Analysis of Maternal Critical Care at the Mid Yorkshire Hospitals NHS Trust

Introduction: Perinatal admissions to Critical Care are increasing due to rising maternal age, obesity, and comorbid disease.1 The MBRRACE Report 2021 stated that of 191 maternal deaths in 2017-2019, only 17% had good care.2 Since the COVID-19 pandemic, there was a subjective increase in perinatal admissions to Mid Yorkshire Hospitals Critical Care. Objective(s): To investigate whether MYH Critical Care maternal admissions have increased, if there has been a change in admission trends and to evaluate the care of critically ill pregnant and postpartum women compared to FICM standards.3 Methods: Retrospective audit of notes of all pregnant and up to 6 weeks postpartum women admitted to critical care between 24/02/2019 and 05/09/2021. Data collected included gestation, duration of admission, organ support, days reviewed by obstetrics and mortality outcomes. Result(s): * There was 1 maternal death and 3 fetal deaths during the study period * 50% of the admissions were antenatal and 50% were postnatal * During the COVID-19 pandemic we have seen a 47% increased rate of admissions from 1 per 29 critical care bed days to 1 per 19 critical care bed days * 50% of patients were supported with ventilation and CPAP during admission, 13% with CPAP only. Prior to the COVID pandemic, no maternal admission required CPAP on our Critical Care unit during the data collection period * 63% of patients were reviewed by obstetrics at least one during their admission, but obstetric review was documented on only 37 of 112 patient days * There is no critical care SOP for perimortem Caesarean section * There is no specialist neonatal resuscitation equipment available on ICU * There is no named ICM consultant responsible for Maternal Critical Care * There is no SOP for support of maternal contact with baby * There is no critical care/obstetric services MDT follow-up Conclusion(s): This study shows that Critical Care admissions have increased, and that care does not follow all the FICM recommendations. Considering this, the following recommendations have been made: * Introduce an SOP and simulation training for peri-mortem section * Introduce neonatal resuscitation equipment box * Nomination of a named ICM Consultant lead for Maternal Critical Care to ensure quality of care and act as liaison * Train critical care staff in supporting contact between a mother and baby, with support from midwifery services * Introduction of Obstetric and Critical Care MDT follow-up.

Pregnancy Outcomes in Women with Sickle Cell Disease in Ireland: A Retrospective Review

Background: Sickle cell disease (SCD) is one of the most common single gene disorders worldwide and is characterised by significant morbidity and early mortality.[1] Pregnancy in SCD is associated with an increased risk of maternal and foetal complications.[2,3] The 2011 RCOG and the 2021 BSH guidelines[5,6] on the management of pregnancy in SCD have provided the basis for best practice care in the UK over the past decade and is the guidance which we follow in Ireland. To date, there is no published data on outcomes for pregnant women with SCD in Ireland. The number of Irish patients with SCD has risen over the past 20 years. Without a national database, the exact prevalence is not known but currently there are at least 600 adults and children with SCD in Ireland, whose population is just over 5 million.[4] Aims: Our study assesses outcomes of pregnant patients with SCD from 2015 to 2022. Our aims were to: * Assess adherence to current guidelines * Assess pregnancy outcomes and maternal complications * Assess transfusion rates amongst our patient cohort. Method(s): This is a retrospective cohort study. We do not have a directly matched cohort, but have compared our findings to published data on Irish pregnancy outcomes from the Irish Maternity Indicator System National Report and have correlated our findings with studies of women with SCD who were managed in UK centres.[8,9,10] Results: We reviewed outcomes of 29 pregnancies in 19 women over a 7-year period. The median age was 29 (range 20-41) and the predominant maternal sickle genotype was HbSS (65.5%). Before conception, 55.2% of cases had pre-existing complications of SCD, including acute chest syndrome (ACS), pulmonary hypertension (PHTN) and prior stroke. In accordance with current guidelines, 100% of women (n=29) were prescribed folic acid, penicillin, and aspirin prophylaxis. 51.7% (n=15) of women had documented maternal complications during pregnancy, including ACS (34%), vaso-occlusive crisis (34%), gestational diabetes (10%), VTE (3%) and UTI (3%). Two women (7%) developed Covid-19 pneumonitis despite vaccination. There was one case of maternal bacteraemia (3%). 65.5% of cases (n=19) required blood transfusion during pregnancy. One woman was already on a blood transfusion programme for disease modification prior to pregnancy. In 6 cases (20.6%), a transfusion programme was commenced during pregnancy due to prior pregnancy complications or intrauterine growth restriction. During pregnancy, 27.6% (n=8) of women required emergency red cell exchange for ACS. Prior studies have suggested that between 30% and 70% of pregnant women with SCD require at least one blood transfusion during pregnancy.[8,9,10] By comparison, only 2.6% of the Irish general obstetric population required transfusion during pregnancy.[7] 20.6% (n=6) of births were preterm at <37 weeks' gestation. There was one live preterm birth (3%) at <34 weeks and one intrauterine death (3%) at 23 weeks' gestation. Similar to UK data[9], 31% of women required critical care stay (n=9) during pregnancy, in comparison with 1.44% nationwide in 2020.[7] Conclusion(s): It is well established that pregnancy in SCD is high risk, and despite adherence to current guidelines, we have shown very high rates of critical care admission, significant transfusion requirement and hospital admissions. Our findings are comparable to published UK outcomes and they further support the need for a comprehensive specialist care setting for this patient cohort.

Determination of the Effects of Prenatal Remdesivir Exposure on Placenta Morphology, Placental IgG Transfer, and Fetal Growth in a Humanized Mouse Model

Remdesivir (RDV) is an antiviral medication used most recently for the treatment of COVID-19. Although no adverse effects were observed on perinatal parameters in reproductive and development toxicology studies at doses up to four-fold clinical area under the curve (AUC) exposures, some researchers have reported that therapeutic levels of RDV may impair early embryogenesis, as observed by in vitro studies. In addition, the influence of prenatal RDV exposure on maternal IgG transfer in the placenta is still unknown. Administration of RDV in pregnant humanized mouse model (Tg32), which expresses the human Fc gamma receptor and transporter (FCGRT) gene, was used to further evaluate potential effects on IgG transfer and concurrent perinatal endpoints. Animals were dosed daily from gestational days (GDs) 10- 14 with 25 mg/kg RDV (GS-5734) via intravenous injection (n=3-5 per group). Concurrent vehicle control animals were dosed intravenously with 12% sulfobutyl ether- beta-cyclodextrin in water (pH3.5;NaOH/HCl). All animals were administered 2 mg/kg human IgG via intravenous injection on GD 14. Placentae and fetuses were collected from dams on GD 14, 15, 16, and 18 and evaluated using histopathology and qPCR for inflammation markers. No abnormal morphologies (necrosis/apoptosis) of placentae were observed between the concurrent control and RDVdosed groups. Additionally, no differences in maternal body weights were observed. There were no statistically significant differences in placenta weights. There were no statistically significant changes in pregnancy parameters (implantation sites and dead fetuses/litter) and fetal weights between the RDV-dosed group and concurrent controls at GD 14, 15, 16, and 18. No changes were observed in transcript levels of inflammation markers in the RDV-dosed group when compared to the concurrent control group. There was a slightly lower ratio of fetal IgG level to maternal IgG levels in the RDV-dosed group;however, no statistically significant differences were observed between the RDV-dosed group and concurrent controls on GD 14, 15, 16, and 18. Our results suggest that a daily dose of 25 mg/kg RDV on GDs 10-14 in humanized mice did not cause adverse effects on placenta and fetal development. (Funded by the Perinatal Health Center of Excellence: E0300201.).

Stillbirth Rates before and during the COVID-19 Pandemic in Manitoba (Canada) and Japan

Background: Conflicting evidence exists on the impact of the COVID-19 pandemic restrictions on stillbirth rates in developed countries. We aimed to examine and compare the incidence rates of stillbirth before and after the implementation of COVID-19 measures in Canada and Japan. Method(s): We conducted two populationbased studies using mother-infant linked data from JMDC hospitalizations database (JMDC Inc.) in Japan and administrative health databases in Manitoba, Canada, from October 2016 to March 2021. We used interrupted time series analysis (generalized linear models) to investigate the immediate change in level and rebound change in quarterly rates of stillbirth (fetal death > 20 weeks of gestation). We modeled the forecasted trends based on prepandemic data via autoregressive moving average models. Result(s): We included 70,931 and 169,883 pregnancies in Manitoba and Japan during the study period, respectively. On average, stillbirth rates were 0.66% in Manitoba and 0.31% in Japan. The pandemic restrictions were associated with an immediate relative increase in stillbirths in Japan by 19.19% (beta2=0.05;p=0.5693) and in Manitoba by 18.6% (beta2=0.12;p=0.4434). However, the quarterly stillbirth rates decreased (beta3=0.1625, p=0.5066) in Japan and Manitoba (beta3=0.011, p=0.8296) during the pandemic period. During the first quarter of 2021, the absolute differences in the observed and forecasted rates in Manitoba and Japan were 0.04% and -0.05%, respectively. Conclusion(s): Although various approaches were implemented to address the pandemic in Manitoba (Canada) and Japan, we found no evidence of a significant increase in the incidence of stillbirth rates during the first year of the pandemic. Healthcare services in Canada and Japan have experienced substantial changes since the start of the COVID-19 pandemic, with little influence on stillbirth rates at population level. This study will further examine the effect of the pandemic measures on other adverse pregnancy outcomes in both countries.

CASE REPORT: FETAL DEATH in UTERO COMPLICATED by DISSEMINATED INTRAVASCULAR COAGULATION in MATERNAL COVID-19 INFECTION

Background: COVID-19 infection during pregnancy is associated with an increased risk of stillbirth, likely due to placental insufficiency through the associated inflammatory response and hypoperfusion. A spectrum of associated placental changes has been reported. Whilst pregnancy alone is a hypercoagulable state, concurrent COVID-19 further increases the risk of coagulopathy. Disseminated intravascular coagulation (DIC) is uncommon in pregnancy but is increased in both COVID-19 infection and fetal death in utero (FDIU). Method(s): Case report. Informed written consent was obtained from the patient. Result(s): A 31-year-old G5P2 presented with a FDIU at 23 + 3 weeks gestation, in the setting of maternal COVID-19 infection without respiratory symptoms or oxygen requirements. The pregnancy had been uncomplicated, and her presenting issue was two days of reduced fetal movements, when FDIU was confirmed on ultrasound. On admission, the case was further complicated by disseminated intravascular coagulopathy (DIC). This DIC could have resulted from COVID-19 infection, FDIU or a combination of both. Placental histopathology showed evidence of inflammation, with chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The inflammatory response, evidenced by histopathological findings of CHI and MPFD, likely contributed to placental insufficiency and FDIU. Conclusion(s): COVID-19 infection is associated with increased risk of hematological abnormalities, placental inflammation and pregnancy loss. This case is the first to report both DIC and CHI in the context of FDIU in COVID-19 infection. We present this case to highlight the impact of COVID-19 infection on placental function, coagulation disturbances and subsequently adverse pregnancy outcomes.

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

Placental histological findings in COVID-19 term, preterm and metabolic disorders pregnancy

Objective. In the last two years COVID-19 infection has represented a true unknown in the management of pregnancies with maternal COVID-19 positivity. However, it has not represented a serious complication, indeed it has rarely caused premature rupture of the membrane, fetal thrombosis or postnatal complications. Materials and Methods. Our retrospective cohort study included placental samples from 350 patients from San Pietro Fatebenefratelli Hospital collected in a period of 4 months. Inclusion criteria were COVID-19 positivity during childbirth or in the previous two months but also a pregnancy without previous COVID-19 infection. Anamnestic data were carried out for the histological study on each placenta. 59% of patients were COVID-19 positive (15% of these had other associated disorders like gestational diabetes, hypertension, fetal death, preterm birth) 26.5% were preterm and the 14,5% were high-risk pregnancy with COVID-19 negativity. Results. The most frequently represented lesion in a COVID-19 placenta was a mild chronic deciduitis, usually absent in placentas with normal outcome. The same deciduitis was observed in gestational diabetes placentas, although less frequently. Other rare findings were patchy fibrinoid necrosis of capsular decidua, chronic villitis, umbilical cord thrombosis. Severe lesions were rare. Conclusions. COVID-19 does not seem to have a severe impact on the health of the placenta except in rare cases in which predisposing factors coexist and determine a more serious involvement of the fetus and its appendages. COVID-19 determines a constant but mild chronic placental inflammation, that is balanced by the maternal capacity to maintain homeostasis stemming the external injuries.

Maternal outcomes during the COVID-19 Pandemic: A Retrospective analysis of the last 5 years

Aim: Coronavirus disease-2019 has caused a significant health crisis all over the world. This study aimed to compare obstetric and gynecological data during the COVID-19 pandemic period with the previous three years. Material(s) and Method(s): For this purpose, over a 5-year period, from January 2017 to December 2021, patient records from the hospital's electronic data registry were scanned. The extracted data included the number of patients admitted to the outpatient clinic, the number of emergency outpatient visits, the number of patients inserted and removed with an intrauterine device (IUD), abortions, premature rupture of membranes (PROM), intrauterine fetal death (IUFD) and vaginal delivery and cesarean section. Result(s): The number of patients who underwent IUD removal decreased in the last two years. Also, the number of patients who underwent IUD insertion in 2020 was very low compared to other years (p<0.01, for all). It was observed that the number of patients diagnosed with PROM decreased in the last three years (p<0.01, for all). There was a statistically significant decrease in the total number of deliveries in the last two years (p<0.01). Discussion(s): In conclusion, it is seen that the number of outpatients, the number of emergency outpatients, the number of IUDs removed and the total number of deliveries have decreased in the last two years compared to the previous three years. This may be related to the coronavirus infection, which has caused the pandemic for the last two years.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Endouterine fetal death and its impact on the living of the woman and of the couple: a phenomenological study

Objective. Stillbirth affects nearly 2 million babies every year. According to the major scientific societies, fetal intrauterine death is the death of a fetus beyond 22 weeks of gestation during pregnancy or childbirth. The aim of the study is to analyze the impact of the event on the experience of the couple by analyzing any psycho-emotional and social repercussions and the relation with the COVID-19 pandemic. Materials and Methods. A qualitative survey, conducted with phenomenological methodology according to Cohen. The study focuses on individual, semi-structured interviews administered to a sample of ten women with an intrauterine fetal death between January 2020 and September 2021 who gave birth at the U.O.C of Obstetrics and Gynecology of the A.O.U.C Policlinico di Bari. Results. Four main themes emerged from the analysis of the interviews: memory, bereavement, healthcare workers and change. Afterwards thirteen sub-themes were extrapolated and analyzed as can be seen in the table (Table 1). Conclusions. It emerged that post-loss bereavement has an impact on many aspects of the future life of women and couples that does not end at the time of discharge from the hospital. Greater awareness is needed on the subject for women, operators and those around them;more information and Table 1. training, both human and theoretical. It is essential to live this experience with your partner as injured parties in equal measure and this should always be possible, even during a pandemic like the one caused by COVID-19. The couple should be psychologically supported throughout the bereavement process starting from hospitalization.

Moderate to Severe COVID-19 Illness in Pregnancy: The Experience in a Tertiary Centre in the United Kingdom

Background & Purpose: Pregnant women are at higher risk of developing severe COVID-19 compared with non-pregnant women, particularly in the third trimester1. Despite ongoing campaigns, the proportion of pregnant women vaccinated against SARS-CoV-2 is lower than in the general population2. The medium-term effects of COVID-19 during pregnancy are not well characterized. We report a cohort of pregnant women admitted to hospital with moderate-to-severe COVID-19. Method(s): Data from clinical records were retrospectively collected from all pregnant women admitted through the maternity assessment unit at St. Thomas' Hospital, between January 2021 and January 2022, due to COVID-19 requiring oxygen to maintain saturations >94%. Result(s): Fourteen women were identified (age=33.4+/-5.2 years;42.8% Caucasian;28.6% Black), requiring admission at 31+/-4.7 weeks gestation. Only two were double vaccinated (14.2%). Body mass index (BMI) was 27.2+/-6.4 kg/m2. Two women had concomitant co-morbidities (asthma and type 1 diabetes). They were managed in the obstetric high- dependency unit (level 1), barring one that required invasive ventilation for one day. The Delta variant was most commonly implicated (43%). All women requiring oxygen received steroids. Four women received Tocilizumab and three casirivimab/imdevimab;two received both. Four women were delivered by emergency Caesarean section due to maternal or fetal concerns, while the others continued their pregnancies. There was one late intrauterine death at 35 weeks. Women were followed-up for an average of six weeks. At follow-up in the obstetric medicine COVID-19 clinic, all women had complete resolution of COVID-19 on clinical examination, pulse oximetry and chest radiograph. Conclusion(s): In 14 pregnant women requiring admission to hospital for hypoxia secondary to moderate-to-severe COVID-19, concomitant co-morbidities and high BMI were not prevalent. Most were not vaccinated against SARS-CoV-2. Despite experiencing moderate-to-severe COVID-19, they had complete clinical and radiological resolution at six weeks follow-up.

FETAL GROWTH RETARDATION AS A COMPLICATION OF POST-COVID ENDOTHELIITIS: CAUSES, CONSEQUENCES, WAYS OF PREVENTION.

The risk of fetal intrauterine growth retardation (IUGR) is increased in women who have experienced acute infections, as well as in pregnant women with gynecological pathology and endocrine diseases. A woman's lack of nutrition also makes a negative contribution to the development of IUGR. The frequency of IUGR in the population is very variable and depends on a number of reasons. In practically healthy pregnant women, IUGR is registered in 3-5% of cases, in case of complicated obstetric and gynecological diagnosis and complicated pregnancy - in 10-25%. Morphofunctional disorders in the chorion/placenta in pregnant women with COVID-19 on the background of post-covid endotheliitis are the main pathogenetic factor in the development of preeclampsia, ectopic pregnancy, antenatal fetal death, and impaired condition of the fetus and newborns. Sufficient saturation of the pregnant woman's body with the nitric oxide donor L-arginine and L-carnitine (main cofactor of fatty acid metabolism in cells) with the improvement of microcirculation and the correction of hypovolemic disorders in the fetoplacental complex can be considered one of the real ways to prevent IUGR in women in the post-covid period. A review of the scientific literature on pathogenesis, diagnosis, impact on the life and health of a newborn with IUGR in women after COVID-19, as well as the possibilities of medical correction of placental dysfunction during pregnancy was performed. This analysis and our own clinical experience allow us to state the fact that after a coronavirus infection during pregnancy, one of the frequent and threatening for the further development of the child is the formation of placental dysfunction and IUGR. One of the ways to prevent these conditions is to saturate the woman's body with the nitric oxide donor L-arginine from the stage of pre-gravid preparation, which will provide the opportunity for adequate angiogenesis and development of the embryo/fetus. In the case of additional risk factors, such as coronavirus disease, complex therapy blood (Rheosorbilact), in combination with a nitric oxide donor and L-carnitine as an endothelium-protective agent (Tivor-L).Copyright © 2022 Authors. All rights reserved.

Evaluating Outcomes of Extracorporeal Life Support Use in Peripartum Patients: A Single Institution Experience

Background Indications and practice of extracorporeal membrane oxygenation (ECMO) use in pregnant patients are known;however, there is minimal evidence outside of meta-analysis and case series that comprehensively documents the outcomes. This study systematically evaluates the outcomes of ECMO utilization for peripartum patients in the setting of respiratory and/or cardiovascular failure. Methods All peripartum patients from 2018 to 2021 from a single center were screened to see if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. 15 patients met inclusion criteria of requiring ECMO while pregnant or up until 6 weeks postpartum. The patient demographics;operative details;ECMO registry data;critical care characteristics;adverse events per the codes for extracorporeal life support complications;and adverse outcome for maternal, fetus, and neonates were all collected. Results The cohort studied had a mean age of 30.3 years old, was racially diverse, and had few preexisting medical conditions before pregnancy. ECMO was indicated in 10/15 patients due to COVID-19 and 4/15 patients due to cardiac disease. ECMO was intended to be a bridge to recovery for 14/15 patients of which 11/14 patients recovered to discharge. The temporary ventricular decompression therapies used in VA ECMO patients were limited to the Protek Duo Right Ventricular Assist Device and TandemHeart device. No patients required transplantation or a durable mechanical device. Notable complications: 1 intrauterine fetal demise from placental malperfusion before ECMO was started;4 maternal deaths, of which 3 were related to ECMO;4 cardiac arrest events;1 limb ischemia event after ECMO cannulation;4 cannulation site hematomas;0 cannulation site hemorrhage;1 cardiac arrhythmia event;2 patients comprised all the intracranial hemorrhage events;and 2 patients comprised all the Gastrointestinal hemorrhage events. Conclusion To our knowledge;this is the first comprehensive documentation of adverse events in peripartum patients describing maternal, fetal, neonatal, and ECMO related outcomes. This data provides a standard format to evaluate risks of ECMO use in peripartum patients.Copyright © 2023 American College of Cardiology Foundation

Corona virus: Vaccination and course of pregnancy.

The infection with SARS-CoV-2 during pregnancy is associated with significant risks for the mother and also the fetus is at risk due to preterm birth, intrauterine growth restriction, and,-in some cases-, intrauterine fetal death. Despite the fact that IgG-antibodies can be transmitted from the mother to the fetus thrombosis of the placenta may lead to complications. Depending on the course of the disease, the risk of thrombosis for the pregnant woman is increased as well. Therefore, in some cases, heparinization is recommended. Vaccination against COVID-19 protects the mother from severe disease courses as well as from infection-related pregnancy complications. Thus, every pregnant woman should be informed about the option of vaccination even during pregnancy. According to the STIKO, the best time for vaccination is throughout the second trimenon.Copyright © 2022, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

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.

Perinatal Outcomes of COVID-19 in Pregnancy in a Tertiary Care Center in South India

Aim: In light of the severe acute respiratory syndrome by a coronavirus-2 (SARS-CoV-2) pandemic, it was proposed that a variety of complications have occurred in women during pregnancy, which has further extended to the fetus, causing higher rates of morbidity and mortality. The objective of this study was to identify the complications that arose due to the coronavirus and asses how it impacted the pregnancy, the fetus, and the neonate. Materials and methods: Our study was a descriptive and observational study, which investigated the various aspects, obstetric, fetal and neonatal outcomes, and the complications arising in mothers affected with by SARS-CoV-2 virus. All women who tested positive after 20 weeks of gestation were included in the study and their pregnancy was followed up till delivery, and neonatal outcomes were noted. Results: About 220 women infected with SARS-CoV-2 were studied and outcomes were illustrated. The mean age of the study population was 26.87 years [±4.96 Standard Deviation (SD)]. About 90% of the study population had a mild illness. The main obstetric outcomes noted were preterm labor, preeclampsia, eclampsia, intrauterine growth restriction (IUGR), and intrauterine fetal demise (IUD). Only 4.1% required a cesarean section for worsening conditions. Neonatal intensive care unit (ICU) admissions were also noted to be higher, with a possibility of vertical transmission in six babies. Conclusion: Severe acute respiratory syndrome by a coronavirus-2 can have serious implications and can pose a great risk in pregnancy if not caught and treated early. Therefore, it is vital to screen those at high risk for the virus to prevent severe complications from taking a toll on the mother and fetus. Clinical significance: By identifying the main complications occurring in pregnancy, we can prevent the same by anticipating and monitoring carefully, thereby reducing mortality and morbidity rates.

Peripartum Outcomes Associated With COVID-19 Vaccination during Pregnancy: A Systematic Review and Meta-analysis

Background. The risk and benefits of coronavirus disease 2019 (COVID-19) vaccination during pregnancy are under investigation. Pooled evidence regarding neonatal and maternal outcomes in relation to COVID-19 vaccination during pregnancy is scarce. Methods. We searched PubMed and EMBASE databases in April 2022 without language restrictions. We included Prospective trials and observational studies comparing the women who received at least one COVID-19 vaccination during pregnancy with those who did not and reporting neonatal outcomes. Two independent investigators extracted relevant data from each study. Odds ratios (ORs) were calculated using random-effects models. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The primary outcomes were the neonatal outcomes, including preterm birth, small-for-gestational-age (SGA), low Apgar score (< 7 at 5 min), neonatal intensive care units (NICU) admission, and intrauterine fetal death (IFD). The secondary outcomes were maternal outcomes, including maternal SARS-CoV-2 infection, cesarean delivery, postpartum hemorrhage, and chorioamnionitis. Results. Nine observational studies involving 81,349 vaccinated (mean age, 32.0 +/-4.6 years) and 255,346 unvaccinated women during pregnancy (mean age, 30.5+/-5.1 years) were included. COVID-19 vaccination during pregnancy was associated with lower risk of NICU admission (OR, 0.88;95% confidence intervals [CI], 0.80-0.97) and IFD (OR, 0.73;95% CI, 0.57-0.94), whereas it was not associated with preterm birth (OR, 0.89;95% CI, 0.76-1.04), SGA (OR, 0.99;95% CI, 0.94-1.04), and low Apgar score (OR, 0.94;95% CI, 0.87-1.02). COVID-19 vaccination during pregnancy was associated with a lower risk of maternal SARS-CoV-2 infection (OR, 0.46;95% CI, 0.22-0.93), but not associated with increased risk of cesarean delivery (OR, 1.05;95% CI, 0.93-1.20), postpartum hemorrhage (OR, 0.95;95% CI, 0.83-1.07), and chorioamnionitis (OR, 0.95;95% CI, 0.83-1.07). Flowchart of study selection Forest plots showing the odds ratio of neonatal outcomes a: neonatal intensive care units admission, b: intrauterine fetal death, c: preterm birth, d: small for gestational age, e: low Apgar score Forest plots showing the odds ratio of maternal outcomes a: maternal SARS-CoV-2 infection, b: cesarean delivery, c: postpartum hemorrhage, d: chorioamnionitis Conclusion. COVID-19 vaccination during pregnancy did not increase the risk of peripartum outcomes but decreased the risk of NICU admission, IFD, and maternal COVID-19 infection. COVID-19 vaccination should be encouraged for pregnant women.

Maternal thrombocytopenia due to inflammatory changes in the placenta precedes fetal death associated with COVID-19

Introduction: Acute coagulopathy, specific placental change, and fetal death are reported in pregnant women with COVID-19;however, the pathogenesis of them remains unknown. We report two cases of stillbirth in pregnant women with COVID-19 who showed acute coagulopathy and their placentas showed characteristic pathological findings due to COVID-19. Case: Case 1: A 28-year-old pregnant woman (gravida 3, para 2) who had undergone two cesarean sections had a fever of 39 degree and was positive for SARS-CoV-2 at 26 weeks of gestation. She showed thrombocytopenia and subsequent coagulopathy on day 7, and her fetus was dead on day 9. She underwent a cesarean section after blood transfusion and her coagulability thereafter improved. Case 2: A 35-year-old pregnant woman (gravida 3, para 2) who had no symptoms was positive for SARS-CoV-2 at 20 weeks of gestation. She also presented with thrombocytopenia on day 5. Her fetus was dead, and she went into labor spontaneously and virginally delivered a stillborn baby on day 9. Her coagulability thereafter returned to normal. Placental histology of both cases showed intervillous infiltration of histiocytes, necrosis of trophoblast, and fibrin deposition, and the expression of SARS-CoV-2 spike protein was observed in the syncytiotrophoblasts of the villi. Discussion(s): Specific placental changes related to COVID-19 are thought to be the result of an immune response rather than direct infection with SARS-CoV-2. The placental changes induced by COVID-19 might have caused fetal death. When managing pregnant women with COVID-19, thrombopenia may be a predictive marker of fetal death following placental inflammatory changes. Copyright © 2022

Stillbirth during a pandemic: a retrospective cohort study in a high-risk population

Objective: To examine the rate of stillbirth in a high-risk population at a single institution during the initial twelve months of the COVID-19 pandemic. Study Design: Stillbirths, defined as fetal demise at 20 weeks gestation or greater, were identified during the study period and compared to total deliveries at the institution. Seventy-six stillbirths were identified, 26 in the prepandemic cohort and 50 in the pandemic cohort. Demographic and pregnancy information for each stillbirth dyad was extracted by chart review. Patient outcomes were compared between the prepandemic cohort and the pandemic cohort. Result(s): The rate of stillbirth in the pandemic cohort was 19.3 per 1000 versus the prepandemic cohort rate of 8.9 per 1000 (p < 0.001). The pandemic cohort established prenatal care at a later gestational age (p = 0.049), was less likely to have adequate prenatal care (p=0.013) and was less likely to have established care with a maternal-fetal medicine specialist (p = 0.025). Conclusion(s): Stillbirths increased significantly at a tertiary care center in a high-risk population during the initial twelve months of the COVID-19 pandemic. Our findings suggest a relationship between inadequate prenatal care and perinatal outcomes during the COVID-19 pandemic. Disclosure: No Copyright © 2022

Successful cesarean section in a woman with coronavirus and scleroderma: a case report

Background: The incidence of adverse perinatal outcomes including increased risk of miscarriage, preeclampsia, preterm birth and stillbirth is higher in pregnant women with coronavirus. Pregnant women who are infected with the coronavirus have placentas that are abnormal compared to the placentas of healthy women. Examples of these adverse effects have been observed before and include reduced fetal growth, pre-eclampsia, premature birth and stillbirth. Scleroderma is an uncommon connective tissue disease and its most obvious manifestation is skin fibrosis. Patients may also have involvement of visceral organs, as a result, their digestive system, kidney and heart are affected. Scleroderma also exacerbates miscarriage, fetal growth retardation, intrauterine fetal death, and preterm delivery. Pregnant women with these problems need special measures, so this study was performed to report a successful cesarean section in a woman with coronavirus and scleroderma. Case presentation: The patient was a 31-year-old pregnant woman with a gestational age of 29 weeks who presented to Sanandaj Besat Hospital in November 2021 with symptoms of shortness of breath and dyspnea. HRCT-positive, PCR-positive, bilateral pleural effusion, and pulmonary dilatation corona were diagnosed. Due to 3 liters of vaginal bleeding and diagnosis of Decollement 60% and severe preeclampsia underwent emergency cesarean section. The live baby was born weighing 1300 g with Apgar 7. During surgery, he received 3 units of FFB and 3 units of Cryoprecipitate. Microcalcifications and fibrin thrombi were reported in the pathology of intermittent nodules. The diagnosis and treatment of this patient has significant points that are mentioned below. Conclusion(s): Complications of pregnancy and childbirth in pregnant women infected with Corona virus include an increase in premature birth and an increase in the rate of cesarean section. Pregnancy in women with scleroderma at the right time and careful delivery monitoring will increase the probability of successful pregnancy outcome and all patients need counseling. Copyright © 2022 Zare et al. Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.