Analysis of Prolonged Caesarean Section Response Time in True Emergency Obstetric Care during Covid-19 Pandemic Era: Study at Kariadi Tertiary Hospital Indonesia

Intro: COVID-19 pandemic era makes quality of obstetric triage care including caesarean section in obstetric true emergency cases delayed. Maternal fetal triage index (MFTI) score is an instrument used to define true emergency in obstetric cases. Decision to delivery interval (DDI) is time interval from caesarean section decision to delivery within <30 minutes standard in emergency cases.This study was designed to evaluate the decision to delivery time interval and its effect on perinatal outcomes and the associated factors during category-1 emergency caesarean section deliveries. Method(s): A prospective observational descriptive study was conducted from 2020-2022 at Kariadi tertiary Hospital. A total of 40 clients who were undergone category-1 emergency caesarean section were included in this study. This is a indepht analysis pregnant women confirmed with COVID-19 infection and had true emergency cases based on MFTI score (stat-priority 1). Finding(s): Among 346 pregnant women with COVID-19, total 160 C-section cases with 40 eligible data were included in this study. Gestational age mostly in their second and third trimester. Maternal comorbidities were diabetes in pregnancy, HIV, pre eclampsia, SLE and thyroid disease. This study showed that DDI <30 minutes were found in 34 cases (85%), DDI 30-60 minutes as many as 6 (15%), and no (0%) DDI >60 minutes. Emergency cases with the shortest DDI were umbilical cord prolapse 3 (100%), fetal distress 14 (93%), placental abruption 5 (83%), impending uterine rupture 5 (83%), and antepartum hemorrhage 7 (70%). Perinatal outcome were Apgar score lower than 7 at 1 minutes (25%) and stillbirth (5%). Conclusion(s): Most of DDI in this study met the recommendation of <30 minutes, but some cases did not meet the standard. This can be caused by multifactorial factors such as advice from the doctor in charge, patient transfer distance, operating room preparation, and anesthetic preparation due to COVID-19.Copyright © 2023

27th Asia and Oceania Federation of Obstetrics and Gynecology Congress

The proceedings contain 358 papers. The topics discussed include: role of early prophylactic aspirin on Covid-19 outcome in antenatal patients - an audit of a hospital in India;partial intestinal obstruction complicating pregnancy: diagnostic dilemma and management;a case report of uterine rupture recognized during cesarean section at the site of a previous hysteroscopy-related perforation;menstrual characteristics and its related morbidities among adolescent girls living in North Borneo, Malaysia: a questionnaire-based study;the volume of posterior cervical varicose correlates with intraoperative blood loss in placenta previa;implications of large fibroids in pregnancy: a multidisciplinary approach;unexpected ovarian malignancy in postmenopausal women following laparoscopic surgery for adnexal masses - a review of 5 years;post radiotherapy outcome on cervical cancer stage IIIB patients with and without paraaortic lymph nodes enlargement;and evaluation of the relationship between thrombocytosis and clinico-pathological factors of patients with epithelial ovarian cancer.

Increasing volume and the role of gynecologic oncologists in peripartum hysterectomies – A single center study of 109 cases over 7 years (008)

Objectives: To evaluate the surgical volume, surgical outcomes, and the evolving role of gynecologic oncologists in peripartum hysterectomies (PPH). Methods: We conducted an IRB-approved retrospective chart review of PPH cases performed at our institution from June 1, 2014, to June 30, 2021. Clinical-pathologic information was ed into a REDCap database. All analyses were conducted using STATA 17. Results: A total of 109 cases were performed over the 7-year period. Gynecologic oncologists (GYO) involvement in the cases increased from 33% in 2014 to 80% in 2021. The mean age was 36 (range: 23-47) years. Most patients were White (81/109, 74.3%), and the median BMI was 30.7 (range: 21-57) kg/m2. Surgical indications included placenta accreta syndrome (PAS) in 84 (77%) cases, uterine atony in ten (9.2%), uterine rupture in three (2.8%), malignancy in five (4.6%), and hemorrhage other than atony in seven cases (6.4%). Intraoperative complications included bladder injury (or intentional dissection) in eight (7.3%), ureter injury in four (3.7%), vascular injury in three (2.8%), and femoral pseudoaneurysm in one (0.9%) of the cases. Postoperative complications included urinary tract infection in 11 (10.1%), nerve injury in one (0.9%), surgical site infection in 13 (11.2%), and venous thromboembolism in five (4.6%) cases. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) usage started in 2019 with one case followed by six cases in 2020 (31.6%) and 3/16 cases in the first half of 2020 (15.8%). A higher REBOA usage in 2020 corresponded with blood products shortages during the COVID crisis.[Formula presented] Conclusions: Overall volume and complexity of peripartum hysterectomy are increasing. This trend is likely driven by an increased incidence of placenta accreta syndrome cases. Gynecologic oncologists are increasingly delegated as primary surgeons in many institutions. Fellowship training programs should strongly consider training in peripartum hysterectomy for trainees.

RESULTS OF SEVERE MATERNAL MORBIDITY SURVEILLANCE AND NEAR-MISS AUDIT IN SAINT PETERSBURG ACCORDING TO THE VERTICALLY INTEGRATED MEDICAL INFORMATION SYSTEM OF OBSTETRICS AND GYNECOLOGY AND NEONATOLOGY (VIMIS ACU&NEO) REGISTER IN 2021

The article presents the results of the surveillance of severe maternal morbidity (SMM) according to SMM surveillance regulations in the Russian Federation (RF). The study analyzed the SMM Register of the Vertically Integrated Medical Information System of Obstetrics and Gynecology and Neonatology (VIMIS AKU&NEO) and the results of near-miss audit. The analysis included life-threatening maternal conditions without fatal outcome identified according to categories of organ dysfunction using the WHO diagnostic criteria (2011). The study aimed to identify strategies to reduce and prevent maternal mortality (MM) in Saint Petersburg. The authors analyzed the types of SMM registered in level II (51.0%) and level III (49.0%) maternal care providers (MCP) of Saint Petersburg. They also presented characteristics of near-miss cases, of which 12.5% and 83.3% occurred in level II and level III MCPs, respectively. Integral indicators of medical care quality in near-miss groups included near-miss rate, life-threatening condition rate, survival rate index, and mortality rate index. Obstetric pathology, blood pathology, and respiratory pathology were the leading causes of SMM in Saint Petersburg in 2021, which is comparable with the data of SMM registered in the Russian Federation in general. There were no cases of MM in the obstetric pathology group, which was the most frequently registered category of SMM (39.4% of the total number of SMM), including severe pre-eclampsia and eclampsia (83.1% of the group) and uterine rupture (9.6% of the group). The absence of MM in this category of SMM is associated with the implementation of effective and quality medical care in patients at high risk for obstetric and perinatal complications in Saint Petersburg in 2021. Blood pathology was the second most frequently registered category of SMM (36.8% of all SMM, 95.8% of the group);one case of MM was registered in a Level III MCP and one case outside the MCP before ambulance arrival. Both cases were associated with massive blood loss (more than 1000 ml). In 2021, during a pandemic of a novel coronavirus infection (COVID-19) in St. Petersburg, 41 cases of SMM associated with respiratory pathology (9.1% of total SMM) were reported. Of them 39 were identified as near-miss cases (respiratory dysfunction), which accounted for 54, 2% of the total number of near-miss cases with 20 deaths in level III MCPs. These deaths were due to severe or extremely severe bilateral viral or viral bacterial pneumonia complicated by acute respiratory distress syndrome or pulmonary embolism due to COVID-19 (O98. 5, U07.1). The main strategy to prevent and reduce the incidence of near-miss cases and MM based on improving the modern integral model of internal control of the quality of medical care in maternal care providers, near-miss audit, and the introduction into practice of both medical and organizational methodological, including telecommunications and other technologies aimed at improving professional competence. Conclusion: SMM surveillance and near-miss audit allows for a detailed assessment of the nature and quality of medical care to improve pregnancy outcomes.

Maternal mortality in modern world

Aim: to analyze the causes and level of global maternal mortality (MM) according to the data published within the last 7 years. Materials and Methods. Search for publications in the PubMed/MEDLINE database was conducted according to the criteria: meta-analysis, free full-text, English, 2015-2021 period. The PICO principle (Patient/Problem, Intervention, Comparison, Outcome) and the keywords "maternal mortality causes", "maternal death causes", "maternal outcomes" were used. The search was finished on October 13, 2021 after retrieving 137 results. Results. The rate of MM and cause pattern has been changing during COVID-19 pandemic. The first weeks of the COVID-19 lockdown showed that in-hospital mortality among pregnant women increased from 0.13 up to 0.20 % (p = 0.01) and in MM the proportion of respiratory diseases elevated up to 32 % versus 5.6%. Certain geographic regions of the world showed that MM due to COVID-19 reached extremely high values extending 3399 per 100,000 live births as well as increased general MM rate. Heart and vascular diseases (pericarditis, myocardial infarction, thromboembolism) have a significant position among the causes of MM. The rate of MM due to cardiovascular disease was inversely related to the population income level. Cardiomyopathy is the cause of death in 4 % (95 % confidence interval (95 % CI) = 2-7) of mothers in developed countries and 14 % (95 % CI = 10-18) in developing countries. The mortality rate 6 weeks after delivery among women with pregnancy-related myocardial infarction was 5.03 % (95 % Cl = 3,78-6,27), whereas it associated with thromboembolism among women with a mechanical heart valve was related to the agent used to prevent thrombosis, ranging from 0.9 (95 % CI = 0.1-1.6) for vitamin K antagonists up to 3.4 (95 % CI = 0-7.7) for unfractionated heparin per 100 pregnancies with a mechanical heart valve. After 2000, the proportion of anesthesia among immediate MМ causes decreased from 3.5 % (95 % CI = 2.9-4.3) down to 2.4 % (95 % CI = 1.9-2.9) in low- and middle-income countries. High MM odds due to maladjusted pregnancy are still observed: OR (odds ratio) = 17 (95 % CI = 9.6-28.8) for hypertension, OR = 3.70 (95 % CI = 1.72-7.99) for HELLP syndrome with acute kidney injury. Severe obstetric complications cause MM in sub-Saharan Africa and South Asia: bleeding (OR = 28.8;95 % CI = 20.3-40.7), preeclampsia or eclampsia (OR = 9.13;95 % CI = 6.10-13.7), maternal infections in antenatal period (OR = 2.80;95 % CI = 1.63-4.80). About 67 % of pregnant women in such countries obtain no antenatal care (OR = 2.80;95% CI = 1.63-4.80), predominantly giving birth at home in sub-Saharan Africa. In Ethiopia, ММ results from obstructed home delivery resulting in maternal death in 17.27 %, where uterine rupture is cause of death in 7.75 % of women. Conclusion. The COVID-19 pandemic contributed a lot to MM. Diseases of the cardiovascular system markedly elevate the MM risk and long-term mortality after delivery. For countries with traditionally home births in the absence of medical care, a high MM remains due to complicated and protracted labor complicated by uterine rupture.