Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis.

BACKGROUND: Pulmonary hypertension (PH) disproportionately affects women, presenting challenges during pregnancy. Historically, patients with PH are advised to avoid pregnancy; however, recent reports have indicated that the incidence of adverse events in pregnant females with PH may be lower than previously reported. METHODS: We conducted a retrospective cohort study in pregnant patients with PH using the National Readmission Database from January 1, 2016, to December 31, 2020. PH was categorized according to the World Health Organization (WHO) classification. Primary endpoints include maternal mortality and 30-day non-elective readmission rate. Other adverse short term maternal (cardiovascular and obstetric) and fetal outcomes were also analyzed. RESULTS: Among 9,922,142 pregnant women, 3,532 (0.04%) had pulmonary hypertension (PH), with Group 1 PH noted in 1,833 (51.9%), Group 2 PH in 676 (19.1%), Group 3 PH in 604 (17.1%), Group 4 PH in 23 (0.7%), Group 5 PH in 98 (2.8%), and multifactorial PH in 298 (8.4%). PH patients exhibited higher rates of adverse cardiovascular events (15.7% vs. 0.3% without PH, p < 0.001) and mortality (0.9% vs. 0.01% without PH, p < 0.001). Mixed PH and Group 2 PH had the highest prevalence of adverse cardiovascular events among WHO PH groups. Patients with PH had a significantly higher non-elective 30-day readmission rate (10.4% vs. 2.3%) and maternal adverse obstetric events (24.2% vs. 9.1%) compared to those without PH (p < 0.001) (Figure 1). CONCLUSION: Pregnant women with PH had significantly higher adverse event rates, including in-hospital maternal mortality (85-fold), compared to those without PH.

A population-based estimation of maternal mortality in Lagos State, Nigeria using the indirect sisterhood method.

BACKGROUND: Pregnancy and delivery deaths represent a risk to women, particularly those living in low- and middle-income countries (LMICs). This population-based survey was conducted to provide estimates of the maternal mortality ratio (MMR) in Lagos Nigeria. METHODS: A community-based, cross-sectional study was conducted in mapped Wards and Enumeration Areas (EA) of all Local Government Areas (LGAs) in Lagos, among 9,986 women of reproductive age (15-49 years) from April to August 2022 using a 2-stage cluster sampling technique. A semi-structured, pre-tested questionnaire adapted from nationally representative surveys was administered using REDCap by trained field assistants for data collection on socio-demographics, reproductive health, fertility, and maternal mortality. Data were analysed using SPSS and MMR was estimated using the indirect sisterhood method. Ethical approval was obtained from the Lagos State University Teaching Hospital Health Research and Ethics Committee. RESULTS: Most of the respondents (28.7%) were aged 25-29 years. Out of 546 deceased sisters reported, 120 (22%) died from maternal causes. Sisters of the deceased aged 20-24 reported almost half of the deaths (46.7%) as due to maternal causes, while those aged 45-49 reported the highest number of deceased sisters who died from other causes (90.2%). The total fertility rate (TFR) was calculated as 3.807, the Lifetime Risk (LTR) of maternal death was 0.0196 or 1-in-51, and the MMR was 430 per 100,000 [95% CI: 360-510]. CONCLUSION: Our findings show that the maternal mortality rate for Lagos remains unacceptable and has not changed significantly over time in actual terms. There is need to develop and intensify community-based intervention strategies, programs for private hospitals, monitor MMR trends, identify and contextually address barriers at all levels of maternal care.

Primary Ovarian Pregnancy: A Case Report With a Review of the Literature.

Ectopic pregnancy (EP) constitutes 1%-2% of all pregnancies and is one of the leading causes of maternal morbidity and mortality. The most common site of ectopic pregnancy is the ampulla. Ectopic ovarian pregnancy (EOP) is one of the rare events, with an incidence of 0.5%-3% of all pregnancies. The incidence is higher in intrauterine device users or assisted reproductive techniques. The precise aetiology and pathogenesis of EOP remain elusive. Clinically, EOP mirrors the presentation of tubal pregnancy or a ruptured luteal cyst, often leading to life-threatening hypovolemic shock. Transvaginal sonography is the primary diagnostic tool. Still pinpointing the exact location early on poses challenges, and it's usually misinterpreted as a tubo-ovarian mass, hemorrhagic cyst, or luteal cyst. Furthermore, while a suboptimal rise in serum beta-human chorionic gonadotropin (ß-hCG) levels may indicate pregnancy, it doesn't definitively confirm EOP. Only histopathological examination offers a conclusive diagnosis. This paper discusses an EOP case in a young woman who experienced five months of amenorrhea and exhibited no traditional risk factors, underscoring the significant challenges inherent in preoperative diagnosis.

Laparoscopic Management of Unruptured Cornual Ectopic Pregnancy in a 22-Year-Old Primigravida: A Case Report.

Cornual ectopic pregnancy, though rare, presents significant challenges in diagnosis and management. This case report details the clinical presentation and successful treatment of a 22-year-old primigravida experiencing symptoms of abdominal pain, nausea, and vomiting, ultimately diagnosed with an unruptured left cornual ectopic pregnancy. Employing a multidisciplinary approach involving clinical suspicion, beta-human chorionic gonadotropin (ß-hCG) measurements, and transvaginal ultrasound findings, we underscored the importance of timely intervention to avert adverse outcomes. The patient underwent laparoscopic partial salpingectomy, resulting in minimal intraoperative blood loss and postoperative complications. Our experience highlights the effectiveness of laparoscopic intervention in managing cornual ectopic pregnancy and underscores the necessity of tailoring treatment strategies to individual patient circumstances. By adhering to established guidelines and advancing research efforts, we can further enhance outcomes for patients grappling with this challenging condition. This case emphasizes the critical role of early diagnosis, prompt intervention, and ongoing vigilance in the management of cornual ectopic pregnancies.

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study.

BACKGROUND: Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms. OBJECTIVE: We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings. METHODS: We conducted semistructured interviews with 36 participants-15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process. RESULTS: Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems-level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured. CONCLUSIONS: Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

Management and outcomes of pregnant women with cardiovascular diseases in a cardio-obstetric team.

BACKGROUND: Cardiovascular diseases (CVDs) are currently the leading cause of maternal death in Western countries. Although multidisciplinary cardio-obstetric teams are recommended to improve the management of pregnant women with CVD, data supporting this approach are scarce. AIMS: To describe the characteristics and outcomes of pregnant patients with CVD managed within the cardio-obstetric programme of a tertiary centre. METHODS: We included every pregnant patient with history of CVD managed by our cardio-obstetric team between June 2017 and December 2019, and collected all major cardiovascular events (death, heart failure, acute coronary syndromes, stroke, endocarditis and aortic dissection) that occurred during pregnancy, peripartum and the following year. RESULTS: We included 209 consecutive pregnancies in 202 patients. CVDs were predominantly valvular heart diseases (37.8%), rhythm disorders (26.8%), and adult congenital heart diseases (22.5%). Altogether, 47.4% were classified modified World Health Organization (mWHO)>II, 66.5% had CARdiac disease in PREGnancy score (CARPREG II)≥2 and 80 pregnancies (38.3%) were delivered by caesarean section. Major cardiovascular events occurred in 16 pregnancies (7.7%, 95% confidence interval [CI] 4.5-12.2) during pregnancy and in three others (1.5%, 95% CI 0.3-4.1) during 1-year follow-up. Most events (63.1%) occurred in the 16.3% of patients with unknown CVD before pregnancy. CONCLUSIONS: The management of pregnant patients with CVD within a cardio-obstetric team seems encouraging as we found a relatively low rate of cardiovascular events compared to the high-risk profile of our population. However, most of the remaining events occurred in patients without cardiac monitoring before pregnancy.

Relationship between maternal mortality and ritodrine hydrochloride as a tocolytic agent in Japan.

AIM: In Japan, unlike Western countries, tocolytic agents are administered in long-term protocols to treat threatened preterm labor. Evaluating the side effects of this practice is crucial. We examined whether ritodrine hydrochloride had been administered in cases of maternal death, aiming to investigate any relationship between ritodrine administration and maternal death. METHODS: This retrospective cohort study used reports of maternal deaths from multiple institutions in Japan between 2010 and 2020. Data on the reported cases were retrospectively analyzed, and data on the route of administration, administered dose, and clinical findings, including causes of maternal death, were extracted. The amount of tocolytic agents was compared between maternal deaths with ritodrine administration and those without. RESULTS: A total of 390 maternal deaths were reported to the Maternal Death Exploratory Committee in Japan during the study period. Ritodrine hydrochloride was administered in 32 of these cases. The frequencies (n) and median doses (range) of oral or intravenous ritodrine hydrochloride were 34.4% (11) and 945 (5-2100) mg and 84.4% (27) and 4032 (50-18 680) mg, respectively. Frequencies of perinatal cardiomyopathy, cerebral hemorrhage, diabetic ketoacidosis, and pulmonary edema as causes of maternal death were significantly higher with ritodrine administration than without it. CONCLUSIONS: Our results suggest a relationship between long-term administration of ritodrine hydrochloride and an increased risk of maternal death due to perinatal cardiomyopathy, cerebral hemorrhage, diabetic ketoacidosis, and pulmonary edema. In cases where ritodrine should be administered to prevent preterm labor, careful management and monitoring of maternal symptoms are required.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes.

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Maternal mortality review in a major tertiary referral hospital in Liberia, 2018-2021.

Objectives: Anecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020-2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study design: We conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. Method: The maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. Results: There are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14-45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9-10.6, p < 0.001). Conclusion: The maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

Impact of maternal risk factors on ethnic disparities in maternal mortality: a national population-based cohort study.

Background: Ethnic disparities in maternal mortality are consistently reported. This study aimed to investigate the contribution of known risk factors including age, socioeconomic status, and medical comorbidities to observed ethnic disparities in the United Kingdom (UK). Methods: A cohort of all women who died during or up to six weeks after pregnancy in the UK 2009-2019 were identified through national surveillance. No single denominator population included data on all risk factors, therefore we used logistic regression modelling to compare to 1) routine population birth and demographic data (2015-19) (routine data comparator) and 2) combined control groups of four UK Obstetric Surveillance System studies (UKOSS) control comparator)). Findings: There were 801 maternal deaths in the UK between 2009 and 2019 (White: 70%, Asian: 13%, Black: 12%, Chinese/Other: 3%, Mixed: 2%). Using the routine data comparator (n = 3,519,931 maternities) to adjust for demographics, including social deprivation, women of Black ethnicity remained at significantly increased risk of maternal death compared with women of white ethnicity (adjusted OR 2.43 (95% Confidence Interval 1.92-3.08)). The risk was greatest in women of Caribbean ethnicity (aOR 3.55 (2.30-5.48)). Among women of White ethnicity, risk of mortality increased as deprivation increased, but women of Black ethnicity had greater risk irrespective of deprivation. Using the UKOSS control comparator (n = 2210), after multiple adjustments including smoking, body mass index, and comorbidities, women of Black and Asian ethnicity remained at increased risk (aOR 3.13 (2.21-4.43) and 1.57 (1.16-2.12) respectively). Interpretation: Known risk factors do not fully explain ethnic disparities in maternal mortality. The impact of socioeconomic deprivation appears to differ between ethnic groups. Funding: This research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-127-21202.

Society for Maternal-Fetal Medicine Position Statement: Extending Medicaid coverage for 12 months postpartum.

The Society for Maternal-Fetal Medicine supports federal and state policies that expand Medicaid eligibility and extend Medicaid coverage through 12 months postpartum to address the maternal morbidity and mortality crisis and improve health equity. Access to coverage is essential to optimize maternal health following pregnancy and childbirth and avoid preventable causes of maternal morbidity and mortality that extend throughout the first year postpartum. The Society opposes policies such as work requirements or limitations on coverage for undocumented individuals that unnecessarily impose restrictions on Medicaid eligibility for beneficiaries.

Society for Maternal-Fetal Medicine Position Statement: Access to abortion care.

The Society for Maternal-Fetal Medicine (SMFM) supports the right of all individuals to access the full spectrum of reproductive health services, including abortion care. Reproductive health decisions are best made by each individual with guidance and support from their healthcare providers.

Temporal trends and spatial clusters of high risk for maternal death due to COVID-19 pre and during COVID-19 vaccination in Brazil: a national population-based ecological study.

OBJECTIVE: This study comprehensively analyzed the temporal and spatial dynamics of COVID-19 cases and deaths within the obstetric population in Brazil, comparing the periods before and during mass COVID-19 vaccination. We explored the trends and geographical patterns of COVID-19 cases and maternal deaths over time. We also examined their correlation with the SARS-CoV-2 variant circulating and the social determinants of health. STUDY DESIGN: This is a nationwide population-based ecological study. METHODS: We obtained data on COVID-19 cases, deaths, socioeconomic status, and vulnerability information for Brazil's 5570 municipalities for both the pre-COVID-19 vaccination and COVID-19 vaccination periods. A Bayesian model was used to mitigate indicator fluctuations. The spatial correlation of maternal cases and fatalities with socioeconomic and vulnerability indicators was assessed using bivariate Moran. RESULTS: From March 2020 to June 2023, a total of 23,823 cases and 1991 maternal fatalities were recorded among pregnant and postpartum women. The temporal trends in maternal incidence and mortality rates fluctuated over the study period, largely influenced by widespread COVID-19 vaccination and the dominant SARS-CoV-2 variant. There was a significant reduction in maternal mortality due to COVID-19 following the introduction of vaccination. The geographical distribution of COVID-19 cases and maternal deaths exhibited marked heterogeneity in both periods, with distinct spatial clusters predominantly observed in the North, Northeast, and Central West regions. Municipalities with the highest Human Development Index reported the highest incidence rates, while those with the highest levels of social vulnerability exhibited elevated mortality and fatality rates. CONCLUSION: Despite the circulation of highly transmissible variants of concern, maternal mortality due to COVID-19 was significantly reduced following the mass vaccination. There was a heterogeneous distribution of cases and fatalities in both periods (before and during mass vaccination). Smaller municipalities and those grappling with social vulnerability issues experienced the highest rates of maternal mortality and fatalities.

Assessment of socio demographic factors on termination of pregnancy in Ghana.

AIM: Assessing the socio-demographic factors on termination of pregnancy in Ghana. DESIGN: Cross-sectional study, using data source from the Demographic Health Survey (DHS). METHODS: Data pooled from the most recent DHS conducted in Ghana, with variables of interest with rural and urban population coverage. A systematic search of the literature was performed using PubMed, Google Scholar and Elsevier PubMed for the secondary data. Descriptive and logistic regression analysis was performed using Python Pandas' software to estimate the independent effects of the socio-demographic factors on termination of pregnancy in Ghana. RESULTS: Reported using odds and adjusted OR AOR at 95% confidence level and statistical significance at a p-value of (p > 0.05). Age, place of residence, occupation, currently pregnant, woman's individual sample weight, completeness of current pregnancy, living children + current pregnancy, ethnicity and number of living children significantly predicted the outcome variable. PATIENT OR PUBLIC CONTRIBUTION: Nurses have an important role to play in providing support, education and counselling to people, and must be equipped with the knowledge and skills (including non-judgmental and compassionate care) necessary to provide care that is sensitive to the diverse needs of people from different socio-demographic backgrounds.

Infection Prevention and Control: Baseline Knowledge and Practices of TBAs in Rural Kano, Northwestern Nigeria.

BACKGROUND: Maternal infections remain a significant contributor to maternal mortality worldwide. Majority of births in northern Nigeria occur at home and are attended by Traditional Birth Attendants (TBAs). Little has been documented about their knowledge and practice on infection prevention and control practices in Kano, northern Nigeria. OBJECTIVES: This study evaluated the level as well as factors associated with TBAs' infection prevention and control knowledge and practices. METHODS: The study is the baseline phase of a quasi-experimental study, conducted in a rural LGA in Kano State, Nigeria. Using an adapted tool, 163 eligible TBAs were surveyed. Knowledge and practice of IPC were scored, aggregated, and dichotomized into good or poor. Binary logistic regression analysis was used to predict knowledge and practice of IPC. RESULTS: Majority (79.1%) of the TBAs exhibited poor IPC knowledge but many (78.5%) reported good practice. Good knowledge of IPC was predicted by the TBAs' age: a six-fold increased likelihood (AOR=6.25, 95% CI: 1.02- 38.53) and almost five-fold increased likelihood (AOR=4.75, 95% CI: 1.39- 16.24) for those in their second and fourth decades of life. TBAs who reported poor practice of IPC were 83% less likely (AOR=0.17, 95% CI: 0.03- 0.92) to have good knowledge of IPC. TBAs' practice was only linked to previous training (AOR=0.17, 95% CI: 0.04- 0.76). CONCLUSION: TBAs knowledge of IPC was low although reported practice was good. The need for tailored training interventions to enhance knowledge and skills for safe delivery care is paramount to improve maternal and neonatal outcomes.

CONTEXTE: Les infections maternelles restent une contribution significative à la mortalité maternelle dans le monde. La majorité des accouchements dans le nord du Nigeria ont lieu à domicile et sont assistés par des TBA. Peu de choses ont été documentées sur leurs connaissances et leurs pratiques en matière de prévention et de contrôle des infections à Kano, dans le nord du Nigeria. OBJECTIFS: Cette étude a évalué le niveau de connaissances et de pratiques des TBA en matière de prévention et de contrôle des infections, ainsi que les facteurs associés. MÉTHODES: L'étude est la phase de base d'une étude quasiexpérimentale, menée dans une LGA rurale de l'État de Kano, au Nigeria. En utilisant un outil adapté, 163 TBA éligibles ont été interrogés. Les connaissances et les pratiques en matière de PCI ont été évaluées, agrégées et dichotomisées en bonnes ou mauvaises. Une analyse de régression logistique binaire a été utilisée pour prédire les connaissances et les pratiques en matière de PCI. RÉSULTATS: La majorité (79,1 %) des TBA présentaient des connaissances médiocres en PCI, mais beaucoup (78,5 %) ont déclaré avoir de bonnes pratiques. De bonnes connaissances en PCI étaient prédites par l'âge des TBA : une probabilité multipliée par six (AOR=6,25, IC à 95 % : 1,02-38,53) et presque multipliée par cinq (AOR=4,75, IC à 95 % : 1,39-16,24) pour ceux dans leur deuxième et quatrième décennies de vie. Les TBA qui ont déclaré une mauvaise pratique de la PCI étaient 83 % moins susceptibles (AOR=0,17, IC à 95 % : 0,03-0,92) d'avoir de bonnes connaissances en PCI. La pratique des TBA était uniquement liée à une formation antérieure (AOR=0,17, IC à 95 % : 0,04­0,76). CONCLUSION: Les connaissances des TBA en matière de PCI étaient faibles bien que les pratiques déclarées étaient bonnes. La nécessité d'interventions de formation sur mesure pour améliorer les connaissances et les compétences en matière de soins de l'accouchement sécurisés est primordiale pour améliorer les résultats maternels et néonatals. MOTS-CLÉS: Accoucheuses Traditionnelles, Mortalité Maternelle, Infection Maternelle, Nigeria.

The unequal impact of the pandemic at subnational levels and educational attainment-related inequalities in COVID-19 mortality, Brazil, 2020-2021.

OBJECTIVES: We estimated COVID-19 mortality indicators in 2020-2021 to show the epidemic's impact at subnational levels and to analyze educational attainment-related inequalities in COVID-19 mortality in Brazil. STUDY DESIGN: This was an ecological study with secondary mortality information. METHODS: Crude and age-standardized COVID-19 mortality rates were calculated by gender, major regions, and states. The COVID-19 proportional mortality (percentage) was estimated by gender and age in each region. Measures of education-related inequalities in COVID-19 mortality were calculated per state, in each of which the COVID-19 maternal mortality rate (MMR) was estimated by the number of COVID-19 maternal deaths per 100,000 live births (LBs). RESULTS: The analysis of mortality rates at subnational levels showed critical regional differences. The North region proved to be the most affected by the pandemic, followed by the Center-West, with age-standardized COVID-19 mortality rates above 2 per 1000 inhabitants. The peak of COVID-19 mortality occurred in mid-March/April 2021 in all regions. Great inequality by educational level was found, with the illiterate population being the most negatively impacted in all states. The proportional mortality showed that males and females aged 50-69 years were the most affected. The MMR reached critical values (>100/100,000 LB) in several states of the North, Northeast, Southeast, and Center-West regions. CONCLUSIONS: This study highlights stark regional and educational disparities in COVID-19 mortality in Brazil. Exacerbated by the pandemic, these inequalities reveal potential areas for intervention to reduce disparities. The results also revealed high MMRs in certain states, underscoring pre-existing healthcare access challenges that worsened during the pandemic.

Conservative Management of a Case of Peripartum Cardiomyopathy in a Young Multigravida.

Peripartum cardiomyopathy (PPCM) is a rare disorder that generally affects the elderly multigravida females. It is a type of dilated cardiomyopathy that generally affects the last trimester of pregnancy or early postpartum period. Several risk factors are associated with the development of PPCM. Even though PPCM has greater morbidity, if managed promptly, it can be reverted with minimal morbidity or mortality. We present a case of a young woman, multigravida, with moderate anemia corrected, who was taken for emergency lower segment cesarean section, without previous cardiac evaluation, and ended up with pulmonary edema intraoperatively. Later on, her evaluation was done which came out to be PPCM. She was managed conservatively thereafter with no significant morbidity and a good maternal and perinatal outcome. We should be alert in diagnosing a case of PPCM with prompt treatment to reduce mortality. Cardiovascular conditions cause approximately 26 percent of pregnancy-related deaths which include valvular heart disease and congenital heart disease. Appropriate diagnosis and management are necessary for preventing mishaps.

Ectopic pregnancy located at pelvic wall and liver: Two uncommon case reports from Vietnam and mini-review literature.

INTRODUCTION AND IMPORTANCE: Abdominal ectopic pregnancy (AEP) located at hepatic region and pelvic-wall ectopic pregnancy (EP) are rare entities, that provoking a potentially life-threatening condition. Due to insufficient data, a proper management of non-specific types remains a challenge for all gynecologists worldwide. CASE PRESENTATION: Two child-bearing age women were hospitalized due to delayed menstruation and a urine pregnancy test was positive without a determination of intrauterine pregnancy. The first EP case was located at the pelvic wall which identified incidentally during laparoscopy for a presumed tubal ectopic pregnancy on ultrasonography throughout. The second EP case was found at the hepatic region due to intermittent pain rising from the right upper quadrant region and serial ultrasonic findings. In our management, both cases were successfully assessed by laparoscopy and laparotomy without requiring further intervention, respectively. CLINICAL DISCUSSION: An accurate diagnosis of EP location at liver and pelvic wall is totally difficult since its uncommon location. An initial assessment should be based on clinical symptoms and the treatment remains controversial. The surgical management including laparotomy and laparoscopy depends on clinical evaluation, experience of surgeon, and interdisciplinary team. Thus, these abnormal sites of ectopic pregnancy ought to take into consideration for all gynecologists in an emergency condition with a major hemorrhage. CONCLUSIONS: In reproductive age women, primary EP at liver and pelvic wall should be considered with high index of suspicion if intrauterine pregnancy is totally excluded. Timely diagnosis, rational management by surgical excision, and a multidisciplinary team can reduce substantially adverse outcomes.

The timing of antenatal care access for adolescent pregnancies in Cape Town, South Africa.

BACKGROUND:  Late antenatal care (ANC)-seeking among pregnant adolescents threatens their health outcomes, and the health outcomes of their new-borns. South Africa has experienced a rapid increase in adolescent pregnancies during the COVID-19 pandemic, adding to the existing concerns around adolescent pregnancy care-seeking behaviour. AIM:  The main aim of this study was to investigate the causes and covariates of late ANC access among adolescents in the Cape Town Metropole, South Africa. SETTING:  Three public healthcare facilities in the Cape Town Metropole, 2018-2019. METHODS:  A retrospective, cross-sectional study on ANC seeking behaviour was conducted, surveying 202 adolescents. Late attendance was defined as attending ≥ 3 months. For this study, adolescents were defined as women aged 16-18 years. The sample was restricted to adolescents who used public healthcare facilities or who did not attend at all. Data were analysed using univariate, bivariate and multivariate methods. RESULTS:  A total of 50.8% (n = 99/195) of the pregnant adolescents in the sample had their first ANC visit 3 months. 14.9% (n = 29/195) did not attend at all. Major contributors to delayed care-seeking include poor pregnancy identification (n = 45/99, 45.5%), and a lack of information about ANC. Age, education, and alcohol consumption were significant predictors of delayed care-seeking. CONCLUSION:  Delayed ANC attendance contributes to negative long-term health outcomes for pregnant adolescents and their new-borns. Improving access to pregnancy tests in the public sector could benefit adolescents with earlier pregnancy identification. Adolescents need to be made aware of their care seeking options.Contribution: There is evidence of long-term health impacts of late ANC attendance by pregnant adolescents, but there is an absence of evidence on the timing and barriers of late care-seeking behaviour. In this study, late ANC attendance among adolescents was associated with late pregnancy identification and poor knowledge of care options.

Hospital padrino: a collaborative strategy model to tackle maternal mortality: a mixed methods study in a middle-income region.

Background: Reducing maternal mortality ratio (MMR) remains a paramount goal for low- and middle-income countries (LMICs), especially after COVID-19's devastating impact on maternal health indicators. We describe our experience implementing the Hospital Padrino Strategy (HPS), a collaborative model between a high-complexity hospital (Fundación Valle del Lili) and 43 medium- and low-complexity hospitals in one Colombian department (an administrative and territorial division) from 2021 to 2022, to sustain the trend towards reducing MMR. The study aimed to assess the effects of implementing HPS on both hospital performance and maternal health indicators in Valle del Cauca department (VCD). Methods: A mixed-methods study was conducted, comprising two phases. In the first phase, we investigated a cohort of hospitals through prospective follow-up to assess the outcomes of HPS implementation on hospital performance and maternal health indicators in VCD. In the second phase, qualitative data were collected through focus groups with 131 health workers from 33 hospitals to explore the implications of the HPS implementation on healthcare personnel. All data were obtained from records within the HPS implementation and from the Health Secretary of VCD. Findings: Evidence shows that in the context of HPS, 51 workshops involved 980 healthcare workers, covering the entire territory. Substantial improvements were observed in hospital conditions and healthcare personnel's technical competencies when providing obstetric care. Seven hundred eighty-five pregnant women with obstetric or perinatal emergencies received care through telehealth systems, with a progressive increase in technology adoption. Nine percent required Intensive Care Unit (ICU) admission, and none died. The MMR decreased from 78.8 in 2021 to 12.0 cases per 100,000 live births by 2022. Improvements in indicators and conducted training sessions instilled confidence and empowerment among the healthcare teams in the sponsored hospitals, as evidenced in focus groups derived from a sample of 131 healthcare workers from 33 hospitals. Interpretation: Implementing the Hospital Padrino Strategy led to a significant MMR reduction, and consolidated a model of social healthcare innovation replicable in LMICs. Funding: The Hospital Padrino Strategy was funded by the Fundación Valle del Lili and the Health Secretary of Valle del Cauca. Furthermore, this study received funding from a general grant for research from Tecnoquimicas S.A.