Perinatal outcomes among pregnant patients with peripartum coronavirus disease 2019 infection.

PURPOSE: Evaluate maternal and neonatal outcomes in peripartum coronavirus disease 2019 (COVID-19) positive women. METHODS: A retrospective cohort study was conducted, comparing outcomes between women with and without peripartum COVID-19. All singleton deliveries from June 2020 to January 2022 were included. Univariate analysis was followed by multivariate analysis. RESULTS: Of 26,827 singleton deliveries, 563 women had peripartum COVID-19, associated with preterm deliveries both near-term and remote from term [adjusted odds ratio (aOR) 1.6 and 2.0, respectively, p = 0.007 and 0.003]. Women with peripartum COVID-19 had a significantly higher rate of disseminated intravascular coagulation (DIC) (aOR 23.0, p < 0.001). Conversely, peripartum COVID-19 peripartum COVID-19 was negatively associated with premature rupture of membranes and prolonged maternal length of stay (aOR 0.7 and 0.5, respectively, p = 0.006 and <0.001). In cesarean delivery (CDs), patients with COVID-19 had higher rate of urgent CDs (75.5 vs. 56.1%, p < 0.001), higher rate of regional anesthesia (74.5 vs. 64.9%, p = 0.049), and longer anesthesia duration (86.1 vs. 53.4 min, p < 0.001). CD rate due to non-reassuring fetal heart rate (NRFHR) was significantly higher in women with COVID-19 (29.6 vs. 17.4%, p = 0.002). Conversely, CDs rate due to history of previous single CD was significantly higher in patients without COVID-19 diagnosis (13.6 vs. 4.1%, p = 0.006). Concerning neonatal outcomes, an association has been observed between COVID-19 and low one-minute APGAR score <5, as well as neonatal COVID-19 infection (aOR 61.8 and 1.7 respectively, p < 0.001 and p = 0.037). CONCLUSIONS: Peripartum COVID-19 is associated with preterm deliveries, urgent CDs and DIC, potentially aligning with the infection's pathophysiology and coagulation alterations.

Timing of planned cesarean delivery among patients with two previous cesarean sections.

OBJECTIVES: The timing of planned repeat cesarean delivery (CD) is debateful in clinical practice. Planned repeat CD is typically scheduled before the spontaneous onset of labor to minimize the risk of uterine rupture during labor and the associated risk for fetal compromise. This timing should be balanced with the potential risk of delivering an infant who could benefit from additional maturation in utero. We aim to study the influence of gestational age at the time of repeat CD on maternal and fetal complications. STUDY DESIGN: A population-based retrospective cohort study including all term singleton third CDs (≥ 37 weeks of gestation), between February-2020 and January-2022 at a tertiary medical center was conducted. Maternal and neonatal adverse outcomes were compared by gestational age at the time of the CD. A logistic regression models were constructed to adjust for confounders. RESULTS: The study population included624 third CDs. Among them, two study groups were defined: 199 were at 37 + 0 to 37 + 6 weeks of gestation, and 44 were at ≥ 39 weeks of gestation at the time of delivery. 381 were at 38 + 0 to 38 + 6 weeks. Since our routine practice is to schedule elective CD at 38 + 0 to 38 + 6 weeks of gestation, we defined this group as the comparison group. In a multivariate analysis, both study groups were associated with significantly higher rates of emergent CDs after adjusting for maternal age, parity, ethnicity, premature rapture of membranes, spontaneous onset of labor and birthweight. After adjusting also for emergent CDs, CDs at 37 + 0 to 37 + 6 weeks of gestation were significantly associated with maternal and neonatal length of stay exceeding 4 days. Additionally, CDs at 37 + 0 to 37 + 6 weeks of gestation were also associated with composite of adverse neonatal and maternal outcomes. CONCLUSIONS: Our study demonstrated that scheduling third CD at 38 + 0 to 38 + 6 weeks is associated with reduced risk of emergent CD, as well as beneficial maternal and neonatal outcomes.

The association between aspartate aminotransferase (AST) to platelets (PLT) ratio (APRI) and the development of intrahepatic cholestasis in pregnancy and other related complications.

OBJECTIVE: To assess the association between aspartate aminotransferase (AST) to platelet count ratio index (APRI score), during the first and third trimesters of pregnancy and the development of intrahepatic cholestasis in pregnancy (ICP). METHODS: Case-control study was conducted. The study included patients diagnosed with ICP by elevated bile acids (n = 118) and a control group of women with symptoms such as elevated liver enzymes or pruritus with normal level of bile acids (n = 127) who attended a large tertiary teaching medical center between the years 2014 and 2021. The groups were compared in terms of obstetrical characteristics, perinatal outcomes, first- and third-trimester laboratory tests, and APRI scores during the first and third trimester. A receiver operating characteristic (ROC) analysis was performed to determine the APRI score cutoff value that could predict ICP. RESULTS: The third-trimester APRI scores of patients with ICP were significantly higher than those of the control group (P < 0.001). The ROC analysis revealed that the cutoff value for the APRI score was 0.42 with 65.3% sensitivity and 73.2% specificity. CONCLUSION: Our results suggest that the third-trimester APRI score is positively associated with ICP.

Can we predict peritoneal adhesions formation after cesarean delivery?

OBJECTIVE: To examine demographic and obstetrical factors that are associated with adhesion formation following cesarean delivery. METHODS: We conducted a population-based study that included all women over 18 years og age who underwent two cesarean deliveries between the years 1988 and 2016 in a large tertiary medical center. We excluded women with adhesions already diagnosed during the first cesarean delivery, history of other abdominal or pelvic surgery, history of pelvic infection or pelvic inflammatory disease, history of endometriosis and history of uterine Müllerian anomalies. In addition, women with a classical or T-shaped uterine incision, non-singleton pregnancies, and fetal chromosomal or structural abnormalities were excluded. RESULTS: During the study period, 32.6% (n = 2283) of women were diagnosed with peritoneal adhesions during the second cesarean delivery. Factors found to be significantly associated with peritoneal adhesions were maternal age 35 years or older at the first cesarean delivery, Bedouin Arab ethnicity, composite of intrapartum and postpartum infectious morbidity, and cesarean deliveries that were performed after the onset of labor. In contrast, having a previous vaginal birth was found to be protective. CONCLUSIONS: Our results suggest that a woman's characteristics at her first cesarean delivery and her obstetrical history may be predictive of the likelihood of adhesion formation.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery.

PURPOSE: To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes. METHODS: A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed. RESULTS: Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001). CONCLUSION: Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

Peritoneal adhesions during cesarean delivery are an independent risk factor for peri-partum hemorrhagic complications.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions at the second cesarean delivery (CD) are associated with peri-partum hemorrhagic complications. STUDY DESIGN: A retrospective cohort study was undertaken, comparing hemorrhagic complications in the second CD, between women with and without adhesions. All women with two CDs who delivered a singleton in their second CD between the years 1988-2016 at a large regional medical center in Israel were included. Women with adhesions diagnosed at the first CD and women with a history of other abdominal or pelvic surgery, pelvic infection or inflammatory disease, endometriosis, uterine Mullerian anomalies and fetal chromosomal or structural abnormalities were excluded from the analysis, resulting in a sample of 7925 women. Peri-partum hemorrhagic complications were defined as a composite of vessel ligation, B lynch procedure during the CD or uterine rupture, third stage or immediate postpartum hemorrhage, blood component transfusion, hemorrhagic shock and maternal anemia [hemoglobin (Hb) levels prior to maternal discharge below 9.0 g\dl]. In order to identify variables that are independently associated with the composite peri-partum hemorrhagic complications a multivariate logistic regression analysis was performed, to control for potential confounders. In addition, a linear regression model was constructed with Hb levels as the outcome variable. RESULTS: During the study period, 32.6 % of patients (n = 2581) suffered from adhesions during the second CD. After adjusting for potential confounders, peri-partum hemorrhagic complications were found to be significantly associated with the presence of peritoneal adhesions (adjusted OR 1.18, CI 1.04-1.33, P = 0.008). A multivariate linear regression analysis revealed that peritoneal adhesions were independently associated with a decline in post-partum Hb levels (ß=-0.055, P < 0.001). CONCLUSION: Adhesions attributable to a previous CD increase the risk for hemorrhagic complications. Interventions aimed at preventing adhesions formation during the primary CD may have a role in reducing hemorrhagic complications in subsequent CDs.

Peritoneal adhesions are an independent risk factor for peri- and post-partum infectious morbidity.

OBJECTIVE: To investigate whether the presence of peritoneal adhesions during a second cesarean delivery resulting from the first cesarean delivery, are associated with peri- and post-partum infectious morbidity. STUDY DESIGN: A retrospective cohort study was undertaken, comparing maternal peri- and immediate post-partum infectious morbidity during the second cesarean delivery, between women with and without adhesions resulting from the first cesarean delivery. All women over 18 years old at their second cesarean delivery, with a singleton pregnancy between the years 1988-2016 were included in the analysis. Patients with previously diagnosed adhesions during the first cesarean delivery, a history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies, and births of newborns with known chromosomal or structural abnormalities were excluded from the analysis, resulting in a study population of 7925 women. Infectious morbidity was defined as a composite of chorioamnionitis, post-partum fever, urinary tract infection and surgical wound infection or disruption. In order to identify factors that are independently associated with infectious morbidity, multivariate logistic regression analyses were constructed to control for potential confounders. RESULTS: During the study period, 32.6% (n = 2581) women were diagnosed with adhesions at the second cesarean delivery. Second cesarean deliveries complicated with adhesions were characterized by higher rates of peri- and post-partum maternal infectious morbidity (6.5% vs. 9%, p < 0.001). Our study population comprises two ethnic groups- Jewish (54.3%) and Bedouin Arabs (45.7%). We have tested interactions with adhesions of all predictor variables in the model. Since we found a strong interaction between adhesions and ethnicity, stratified data are presented. Infectious morbidity was significantly associated with the presence of peritoneal adhesions only among Jewish women (adjusted OR 2.09, PV < 0.001, 95% CI 1.56-2.80), adjusting for potential confounding variables and significant interactions. CONCLUSION: Cesarean delivery complicated with adhesions attributable to a previous cesarean delivery, increase the risk for peri- and immediate post-partum infectious morbidity among Jewish women.