Parvovirus B19 in Pregnancy.

Importance: Although the risk of parvovirus B19 infection during pregnancy and subsequent risk of adverse fetal outcome are low, understanding management practices is essential for proper treatment of fetuses with nonimmune hydrops fetalis. In addition, continued investigation into delivery management, breastfeeding recommendations, and congenital abnormalities associated with pregnancies complicated by parvovirus B19 infection is needed. Objective: This review describes the risks associated with parvovirus B19 infection during pregnancy and the management strategies for fetuses with vertically transmitted infections. Evidence Acquisition: Original articles were obtained from literature search in PubMed, Medline, and OVID; pertinent articles were reviewed. Results: Parvovirus B19 is a viral infection associated with negative pregnancy outcomes. Up to 50% of people of reproductive age are susceptible to the virus. The incidence of B19 in pregnancy is between 0.61% and 1.24%, and, overall, there is 30% risk of vertical transmission when infection is acquired during pregnancy. Although most pregnancies progress without negative outcomes, viral infection of the fetus may result in severe anemia, congestive heart failure, and hydrops fetalis. In addition, vertical transmission carries a 5% to 10% chance of fetal loss. In pregnancies affected by fetal B19 infection, Doppler examination of the middle cerebral artery peak systolic velocity should be initiated to surveil for fetal anemia. In the case of severe fetal anemia, standard fetal therapy involves an intrauterine transfusion of red blood cells with the goal of raising hematocrit levels to approximately 40% to 50% of total blood volume. One transfusion is usually sufficient, although continued surveillance may indicate the need for subsequent transfusions. There are fewer epidemiologic data concerning neonatal risks of congenital parvovirus, although case reports have shown that fetuses with severe anemia in utero may have persistent anemia, thrombocytopenia, and edema in the neonatal period. Conclusions and Relevance: Parvovirus B19 is a common virus; seropositivity in the geriatric population reportedly reaches 85%. Within the pregnant population, up to 50% of patients have not previously been exposed to the virus and consequently lack protective immunity. Concern for parvovirus B19 infection in pregnancy largely surrounds the consequences of vertical transmission of the virus to the fetus. Should vertical transmission occur, the overall risk of fetal loss is between 5% and 10%. Thus, understanding the incidence, risks, and management strategies of pregnancies complicated by parvovirus B19 is essential to optimizing care and outcomes. Further, there is currently a gap in evidence regarding delivery management, breastfeeding recommendations, and the risks of congenital abnormalities in pregnancies complicated by parvovirus B19. Additional investigations into optimal delivery management, feeding plans, and recommended neonatal surveillance are needed in this cohort of patients.

Severe pulmonary hypertension and circulatory failure associated with Congenital syphilis. Case report.

BACKGROUND: Congenital syphilis is a vertical infection caused by Treponema pallidum. Despite the implementation of preventive strategies during pregnancy, its incidence is increasing, and it constitutes an important public health problem. Most patients with congenital syphilis are asymptomatic; however, a small group may develop severe disease at birth with the need of advanced resuscitation in the delivery room, acute hypoxemic respiratory failure, and hemodynamic instability. Therefore, awareness is needed. METHODS AND RESULTS: This series describes the clinical course of two late preterm infants with congenital syphilis who developed acute hypoxemic respiratory failure, pulmonary hypertension, and circulatory collapse early after birth. Integrated hemodynamic evaluation with neonatologist-performed echocardiography (NPE) and therapeutic management is provided. CONCLUSIONS: A comprehensive hemodynamic evaluation including early and serial functional echocardiography in these patients is needed to address the underlying complex pathophysiology and to help to establish accurate treatment.

Varicella in the 21st Century.

Varicella is a highly contagious disease caused by the varicella-zoster virus and has a wide range of clinical presentations. Varicella can cause mild disease in infants born to infected persons who are immunized as a result of previous vaccination or previous clinical or subclinical infection. However, varicella can also lead to severe life-threatening disease in infants, particularly for those born to nonimmunized persons. In this review, we will summarize the natural history of varicella-zoster infection in pregnant persons, infants with congenital varicella syndrome, and infants with postnatal varicella infection. We will also provide guidance about isolation recommendations and chemoprophylaxis for exposed hospitalized infants. Finally, we will describe risk factors for developing disseminated disease and review the approach to treatment of infected infants.

Outcome of pregnant women admitted to critical care unit with confirmed severe COVID-19: A center experience.

OBJECTIVES: To explore the traits and risk factors of pregnant women admitted to intensive care units (ICUs) with COVID-19. Moreover, the study classifies outcomes based on differing levels of required respiratory support during their intensive care stay. METHODS: This retrospective and descriptive study included all pregnant women with COVID-19 admitted to the adult critical care unit at a specialized tertiary hospital in Riyadh, Saudi Arabia. Between January 2020 and December 2022. A total of 38 pregnant women were identified and were eligible for our study. RESULTS: The mean age of the patients was 32.9 (19-45) years, and the average Acute Physiology and Chronic Health Evaluation IV (APACHI IV) score was 49.9 (21-106). Approximately 60.5% of the patients suffered from superimposed infections during their ICU stay. Approximately 81.6% patients were delivered by C-section, 33 of the newborns survived, and 5 died. The crude mortality rate among pregnant women in our cohort was 15.8%. Patients treated with high-flow nasal cannula (HFNC) were mostly discharged or delivered normally, while the mechanical ventilation (MV) and extracorporeal membrane oxygenation groups mostly underwent C-sections. Most of the surviving newborns were on HFNC and MV. Patients with multiple infections had the longest ICU stay and had the highest risk of death. CONCLUSION: The results of this study highlight the characteristics of pregnant women admitted to the ICU at a specialized tertiary healthcare center in Saudi Arabia. The APACHI IV scores accurately predicted patient's mortality, duration of MV, and length of ICU stay. In our study, we shared our experience of managing severe COVID-19 infections in pregnant patients.

Management of neonates with maternal prenatal coronavirus infection and influencing factors.

The coronavirus disease 2019 (COVID-19) in pregnancy causes adverse outcomes for both the mother and the fetus. Neonates are at risk of vertical transmission and in-utero infection. Additionally, intensive care unit (ICU) admission and impairment in the organ systems of the mother are associated with neonatal outcomes, including impaired intrauterine growth, prematurity, and neonatal ICU admission. The management of neonates born from infected mothers has changed over the progress of the pandemic. At the beginning of the pandemic, cesarean section, immediate separation of mother-infant dyads, isolation of neonates, and avoiding of skin-to-skin contact, breast milk, and breastfeeding were the main practices to reduce vertical and horizontal transmission risk in the era of insufficient knowledge. The effects of antenatal steroids and delayed cord clamping on COVID-19 were also not known. As the pandemic progressed, data showed that prenatal, delivery room, and postnatal care of neonates can be performed as pre-pandemic practices. Variants and vaccines that affect clinical course and outcomes have emerged during the pandemic. The severity of the disease and the timing of infection in pregnancy also influence maternal and neonatal outcomes. The knowledge and lessons from COVID-19 will be helpful for the next pandemic if it happens. IMPACT: Prenatal infection with COVID-19 is associated with adverse maternal and neonatal outcomes. Our review includes the management of neonates with prenatal COVID-19 infection exposure, maternal-fetal, delivery room, and postnatal care of neonates, clinical features, treatment of neonates, and influencing factors such as variants, vaccination, severity of maternal disease, and timing of infection during pregnancy. There is a growing body of data and evidence about the COVID-19 pandemic. The knowledge and lessons from the pandemic will be helpful for the next pandemic if it happens.

Perinatal care in SARS-CoV-2 infected women: the lesson learnt from a national prospective cohort study during the pandemic in Italy.

BACKGROUND: Despite the growing importance given to ensuring high-quality childbirth, perinatal good practices have been rapidly disrupted by SARS-CoV-2 pandemic. This study aimed at describing the childbirth care provided to infected women during two years of COVID-19 emergency in Italy. METHODS: A prospective cohort study enrolling all women who gave birth with a confirmed SARS-CoV-2 infection within 7 days from hospital admission in the 218 maternity units active in Italy during the periods February 25, 2020-June 30, 2021, and January 1-May 31, 2022. Perinatal care was assessed by evaluating the prevalence of the following indicators during the pandemic: presence of a labour companion; skin-to-skin; no mother-child separation at birth; rooming-in; breastfeeding. Logistic regression models including women' socio-demographic, obstetric and medical characteristics, were used to assess the association between the adherence to perinatal practices and different pandemic phases. RESULTS: During the study period, 5,360 SARS-CoV-2 positive women were enrolled. Overall, among those who had a vaginal delivery (n = 3,574; 66.8%), 37.5% had a labour companion, 70.5% of newborns were not separated from their mothers at birth, 88.1% were roomed-in, and 88.0% breastfed. These four indicators showed similar variations in the study period with a negative peak between September 2020 and January 2021 and a gradual increase during the Alpha and Omicron waves. Skin-to-skin (mean value 66.2%) had its lowest level at the beginning of the pandemic and gradually increased throughout the study period. Among women who had a caesarean section (n = 1,777; 33.2%), all the indicators showed notably worse outcomes with similar variations in the study period. Multiple logistic regression analyses confirm the observed variations during the pandemic and show a lower adherence to good practices in southern regions and in maternity units with a higher annual number of births. CONCLUSIONS: Despite the rising trend in the studied indicators, we observed concerning substandard childbirth care during the SARS-CoV-2 pandemic. Continued efforts are necessary to underscore the significance of the experience of care as a vital component in enhancing the quality of family-centred care policies.

Ocular Involvement in Congenital Infections - TORCH. / Augenbeteiligung bei kongenitalen Infektionen ­ TORCH.

This review summarises the ophthalmological findings in congenital infections. Intrauterine infections are an important cause of childhood blindness. The most common infections are grouped under the acronym TORCH, which stands for Toxoplasma gondii, others, rubella, CMV, and herpes simplex. Overall, these infections are not very common in first-world countries during pregnancy, but are of particular importance because of the threat to vision. Diagnosis of infection or reactivation is a gynaecological challenge. However, ophthalmological examination of newborns can be appropriately targeted if the causative agent is known. The most important therapeutic agents used in the newborn are summarised.

Critical care, maternal and neonatal outcomes of pregnant women with COVID-19 admitted to eight intensive care units during the wildtype, alpha and delta waves of the pandemic across the North West of England-a retrospective review.

INTRODUCTION: Few studies have described obstetric and critical care outcomes in pregnant women with COVID-19 needing intensive care unit (ICU) admission. MATERIAL AND METHODS: Obstetric and critical care outcomes of COVID-19 women admitted to eight ICUs from April 1, 2020 to September 15, 2021, in the North West of England were retrospectively analyzed. Women admitted to ICU were assigned to three groups: antepartum women discharged from ICU prior to delivery (antepartum ICU-discharged group), antepartum women who had expedited delivery (antepartum ICU-delivered group) and a postpartum group. Our aims were to describe maternal characteristics and assess how delivery influenced the obstetric and critical care outcomes in these women. RESULTS: During the study period, 615 women tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of whom 62 (10.1%) needed ICU admission due to symptomatic COVID-19. Pregnancy loss (3.2%) was recorded in two women. Detailed obstetric and critical outcomes from 60 women are reported. Nine antepartum women (15%) admitted to ICU were discharged and continued their pregnancy, 13 antepartum women (21.7%) had expedited delivery by cesarean birth after ICU admission and 38 (63.3%) women were admitted to ICU during the postpartum period. Antepartum ICU-discharged women contracted the SARS-CoV-2 at an earlier median gestational age (23 weeks; p = 0.0003) and needed ICU admission at an earlier median gestational age (28 weeks, p = 0.03) compared with antepartum ICU-delivered (28 and 32 weeks) and postpartum women (35.5 and 36 weeks). Antepartum ICU-discharged women had the lowest rate of mechanical ventilation receipt (11.1%) compared with antepartum ICU-delivered women (52.3%) and postpartum women (44.3%) but the difference was not statistically significant (p = 0.13). No significant differences were observed in the frequency and severity of critical care complications in the antepartum ICU-discharged, antepartum-ICU delivered and postpartum women. CONCLUSIONS: Of the women admitted to ICU antepartum, 40% were discharged while remaining pregnant and 60% had expedited delivery. Antepartum women who were discharged from ICU without giving birth may receive lower rates of mechanical ventilation than those who delivered in ICU or admitted postpartum; however, further studies are needed to confirm or refute this association.

Barriers to optimal management of syphilis in pregnancy and congenital syphilis in south-east Queensland: a qualitative investigation.

BACKGROUND: Australia, like many high-income countries, is experiencing a resurgence of infectious syphilis in pregnancy and congenital syphilis. Evaluations of public health notifications and clinical records suggest that healthcare systems may not be providing optimal care to women and their neonates. This study aims to explore the barriers to optimal management of syphilis in pregnancy and congenital syphilis to identify key areas for improvement. METHODS: Between 2021 and 2022, 34 healthcare workers (HCW) practicing in south-east Queensland (SEQ) Australia were recruited to complete semi-structured interviews regarding their perceptions towards management of syphilis in pregnancy and congenital syphilis. Interviews were analysed thematically. RESULTS: Thematic analysis identified four themes related to the management of syphilis in pregnancy. These included poor communication between disciplines, services, and teams from delivery through to management and post-delivery, lack of formal internal and external referral pathways, unclear and often complex maternal and congenital syphilis management procedures, and limited HCW knowledge of infectious syphilis in pregnancy and congenital syphilis. CONCLUSION: As congenital syphilis numbers continue to rise in SEQ, it is imperative that healthcare systems and HCWs identify and address gaps in the provision of health care.

Predicting adverse outcomes in pregnant patients positive for SARS-CoV-2: a machine learning approach- a retrospective cohort study.

BACKGROUND: Pregnant people are particularly vulnerable to SARS-CoV-2 infection and to ensuing severe illness. Predicting adverse maternal and perinatal outcomes could aid clinicians in deciding on hospital admission and early initiation of treatment in affected individuals, streamlining the triaging processes. METHODS: An international repository of 1501 SARS-CoV-2-positive cases in pregnancy was created, consisting of demographic variables, patient comorbidities, laboratory markers, respiratory parameters, and COVID-19-related symptoms. Data were filtered, preprocessed, and feature selection methods were used to obtain the optimal feature subset for training a variety of machine learning models to predict maternal or fetal/neonatal death or critical illness. RESULTS: The Random Forest model demonstrated the best performance among the trained models, correctly identifying 83.3% of the high-risk patients and 92.5% of the low-risk patients, with an overall accuracy of 89.0%, an AUC of 0.90 (95% Confidence Interval 0.83 to 0.95), and a recall, precision, and F1 score of 0.85, 0.94, and 0.89, respectively. This was achieved using a feature subset of 25 features containing patient characteristics, symptoms, clinical signs, and laboratory markers. These included maternal BMI, gravidity, parity, existence of pre-existing conditions, nicotine exposure, anti-hypertensive medication administration, fetal malformations, antenatal corticosteroid administration, presence of dyspnea, sore throat, fever, fatigue, duration of symptom phase, existence of COVID-19-related pneumonia, need for maternal oxygen administration, disease-related inpatient treatment, and lab markers including sFLT-1/PlGF ratio, platelet count, and LDH. CONCLUSIONS: We present the first COVID-19 prognostication pipeline specifically for pregnant patients while utilizing a large SARS-CoV-2 in pregnancy data repository. Our model accurately identifies those at risk of severe illness or clinical deterioration, presenting a promising tool for advancing personalized medicine in pregnant patients with COVID-19.

Increased risk of severe COVID-19 in pregnancy in a multicenter propensity score-matched study.

OBJECTIVES: To explore the association between COVID-19 severity and pregnancy using measures such as COVID-19 ordinal scale severity score, hospitalization, intensive care unit (ICU) admission, oxygen supplementation, invasive mechanical ventilation, and death. METHODS: We conducted a retrospective, multicenter cohort study to understand the association between COVID-19 severity and pregnancy. We reviewed consecutive charts of adult females, ages 18-45, with laboratory testing for SARS-CoV-2 infection between March 1, 2020, and August 31, 2020. Cases were patients diagnosed with COVID-19 during pregnancy, whereas controls were not pregnant at the time of COVID-19 diagnosis. Primary endpoints were the COVID-19 severity score at presentation (within four hours) and the nadir of the clinical course. The secondary endpoints were the proportion of patients requiring hospitalization, ICU admission, oxygen supplementation, invasive mechanical ventilation, and death. RESULTS: A higher proportion of pregnant women had moderate to severe COVID-19 disease at the nadir of the clinical course than non-pregnant women (25 vs. 16.1 %, p=0.04, respectively). There was a higher rate of hospitalization (25.6 vs. 17.2 %), ICU admission (8.9 vs. 4.4 %), need for vasoactive substances (5.0 vs. 2.8 %), and invasive mechanical ventilation (5.6 vs. 2.8 %) in the pregnant cohort. These differences were not significant after applying propensity score matching.We found a high rate of pregnancy complications in our population (40.7 %). The most worrisome is the rate of hypertensive disorders of pregnancy (20.1 %). CONCLUSIONS: In our propensity score-matched study, COVID-19 in pregnancy is associated with an increased risk of disease severity and pregnancy complications.

Variations across Europe in hospitalization and management of pregnant women with SARS-CoV-2 during the initial phase of the pandemic: Multi-national population-based cohort study using the International Network of Obstetric Survey Systems (INOSS).

INTRODUCTION: The majority of data on COVID-19 in pregnancy are not from sound population-based active surveillance systems. MATERIAL AND METHODS: We conducted a multi-national study of population-based national or regional prospective cohorts using standardized definitions within the International Network of Obstetric Survey systems (INOSS). From a source population of women giving birth between March 1 and August 31, 2020, we included pregnant women admitted to hospital with a positive SARS-CoV-2 PCR test ≤7 days prior to or during admission and up to 2 days after birth. The admissions were further categorized as COVID-19-related or non-COVID-19-related. The primary outcome of interest was incidence of COVID-19-related hospital admission. Secondary outcomes included severe maternal disease (ICU admission and mechanical ventilation) and COVID-19-directed medical treatment. RESULTS: In a source population of 816 628 maternities, a total of 2338 pregnant women were admitted with SARS-CoV-2; among them 940 (40%) were COVID-19-related admissions. The pooled incidence estimate for COVID-19-related admission was 0.59 (95% confidence interval 0.27-1.02) per 1000 maternities, with notable heterogeneity across countries (I2 = 97.3%, P = 0.00). In the COVID-19 admission group, between 8% and 17% of the women were admitted to intensive care, and 5%-13% needed mechanical ventilation. Thromboprophylaxis was the most frequent treatment given during COVID-19-related admission (range 14%-55%). Among 908 infants born to women in the COVID-19-related admission group, 5 (0.6%) stillbirths were reported. CONCLUSIONS: During the initial months of the pandemic, we found substantial variations in incidence of COVID-19-related admissions in nine European countries. Few pregnant women received COVID-19-directed medical treatment. Several barriers to rapid surveillance were identified. Investment in robust surveillance should be prioritized to prepare for future pandemics.

Urinary Tract Infections in Pregnant Individuals.

SUMMARY: Urinary tract infection (UTI) is one of the more common perinatal complications, affecting approximately 8% of pregnancies (1, 2). These infections represent a spectrum, from asymptomatic bacteriuria, to symptomatic acute cystitis, to the most serious, pyelonephritis. The presence of UTIs has been associated with adverse pregnancy outcomes, including increased rates of preterm delivery and low birth weight. Screening for and treating asymptomatic bacteriuria have been shown in multiple studies to reduce the incidence of pyelonephritis in pregnancy (3-5). Given the frequency at which UTIs are encountered in pregnancy, the ability to recognize, diagnose, and treat them is essential for those providing care to pregnant individuals. This Clinical Consensus document was developed using an established protocol in conjunction with the authors listed.

Midwifery care for a COVID-19 cohort of women in Northern Italy: two years of pandemic.

BACKGROUND: The rapid development of the COVID-19 pandemic has altered the context of healthcare around the world. SARS-CoV-2 positive pregnant and postnatal women, being at greater risk of complications, require continuous midwifery surveillance as well as specialized medical care. Scientific literature lacks studies related to midwifery care models in hospital settings during the pandemic. The aim of this work is to describe hospitalizations in an obstetric-gynecological COVID care unit and to provide a descriptive analysis of the organizational and care model adopted. METHODS: A cohort retrospective descriptive study was carried out. The sample was stratified by COVID-related care complexity and by obstetric risk. The sample recruited pregnant women, postnatal women, and gynecological patients with confirmed SARS-CoV-2 infection admitted to the obstetric-gynecological COVID unit of a birth center in Northern Italy, from March 16, 2020, to March 16, 2022. RESULTS: A number of 1037 women were hospitalized, and of these, 551 were SARS-CoV-2 positive women. The 551 SARS-CoV-2 positive women included 362 pregnant women, 132 postnatal women, 9 gynecological patients with medical diagnosis while 17 with a surgical path, and 31 women undergoing voluntary interruption of pregnancy. The final sample included 536 women. 68.6% of women requested a low care complexity, 22.8% a medium one, and 8.6% a high care complexity. Among the obstetric women population, the majority (70.6%) showed a high obstetric risk. CONCLUSIONS: The COVID-19 cohort of women required different levels of care with various care complexity and levels of obstetric risk. The model adopted allowed the acquisition of new technical and professional skills as well as the sharing of responsibilities and competences according to the care model of the Buddy System. Future studies could investigate COVID-related care models adopted internationally, but also deepen the technical and professional skills developed by midwives during the pandemic in order to enrich, improve and support midwifery profession.

Cytomegalovirus in Pregnancy.

Cytomegalovirus is a pervasive DNA herpesvirus that, while clinically insignificant to an immunocompetent adult host, can cause significant morbidity to a congenitally infected fetus. Although detection is often possible with several common ultrasonographic markers and good diagnostic accuracy using polymerase chain reaction testing of amniotic fluid, there are no proven prenatal prevention or antenatal treatment options. Therefore, universal screening is not currently recommended in pregnancy. Strategies that have been studied in the past include immunoglobulins, antivirals, and the development of a vaccine. In this review, we will further discuss the themes above, along with future direction for prevention and treatment.

Congenital Syphilis Infection: A Case Study.

Congenital syphilis (CS) infection occurs by way of vertical transmission of the bacteria Treponema pallidum from mother to fetus. While nearly eliminated by the turn of the twenty-first century, CS has resurged in recent years and currently represents a worldwide public health calamity secondary to insufficient prenatal care and inadequate maternal treatment. Fetal and neonatal consequences include stillbirth, cutaneous and visceral symptoms, asymptomatic infection, and death. Given the rise in cases in both wealthy and resource-poor areas, neonatal clinicians are obligated to maintain acumen specific to risk factors, manifestations, and treatment regimens. However, limited data guide postnatal treatment regimens, particularly in preterm neonates. We present a case report of a preterm female with CS and integrated review of the literature. Our findings indicate that CS is preventable through efficient and judicious perinatal screening, early detection, and adequate treatment of maternal syphilis during pregnancy.

Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis.

Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).

Adverse outcomes and maternal complications in pregnant women with severe-critical COVID-19: a tertiary center experience.

OBJECTIVES: This study aimed to present perinatal outcomes, clinical challenges, and basic ICU management in pregnant women with severe-critical COVID-19 at our tertiary referral center. METHODS: In this prospective cohort study, patients were divided into two groups, whether they survived or not. Clinical characteristics, obstetric and neonatal outcomes, initial laboratory test results and radiologic imaging findings, arterial blood gas parameters at ICU admission, and ICU complications and interventions were compared between groups. RESULTS: 157 of the patients survived, and 34 of the patients died. Asthma was the leading health problem among the non-survivors. Fifty-eight patients were intubated, and 24 of them were weaned off and discharged healthfully. Of the 10 patients who underwent ECMO, only 1 survived (p<0.001). Preterm labor was the most common pregnancy complication. Maternal deterioration was the most common indication for a cesarean section. Higher neutrophil-to-lymphocyte-ratio (NLR) values, the need for prone positioning, and the occurrence of an ICU complication were important parameters that influenced maternal mortality (p<0.05). CONCLUSIONS: Overweight pregnant women and pregnant women with comorbidities, especially asthma, may have a higher risk of mortality related to COVID-19. A worsening maternal health condition can lead to increased rates of cesarean delivery and iatrogenic prematurity.

Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum.

Importance: Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective: To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants: This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures: ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures: The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results: From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance: In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.