Sars-CoV-2 in the second half of pregnancy: Maternal and perinatal outcomes / Sars-CoV-2 in the second half of pregnancy: Maternal and perinatal outcomes / SARS-CoV-2 en la segunda mitad del embarazo: resultados materno - perinatales

RESUMEN Introducción . La pandemia por COVID-19 es una emergencia sanitaria y social mundial. El conocimiento sobre su efecto en las gestantes es todavía limitado. Objetivo . Describir los resultados materno-perinatales de COVID-19 según clasificación de severidad en mujeres hospitalizadas en la segunda mitad del embarazo. Métodos . Estudio observacional, descriptivo, retrospectivo, desde marzo hasta julio del 2020, en el Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Perú. Se incluyeron a todas las gestantes hospitalizadas con RT-PCR y/o prueba rápida positiva para SARS-CoV-2. Se excluyeron los embarazos menores a 20 semanas y las altas epidemiológicas. Las características maternas al ingreso y los resultados materno-perinatales fueron agrupados según la clasificación clínica de la enfermedad. Las variables cualitativas son presentadas en recuentos y porcentajes; y las cuantitativas, en medianas y rangos. Resultados . Se estudiaron 247 gestantes. La mayoría correspondía al tercer trimestre (76%). La presentación más frecuente de la virosis fue asintomática (83%) y los casos de neumonía severa fueron pocos (3,2%). La tasa de cesárea fue alta (60%), aunque los partos vaginales se duplicaron en el tiempo (0-24% a 44%). Los casos severos tuvieron mayor tasa de cesárea (100%) y parto prematuro iatrogénico (100%). No se reportaron muertes maternas. Se registraron 9 óbitos fetales y 5 neonatos positivos para SARS-CoV-2, ambos entre las asintomáticas y leves. Conclusiones . En nuestra institución, la posibilidad de cesárea y de parto prematuro iatrogénico fue mayor en los casos severos. La tasa de parto vaginal aumentó en los últimos meses. No se identificaron complicaciones perinatales relacionadas al COVID-19.

ABSTRACT Introduction: The COVID-19 pandemic is a global health and social emergency. Knowledge is still limited about its effect on pregnant women. Objective: To describe maternal-perinatal outcomes of COVID-19 according to severity classification in women hospitalized in the second half of pregnancy. Methods: Retrospective, descriptive, observational study from March to July 2020 at Edgardo Rebagliati Martins National Hospital. All hospitalized pregnant women with RT-PCR and/ or rapid positive test for SARS-CoV-2 were included. Pregnancies less than 20 weeks and epidemiological discharges were excluded. Maternal characteristics at admission and maternal-perinatal outcomes were grouped according to the clinical classification of the disease. The qualitative variables are presented in counts and percentages; and quantitative ones, in medians and ranges. Results: 247 pregnant women were studied. Most of them were in the third trimester (76%). The most frequent presentation of the disease was asymptomatic (83%), and cases of severe pneumonia were few (3.2%). The cesarean section rate was high (60%), although vaginal deliveries doubled over time (0-24 a 44%). Severe cases had a higher rate of cesarean section (100%) and iatrogenic preterm delivery (75%). No maternal deaths were reported. There were 9 stillbirths and 5 positive neonates for SARS-CoV-2, both among asymptomatic and mild patients. 9 stillbirths and 5 positive neonates for SARS-CoV-2, both among asymptomatic and mild cases. Conclusions: The possibility of cesarean section and iatrogenic preterm delivery is greater in severe cases. The vaginal delivery rate increased in recent months. No perinatal complications related to COVID-19 were identified.

Changes in birth outcomes and utilization of prenatal care during the COVID-19 pandemic in 2020: a secondary analysis of vital statistics in Colombia.

BACKGROUND: Birth outcomes could have been affected by the COVID-19 pandemic through changes in access to prenatal services and other pathways. The aim of this study was to examine the effects of the COVID-19 pandemic on fetal death, birth weight, gestational age, number of prenatal visits, and caesarean delivery in 2020 in Colombia. METHODS: We conducted a secondary analysis of data on 3,140,010 pregnancies and 2,993,534 live births from population-based birth certificate and fetal death certificate records in Colombia between 2016 and 2020. Outcomes were compared separately for each month during 2020 with the same month in 2019 and pre-pandemic trends were examined in regression models controlling for maternal age, educational level, marital status, type of health insurance, place of residence (urban/rural), municipality of birth, and the number of pregnancies the mother has had before last pregnancy. RESULTS: We found some evidence for a decline in miscarriage risk in some months after the pandemic start, while there was an apparent lagging increase in stillbirth risk, although not statistically significant after correction for multiple comparisons. Birth weight increased during the onset of the pandemic, a change that does not appear to be driven by pre-pandemic trends. Specifically, mean birth weight was higher in 2020 than 2019 for births in April through December by about 12 to 21 g (p < 0.01). There was also a lower risk of gestational age at/below 37 weeks in 2020 for two months following the pandemic (April, June), but a higher risk in October. Finally, there was a decline in prenatal visits in 2020 especially in June-October, but no evidence of a change in C-section delivery. CONCLUSIONS: The study findings suggest mixed early effects of the pandemic on perinatal outcomes and prenatal care utilization in Colombia. While there was a significant decline in prenatal visits, other factors may have had counter effects on perinatal health including an increase in birth weight on average.

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.

SARS-CoV-2 placentitis, stillbirth, and maternal COVID-19 vaccination: clinical-pathologic correlations.

Stillbirth is a recognized complication of COVID-19 in pregnant women that has recently been demonstrated to be caused by SARS-CoV-2 infection of the placenta. Multiple global studies have found that the placental pathology present in cases of stillbirth consists of a combination of concurrent destructive findings that include increased fibrin deposition that typically reaches the level of massive perivillous fibrin deposition, chronic histiocytic intervillositis, and trophoblast necrosis. These 3 pathologic lesions, collectively termed SARS-CoV-2 placentitis, can cause severe and diffuse placental parenchymal destruction that can affect >75% of the placenta, effectively rendering it incapable of performing its function of oxygenating the fetus and leading to stillbirth and neonatal death via malperfusion and placental insufficiency. Placental infection and destruction can occur in the absence of demonstrable fetal infection. Development of SARS-CoV-2 placentitis is a complex process that may have both an infectious and immunologic basis. An important observation is that in all reported cases of SARS-CoV-2 placentitis causing stillbirth and neonatal death, the mothers were unvaccinated. SARS-CoV-2 placentitis is likely the result of an episode of SARS-CoV-2 viremia at some time during the pregnancy. This article discusses clinical and pathologic aspects of the relationship between maternal COVID-19 vaccination, SARS-CoV-2 placentitis, and perinatal death.

The Association Between COVID-19 Infection and Preterm Complications in Salah Al-Din General Hospital

Background: The release of inflammatory cytokines is considered to have a role in COVID-19's pathogenesis. However, irregularities in the formation of blood clots may have also had a role in the fatal outcome Aim: To determine if COVID-19 infection is linked to preterm birth, premature membrane rupture, admission to the neonatal intensive care unit, stillbirth, placental abruption, or maternal mortality. Patients and methods: In the months between October 2021 and March 2022, researchers in the Department of Gynecology and Obstetrics at the Salah Al-din Teaching Hospital in the Iraqi province of Salah Al-din conducted a cross-sectional study. Women who presented to the Gynecology and Obstetrics Department with symptoms suggesting a COVID 19 infection and premature birth difficulties made for a convenient sample. Fifty females participated in the research. Characteristics of the participants were reported as both raw numbers and percentages. The Chi-square test and Fisher's exact test were used to evaluate the differences in clinical features and complications between the infected and healthy pregnant women groups. For statistical significance, a p value of less than 0.05 was used. Results: Fifty pregnant patients were evaluated during the study. There were 17 (34.6%) confirmed cases of COVID-19 infection and 33 (66.6%) cases where the RT-PCR result was negative. Statistically, both IgG and IgM were significant (p 0.05). Participants averaged 33.06 years old (7.43). Significant statistical correlation between older age group and exposure to the virus, with the majority of cases occurring in the age range (35-49 years). There is no clear correlation between the mother's health and COVID-19 infection. Fatigue (90%), dyspnea (80%), cough (70%), headache (64%), sore throat (40%) and a loss of taste and smell (26%), were the next most prevalent symptoms after fever. Fever, dyspnea, and a loss of taste and smell were significantly correlated with the group that was exposed to the disease. C-reactive protein, E-selectin, and S. ferritin are all significantly correlated with COVID-19 infection exposure (p values 0.05). Most of the pregnant women in the study had normal levels of both platelets and white blood cells, with 90% and 60%, respectively, having normal Pit and WBC. Approximately 52% of the pregnant women in the study gave birth to premature babies, with a mean gestational age (GA) of 31 weeks + 2 days. A strong correlation between a maternal history of GDM and increased S. Ferritin and premature births exposed to COVID-19 was discovered. Significant correlation was established between premature vaginal delivery and exposure to COVID-19, with 16 instances (32% of total) compared to 10 cases (20% of total). Statistics also show that there was a considerable increase in the rate of preterm prolabor membrane rupture (PPROM) from the previous term, with 19 instances (38%). Occurrences of obstetric problems such as antepartum haemorrhage (APH) and severe postpartum haemorrhage (PPH) were documented, although there was no statistically significant link between them (p value > 0.05). However, the incidence of these side effects is greater in COVID-19 patients than in those who were not exposed to the virus. There were no maternal deaths observed, however the rate of stillbirths was significantly greater among individuals with COVID-19 compared to those who had not been exposed during pregnancy. Babies of mothers infected with COVID-19 are more likely to be admitted to the Neonatal Intensive Care Unit (NICLJ) for care than those of moms without the virus. Pregnant women with COVID-19 are at increased risk for premature delivery and preterm prelabor rupture of membranes, and the condition also affects NICU admissions. The aim of our study was to determine if COVID-19 infection is linked to preterm birth, premature membrane rupture, admission to the neonatal intensive care unit, stillbirth, placental abruption, or maternal mortality.

MANAGEMENT OF AUTOIMMUNE HAEMOLYTIC ANAEMIA DURING PREGNANCY OR POST-PARTUM: AN INTERNATIONAL MULTI-CENTRE EXPERIENCE

Background: Autoimmune haemolytic anaemia (AIHA) during pregnancy is a rare finding, and few is known about maternal and foetal outcomes. AIHA may either develop or relapse during gestation and postpartum or be an issue in a patient on active therapy who becomes pregnant. AIHA management during pregnancy and lactation is not standardized and drug use is often limited by safety concerns. Aims: We studied AIHA impact on pregnancy focusing on disease severity, treatment need and maternal/foetal outcome. Methods: Through a multicentric retrospective cohort study, we identified 38 pregnancies occurred in 28 women from 1997 to 2021 in 10 European centres in Italy, Denmark, France, the Netherlands, USA, and Spain. All included patients had a previous AIHA history or developed/exacerbated AIHA during gestation or postpartum. AIHA was classified according to the direct antiglobulin test. Results: We registered 18 warm AIHA (10 IgG;8 IgG+C3d), 2 cold agglutinin disease, 3 mixed and 5 atypical forms (Table 1). Evans syndrome (i.e., association of AIHA and immune thrombocytopenia or neutropenia) was present in 4. Mean age at AIHA diagnosis was 27 (3-39) and at pregnancy 32 (21-41) years. AIHA diagnosis predated pregnancy in 15 women and had required at least 1 therapy line in all of them, and >2 lines in 12 (rituximab, N=7;cytotoxic immunosuppressants, N=6;splenectomy, N=5). Among these 15 patients, 6 had a relapse during pregnancy, 3 during postpartum and 9 were on active treatment at the time of pregnancy (steroids, N=8;cyclosporine, N=1;azathioprine, N=1;the latter stopped after positive pregnancy test). A patient with a previous AIHA, relapsed as immune thrombocytopenic purpura during pregnancy. Further 8 patients had an AIHA onset during gestation and 2 postpartum. A patient had AIHA onset during the postpartum of the 1st pregnancy and relapsed during the 2nd one. In the 20 women experiencing AIHA during pregnancy/postpartum, median Hb and LDH levels were 6,4 g/dL (3,1 - 8,7) and 588 UI/L (269-1631), respectively. Management consisted in blood transfusions (N=10) and prompt establishment of steroid therapy+/-IVIG (N=20), all with response (complete N=13, partial N=7). After delivery, rituximab was necessary in 4 patients and cyclosporine was added in one. Anti-thrombotic prophylaxis was given in 7 patients. Overall, we registered 10 obstetric complications (10/38, 26%), including 4 early miscarriages, a premature rupture of membranes, a placental detachment, 2 preeclampsia, a postpartum infection and a biliary colic. Apart from the case of biliary colic and one of the two cases of preeclampsia, 8/10 complications occurred during active haemolysis and treatment for AIHA. Nine foetal adverse events (9/38, 24%) were reported: a transitory respiratory distress of the new-born in a mother with active AIHA, 3 cases of foetal growth restriction, a preterm birth, an infant reporting neurologic sequelae, a case of AIHA of the new-born requiring intravenous immunoglobulins, blood transfusions and plasma exchange, and 2 perinatal deaths. The latter both occurred in women on active AIHA therapy and were secondary to a massive placental detachment and a symptomatic SARS-CoV-2 infection. (Figure Presented ) Summary/Conclusion: AIHA developing/reactivating during pregnancy or postpartum is rare (about 5%) but mainly severe requiring steroid therapy and transfusions. Importantly, severe maternal and foetal complications may occur in up to 26% of cases mostly associated with active disease, pinpointing the importance of maintaining a high level of awareness. Passive maternal autoantibodies transfer to the foetus seems a rare event.

COVID-19 and Pregnancy: A narrative review of maternal and perinatal outcomes.

As of August 11, 2021, approximately 206 million people worldwide had been infected with SARS-CoV-2. However, limited data are available regarding the effects of COVID-19 infection on pregnancy and maternal and perinatal outcomes. This review aimed to resolve this gap in literature. The MEDLINE®, SCOPUS and Cumulative Index to Nursing and Allied Health Literature databases were searched to identify relevant English-language articles published between January 2020 and February 2021. A total of 17 articles describing the outcomes of 762 pregnancies were identified. There were 613 babies born, including 16 sets of twins. Within the cases studied, 12 (1.6%) maternal deaths and eight (1.3%) stillbirths were reported. A small proportion of mothers (3.9%) required admission to the intensive care unit, usually due to associated comorbidities. Rates of caesarean and preterm delivery ranged from 27-100% and 4-50%, respectively. Further research is necessary to determine the effect of COVID-19 infection on early pregnancy.

FINDINGS FROM A QUALITATIVE SURVEY IN THE ASIA-PACIFIC REGION ON MATERNAL AND PERINATAL DEATH SURVEILLANCE AND RESPONSE (MPDSR) AND MATERNAL HEALTH SERVICE DISRUPTIONS DURING THE COVID-19 PANDEMIC 2020-2021

Background: COVID-19 and associated public health measures in low- and middle-income countries (LMIC) in the Asia Pacific Region have resulted in significant health service disruptions including disruption to MPDSR systems. Reports indicate maternal and perinatal mortality is rising due to both direct and indirect pandemic responses. Methods: We undertook a rapid stocktake process to understand the impact of COVID-19 on service provision and MPDSR. Data were collected by survey of 22 countries utilising a Likert scale measuring respondents' agreement with statements regarding MPDSR practices and health service disruptions. UNFPA representatives in identified countries were responsible for completing the survey. Results: Seventeen of the 22 country surveys were returned. Most frequently reported disruptions to MPDSR systems were lack of completion or delay of death reviews at both facility and country level and decreases in number of community death notifications. Redeployment of both maternity staff and those responsible for MPDSR activities was identified as a key issue. More than half of countries reported that MPDSR key contacts were redeployed to other COVID-19 duties. Countries where MPDSR had been in use for greater than 5 years reported less disruptions. Other COVID-19 related service disruptions included shortages of life-saving drugs, reduced operating theatre availability, and difficulty accessing emergency transport. Conclusions: Countries with embedded MPDSR systems and early prioritisation of maternal and newborn health reported less service disruptions. Urgent investment is needed to strengthen and scale up MPDSR processes to ensure that gains made prepandemic reducing global maternal and newborn deaths will not be lost.

COMPARATIVE ANALYSIS OF STILLBIRTH CAUSES AND RATES IN THE RUSSIAN FEDERATION IN 2019 AND 2020

Aim: To make a comparative analysis of causes and rates of early neonatal mortality in the Russian Federation in 2019 and 2020. Materials and methods: This study was based on the analysis of statistical forms А-05 of the Federal State Statistics Service (Rosstat) for the years 2019–2020. These forms included medical records of perinatal deaths related to stillbirths. Stillbirth rates were calculated as the ratio of stillbirths to the total number of babies born alive and dead multiplied by 1000. Results: In 2020, the number of babies born alive decreased by 7.6%, and the number of babies born dead increased by 1.12% versus the data reported in 2019. In 2020, the rate of stillbirth (5.67‰) increased by 4.2% versus the rate in 2019 (5.44‰). Most of all, the increase in stillbirths was noted in the South and Siberian Federal Districts. In general, the most common causes of stillbirths in the Russian Federation were respiratory disorders: the number of antenatal hypoxia was 78.2 (80.5%) and fetal intrapartum hypoxia was 6.7 (5.0%) of total number of stillbirths in 2019 and 2020, respectively. The proportion of congenital anomalies as the main disease was 6.7 (5.4%) of total number of stillbirths in 2019 and 2020, respectively. It was noted, that the number of stillborn babies with unknown causes of death increased by 52.2% in 2020 (4.7% of total number of stillborn babies) versus 2019 (3.1% of total number of stillborn babies)). Significant differences between the rates of major diseases that caused stillbirths were registered in different Federal Districts of the Russian Federation. Conclusion: According to Rosstat data, in 2020 (due to COVID-19 pandemic), the absolute number of babies born dead increased by 1.1% and the rate of stillbirths increased by 4.2% compared to 2019. Increased proportion of respiratory diseases, in particular, antenatal hypoxia and congenital pneumonia, reflects the direct and indirect effects of SARS-CoV-2 infection.

ADVERSE PREGNANCY OUTCOMES ASSOCIATED with COVID-19 INFECTION in WESTERN KENYA

Background: The COVID-19 pandemic has caused over 240 million infections and 5 million deaths. Little is known about the impact of COVID-19 on pregnancy outcomes in Sub-Saharan Africa. We followed a cohort of COVID-infected and uninfected pregnant women in Kenya until six weeks postpartum to assess the burden of COVID-19 and its association with poor maternal and neonatal outcomes. Methods: We conducted repeat SARS-CoV-2 testing using polymerase chain reaction (PCR) on pregnant women enrolled in an antenatal COVID-19 cohort study (AnCOV). Those infected were managed according to Kenya Ministry of Health COVID-19 clinical guidelines. Adverse pregnancies outcomes were compared among SARS-CoV-2 infected and uninfected women using multivariate log-binomial generalized linear models. Results: Between August 2020 and August 2021, 1688 pregnant women were enrolled;998 completed pregnancy follow-up. Of those, 259 (26.0%) had adverse outcomes, and 169 (22%) tested positive for SARS-CoV-2, of whom 93 (55%) were symptomatic. The most prevalent symptoms included cough (76.1%), headache (47.9%), anorexia (41%), anosmia (35.0%), fatigue (30.8%), joint pains (29.1%), fever (28.2%), runny nose (23.1%), chills (19.7%) and myalgia (12.8%). Fourteen COVID-19 pregnant women required hospitalization;none were admitted in ICU. Very low birthweight (<1500g) (adjusted relative risk (aRR) 4.78, 95% CI 1.11-20.49), very preterm birth (<34 weeks) (aRR=2.57, 1.34-4.90) and preterm birth (<37 weeks) (aRR=1.54, 1.03-2.29) were more common among women with COVID-19. There were no significant associations between COVID-19 in pregnancy and hypertensive disorders of pregnancy, preeclampsia, stillbirths and perinatal deaths. Conclusion: SARS-CoV-2 infection increases the risk of very low birth weights and very preterm births in western Kenya.

Preliminary findings on the experiences of care for parents who suffered perinatal bereavement during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic poses an unprecedented risk to the global population. Maternity care in the UK was subject to many iterations of guidance on how best to reconfigure services to keep women, their families and babies, and healthcare professionals safe. Parents who experience a pregnancy loss or perinatal death require particular care and support. PUDDLES is an international collaboration investigating the experiences of recently bereaved parents who suffered a late miscarriage, stillbirth, or neonatal death during the global COVID-19 pandemic, in seven countries. In this study, we aim to present early findings from qualitative work undertaken with recently bereaved parents in the United Kingdom about how access to healthcare and support services was negotiated during the pandemic. METHODS: In-depth semi-structured interviews were undertaken with parents (N = 24) who had suffered a late miscarriage (n = 5; all mothers), stillbirth (n = 16; 13 mothers, 1 father, 1 joint interview involving both parents), or neonatal death (n = 3; all mothers). Data were analysed using a template analysis with the aim of investigating bereaved parents' access to services, care, and networks of support, during the pandemic after their bereavement. RESULTS: All parents had experience of utilising reconfigured maternity and/or neonatal, and bereavement care services during the pandemic. The themes utilised in the template analysis were: 1) The Shock & Confusion Associated with Necessary Restrictions to Daily Life; 2) Fragmented Care and Far Away Families; 3) Keeping Safe by Staying Away; and 4) Impersonal Care and Support Through a Screen. Results suggest access to maternity, neonatal, and bereavement care services were all significantly reduced, and parents' experiences were notably affected by service reconfigurations. CONCLUSIONS: Our findings, whilst preliminary, are important to document now, to help inform care and service provision as the pandemic continues and to provide learning for ongoing and future health system shocks. We draw conclusions on how to enable development of safe and appropriate services during this pandemic and any future health crises, to best support parents who experience a pregnancy loss or whose babies die.

Preterm birth, stillbirth and early neonatal mortality during the Danish COVID-19 lockdown.

Using provisional or opportunistic data, three nationwide studies (The Netherlands, the USA and Denmark) have identified a reduction in preterm or extremely preterm births during periods of COVID-19 restrictions. However, none of the studies accounted for perinatal deaths. To determine whether the reduction in extremely preterm births, observed in Denmark during the COVID-19 lockdown, could be the result of an increase in perinatal deaths and to assess the impact of extended COVID-19 restrictions, we performed a nationwide Danish register-based prevalence proportion study. We examined all singleton pregnancies delivered in Denmark during the COVID-19 strict lockdown calendar periods (March 12-April 14, 2015-2020, N = 31,164 births) and the extended calendar periods of COVID-19 restrictions (February 27-September 30, 2015-2020, N = 214,862 births). The extremely preterm birth rate was reduced (OR 0.27, 95% CI 0.07 to 0.86) during the strict lockdown period in 2020, while perinatal mortality was not significantly different. During the extended period of restrictions in 2020, the extremely preterm birth rate was marginally reduced, and a significant reduction in the stillbirth rate (OR 0.69, 0.50 to 0.95) was observed. No changes in early neonatal mortality rates were found.Conclusion: Stillbirth and extremely preterm birth rates were reduced in Denmark during the period of COVID-19 restrictions and lockdown, respectively, suggesting that aspects of these containment and control measures confer an element of protection. The present observational study does not allow for causal inference; however, the results support the design of studies to ascertain whether behavioural or social changes for pregnant women may improve pregnancy outcomes. What is Known: • The aetiologies of preterm birth and stillbirth are multifaceted and linked to a wide range of socio-demographic, medical, obstetric, foetal, psychosocial and environmental factors. • The COVID-19 lockdown saw a reduction in extremely preterm births in Denmark and other high-income countries. An urgent question is whether this reduction can be explained by increased perinatal mortality. What is New: • The reduction in extremely preterm births during the Danish COVID-19 lockdown was not a consequence of increased perinatal mortality, which remained unchanged during this period. • The stillbirth rate was reduced throughout the extended period of COVID-19 restrictions.

Ultrasound and Doppler findings in pregnant women with SARS-CoV-2 infection.

OBJECTIVES: To describe and compare ultrasound and Doppler findings in pregnant women who were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with findings in those who were SARS-CoV-2-negative, evaluated during the pandemic period. METHODS: In this retrospective case-control study, we analyzed data from 106 pregnant women who tested positive for SARS-CoV-2 at the time of, or within 1 week of, an ultrasound scan between 1 May and 31 August 2020. Scans were either performed for routine fetal evaluation or indicated due to a positive SARS-CoV-2 test. Forty-nine women were symptomatic and 57 were asymptomatic. For comparison, we analyzed data from 103 pregnant women matched for maternal age, parity, body mass index and gestational age at the time of the ultrasound scan. These control women did not report symptoms of SARS-CoV-2 infection at the time of the ultrasound scan or at the time of admission for delivery and had a negative SARS-CoV-2 test at admission for delivery. Fetal biometry, fetal anatomy, amniotic fluid volume and Doppler parameters, including umbilical and fetal middle cerebral artery pulsatility indices, cerebroplacental ratio and biophysical profile (BPP), were evaluated as indicated. Biometric and Doppler values were converted to Z-scores for comparison. Our primary outcome, an adverse prenatal composite outcome (APCO) included any one or more of: small-for-gestational-age (SGA) fetus, oligohydramnios, abnormal BPP, abnormal Doppler velocimetry and fetal death. Comorbidities, delivery information and neonatal outcome were compared between the two groups. RESULTS: Eighty-seven (82.1%) women who were positive for SARS-CoV-2 had a body mass index > 25 kg/m2 . SARS-CoV-2-positive women had a higher prevalence of diabetes (26/106 (24.5%) vs 13/103 (12.6%); P = 0.03), but not of pre-eclampsia (21/106 (19.8%) vs 11/103 (10.7%); P = 0.08), compared with controls. The prevalence of APCO was not significantly different between SARS-CoV-2-positive women (19/106 (17.9%)) and controls (9/103 (8.7%)) (P = 0.06). There were no differences between SARS-CoV-2-positive women and controls in the prevalence of SGA fetuses (12/106 (11.3%) vs 6/103 (5.8%); P = 0.17), fetuses with abnormal Doppler evaluation (8/106 (7.5%) vs 2/103 (1.9%); P = 0.08) and fetuses with abnormal BPP (4/106 (3.8%) vs 0/103 (0%); P = 0.14). There were two fetal deaths in women who were positive for SARS-CoV-2 and these women had a higher rate of preterm delivery ≤ 35 weeks of gestation (22/106 (20.8%) vs 9/103 (8.7%); odds ratio, 2.73 (95% CI, 1.19-6.3); P = 0.01) compared with controls. CONCLUSIONS: There were no significant differences in abnormal fetal ultrasound and Doppler findings observed between pregnant women who were positive for SARS-CoV-2 and controls. However, preterm delivery ≤ 35 weeks was more frequent among SARS-CoV-2-positive women. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy-related death disparities in non-Hispanic Black women.

While the rate of pregnancy-related death steadily increases in the United States, this tragic outcome is disproportionately devastating US-born non-Hispanic Black women at a rate that is three to four times that of their White and non-Black Hispanic counterparts. These disparities persist despite controlling for variables such as socioeconomic status, education levels, and geographical location. Pregnancy-related deaths in Black women are largely cardiovascular in etiology, and while these complications also occur in women of other ethnic backgrounds, they often are more severe and more deadly in Black women. This population often lacks adequate prenatal care likely because they face personal and structural barriers. Reversal of barriers during the prenatal period, the implementation of medical protocols during delivery, and the assurance of close follow-up during the postpartum year are vital in improving outcomes. This article will detail seven specific concerns within perinatal care and pregnancy-related death, and offer potential solutions to addressing them. Pregnancy-related death in Black women is not as an isolated event, but rather is one adverse outcome that exists on a broad spectrum of adverse outcomes. Now is the time to reckon with the reality that our nation's Black women are dying at a disproportionate rate compared to women of other ethnicities due to pregnancy-related complications and suffering lifelong consequences even if they escape this fatal outcome. This is a call to action to understand this deeply devastating, multi-factorial issue so we may strive to eliminate this highly preventable and tragic event altogether.

The impact of the Covid-19 pandemic on maternity services: A review of maternal and neonatal outcomes before, during and after the pandemic.

OBJECTIVE: To explore any apparent trends in maternal or neonatal outcomes during the Covid-19 pandemic by comparing the maternity outcomes before, during and after the pandemic. STUDY DESIGN: A retrospective review was performed of maternity statistics recorded on the hospital database of a large tertiary referral centre in Dublin with over 8000 deliveries per annum from 1st January to 31st July 2020. This time period represented the months prior to, during the peak and following the pandemic in Ireland. RESULTS: There was no correlation between the monthly number of Covid deaths and the monthly number of perinatal deaths (r = 0.465, NS), preterm births (r = 0.339, NS) or hypertensive pregnancies (r = 0.48, NS). Compared to the combined numbers for the same month in 2018 and 2019, there were no significant changes in perinatal deaths or preterm births in the months when Covid deaths were at their height. The rate of preterm birth was significantly less common in January-July 2020 compared to January-July in 2018/2019 (7.4 % v 8.6 %, chi-sq 4.53, P = 0.03). CONCLUSION: The was no evidence of a negative impact of the Covid-19 pandemic on maternity services, as demonstrated by maternal and neonatal outcomes.

Death of a neonate born to a critically ill mother with COVID-19: a case report / 中华围产医学杂志

We report a critically ill pregnant woman in the third trimester with severe pneumonia due to COVID-19 who presented to Xiaolan People's Hospital of Zhongshan in February 2020. The 32-year-old patient was admitted at 35 +2 gestational weeks with a 4-day history of a sore throat and a fever for three hours. The patient had been to Xiaogan City, Hubei Province, and the symptoms occurred during a period of self-isolation after back home. The condition of the patient deteriorated rapidly, with left-sided chest and back pain, shortness of breath, dizziness, progressing to respiratory failure and septic shock 7 hours after her admission. In view of her critical condition and a history of two previous cesarean sections, an emergency cesarean section was performed. Blood gas analysis of the mother before the operation suggested respiratory failure, respiratory acidosis, and metabolic acidosis. During the operation, a baby boy was born. The Apgar score of the boy, birth weight of 2 700 g, was one at 1, 5 and 10 minutes despite the resuscitation efforts. The neonate died after withdrawing treatment. The patient was treated with tracheal intubation ventilator and other supportive treatments after the operation. The result of the new coronavirus nucleic acid test, taken on admission, but which was reported after delivery, was positive. The patient was transferred to the designated hospital for further treatment and was recovering with the withdrawal of extracorporeal membrane oxygenation and ventilation support at 26 and 36 days after surgery, respectively.