Early suppression policies protected pregnant women from COVID-19 in 2020: A population-based surveillance from the Nordic countries.

INTRODUCTION: The Coronavirus 2019 Disease (COVID-19) pandemic reached the Nordic countries in March 2020. Public health interventions to limit viral transmission varied across different countries both in timing and in magnitude. Interventions indicated by an Oxford Stringency Index ≥50 were implemented early (March 13-17, 2020) in Denmark, Finland, Norway and Iceland, and on March 26, 2020 in Sweden. The aim of the current study was to assess the incidence of COVID-19-related admissions of pregnant women in the Nordic countries in relation to the different national public health strategies during the first year of the pandemic. MATERIAL AND METHODS: This is a meta-analysis of population-based cohort studies in the five Nordic countries with national or regional surveillance in the Nordic Obstetric Surveillance System (NOSS) collaboration: national data from Denmark, Finland, Iceland and Norway, and regional data covering 31% of births in Sweden. The source population consisted of women giving birth in the included areas March 1-December 31, 2020. Pregnant women with a positive SARS-CoV-2 PCR test ≤14 days before hospital admission were included, and admissions were stratified as either COVID-19-related or non-COVID (other obstetric healthcare). Information about public health policies was retrieved retrospectively. RESULTS: In total, 392 382 maternities were considered. Of these, 600 women were diagnosed with SARS-CoV-2 infection and 137 (22.8%) were admitted for COVID-19 symptoms. The pooled incidence of COVID-19 admissions per 1000 maternities was 0.5 (95% confidence interval [CI] 0.2 to 1.2, I2 = 77.6, tau2 = 0.68, P = 0.0), ranging from no admissions in Iceland to 1.9 admissions in the Swedish regions. Interventions to restrict viral transmission were less stringent in Sweden than in the other Nordic countries. CONCLUSIONS: There was a clear variation in pregnant women's risk of COVID-19 admission across countries with similar healthcare systems but different public health interventions to limit viral transmission. The meta-analysis indicates that early suppression policies protected pregnant women from severe COVID-19 disease prior to the availability of individual protection with vaccines.

Exploring trends of severe postpartum haemorrhage: a hospital-based study.

BACKGROUND: Over the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH. METHODS: We estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends. RESULTS: Among 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period. CONCLUSION: We found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.

Haemostatic support in postpartum haemorrhage: A review of the literature and expert opinion.

Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.

Duration of labor and the risk of severe postpartum hemorrhage: A case-control study.

OBJECTIVE: Our main objective was to investigate the association between duration of active labor and severe postpartum hemorrhage. We examined the effect of the total duration of active labor, the effect of each stage of active labor, and the gradient effect of duration of labor on severe postpartum hemorrhage. METHODS: A case-control study was generated from a source population of all women admitted for delivery at Oslo University Hospital and Drammen Hospital in Buskerud municipality during the time period January 1, 2008 to December 31, 2011. The study population included all cases of severe postpartum hemorrhage (n = 859) and a random sample of controls (n = 1755). Severe postpartum hemorrhage was defined as postpartum blood loss ≥1500 mL or need for blood transfusion. Prolonged labor was defined as duration of active labor >12 hours according to the definition of the World Health Organization. We used logistic multivariable regression in the analysis. RESULTS: We observed a significantly longer mean duration of labor in women who experienced severe postpartum hemorrhage compared to controls (5.4 versus 3.8 hours, p<0.001). Women with severe postpartum hemorrhage also had a longer duration of all stages of active labor compared to controls. The association between the duration of active labor and severe postpartum changed from a linear dose-response association to a threshold association after adjusting for augmentation with oxytocin, induction of labor, primiparity, and fever during labor. Compared to controls, women with severe postpartum hemorrhage were more likely to have a prolonged labor >12 hours (adjusted odds ratio = 2.44, 95% confidence interval: 1.69-3.53, p< 0.001). CONCLUSION: Prolonged active labor (duration >12 hours) was associated with severe postpartum hemorrhage. Increased vigilance seems required when the labor is prolonged to reduce the risk of severe postpartum hemorrhage.

Risk factors for severe postpartum hemorrhage: a case-control study.

BACKGROUND: In high-income countries, the incidence of severe postpartum hemorrhage (PPH) has increased. This has important public health relevance because severe PPH is a leading cause of major maternal morbidity. However, few studies have identified risk factors for severe PPH within a contemporary obstetric cohort. METHODS: We performed a case-control study to identify risk factors for severe PPH among a cohort of women who delivered at one of three hospitals in Norway between 2008 and 2011. A case (severe PPH) was classified by an estimated blood loss ≥1500 mL or the need for blood transfusion for excessive postpartum bleeding. Using logistic regression, we applied a pragmatic strategy to identify independent risk factors for severe PPH. RESULTS: Among a total of 43,105 deliveries occurring between 2008 and 2011, we identified 1064 cases and 2059 random controls. The frequency of severe PPH was 2.5% (95% confidence interval (CI): 2.32-2.62). The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%). The strongest risk factors were a history of severe PPH (adjusted OR (aOR) = 8.97, 95% CI: 5.25-15.33), anticoagulant medication (aOR = 4.79, 95% CI: 2.72-8.41), anemia at booking (aOR = 4.27, 95% CI: 2.79-6.54), severe pre-eclampsia or HELLP syndrome (aOR = 3.03, 95% CI: 1.74-5.27), uterine fibromas (aOR = 2.71, 95% CI: 1.69-4.35), multiple pregnancy (aOR = 2.11, 95% CI: 1.39-3.22) and assisted reproductive technologies (aOR = 1.88, 95% CI: 1.33-2.65). CONCLUSIONS: Based on our findings, women with a history of severe PPH are at highest risk of severe PPH. As well as other established clinical risk factors for PPH, a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH.

Maternal deaths in Norway 2005-2009.

BACKGROUND: Norway has low maternal mortality, but such deaths are underreported even in high-income countries. Our goal was to identify the exact number of maternal deaths, the causes of death and the potential for improvement through medical care in Norway. MATERIAL AND METHOD: We traced maternal deaths in the period from 1 January 2005 to 31 December 2009 by linking the Medical Birth Registry and the Cause of Death Registry, supplemented with data from maternity clinics. We identified the cause of death and the lessons that could be learned by a meticulous review of each case. RESULTS: We found 26 maternal deaths during the period, 14 of which were due to direct causes and 12 to indirect causes. The maternal mortality ratio was 8.7/100,000 live births. Fourteen of the deaths were registered in official statistics. Of the 12 deaths that were not included in the statistics, 11 were found through matching the registers and one had been reported directly by the hospital. The most common causes of death were hypertensive disorders during pregnancy (n = 6), thromboembolism (n = 4) and mental illness (n = 4). None of the deaths due to thromboembolism appeared in official statistics. The same applied to nine of the 12 indirect maternal deaths. We found a potential for improved medical care in 14 of 26 cases. Half of these were deaths due to hypertensive disorders during pregnancy or thromboembolism. INTERPRETATION: Maternal death was considerably underreported in Norwegian official statistics during the period studied. Greater attention should be given to better blood-pressure treatment, stabilisation and timely delivery in the case of hypertension during pregnancy, and to screening for possible pulmonary embolism. The same applies to mental illness and internal medical disorders in pregnant women.