Maternal and neonatal outcomes of COVID-19 in a high-risk pregnant cohort with and without HIV.

BACKGROUND: The impact of SARS-CoV-2 infection in pregnant women living with HIV (PLHIV) has not been described previously. OBJECTIVES: To describe the clinical presentation and outcomes of a cohort of women with high-risk pregnancies with confirmed COVID-19 to determine whether risk factors for disease severity and adverse outcomes of COVID-19 differed in pregnant women without HIV compared with PLHIV. METHODS: We prospectively enrolled pregnant women with COVID-19 attending the high-risk obstetric service at Tygerberg Hospital, Cape Town, South Africa, from 1 May to 31 July 2020, with follow-up until 31 October 2020. Women were considered high risk if they required specialist care for maternal, neonatal and/or anaesthetic conditions. Common maternal or obstetric conditions included hypertensive disorders, morbid obesity (body mass index (BMI) ≥40 kg/m2) and diabetes. Information on demographics, clinical features, and maternal and neonatal outcomes was collected and compared for PLHIV v. pregnant women without HIV. RESULTS: One hundred women (72 without HIV and 28 PLHIV) with high-risk pregnancies had laboratory-confirmed COVID-19. Among the 28 PLHIV, the median (interquartile range) CD4 count was 441 (317 - 603) cells/µL, and 19/26 (73%) were virologically suppressed. COVID-19 was diagnosed predominantly in the third trimester (81%). Obesity (BMI ≥30 in n=61/81; 75%) and hypertensive disorders were frequent comorbidities. Of the 100 women, 40% developed severe or critical COVID-19, 15% required intensive care unit admission and 6% needed invasive ventilation. Eight women died, 1 from advanced HIV disease complicated by bacteraemia and urosepsis. The crude maternal mortality rate was substantially higher in women with COVID-19 compared with all other deliveries at our institution during this period (8/91 (9%) v. 7/4 058 (0.2%); p<0.001). Neonatal outcomes were favourable. No significant differences in COVID-19 risk factors, disease severity, and maternal/neonatal outcome were noted for PLHIV v. those without HIV. CONCLUSIONS: In this cohort of high-risk pregnant women, the impact of COVID-19 was severe, significantly increasing maternal mortality risk compared with baseline rates. Virally suppressed HIV infection was not associated with worse COVID-19 outcomes in pregnancy.

Invasive versus non-invasive monitoring of acute severe hypertension in women with pre-eclampsia.

OBJECTIVE: To compare the accuracy of two non-invasive methods of blood-pressure measurement with intra-arterial measurement in women with pre-eclampsia and acute severe hypertension. METHODS: This descriptive, cross-sectional study prospectively enrolled 23 women with pre-eclampsia and acute severe hypertension for continuous intra-arterial blood-pressure monitoring. Simultaneous monitoring was performed with a manual and an automated, non-invasive device during episodes of severe hypertension. The paired T-test was used to compare measured values. The accuracy of a MAP⩾125mmHg in detecting a systolic blood pressure⩾160mmHg was determined. RESULTS: There was a weak correlation between intra-arterial and automated as well as intra-arterial and manual systolic values (r=0.34, p<0.01; r=0.41, p<0.00, respectively). Better correlation was found amongst diastolic values. The differences between the mean intra-arterial (94±11mmHg) and automated (96±12mmHg) diastolic values as well as intra-arterial and manual diastolic measurements (94±14mmHg) were not significant (p=0.20, 0.65, respectively). A mean arterial pressure⩾125mmHg was not accurate in detecting a systolic value⩾160mmHg, with low sensitivities (17.2-35.9%) and specificities (0-50%) for all three methods. CONCLUSIONS: When compared to intra-arterial monitoring, the automated and manual methods showed weak correlation with systolic but better correlation with diastolic values. A mean arterial pressure⩾125mmHg was not accurate in detecting systolic peaks. When protection against cerebral haemorrhage is paramount, intra-arterial measurement of systolic values is best.

Oral misoprostol versus intracervical dinoprostone for induction of labor.

OBJECTIVES: To compare oral misoprostol with dinoprostone for induction of labor and their effects on the fetal heart rate patterns. METHODS: In a randomized controlled trial, 200 patients received either misoprostol 50 mug orally for every 4 h, or dinoprostone 0.5 mg intracervically for every 6 h. Cardiotocographic recordings, in 10-min windows 30, 60, and 80 min after prostaglandin administration during induction and continuously during labor, were compared between the two groups. Primary outcome for effectiveness and safety was assessed in terms of the number of vaginal deliveries within 24 h and fetal heart rate abnormalities during induction and labor respectively. RESULTS: Data from 96 patients in the misoprostol group and 95 in the dinoprostone group were analyzed. There were no significant differences in respect of the number of vaginal deliveries within 24 h (RR 1.12; 95% CI 0.88-1.42). The frequency of suspicious and pathological fetal heart rate patterns did not differ significantly but significantly more cardiotocographs in the dinoprostone group had non-reassuring baseline variability 60 min after dose administration (RR 0.33; 95% CI 0.14-0.77). Maternal and neonatal outcomes did not differ significantly. CONCLUSION: Oral misoprostol is as effective as intracervical dinoprostone for induction of labor with no difference in the frequency of fetal heart rate abnormalities.