Changes in the obstetrical emergency department profile during the COVID-19 pandemic.

BACKGROUND: The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection. OBJECTIVES: To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department. STUDY DESIGN: A retrospective cohort study in one medical center. The population was women > 20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department. RESULTS: During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6, p = .001). Higher proportions of women in the COVID-19 cohort presented in active labor, defined by cervical dilation of at least 5 cm on admission to the labor ward [37 (9.3%) vs 28 (5.1%), p = .013)] and with premature rupture of membranes [82 (20.6%) vs 60 (11.0%), p < .001)], and consequently with more admissions to the delivery room [198 (49.7%) vs 189 (34.7%), p < .001)]. We also recorded a significant increase in urgent obstetrical events in the emergency department during the recorded COVID-19 pandemic [23 (5.8%) vs 12 (2.2%)), p = .004]. However, the rates of neonatal and maternal morbidity did not change. During the outbreak the proportion of visits during the night was higher than during the matched period of the previous year: [138 (34.7%) vs 145 (26.6%)), p = .008]. In a multivariate logistic regression, the higher rates of admission to the delivery room during active labor and of urgent events during the pandemic outbreak compared to the matched period in the previous year remained statistically significant. CONCLUSIONS: The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Maternal and Neonatal SARS-CoV-2 Immunoglobulin G Antibody Levels at Delivery After Receipt of the BNT162b2 Messenger RNA COVID-19 Vaccine During the Second Trimester of Pregnancy.

IMPORTANCE: BNT162b2 messenger RNA (mRNA) COVID-19 vaccination in the third trimester was found to be associated with a strong maternal humoral IgG response that crossed the placenta and approached maternal titers in the newborn. OBJECTIVE: To evaluate maternal and neonatal SARS-CoV-2 immunoglobulin G (IgG) antibody levels at birth after mRNA COVID-19 vaccination during the second trimester of pregnancy. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study, conducted at a single medical center in Haifa, Israel, from May to July 2021, included women with a singleton pregnancy over 24 weeks of gestation at least 7 days after receipt of their second COVID-19 vaccine dose who were not known to be previously infected with COVID-19. EXPOSURES: BNT162b2 (Pfizer/BioNTech) vaccination. MAIN OUTCOMES AND MEASURES: The primary outcomes were SARS-CoV-2 IgG antibody titers measured in the parturient at admission and in the umbilical cord blood within 30 minutes after delivery. Secondary outcomes were the correlation between antibody titers, feto-maternal characteristics, maternal adverse effects after vaccination, and time interval from vaccination to delivery. RESULTS: Antibody levels were measured for 129 women (mean [SD] age, 31.9 [4.9] years) and 114 neonates, with 100% of the tests having positive results. The mean (SD) gestational age at administration of the second vaccine dose was 24.9 (3.3) weeks. Neonatal IgG titers were 2.6 times higher than maternal titers (median [range], 3315.7 [350.1-17 643.5] AU/mL vs 1185.2 [146.6-32 415.1] AU/mL). A positive correlation was demonstrated between maternal and neonatal antibodies (r = 0.92; 95% CI, 0.89-0.94). Multivariable analysis revealed that for each week that passed since receipt of the second vaccine dose, maternal and neonatal antibody levels changed by -10.9% (95% CI, -17.2% to -4.2%; P = .002) and -11.7% (95% CI, -19.0 to -3.8%; P = .005), respectively. For each 1-year increase in the mother's age, maternal and neonatal antibody levels changed by -3.1% (95% CI, -5.3% to -0.9%; P = .007) and -2.7% (95% CI, -5.2% to -0.1%; P = .04), respectively. CONCLUSIONS AND RELEVANCE: In this cohort study, receipt of the BNT162b2 mRNA COVID-19 vaccine during the second trimester of pregnancy was associated with maternal and neonatal humoral responses, as reflected in maternal and neonatal SARS-CoV-2 IgG antibody levels measured after delivery. These findings support COVID-19 vaccination of pregnant individuals during the second trimester to achieve maternal protection and newborn safety during the pandemic.

Group B Streptococcus real-time PCR may potentially reduce intrapartum maternal antibiotic treatment.

BACKGROUND: Protocols for preventing early-onset group B streptococcal (GBS) neonatal infection may result in unnecessary antibiotics administration. Real-time polymerase chain reaction (PCR) can provide a result within 30-60 min and has been found to be specific and sensitive for defining intrapartum GBS status. OBJECTIVE: To evaluate whether implementation of GBS fast real-time PCR to all women who require GBS prophylaxis may reduce the use of maternal prophylactic antibiotics. METHODS: This prospective cohort study included women admitted to a single delivery ward who required prophylactic antibiotics either due to a positive antepartum GBS culture screening performed at 35-37 weeks or due to an unknown GBS status with an intrapartum risk factor. All the women were tested by a double vaginal swab (real-time PCR and culture) as soon as it became apparent, they required antibiotic prophylaxis and prior to its administration. RESULTS: Between May 2019 and August 2020, 303 women met eligibility criteria and were enrolled, but four were excluded from the analysis due to failed culture or PCR tests. Of 299 women included in the study, 208 (69.5%) and 180 (60.2%) women, showed no evidence of GBS on intrapartum culture or PCR, respectively. Of 89 GBS antepartum carriers, 43 (48.3%) and 32 (35.9%) had negative intrapartum culture and PCR results, respectively. Of the 210 women with risk factors, 165 (78.5%) were culture negative and 148 (70.4%) had a negative PCR. Using intrapartum culture as the gold standard, intrapartum GBS real-time PCR was found to have a sensitivity of 97.8% (95% confidence interval [CI] 92.3, 99.7) and a specificity of 85.6% (95% CI 80.1, 90.1). CONCLUSIONS: Compared with antepartum universal culture screening or intrapartum risk-factor assessment, the need for maternal antibiotic treatment may be substantially reduced by implementation of intrapartum GBS real-time PCR, without compromising the sensitivity of GBS detection.

Guided training has a beneficial effect on umbilical cord blood sampling quality.

OBJECTIVE: Umbilical cord arterial blood gas analysis is important for neonatal assessment at birth, particularly for determining asphyxia. In April 2019, our labor ward faculty held systemic teaching sessions for midwives, aimed to describe and to exercise proper sampling from both the umbilical cord artery and vein, to ensure biological validity of the values obtained. Our aim was to estimate the rates of inadequate umbilical blood sampling and to evaluate the effect of guided training on the quality of sampling. STUDY DESIGN: This retrospective interventional cohort study included all the women admitted to the delivery room, with a record of postpartum umbilical cord blood sampling. Umbilical cord sampling was considered adequate if two measurements were recorded with a veno-arterial pH gradient of at least 0.02 and an arterio-venous pCO2 gradient of no less than 0.5 kPa. Rates of inadequate sampling were compared between women who gave birth in the year preceding and the year following the guidance. Clinical characteristics were compared between the groups of adequate and inadequate sampling. RESULTS: Overall, 3,779 women gave birth in the year preceding guidance, and 3,649 in the subsequent year. Of these, 1,112 (29.4%) and 1,105 (30.2%), respectively, underwent umbilical sampling. In the year following the guidance, 750 (67.8%) adequate samples were drawn compared to 692 (62.2%) prior the guidance. This difference demonstrated significant improvement (OR 1.28, 95% CI 1.07-1.52, P = 0.006) in umbilical vessel sampling. Following multivariate logistic regression, inadequate sampling was associated with newborn weight below 2500 g (aOR 1.6, 95% CI 1.2-2.1, p = 0.001), spontaneous vaginal delivery with a possible fetal metabolic abnormality (aOR 2.2, 95% CI 1.7-2.7, p < 0.001), and vacuum deliveries (aOR 1.9, 95% CI 1.5-2.5, p < 0.001). CONCLUSIONS: Guided training of proper umbilical blood sampling may reduce the rate of inadequate postpartum blood gas results. Labor wards should consider carrying out annual demonstrations of proper umbilical blood collection, with emphasis on factors that affect the quality of the samplings.

Can recurrent cesarean section due to arrest of descent be predicted by newborn weight difference?

OBJECTIVE: To evaluate if newborn weight difference is associated with the mode of delivery in women with a previous cesarean section due to arrest of descent. STUDY DESIGN: This retrospective cohort analysis included all women admitted to the delivery room of Carmel Medical Center with a singleton fetus at vertex presentation and a prior cesarean section for arrest of descent. A comparison was made between women who had a subsequent successful vaginal birth after cesarean delivery vs. a repeat cesarean section for arrest of descent. The primary outcome was newborn weight difference between the previous cesarean section and the present delivery. Secondary outcomes were gestational age, gravidity, age, induction of labor, previous vaginal birth and epidural analgesia. RESULTS: Of 179 women with a prior cesarean section due to arrest of descent, 55 women (30.7 %) underwent an elective repeat cesarean section. Of the remaining 124 women, 95 women (76.6 %) achieved a vaginal delivery. Out of the 29 cases who underwent a repeat cesarean section, 18 women had a cesarean section for arrest of descent. Women who achieved vaginal delivery were more likely to be with higher gravidity, a previous vaginal delivery and a lower rate of epidural anesthesia. Following multivariate logistic regression, the women who required a cesarean section due to arrest of descent, had significantly higher birth weight in the current than in the previous pregnancy, compared to women achieving vaginal delivery (Odds Ratio 4.7, CI 95 % 1.4-15.7, P = 0.012). CONCLUSION: Current birth weight higher than the previous newborn weight in a cesarean section for arrest of descent is associated with lower likelihood of successful vaginal birth after cesarean delivery and therefore should be taken in consideration during fetal weight estimation and the decision on the mode of delivery. This issue should be explored in future prospective large-cohort studies.