Levels and Trends of Maternal Mortality and Morbidity by Cause in North Africa and Middle East, 1990 to 2019: An Analysis for the Global Burden of Disease Study 2019

Background: Since 1990, the maternal mortality significantly decreased at global scale as well as the North Africa and Middle East. However, estimates for mortality and morbidity by cause and age at national scale in this region are not available. Method(s): This study is part of the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019. Here we report maternal mortality and morbidity by age and cause across 21 countries in the region from 1990 to 2019. Result(s): Between 1990 and 2019, maternal mortality ratio (MMR) dropped from 148.8 (129.6-171.2) to 94.3 (73.4-121.1) per 100 000 live births in North Africa and Middle East. In 1990, MMR ranged from 6.0 (5.3-6.8) in Kuwait to 502.9 (375.2-655.3) per 100 000 live births in Afghanistan. Respective figures for 2019 were 5.1 (4.0-6.4) in Kuwait to 269.9 (195.8-368.6) in Afghanistan. Percentages of deaths under 25 years was 26.0% in 1990 and 23.8% in 2019. Maternal hemorrhage, indirect maternal deaths, and other maternal disorders rank 1st to 3rd in the entire region. Ultimately, there was an evident decrease in MMR along with increase in socio-demographic index from 1990 to 2019 in all countries in the region and an evident convergence across nations. Conclusion(s): MMR has significantly declined in the region since 1990 and only five countries (Afghanistan, Sudan, Yemen, Morocco, and Algeria) out of 21 nations didn't achieve the Sustainable Development Goal (SDG) target of 70 deaths per 100 000 live births in 2019. Despite the convergence in trends, there are still disparities across countries.Copyright © 2022 Academy of Medical Sciences of I.R. Iran. All rights reserved.

Ethical Lessons Learned from the COVID-19 Pandemic in Perinatal Medicine

The COVID-19 pandemic is unprecedented in our lifetime, especially in perinatology. The gold standard is to strongly recommend COVID-19 vaccinations to those trying to get pregnant, to those who are pregnant, and to those who are postpartum. When the benefits of vaccines far outweigh the risks, it is unethical to disseminate wrong information and discourage patients from becoming vaccinated. COVID-19 vaccinations and boosters prevent severe diseases and adverse pregnancy and neonatal outcomes. A pregnant patient's vaccination also protects the newborn infant because maternal antibodies protect the fetus and newborn. COVID-19 vaccinations and boosters in pregnancy are safe for the pregnant patient and her fetus. The three root causes of physician hesitancy-misapplication of therapeutic nihilism, misapplication of shared decision-making, and misapplication of respect for autonomy should not be ignored and need to be addressed. It is important that we heed Brent 's insightful recommendations. Doing nothing with respect to vaccination is not an option, whether it applies to COVID-19 vaccines or to future pandemics. Physician hesitation is not an option. When there is sufficient evidence of vaccine safety and effectiveness without documented risks, vaccine recommendations before, during, and after pregnancy should be explicitly made to prevent maternal, fetal, and neonatal morbidity and mortality.Copyright © The Author(s). 2023.

Maternal and Perinatal Outcomes of SARS-CoV-2 and Variants in Pregnancy

Pregnancy is a physiological state that predisposes women to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, a disease that can cause adverse maternal and perinatal outcomes. The severity of coronavirus disease 2019 (COVID-19) disease is known to vary by viral strain;however, evidence for the effects of this virus in pregnant women has yet to be fully elucidated. In this review, we describe maternal and perinatal outcomes, vaccination, and vertical transmission, among pregnant women infected with the different SARS-CoV-2 variants identified to date. We also summarize existing evidence for maternal and perinatal outcomes in pregnant women with specific information relating to SARS-CoV-2 variants. Our analysis showed that Omicron infection was associated with fewer severe maternal and perinatal adverse outcomes while the Delta variant was associated with worse pregnancy outcomes. Maternal deaths arising from COVID-19 were found to be rare (<1.0%), irrespective of whether the virus was a wild-Type strain or a variant. Severe maternal morbidity was more frequent for the Delta variant (10.3%), followed by the Alpha (4.7%), wild-Type (4.5%), and Omicron (2.9%) variants. The rates of stillbirth were 0.8%, 4.1%, 3.1%, and 2.3%, respectively, in pregnancies infected with the wild-Type strain, Alpha, Delta, and Omicron variants, respectively. Preterm birth and admission to neonatal intensive care units were more common for cases with the Delta infection (19.0% and 18.62%, respectively), while risks were similar for those infected with the wild-Type (14.7% and 11.2%, respectively), Alpha (14.9% and 13.1%), and Omicron variants (13.2% and 13.8%, respectively). As COVID-19 remains a global pandemic, and new SARS-CoV-2 variants continue to emerge, research relating to the specific impact of new variants on pregnant women needs to be expanded.Copyright © Wolters Kluwer Health, Inc. All rights reserved.

Evaluating the Effect of COVID-19 on Pregnant Women: A Case-Control Study

Background: Pregnant women experience physiological changes that make them more susceptible to respiratory infections, including COVID-19. Given the potential impact of COVID-19 on pregnancy, it is crucial to continue to investigate the effect of the pandemic on pregnant women and their infants. This information will be important for informing for all the stakeholders including clinical care, and public health policies. Method(s): This study is a retrospective observational analytical study conducted in the Department of Obstetrics and Gynecology at SMGS hospital, Jammu. The study included 180 pregnant females who reported to emergency Obstetrics and Gynecology from 1st April to 30 June 2020. The sample size of 180 patients was divided into two groups: Group 1 included 90 COVID-19 positive pregnant females and Group 2 included 90 COVID-19 negative pregnant females. Result(s): No significant differences were found in age, parity, gestational age, comorbidities, mode of delivery, maternal complications, neonatal Apgar scores, or birth weight. The prevalence of comorbidities and maternal complications was similar in both groups, and most neonates had normal Apgar scores and birth weights. Conclusion(s): Therefore, it is suggested that appropriate management and care should be provided to all pregnant women, regardless of their COVID-19 status, to minimize any potential adverse outcomes.Copyright © 2022, Anka Publishers. All rights reserved.

Third level care experience during SARS-CoV-2 pandemic

Objective. As the SARS-CoV-2 Pandemic has widely changed pregnancy experience and assessment, the inpatient and outpatient services have had to be re-organized. Since March 2020, Careggi University Hospital (CUH) has provided a dedicated COVID-pathway: spaces for women with unknown swab status and a COVID-19 ward delivery room. The aim of this study is to analyze the inpatient and outpatient COVID-19 related activities in CUH. Materials and Methods. We prospectively collected data from consecutive COVID-19 pregnancies referred from 2020 to 2022, included in the local branch of the ItOSS surveillance. All patients experienced COVID-19 in pregnancy at various stages of severity and gestational ages. Results. From March 2020 to June 2022, 165 COVID-19 deliveries occurred (169 newborns), while 16 pregnant positive women were admitted without delivering. A single emergency C-section (CS) was performed because of Sars-CoV-2 related ARDS, 15 women experienced serious maternal morbidity and 5 needed ECMO. A single maternal death occurred four months after delivery (C-section). Considering ECMO supported cases during pregnancy or postpartum, the first one tested positive for COVID-19 during the second trimester. She developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a CS at term was performed following obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation and experienced a precipitous vaginal delivery at 31 weeks+6 days of gestation while on ECMO. She was discharged 1 month later in good general conditions. The third patient was an obese (BMI 38) 43-year-old woman who had performed an IVF with embryo donation;she tested positive at 38 weeks+2 days of gestation. A CS was performed because of the worsening of her condition. After the delivery she was admitted in ICU and she underwent ECMO. She died 143 days after the CS by sepsis and multiple organ failure (MOF). For all these pregnancies neonatal outcomes were positive. No perinatal death occurred and only one baby tested positive for SARS-CoV-2 infection at nasal swab sampling (case 3). The anesthesiology team performed neuroassial analgesia intrapartum in all the positive women who needed/requested it. Monoclonal Antibodies (mAbs) have been widely used to treat mild to moderate COVID-19 outpatients (NIH and RCOG recommendations) at risk for developing severe disease. Regarding this specifical therapy, an essential role in the management of the pregnant outpatient was played by the Infectious Disease Department. All patients above 28 weeks requiring hospitalization received LMWH prophylaxis, which was administrated under 28 weeks only in presence of additional risk factors (obesity, IVF, etc.). All new mothers received a ten days LMWH prophylaxis. On the outpatient side, we performed 22 teleconsultations, 43 obstetric ultrasounds (including I trimester screening), 90 obstetric checks with clinical evaluation and home therapy management, 32 fetal monitoring and 47 naso-pharingeal swabs. Conclusions. At Careggi Hospital Maternal Department an extensive re-organization of inpatient and outpatient services has been performed in order to guarantee good practice and management of all pregnant women during the SARS-CoV-2 pandemic. This was only possible thanks to a wide multidisciplinary group which enhanced every professional.

Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies.

INTRODUCTION: The pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has exposed vulnerable populations to an unprecedented global health crisis. The knowledge gained from previous human coronavirus outbreaks suggests that pregnant women and their fetuses are particularly susceptible to poor outcomes. The objective of this study was to summarize the clinical manifestations and maternal and perinatal outcomes of COVID-19 during pregnancy. MATERIAL AND METHODS: We searched databases for all case reports and series from 12 February to 4 April 2020. Multiple terms and combinations were used including COVID-19, pregnancy, maternal mortality, maternal morbidity, complications, clinical manifestations, neonatal morbidity, intrauterine fetal death, neonatal mortality and SARS-CoV-2. Eligibility criteria included peer-reviewed publications written in English or Chinese and quantitative real-time polymerase chain reaction (PCR) or dual fluorescence PCR-confirmed SARS-CoV-2 infection. Unpublished reports, unspecified date and location of the study or suspicion of duplicate reporting, cases with suspected COVID-19 that were not confirmed by a laboratory test, and unreported maternal or perinatal outcomes were excluded. Data on clinical manifestations, maternal and perinatal outcomes including vertical transmission were extracted and analyzed. RESULTS: Eighteen articles reporting data from 108 pregnancies between 8 December 2019 and 1 April 2020 were included in the current study. Most reports described women presenting in the third trimester with fever (68%) and coughing (34%). Lymphocytopenia (59%) with elevated C-reactive protein (70%) was observed and 91% of the women were delivered by cesarean section. Three maternal intensive care unit admissions were noted but no maternal deaths. One neonatal death and one intrauterine death were also reported. CONCLUSIONS: Although the majority of mothers were discharged without any major complications, severe maternal morbidity as a result of COVID-19 and perinatal deaths were reported. Vertical transmission of the COVID-19 could not be ruled out. Careful monitoring of pregnancies with COVID-19 and measures to prevent neonatal infection are warranted.

Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members.

INTRODUCTION: The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use. METHODS: This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color. RESULTS: The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models. CONCLUSION: Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Characterization of obstetric patients in the emergency of the Regional Teaching Hospital Ambato.

Introduction: The management of the obstetric patient is a matter of great importance, since it is necessary to guarantee the termination of the pregnancy with satisfactory results for the mother and the child, thus avoiding possible maternal or infant deaths. The general objective of our study was to describe obstetric morbidity and mortality in the emergency department of the Ambato Regional Teaching Hospital during the peak of the COVID-19 pandemic. Methodology: Hospital emergency care records were studied in the period January-September 2020, through an observational, retrospective, descriptive study. In this work, emphasis is placed on the obstetric patient in the period during pregnancy and around childbirth, including the immediate puerperium. Results and Conclusion(s): it was evidenced that in the emergency service of the Ambato Regional Teaching Hospital of a total of 1082 patients treated in the emergency room, 92 of these corre-sponded to obstetric patients. The highest morbidity corre-sponded to eutocic deliveries with 39 patients. In the emergency department, 126 Reverse Transcription Polymerase Chain Reaction (RT-PCR) tests were performed, 92 of them on all the obstetric patients seen in the emergency department, resulting in the virus being identified in 46 patients. The most affected age group in COVID patients was 18 to 33 years old, with overall age of 27 years. COVID morbidity predominated in obstetric patients, in the third trimester of pregnancy, 11 of them with fetal distress. Copyright © 2022, Venezuelan Society of Pharmacology and Clinical and Therapeutic Pharmacology. All rights reserved.

Identifying women with postdelivery posttraumatic stress disorder using natural language processing of personal childbirth narratives.

BACKGROUND: Maternal mental disorders are considered a leading complication of childbirth and a common contributor to maternal death. In addition to undermining maternal welfare, untreated postpartum psychopathology can result in child emotional and physical neglect and associated significant pediatric health costs. Some women may experience traumatic childbirth and develop posttraumatic stress disorder symptoms after delivery (childbirth-related posttraumatic stress disorder). Although women are routinely screened for postpartum depression in the United States, there is no recommended protocol to inform the identification of women who are likely to experience childbirth-related posttraumatic stress disorder. Advancements in computational methods of free text have shown promise in informing the diagnosis of psychiatric conditions. Although the language in narratives of stressful events has been associated with posttrauma outcomes, whether the narratives of childbirth processed via machine learning can be useful for childbirth-related posttraumatic stress disorder screening is unknown. OBJECTIVE: This study aimed to examine the use of written narrative accounts of personal childbirth experiences for the identification of women with childbirth-related posttraumatic stress disorder. To this end, we developed a model based on natural language processing and machine learning algorithms to identify childbirth-related posttraumatic stress disorder via the classification of birth narratives. STUDY DESIGN: Overall, 1127 eligible postpartum women who enrolled in a study survey during the COVID-19 pandemic provided short written childbirth narrative accounts in which they were instructed to focus on the most distressing aspects of their childbirth experience. They also completed a posttraumatic stress disorder symptom screen to determine childbirth-related posttraumatic stress disorder. After the exclusion criteria were applied, data from 995 participants were analyzed. A machine learning-based Sentence-Transformers natural language processing model was used to represent narratives as vectors that served as inputs for a neural network machine learning model developed in this study to identify participants with childbirth-related posttraumatic stress disorder. RESULTS: The machine learning model derived from natural language processing of childbirth narratives achieved good performance (area under the curve, 0.75; F1 score, 0.76; sensitivity, 0.8; specificity, 0.70). Moreover, women with childbirth-related posttraumatic stress disorder generated longer narratives (t test results: t=2.30; p=.02) and used more negative emotional expressions (Wilcoxon test: sadness: p=8.90e-04; W=31,017; anger: p=1.32e-02; W=35,005.50) and death-related words (Wilcoxon test: p=3.48e-05; W=34,538) in describing their childbirth experience than those with no childbirth-related posttraumatic stress disorder. CONCLUSION: This study provided proof of concept that personal childbirth narrative accounts generated in the early postpartum period and analyzed via advanced computational methods can detect with relatively high accuracy women who are likely to endorse childbirth-related posttraumatic stress disorder and those at low risk. This suggests that birth narratives could be promising for informing low-cost, noninvasive tools for maternal mental health screening, and more research that used machine learning to predict early signs of maternal psychiatric morbidity is warranted.

The Burden of Unsafe Abortion Six Years before the COVID-19 Era in a Nigerian Tertiary Hospital: An Analytical Retrospective Study.

BACKGROUND: Unsafe abortion remains a leading cause of maternal mortality and morbidity, especially in developing countries with restrictive abortion laws. Disease containment measures during the COVID-19 pandemic have reduced access to contraception and safe abortion care, potentially increasing rates of unintended pregnancies and unsafe abortion. OBJECTIVE: To evaluate the morbidity and mortality burden of unsafe abortion before the COVID-19 pandemic. METHODS: A six-year analytical retrospective study of unsafe abortion at the Federal Medical Centre, Lokoja, Nigeria. All case records of unsafe abortion managed within the study period were retrieved, and relevant data extracted using a purpose-designed proforma. Data obtained was analysed using the IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Associations between categorical independent and outcome variables were assessed using the Chi square test at 95% confidence level. A p-value of <0.05 was considered statistically significant. RESULTS: The prevalence of unsafe abortion was 8.6 per 1,000 deliveries. More than one-half (37, 52.9%) were medical abortions using misoprostol tablets. The mean age of the women was 23.15+ 3.96 years, and most of them were single (49, 70%), with primary/ secondary education (42, 60%), and of low socioeconomic status (67, 95.7%). Nearly one-half (33, 47.1%) had either never used any modern contraceptive (9, 12.9%) or only used emergency contraception (24, 34.3%). The predominant complications of unsafe abortion included retained product of conception (69, 98.6%), haemorrhagic shock (22,31.4%), and sepsis (19, 27.1%). There were two maternal deaths, giving a case fatality rate of 2.9%. CONCLUSION: Unsafe abortion remains a significant cause of maternal mortality and morbidity in our setting. Improving access to effective modern contraceptives and liberalizing our abortion laws may reduce maternal morbidity and mortality from unsafe abortion.

CONTEXTE: L'avortement à risque reste l'une des principales causes de mortalité et de morbidité maternelles, en particulier dans les pays en développement où les lois sur l'avortement sont restrictives. Les mesures de confinement de la maladie pendant la pandémie de COVID-19 ont réduit l'accès à la contraception et aux soins d'avortement sûrs, augmentant potentiellement les taux de grossesses non désirées et d'avortements à risque. OBJECTIF: Évaluer le fardeau de morbidité et de mortalité de l'avortement à risque avant la pandémie de COVID-19. METHODES: Une étude rétrospective analytique de six ans sur l'avortement à risque au Fédéral Médical Center, Lokoja, Nigeria. Tous les dossiers de tous les cas d'avortement à risque pris en charge au cours de la période d'étude ont été récupérés et les données pertinentes extraites à l'aide d'un formulaire conçu à cet effet. Les données obtenues ont été analysées à l'aide d'IBM SPSS Statistiques pour Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Les associations entre les variables indépendantes catégorielles et les variables de résultat ont été évaluées à l'aide du test du chi carré à un niveau de confiance de 95 %. Une valeur de p <0,05 était considérée comme statistiquement significative. RESULTATS: L'prévalence des avortements à risque était de 8,6 pour 1000 accouchements. Plus de la moitié (37, 52,9%) étaient des avortements médicamenteux utilisant comprimés de misoprostol. L'âge moyen des femmes était de 23,15+ 3,96 ans, et la plupart d'entre elles étaient célibataires (49, 70%), avec une éducation primaire/secondaire (42, 60%) et de statut socio-économique bas (67, 95,7%). Près de la moitié (33, 47,1%) n'avaient jamais utilisé de contraceptif moderne (9,12,9%) ou n'avaient utilisé qu'une contraception d'urgence (24, 34,3%). Les complications prédominantes comprenaient la rétention du produit de conception (69, 98,6 %), le choc hémorragique (22, 31,4 %) et la septicémie (19, 27,1 %). Il y a eu deux décès maternels, soit un taux de létalité de 2,9 %. CONCLUSION: L'avortement à risque reste une cause importante de mortalité et de morbidité maternelles dans notre contexte. L'amélioration de l'accès à des contraceptifs modernes efficaces et la libéralisation de nos lois sur l'avortement réduiront la morbidité et la mortalité maternelles dues à l'avortement à risque. Mots-clés: Planification familiale, Avortement illégal/criminel, morbidité et mortalité maternelles, Produit de la conception retenu, Besoin non satisfait.

Aftermath of COVID-19 Pandemic-A Comparative Retrospective Single Center Study during the First, Second and Third Wave of COVID-19 in Tertiary Care Institute in North India

Background: At the onset of Covid-19 pandemic, it was an unknown entity in terms of risk status of the pregnant women for fetomaternal outcome. Both fetus and pregnant women were considered as groups under special concern due to their unique physiological characteristics. Method(s): A retrospective study was conducted in department of Obstetrics & Gynaecology along with Paediatrics department in Maharishi Markandeshwar Medical College and Hospital, Solan on pregnant females admitted to the Covid-19 Ward/ ICU over a period from August 2020 till 31st March 2022. Participants were included into 3 waves of pandemic based upon time of presentation and these 3 groups were further studied for the various fetomaternal parameters such as maternal age, symptom status, need for respiratory support, maternal mortality, abortions, still births, gestational age and weight of newborn and other morbidity and mortality in newborns. Result(s): A total of 171 pregnant were included in the study, of whom 47, 64 and 60 were seen in 1st, 2nd and 3rd waves respectively. Majority of subjects were asymptomatic in 1st, 2nd & 3rd wave, (p=0.30). Age wise distribution of the patients showed majority subjects in the age group of 20-30 years (p= 0.94). LSCS rates in 3 waves were not different significantly (p = 0.67). Maternal mortality rates and need for respiratory support were in similar proportions in all 3 waves (p=0.71) and (p=0.73) respectively. No significant difference was seen in maternal morbidity and neonatal outcome. Conclusion(s): The study showed no significant difference between the waves of Covid-19 pandemic in terms of fetomaternal outcome except no maternal mortality in 3rd wave. Copyright © 2022 Ubiquity Press. All rights reserved.

Clinical Profile of COVID-19 Positive Obstetric Patients Admitted to a Tertiary Care Hospital during the Two Waves of COVID-19

Background: Coronavirus disease 2019 (COVID-19), a global pandemic which undoubtedly hit the whole world so hard. There have been multiple waves across the globe of varying time, duration, and intensity, India has also witnessed two waves sweeping the entire nation. The second wave had startling intensity with massively increased oxygen requirement, intensive care unit (ICU) admissions. The effect was even more pronounced in the pregnant women as there was increased maternal morbidity and mortality. However, there are limited reports on the impact of COVID-19 during pregnancy. Objective: This study is aimed at highlighting the variance in clinical profile of pregnant patients in first and second wave of COVID-19 in India. Materials and methods: A retrospective observational comparative hospital-based study was conducted in a tertiary care hospital in Delhi during the two waves of COVID-19. The first wave in India lasted from May 2020 to October 2020, and the second wave lasted from April 2021 to June 2021.We obtained the medical records and compiled clinical and outcome data for all pregnant patients, who were admitted in the Department of Obstetrics and Gynaecology of our Hospital during the first and second wave of pandemic with a laboratory-confirmed report of SARS-CoV-2. Results and conclusion: The second wave definitely saw more number of symptomatic patients, an increase in symptom of shortness of breath, increase in oxygen requirement, ICU admissions, marginally increase lower segment cesarean section (LSCS) rates and associated comorbidity such as hypertensive disease of pregnancy.

General anaesthesia for operative obstetrics

General anaesthesia in obstetrics is reducing. Obstetric surgery is often urgent, requiring effective team communication and a rapid, focused preoperative assessment. Physiological changes of pregnancy increase the incidence of aspiration, desaturation and failed intubation. In addition, the rapidly evolving circumstances add additional stress impacting on performance. Hypotension from aortocaval compression is common and minimized by left lateral tilt or uterine displacement. Rapid sequence induction with tracheal intubation remains gold standard but supraglottic devices are advocated in the event of failed intubation. Awareness remains relatively common and adequate depth of anaesthesia should be maintained and monitored. Complications are more common in obese pregnant patients, whilst women with pre-eclampsia are at particular risk of hypertensive responses to intubation and extubation, intravenous opiates can ameliorate this. Improved multidisciplinary communication on the delivery suite allows for pre-emptive assessment of patients at risk of requiring an operative delivery. With diminishing individual experience of general anaesthesia in obstetrics and delivery suite often being covered by junior doctors, simulation exercises can improve confidence, performance and team working.

A rare case of morbidly adherent placenta in an unscarred uterus: A case report

Introduction: Morbidly adherent placenta (MAP) refers to any placental implantation with abnormally firm adherence to myometrium. The American College of Obstetricians and Gynecologists cites the incidence be as high as 1 in 533 deliveries. There are three degrees of morbidly adherent placenta: placenta accreta, increta and percreta. The rate of morbidly adherent placenta with previous caesarean section scar and unscarred uterus also increased significantly. Previous caesarean section and co-existing placenta previa remained the major risk factors. We report a case of an adherent placenta in the absent of prior risk factors and discuss modalities of management options available. Case Description: A 46-years-old female patient without history of scarred uterus, gravida 8, para 7, pregnant at 39 weeks admitted for Covid-19 positive in active phase of labour with foetal distress, hence the indication for an emergency caesarean section. The diagnosis of adherent placenta is made during the caesarean. She was successfully managed surgically with subtotal hysterectomy in view of age and parity of the patient. Discussion: Morbidly adherent placenta often associated with severe maternal morbidity and mortality. Hence, early detection, high index of clinical suspicion and timely decision may reduce patient morbidity as the surgeon strategizes on the best management of the case, mainly in anticipating the difficulty that may be encountered during surgery.

Examining the impact of trimester of diagnosis on COVID-19 disease progression in pregnancy.

BACKGROUND: COVID-19 infection is associated with increased morbidity in pregnancy and adverse maternal and neonatal outcomes. Little is currently known about how the timing of infection during pregnancy affects these outcomes. OBJECTIVE: This study aimed to evaluate the effect of trimester of COVID-19 infection on disease progression and severity in pregnant patients. STUDY DESIGN: This was a prospective cohort study of pregnant patients diagnosed with COVID-19 infection who delivered at a single urban hospital. Universal testing for SARS-CoV-2 was performed at hospital admission and for symptomatic patients in inpatient, emergency department, and outpatient settings. Disease severity was defined as asymptomatic, mild, moderate, severe, or critical on the basis of National Institutes of Health criteria. We evaluated disease progression from asymptomatic to symptomatic infection and from asymptomatic or mild infection to moderate, severe, or critical illness, and stratified by trimester of COVID-19 diagnosis. Primary outcomes included progression of COVID-19 disease severity and a composite obstetrical outcome, which included delivery at <37 weeks, preeclampsia with severe features, abruption, excess blood loss at delivery (>500 mL for vaginal or >1000 mL for cesarean delivery), and stillbirth. RESULTS: From March 18, 2020 to September 30, 2021, 1326 pregnant patients were diagnosed with COVID-19 and delivered at our institution, including 103 (8%) first-, 355 (27%) second-, and 868 (65%) third-trimester patients. First-trimester patients were older and had more medical comorbidities; 86% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 3 of 18 (17%) first-trimester, 20 of 47 (43%) second-trimester, and 34 of 574 (6%) third-trimester patients were admitted for the indication of COVID-19 illness. Across all trimesters, 1195 (90%) of 1326 COVID-19 infections were asymptomatic or mild, and 45 (10%) of 436 initially asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 4 (4%) of 93 first-, 18 (5%) of 337 second-, and 49 (6%) of 836 third-trimester patients developed moderate, severe, or critical illness (P=.80). There was no significant difference in composite obstetrical outcome with respect to trimester of COVID-19 diagnosis (24% first-trimester, 28% second-trimester, 28% third-trimester patients; P=.69). CONCLUSION: Moderate, severe, or critical illness develops in almost 10% of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.

RESULTS OF SEVERE MATERNAL MORBIDITY SURVEILLANCE AND NEAR-MISS AUDIT IN SAINT PETERSBURG ACCORDING TO THE VERTICALLY INTEGRATED MEDICAL INFORMATION SYSTEM OF OBSTETRICS AND GYNECOLOGY AND NEONATOLOGY (VIMIS ACU&NEO) REGISTER IN 2021

The article presents the results of the surveillance of severe maternal morbidity (SMM) according to SMM surveillance regulations in the Russian Federation (RF). The study analyzed the SMM Register of the Vertically Integrated Medical Information System of Obstetrics and Gynecology and Neonatology (VIMIS AKU&NEO) and the results of near-miss audit. The analysis included life-threatening maternal conditions without fatal outcome identified according to categories of organ dysfunction using the WHO diagnostic criteria (2011). The study aimed to identify strategies to reduce and prevent maternal mortality (MM) in Saint Petersburg. The authors analyzed the types of SMM registered in level II (51.0%) and level III (49.0%) maternal care providers (MCP) of Saint Petersburg. They also presented characteristics of near-miss cases, of which 12.5% and 83.3% occurred in level II and level III MCPs, respectively. Integral indicators of medical care quality in near-miss groups included near-miss rate, life-threatening condition rate, survival rate index, and mortality rate index. Obstetric pathology, blood pathology, and respiratory pathology were the leading causes of SMM in Saint Petersburg in 2021, which is comparable with the data of SMM registered in the Russian Federation in general. There were no cases of MM in the obstetric pathology group, which was the most frequently registered category of SMM (39.4% of the total number of SMM), including severe pre-eclampsia and eclampsia (83.1% of the group) and uterine rupture (9.6% of the group). The absence of MM in this category of SMM is associated with the implementation of effective and quality medical care in patients at high risk for obstetric and perinatal complications in Saint Petersburg in 2021. Blood pathology was the second most frequently registered category of SMM (36.8% of all SMM, 95.8% of the group);one case of MM was registered in a Level III MCP and one case outside the MCP before ambulance arrival. Both cases were associated with massive blood loss (more than 1000 ml). In 2021, during a pandemic of a novel coronavirus infection (COVID-19) in St. Petersburg, 41 cases of SMM associated with respiratory pathology (9.1% of total SMM) were reported. Of them 39 were identified as near-miss cases (respiratory dysfunction), which accounted for 54, 2% of the total number of near-miss cases with 20 deaths in level III MCPs. These deaths were due to severe or extremely severe bilateral viral or viral bacterial pneumonia complicated by acute respiratory distress syndrome or pulmonary embolism due to COVID-19 (O98. 5, U07.1). The main strategy to prevent and reduce the incidence of near-miss cases and MM based on improving the modern integral model of internal control of the quality of medical care in maternal care providers, near-miss audit, and the introduction into practice of both medical and organizational methodological, including telecommunications and other technologies aimed at improving professional competence. Conclusion: SMM surveillance and near-miss audit allows for a detailed assessment of the nature and quality of medical care to improve pregnancy outcomes.

Severe maternal morbidity in a tertiary maternity hospital in Ireland in 2021

Objective: Severe Maternal Morbidity (SMM) can be considered a marker of both maternity care and maternal mortality. The aim of this study was to review SMM in 2021 within the National Maternity Hospital (NMH), a tertiary level unit in Dublin, Ireland, with more than 9,000 births per year. Design: The study was a retrospective cohort study of women who experienced SMM in the NMH, Dublin in 2021. Methods: SMM was defined using the criteria established by the National Perinatal Epidemiology Centre (NPEC) in University College Cork. There are 17 reportable morbidities including Major Obstetric Haemorrhage (MOH), Eclampsia, Peripartum Hysterectomy, Anaesthetic complications etc. Data was prospectively recorded from a variety of sources including HDU, Pathology, Placenta Accreta Team, Maternal Medicine Team, Microbiology, Haematology, Anaesthesiology, Labour Ward. Data was included from Jan 1st 2021 to December 31st of the same year. Results: Using the NPEC criteria, 41 women experience at least one SMM during this time, of which four had more than one SMM. As with previous audits and in parallel with National and International data, the most common SMM was MOH with 18 cases. Five women underwent a Peripartum Hysterectomy. Seven women had Renal/Liver Dysfunction, mostly as a result of Pre-eclampsia. Of note, given the context of the COVID pandemic, there were no patients with septic shock due to a COVID infection. There was one late maternal death due to metastatic carcinoma diagnosed during pregnancy. Conclusion: This study highlights the importance of ongoing training for new and established staff members in obstetric emergencies, such as MOH. It also demonstrates importance of audit in the clinical setting, where ongoing reviews highlight issues of importance.

USE OF TOCILIZUMAB IN COVID-19 POSITIVE PREGNANT WOMEN

Background: Tocilizumab reduces the need for mechanical ventilation and improves survival in COVID-19 patients. There is limited evidence on Tocilizumab use in pregnant patients with COVID-19. Methods: Case series of pregnant patients with COVID-19 treated with Tocilizumab during hospitalisation between June to November 2021. Demographic data, maternal morbidity and neonatal outcomes were collected. Results: Ten pregnant patients received Tocilizumab. Six patients received a single dose of 800 mcg, 2 patients received a single dose of 600 mcg, and 2 patients received a double dose of 800 mcg and 600 mcg respectively. Three patients received Tocilizumab postpartum, with 6 receiving it in the second and third trimester (mean gestational age 29.5 +/- 3.9 weeks). Antenatal patients received Tocilizumab at a median of 84 (IQR 63) days before delivery. In five patients, there was a trend in improvement of respiratory rate following administration of Tocilizumab (Table1). Birth outcomes were available for 8 patients. There were no significant adverse maternal outcomes or opportunistic infections, with only 1 patient experiencing chorioamnionitis with no long term sequalae. All neonates were born with Apgar of 91 and 95. One infant was identified as having Lenticulostriatal vasculopathy and another was diagnosed with gastroenteritis, but no causative bacterial or viral organism was identified. One infant tested positive for COVID-19 on Day 5. Out of the 8 neonates who were born, 7 were breastfed and none of the neonates in this study experienced any adverse outcomes until discharge. Conclusions: Tocilizumab is efficacious and safe for COVID- 19 in pregnancy for the women and neonates. (Table Presented).