A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality.

BACKGROUND: Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. METHODS: National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009 and 18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received. The care of a stratified random sample of 54 women who died during or up to a year after the end of pregnancy between 2009 and 18, (18 from the aggregated group of Black women, 19 from the Asian aggregated group and 17 from the White aggregated group) was re-examined specifically to describe any structural or cultural biases or discrimination identified. FINDINGS: There were no major differences causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). INTERPRETATION: This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. FUNDING: This research is funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21,202. MK is an NIHR Senior Investigator. SK is part funded and FCS fully funded by the National Institute for Health Research (NIHR) Applied Research Centre (ARC) West Midlands. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study.

OBJECTIVE: To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN: Retrospective cohort study. SETTING: Six specialist centres managing pregnant women with neurological disorders. POPULATION: Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS: Retrospective case notes review. MAIN OUTCOME MEASURES: Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS: Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION: In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT: Women with cerebrovascular malformations have high rates of vaginal delivery.

Pregnancy and neonatal outcomes in COVID-19: study protocol for a global registry of women with suspected or confirmed SARS-CoV-2 infection in pregnancy and their neonates, understanding natural history to guide treatment and prevention.

INTRODUCTION: Previous novel COVID-19 pandemics, SARS and middle east respiratory syndrome observed an association of infection in pregnancy with preterm delivery, stillbirth and increased maternal mortality. COVID-19, caused by SARS-CoV-2 infection, is the largest pandemic in living memory.Rapid accrual of robust case data on women in pregnancy and their babies affected by suspected COVID-19 or confirmed SARS-CoV-2 infection will inform clinical management and preventative strategies in the current pandemic and future outbreaks. METHODS AND ANALYSIS: The pregnancy and neonatal outcomes in COVID-19 (PAN-COVID) registry are an observational study collecting focused data on outcomes of pregnant mothers who have had suspected COVID-19 in pregnancy or confirmed SARS-CoV-2 infection and their neonates via a web-portal. Among the women recruited to the PAN-COVID registry, the study will evaluate the incidence of: (1) miscarriage and pregnancy loss, (2) fetal growth restriction and stillbirth, (3) preterm delivery, (4) vertical transmission (suspected or confirmed) and early onset neonatal SARS-CoV-2 infection.Data will be centre based and collected on individual women and their babies. Verbal consent will be obtained, to reduce face-to-face contact in the pandemic while allowing identifiable data collection for linkage. Statistical analysis of the data will be carried out on a pseudonymised data set by the study statistician. Regular reports will be distributed to collaborators on the study research questions. ETHICS AND DISSEMINATION: This study has received research ethics approval in the UK. For international centres, evidence of appropriate local approval will be required to participate, prior to entry of data to the database. The reports will be published regularly. The outputs of the study will be regularly disseminated to participants and collaborators on the study website (https://pan-covid.org) and social media channels as well as dissemination to scientific meetings and journals. STUDY REGISTRATION NUMBER: ISRCTN68026880.

Comparing the relation between ultrasound-estimated fetal weight and birthweight in cohort of small-for-gestational-age fetuses.

INTRODUCTION: Small-for-gestational-age (SGA) confers a higher perinatal risk of adverse outcomes. Birthweight cannot be accurately measured until delivery, therefore accurate estimated fetal weight (EFW) based on ultrasonography is important in identifying this high-risk population. We aimed to establish the sensitivity of detecting SGA infants antenatally in a unit with a selective third-trimester ultrasound policy and to investigate the association between EFW and birthweight in these babies. MATERIAL AND METHODS: A retrospective cohort study was conducted on non-anomalous singleton pregnancies delivered after 36 weeks of gestation where SGA (<10th percentile) was diagnosed at delivery. The EFW at the time of the third-trimester ultrasound scan was recorded using standard Hadlock formulae. RESULTS: In 2017, there were 8392 non-anomalous singleton pregnancies live born after 36 weeks, excluding late bookers. 797 were live-born SGA <10th percentile for birthweight and 464 <5th percentile, who met our inclusion criteria. The antenatal detection rate of SGA was 19.6% for babies with birthweight <10th percentile and 24.1% <5th percentile. There was a significant correlation between the EFW and birthweight of fetuses undergoing ultrasound assessment within 2 weeks of delivery (P < .001, r = 0.73 (Pearson correlation). For these cases, EFW was greater than the birthweight in 65% of cases. After adjusting all EFWs using the discrepancy between EFW and actual birthweight for those babies born within 48 hours of the scan, the mean difference between the birthweight and adjusted EFW 7 days before delivery was 111 g (95% CI 87-136 g) and at 14 days was 200 g (95% CI 153-248 g). Despite adjusting the EFW, 61/213 cases (28.6%) apparently lost weight between the ultrasound scan and delivery. CONCLUSIONS: Small-for-gestational-age infants with a birthweight <10th percentile are poorly identified antenatally with little improvement for those <5th percentile. In SGA babies, ultrasound EFW overestimated birthweight. Discrepancies between birthweight and EFW are not explicable only by the limitations of third-trimester sonography, a reduction in fetal weight close to delivery in a proportion of liveborn SGA babies is plausible.

Macroprolactinomas and Nonfunctioning Pituitary Adenomas and Pregnancy Outcomes.

OBJECTIVE: To examine the monitoring, management, and outcomes of pituitary tumors in pregnancy. METHODS: A national, prospective, observational, population-based case series study was conducted in all U.K. consultant-led obstetric units over 3 years using the U.K. Obstetric Surveillance System. To evaluate rates of adverse pregnancy outcomes, women with a macroprolactinoma (10 mm or greater) or nonfunctioning pituitary adenoma, diagnosed before or during pregnancy, were compared with two comparison groups: 1) a U.K. Obstetric Surveillance System cohort with singleton (n=2,205) or twin (n=27) pregnancy; and 2) data from the Office of National Statistics (n=2,703,102). Main outcome measures were the incidence, management, and frequency of adverse maternal and offspring outcomes of pituitary tumors in pregnancy. RESULTS: There were 71 confirmed cases of pituitary tumors in pregnancy (49 macrolactinoma, 16 nonfunctioning adenomas, three acromegaly, three Cushing's disease). The women with pituitary tumors were 4 years older than comparison women (P<.001). None of the nine women treated with surgery or radiotherapy before pregnancy had symptomatic tumor expansion. This occurred in 6 of 40 women with macroprolactinomas and one of seven nonfunctioning adenomas diagnosed before conception and in three of five women with nonfunctioning adenomas diagnosed in pregnancy. Two women had pituitary apoplexy, both of whom also had symptoms of expansion of tumor or surrounding pituitary tissue. To within the level of accuracy possible, there was no evidence that pituitary tumors were associated with adverse pregnancy outcomes (pregnancy-induced hypertension, preeclampsia, preterm labor, stillbirth). Women with nonfunctioning adenomas were more likely to have cesarean delivery compared with women in a control group (relative risk 2.06, confidence interval 1.26-3.36, P=.035). CONCLUSION: The majority of women with macroprolactinomas and nonfunctioning adenomas have good pregnancy outcomes. Nonfunctioning pituitary adenomas occur more commonly in pregnancy than previously thought and can present de novo with symptoms of pituitary expansion in pregnancy.

Cytomegalovirus may mimic the presentation of intrahepatic cholestasis and hemolysis, elevated liver enzymes and low platelets in immunosuppressed pregnant women.

Most published cases of cytomegalovirus infection in pregnancy relate to congenital abnormalities in neonates infected in early pregnancy, while the mother remains asymptomatic. We describe a diagnostically challenging case of an immunosuppressed woman with scleroderma who developed deranged liver function tests attributed to intrahepatic cholestasis of pregnancy and haemolysis, elevated liver enzymes and low platelets syndrome but was ultimately found to have disseminated cytomegalovirus. Cytomegalovirus can present in a myriad of ways. Clinicians caring for immunocompromised pregnant women should consider cytomegalovirus as a possible differential diagnosis when reviewing abnormal liver function tests.

Myasthenia in pregnancy: best practice guidelines from a U.K. multispecialty working group.

A national U.K. workshop to discuss practical clinical management issues related to pregnancy in women with myasthenia gravis was held in May 2011. The purpose was to develop recommendations to guide general neurologists and obstetricians and facilitate best practice before, during and after pregnancy. The main conclusions were (1) planning should be instituted well in advance of any potential pregnancy to allow time for myasthenic status and drug optimisation; (2) multidisciplinary liaison through the involvement of relevant specialists should occur throughout pregnancy, during delivery and in the neonatal period; (3) provided that their myasthenia is under good control before pregnancy, the majority of women can be reassured that it will remain stable throughout pregnancy and the postpartum months; (4) spontaneous vaginal delivery should be the aim and actively encouraged; (5) those with severe myasthenic weakness need careful, multidisciplinary management with prompt access to specialist advice and facilities; (6) newborn babies born to myasthenic mothers are at risk of transient myasthenic weakness, even if the mother's myasthenia is well-controlled, and should have rapid access to neonatal high-dependency support.

Contraception in women with medical problems.

Women with medical disease have a higher incidence of maternal mortality compared with healthy women, with cardiac disease now being the most common cause of maternal death in the UK. A handful of medical conditions exist where pregnancy is not recommended due to mortality rates approaching 50%. It is imperative that such women have the most reliable methods of contraception available. Contraceptive agents may themselves affect medical disease, or may interact with medications used by such women. There may be a range of contraceptive agents suitable for each medical condition. The contraceptive selected should be tailored to suit the individual. The following points should be considered when deciding on the most appropriate contraceptive agent: efficacy, thrombotic risk (oestrogen containing contraceptives), arterial risks (oestrogen containing contraceptives), infective risk (e.g. insertion of intrauterine device [IUD]), vagal stimulation (e.g. insertion of IUD, ESSURE(®)), bleeding risks with patients on anticoagulants, interaction with concomitant drugs, effects of anaesthesia and ease of use. This review aims to cover the different contraceptive agents available and the best ones to use for certain medical illnesses.