The impact of the COVID-19 pandemic on perinatal services and maternal mental health in the UK.

BACKGROUND: COVID-19 has created many challenges for women in the perinatal phase. This stems from prolonged periods of lockdowns, restricted support networks and media panic, alongside altered healthcare provision. AIMS: We aimed to review the evidence regarding the psychological impact on new and expecting mothers following changes to antenatal and postnatal service provision within the UK throughout the pandemic. METHOD: We conducted a narrative literature search of major databases (PubMed, Medline, Google Scholar). The literature was critically reviewed by experts within the field of antenatal and perinatal mental health. RESULTS: Changes to service provision, including the introduction of telemedicine services, attendance of antenatal appointments without partners or loved ones, and lack of support during the intrapartum period, are associated with increased stress, depression and anxiety. Encouraging women and their partners to engage with aspects of positive psychology through newly introduced digital platforms and virtual service provision has the potential to improve access to holistic care and increase mental well-being. An online course, designed by Imperial College Healthcare NHS Trust in response to changes to service provision, focuses on postnatal recovery inspiration and support for motherhood (PRISM) through a 5-week programme. So far, the course has received positive feedback. CONCLUSIONS: The pandemic has contributed to increased rates of mental illness among pregnant and new mothers in the UK. Although the long-term implications are largely unpredictable, it is important to anticipate increased prevalence and complexity of symptoms, which could be hugely detrimental to an already overburdened National Health Service.

Sports Obstetrics: Implications of Pregnancy in Elite Sportswomen, a Narrative Review.

Increasing numbers of females are participating in elite sports, with a record number having competed at the Tokyo Olympic Games. Importantly, the ages of peak performance and fertility are very likely to coincide; as such, it is inevitable that pregnancy will occur during training and competition. Whilst there is considerable evidence to promote regular exercise in pregnancy, with benefits including a reduction in hypertensive disorders, gestational diabetes, and reduced rates of post-natal depression, few studies have been conducted which include elite athletes. Indeed, there are concerns that high-intensity exercise may lead to increased rates of miscarriage and preterm labour, amongst other pregnancy-related complications. There is minimal guidance on the obstetric management of athletes, and consequently, healthcare professionals frequently adopt a very conservative approach to managing such people. This narrative review summarises the evidence on the antenatal, intrapartum, and postpartum outcomes in elite athletes and provides recommendations for healthcare providers, demonstrating that generally, pregnant athletes can continue their training, with a few notable exceptions. It also summarises the physiological changes that occur in pregnancy and reviews the literature base regarding how these changes may impact performance, with benefits arising from pregnancy-associated cardiovascular adaptations at earlier gestations but later changes causing an increased risk of injury and fatigue.

Rapid quality improvement in a preterm birth clinic care pathway during the COVID-19 pandemic.

BACKGROUND: Preterm birth (PTB) occurs in 8% of births in the UK. At Imperial College Healthcare NHS Trust, our PTB prevention clinic manages the care of approximately 1000 women/year. Women referred to the clinic are seen from 12 weeks of pregnancy with subsequent appointments every 2-4 weeks to measure cervical length (CL) using transvaginal ultrasound (TVUS). Women with a history of cervical weakness or short cervix on TVUS are offered a cervical cerclage. LOCAL PROBLEM: During the COVID-19 outbreak, pregnant women were strongly advised to avoid social mixing and public transport. The National Health Service had to rapidly adopt remote consultation and redesign clinical pathways in order to reduce transmission, exposure and spread among women at high risk of PTB. METHODS: We focused on Specific, Measurable, Achievable, Realistic and Timebound aims and used a driver diagram to visualise our changes. We used a series of Plan Do Study Act cycles to evaluate and adapt change ideas through the UK's national lockdown during the COVID-19 pandemic between 23 March and 29 May 2020. RESULTS: We reduced the number of face-to-face appointments by 54%. This was achieved by increasing remote telephone consultations from 0% to 64%, and by reducing the intensity of surveillance. The rate of regional anaesthetic was increased from 53% to 95% for cerclage placement in order to minimise the number of aerosol-generating procedures. Patient and staff satisfaction responses to these changes were used to tailor practices. No women tested positive for COVID-19 during the study period. CONCLUSIONS: By using quality improvement methodology, we were able to safely and rapidly implement a new care pathway for women at high risk of PTB which was acceptable to patients and staff, and effective in reducing exposure of COVID-19.

Validation of a virtual reality simulator for the use of transvaginal ultrasonography in gynaecology and early pregnancy.

INTRODUCTION: The objective was to validate a virtual reality simulation ultrasound model as a tool for training in the use of transvaginal ultrasonography in gynaecology and early pregnancy. METHODS: Three separate groups consisting of novice and intermediate level residents as well as expert ultrasound examiners were recruited to the study. All were asked to answer a questionnaire regarding demographic data and ultrasound experience. They subsequently completed two modules: basic gynaecology and early pregnancy, followed by corresponding assessments using a high-fidelity simulator (Scantrainer; Medaphor™, Cardiff, UK). Finally, the expert group completed an additional questionnaire about various elements of the simulator using a 5-point Likert scale. RESULTS: Each group consisted of eight participants. Overall, the participants agreed that simulation played a role in training (Novices: 75% (n = 6); Intermediates: 100% (n = 8); Experts: 75% (n = 6)). For the degree of realism of the target objects in the gynaecology and early pregnancy module environments compared to a real-patient environment, the simulator was rated satisfactory or very satisfactory by 88% (n = 7) and 75% (n = 6) of experts, respectively. All experts rated the overall usefulness of the content of the simulator for learning fundamental ultrasound technical skills compared to current training methods to be at least satisfactory. When reviewing the assessment scores, experts scored higher than non-experts in gynaecology (P = 0.002) and early pregnancy modules (P = 0.03). DISCUSSION: Face, content and construct validity were demonstrated by the virtual reality ultrasound simulator, suggesting it may be an effective method for training ultrasound skills in gynaecology and early pregnancy to non-expert residents.

Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study.

OBJECTIVES: This is a pilot study to investigate the type and severity of emotional distress in women after early pregnancy loss (EPL), compared with a control group with ongoing pregnancies. The secondary aim was to assess whether miscarriage or ectopic pregnancy impacted differently on the type and severity of psychological morbidity. DESIGN: This was a prospective survey study. Consecutive women were recruited between January 2012 and July 2013. We emailed women a link to a survey 1, 3 and 9 months after a diagnosis of EPL, and 1 month after the diagnosis of a viable ongoing pregnancy. SETTING: The Early Pregnancy Assessment Unit (EPAU) of a central London teaching hospital. PARTICIPANTS: We recruited 186 women. 128 had a diagnosis of EPL, and 58 of ongoing pregnancies. 11 withdrew consent, and 11 provided an illegible or invalid email address. MAIN OUTCOME MEASURES: Post-traumatic stress disorder (PTSD) was measured using the Post-traumatic Diagnostic Scale (PDS), and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Response rates were 69/114 at 1 month and 44/68 at 3 months in the EPL group, and 20/50 in controls. Psychological morbidity was higher in the EPL group with 28% meeting the criteria for probable PTSD, 32% for anxiety and 16% for depression at 1 month and 38%, 20% and 5%, respectively, at 3 months. In the control group, no women met criteria for PTSD and 10% met criteria for anxiety and depression. There was little difference in type or severity of distress following ectopic pregnancy or miscarriage. CONCLUSIONS: We have shown a large number of women having experienced a miscarriage or ectopic pregnancy fulfil the diagnostic criteria for probable PTSD. Many suffer from moderate-to-severe anxiety, and a lesser number depression. Psychological morbidity, and in particular PTSD symptoms, persists at least 3 months following pregnancy loss.

Starvation ketoacidosis in pregnancy.

Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important implications for fetal survival as ketoacidosis in women with type 1 diabetes mellitus is associated with intrauterine death. This article features four cases of women with vomiting in the third trimester of pregnancy associated with a severe metabolic acidosis. The mechanism underlying ketogenesis, the evidence for accelerated ketogenesis in pregnancy and other similar published cases are reviewed. A proposed strategy for management of these women is presented.

Options and decision-making: hypertensive disorders of pregnancy.

Hypertension remains the most commonly encountered medical condition in pregnant women, complicating up to 15% of all pregnancies. It results in frequent hospital admissions, maternal morbidity and mortality and iatrogenic preterm birth with concomitant neonatal morbidity and mortality. Hypertensive disorders of pregnancy comprise a spectrum of severity ranging from a mild elevation of blood pressure to severe pre-eclampsia and hemolysis, elevated liver enzymes and low platelet syndrome that may result in transient or chronic multiorgan failure. As regular antenatal surveillance is the only manner by which to accurately identify those who are at risk, antenatal care schedules have been designed to detect hypertension and proteinuria. Early referral for specialist care for those who are at risk and those who develop hypertension is encouraged in the hope that this will translate into improved management of women with prophylactic, antihypertensive and anticonvulsant therapy. Advances in the understanding of the pathophysiology of the hypertensive disorders of pregnancy are likely to influence future research into both identifying those who are at risk and the role of interventions, and so lead to improved maternal and neonatal outcomes. This article highlights the pathophysiology of these conditions, the classification and identification of high-risk women, clinical manifestations and options for management.