues due to traumatic birth (when they came for a follow-up visit at five weeks) were also obtained. Simple frequency, percentage, and proportion were calculated using descriptive statistics. Results: A total number of 1827 deliveries were conducted and out them 11 cases underwent emergency peripartum hysterectomy at our institute during the time frame of the COVID-19 pandemic. All of the patients were in their 20s or 30s, with ages ranging from 21 to 34. All of these were unplanned pregnancies and arrived at various gestational ages. Eight cases had the previous scarring on the uterus, with six women having morbidly adhered placenta. All of the women in the study cohort were unbooked, and 72.73 % (eight out of 11) of them were referred to our centre because they had high-risk factors. Due to substantial blood loss, five females required Critical Care Unit (CCU) support. The study sample had a poor newborn outcome, with three early neonatal deaths out of 11 deliveries. As a part of their 5th-week follow-up, after the women had been stabilized and discharged from the ICU, they were asked to share their major issues related to health, psychological status and social interaction. The main worries revolved around the newborn child's and COVID-19 positive husband's health. Pregnant women who delivered during the COVID-19 pandemic had a significant rate of postpartum depression and Post-traumatic Stress Disorder (PTSD). Conclusion: The predominant cause of EPH in the study population was a morbidly adherent placenta. It is critical to protect women's physical and psychological health during traumatic childbirth in order to mitigate the pandemic's already-existing harmful impacts.

An audit of therapeutic anticoagulation with Anti-Xa monitoring during pregnancy

The risk of venous thromboembolism (VTE) increases by 10% in pregnancy to around 1/1000 and is a leading cause of death in pregnant women. Low molecular weight heparins (LMWHs) are the anticoagulant of choice for treatment of acute VTE during pregnancy. The initial dose of LMWH is weight based but currently there is lack of evidence supporting routine Anti-Xa monitoring during pregnancy and LMWH dose adjustments based on Anti-Xa levels. We conducted a retrospective audit of pregnant patients receiving therapeutic dose LMWH between October 2020 and October 2021 in a tertiary referral centre. The aim of this audit was to review LMWH dosages required in pregnancy to achieve peak Anti-Xa levels relative to weight-based and report maternal thrombotic or bleeding outcomes based on dose adjustments. A total of 21 pregnant patients were included who required therapeutic LMWH (Tinzaparin) during pregnancy. Of these, 10 (48%) had an acute VTE in the index pregnancy;one (4%) had recurrence of DVT despite weight adjusted LMWH. Ten (48%) were on long-term anticoagulation for a prior VTE including two with antithrombin deficiency and one with JAK 2 positive myeloproliferative disorder. They were all changed to LMWH during pregnancy. The site of acute VTE in index pregnancy (11) included: five (45%) deep vein thrombosis (DVT), three (28%) pulmonary emboli (PE), two (18%) had thromboses at an unusual site, and one patient (9%) had a superficial thrombophlebitis with gestational age range 7-40 weeks. Majority of pregnant patients (18/21;86%) had at least one peak Anti-Xa measured, and 12 (67%) patients had dose of LMWH increased at least once to achieve a target peak Anti-Xa level of 0.5-0.7 IU/ml. Five required two dose adjustments, and one required three dose adjustments. Nineteen patients have delivered and two have ongoing pregnancy. Twelve patients had spontaneous vaginal delivery, three assisted vaginal delivery and four had caesarean section for obstetric reasons. No patients had a recurrent thrombosis while on therapeutic dose LMWH and with dose adjustments as per peak anti-Xa level. One patient who presented with an acute DVT at 40 weeks of gestational age (GA) was managed with twice daily therapeutic dose Tinzaparin and insertion of an inferior vena cava (IVC) filter for anticoagulation interruption around delivery. The last dose Tinzaparin was 12 h prior to emergency Caesarean Section. She had postpartum haemorrhage with an estimated blood loss of 1800 ml but did not require blood product support and there was no evidence of progression of her symptoms of VTE or bleeding postoperatively when anticoagulation was resumed. Of note, six patients (29%) had a BMI >30 with five (83%) needing at least one adjustment of LMWH dose based on Anti-Xa levels and two (33%) needing > 2 dose increments with LMWH based on Anti-Xa monitoring. One patient had recurrence of PE on weight based LMWH dose with no recurrence of symptoms when the LMWH dose was adjusted to peak Anti-Xa level. None of the patients developed SARS-CoV-2 infection in the reported cohort. Fourteen (67%) pf pregnant had received their COVID-19 vaccination during this period . None of the thrombotic episodes were associated with COVID-19 vaccination. Although this audit study has limitations due to small patient numbers there was no evidence of increase in bleeding or thrombotic risk with ongoing anticoagulation with Anti-Xa monitoring during pregnancy..

From Propped up to Prone: A Paradigm Shift in the Management of Severe COVID Pneumonia!

Coronavirus disease (COVID) pneumonia in the recent times has shown us the importance of prone positioning during the management of moderate to severe hypoxia. In fact, we have rediscovered the benefits of this positional maneuver in coping with the oxygen crisis during the second wave of this dreaded pandemic. While we (the clinicians) derive benefits of this postural therapy for treating our patients, it is imperative for us to know the underlying mechanisms behind improvement in oxygenation in mild to moderate cases of COVID pneumonia. In this brief communication, we try to decipher the miracles of this great life-saver.

Enhancing resident confidence, knowledge, and skills in obstetrics and neonatal resuscitation through simulation

Learning Objectives/Educational Objectives: Objectives included providing hands-on training to improve confidence in high-risk deliveries and neonatal resuscitation, and assuring ACGME delivery requirement compliance. : Introduction/Background: COVID19 has affected offservice rotations for emergency medicine residents by limiting provider numbers in patient care areas. To mitigate the educational impact of decreased exposure to deliveries, we developed an obstetrics (OB) simulation (sim) curriculum. Curricular Design: The curriculum consists of 4 sim sessions: 1) normal vaginal delivery & shoulder dystocia;2) breech, cord prolapse, cord presentation;3) postpartum hemorrhage & perimortem c-section;and 4) breech delivery, neonatal resuscitation, post-partum hemorrhage care. Sessions include a facilitated discussion, practice of techniques and procedures, and a comprehensive, high-fidelity sim. By the end of the 4 sessions, residents complete 13 deliveries, 1 c-section, 2 post-partum hemorrhage resuscitations, and 1 pediatric resuscitation. Throughout the year they will receive monthly e-mailed pearls for spaced repetition of knowledge. Additionally, at the end of the academic year, residents will repeat the final session, perform another c-section, and practice 5 additional deliveries. Impact/Effectiveness: After overwhelmingly positive session feedback from the class of 2020, the curriculum was added as a required adjunct to the OB rotation. The class of 2021 has completed the 4 sessions prior to rotating on OB. Residents completed a 15-item confidence and knowledge assessment prior to the 1st and 4th sessions which demonstrated a significant improvement in both median reported confidence on a 3-point likert scale (1.5 [interquartile range(IQR) 1.2-1.5]) vs 2.1 [IQR 1.9-2.3], p=0.02) and median percentage of correct responses for knowledge-based questions (18 [IQR 12-65] vs 82 [IQR 71-88], p=0.03). Residents will take the quiz at the end of the academic year to assess confidence and knowledge retention, and further refine the OB sim curriculum.

A VERY COMPLICATED COURSE after VAGINAL DELIVERY in TYPE 3 von WILLEBRAND DISEASE with ALLOANTIBODIES to von WILLEBRAND FACTOR and FACTOR VIII

Introduction: Delivery in type 3 VWD with alloantibodies, a rare clinical entity with few treatment options, is a very high-risk situation. Methods: Case report Results: A 28 yo patient with type 3 VWD and alloantibodies to VWF and FVIII became pregnant after extensive preconceptional counselling. Previous ITI was unsuccessful and complicated by anaphylaxis. The pregnancy was complicated by a mild COVID-19 infection in the 2nd trimester, but otherwise uncomplicated. Delivery was induced at 38 4/7 weeks with prostaglandin and rFVIIa (NovoSeven®) started when in active labor. After a rapid vaginal delivery and afterbirth, manual placental removal was performed and a Bakri balloon inserted for ongoing bleeding despite rFVIIa 90μg/kg every 2h. As bleeding still continued, plasma-derived VWF was infused with initial excellent recovery and successful embolization of the aa uterinae was performed. Another infusion of VWF to prevent rebleeding resulted in minimal recovery and an allergic reaction despite prednisolone and clemastine. Rebleeding did not occur and patient was discharged at day 8. At day 12 she was readmitted because of endometritis followed by vaginal bleeding unresponsive to rFVIIa. Re-embolization was performed and off label emicizumab started to prevent rebleeding. A loading dose of 6mg/kg on day 1 and 3mg/kg on day 2 was given, followed by 3mg/kg EOW from the 2nd week onwards. As the infection was uncontrolled by broadspectrum antibiotics, hysterectomy was performed at dag 29, again complicated by diffuse bleeding requiring direct intra-abdominal packing and rFVIIa 90μg/kg every 2 hours in addition to emicizumab. A week after unpacking, asymptomatic pulmonary embolisms and thrombosis of the left v iliaca were discovered on CT. rFVIIa was stopped, prophylactic LMWH started and a third embolization performed when bleeding reoccurred. Two months after delivery she was discharged with low dose LMWH, emicizumab and antibiotics because of an intra-abdominal abcess. Discussion/Conclusion: Delivery in patients with severe bleeding disorders in the presence of alloantibodies is a high-risk situation. Emicizumab was partially helpful in maintaining hemostatic control. Besides bleeding, postpartum patients receiving intensive correction of coagulation and especially with additional risk factors like surgery and infection, are also at risk for thrombotic events.

Efficacy and Safety of Aspirin 162 mg Prophylaxis for Preeclampsia Prevention in High Risk Women

Objective: Numerous studies have evaluated the efficacy and safety of low dose aspirin for preeclampsia prevention in high risk women. Most studies were European based demonstrating efficacy and safety with aspirin 150 mg, with studies in the United States supporting aspirin 81 mg for preeclampsia prevention. There is limited data from the United States evaluating aspirin 162 mg;the aim of this study was to examine the efficacy and safety of aspirin 162 mg vs 81 mg vs no aspirin for preeclampsia prevention. Study Design: A retrospective cohort study was performed at Henry Ford Health System (HFHS) between 2013 and 2020. The ‘no aspirin’ group was composed of women who met high risk criteria prior to October 2015, when aspirin was implemented at HFHS. The ‘aspirin 81 mg’ and ‘aspirin 162 mg’ groups were composed of women who met high risk criteria prophylaxed with the respective aspirin doses after October 2015. Exclusion was made for women with bleeding disorders, sensitivity to aspirin, and covid-19 infection (as applicable). Results: A total of 2,266 women met high risk criteria prior to October 2015 and received no treatment. A total of 944 women received aspirin 81 mg and 387 women received aspirin 162 mg. 322 women (14.2%) without treatment developed preeclampsia, compared to 134 women (14.2%) in the aspirin 81 mg group and 39 (10.1%) in the aspirin 162 mg group. The difference in preeclampsia rates between aspirin 81 mg and aspirin 162 mg was statistically significant (p = 0.043). The risks for postpartum hemorrhage, postpartum hematoma, and intraventricular hemorrhage of the newborn were not statistically different between women in the aspirin 162 mg group compared to the aspirin 81 mg group (p >0.05). Conclusion: We found a 29% reduction in the rate of preeclampsia for high risk women with aspirin 162 mg vs aspirin 81 mg without an increased risk for bleeding. Our study demonstrates that aspirin 162 mg should be recommended for preeclampsia prophylaxis in high risk women. Further studies by other groups are needed to confirm these findings.