Maternal high-care and intensive care units in low- and middle-income countries.

Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.

Subphenotypes of severe early-onset pre-eclampsia at hospital admission. A Latin American single-center exploratory latent class analysis.

OBJECTIVES: To identify distinct subphenotypes of severe early-onset pre-eclampsia in Latin America and analyze biomarker and hemodynamic trends between subphenotypes after hospital admission. METHODS: A single-center prospective cohort study was conducted in Colombia. The latent class analysis identified subphenotypes using clinical variables, biomarkers, laboratory tests, and maternal hemodynamics. Class-defining variables were restricted to measurements at and 24 h after admission. Primary and secondary outcomes were severe maternal and perinatal complications. RESULTS: Among 49 patients, two subphenotypes were identified: Subphenotype 1 (34.7%) had a higher likelihood of an sFlt-1/PlGF ratio ≤ 38, maternal age > 35, and low probability of TPR > 1400, CO <8, and IUGR; Subphenotype 2 (65.3%) had a low likelihood of an sFlt-1/PlGF ratio < 38, maternal age > 35, and high probability of TPR > 1400, CO <8, and IUGR. At 24 h postadmission, 64.7% of subphenotype 1 patients changed to subphenotype 2, while 25% of subphenotype 2 patients were reclassified as subphenotype 1. Subphenotype 1 displayed significant changes in CO and TPR, while subphenotype 2 did not. Maternal complications were more prevalent in subphenotype 2, with an odds ratio of 5.3 (95% CI: 1.3-22.0; P = 0.02), but no significant differences in severe neonatal complications were observed. CONCLUSIONS: We identified two distinct subphenotypes in a Latin American cohort of patients with severe early-onset pre-eclampsia. Subphenotype 2, characterized by higher TPR, sFlt-1, and serum creatinine and lower CO and PlGF at admission, was associated with worse maternal outcomes and appeared less modifiable after in-hospital treatment.

Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis.

OBJECTIVE: Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy. METHODS: Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension. RESULTS: Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome. CONCLUSION: Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.

Coronavirus Disease-2019 in Pregnancy.

Coronavirus disease-2019 (COVID-19) infection during pregnancy is associated with severe complications and adverse effects for the mother, the fetus, and the neonate. The frequency of these outcomes varies according to the region, the gestational age, and the presence of comorbidities. Many COVID-19 interventions, including oxygen therapy, high-flow nasal cannula, and invasive mechanical ventilation, are challenging and require understanding physiologic adaptations of pregnancy. Vaccination is safe during pregnancy and lactation and constitutes the most important intervention to reduce severe disease and complications.

Performance of the INTERGROWTH-21st and World Health Organization fetal growth charts for the detection of small-for-gestational age neonates in Latin America.

OBJECTIVE: To evaluate the performance of INTERGROWTH-21st (IG-21st ) and World Health Organization (WHO) fetal growth charts to identify small-for-gestational-age (SGA) and fetal growth restriction (FGR) neonates, as well as their specific risks for adverse neonatal outcomes. METHODS: Multicenter cross-sectional study including 67 968 live births from 10 maternity units across four Latin American countries. According to each standard, neonates were classified as SGA and FGR (birth weight <10th and less than third centiles, respectively). The relative risk (RR) and diagnostic performance for a low APGAR score and low ponderal index were calculated for each standard. RESULTS: WHO charts identified more neonates as SGA than IG-21st (13.9% vs 7%, respectively). Neonates classified as having FGR by both standards had the highest RR for a low APGAR (RR, 5.57 [95% confidence interval (CI), 3.99-7.78]), followed by those who were SGA by both curves (RR, 3.27 [95% CI, 2.52-4.24]), while neonates with SGA identified by WHO alone did not have an additional risk (RR, 0.87 [95% CI, 0.55-1.39]). Furthermore, the diagnostic odds ratio for a low APGAR was higher when IG-21st was used. CONCLUSION: In a population from Latin America, the WHO charts seem to identify more SGA neonates, but the diagnostic performance of the IG-21st charts for low APGAR score and low ponderal index is better.

Effectiveness of CoronaVac and BNT162b2 COVID-19 mass vaccination in Colombia: A population-based cohort study.

Background: In February 2021, Colombia began mass vaccination against COVID-19 using mainly BNT162b2 and CoronaVac vaccines. We aimed to estimate vaccine effectiveness (VE) to prevent COVID-19 symptomatic cases, hospitalization, critical care admission, and deaths in a cohort of 796,072 insured subjects older than 40 years in northern Colombia, a setting with a high SARS-CoV-2 transmission. Methods: We identified individuals vaccinated between March 1st of 2021 and August 15th of 2021. We included symptomatic cases, hospitalizations, critical care admissions, and deaths in patients with confirmed COVID-19 as main outcomes. We calculated VE for each outcome from the hazard ratio in Cox proportionally hazards regressions (adjusted by age, sex, place of residence, diabetes, human immunodeficiency virus, cancer, hypertension, tuberculosis, neurological diseases, and chronic renal disease), with 95% confidence intervals (CI). Findings: A total of 719,735 insured participants of 40 and more years were followed. We found 21,545 laboratory-confirmed symptomatic COVID-19 among unvaccinated population, along with 2874 hospitalizations, 1061 critical care admissions, and 1329 deaths, for a rate of 207.2 per million person-days, 27.1 per million person-days, 10.0 per million person-days, and 12.5 per million person-days, respectively. We found CoronaVac was not effective for any outcome in subjects above 80 years old; but for people 40-79 years of age, we found two doses of CoronaVac reduced hospitalization (33.1%; 95% CI, 14.5-47.7), critical care admission (47.2%; 95% CI, 18.5-65.8), and death (55.7%; 95% CI, 32.5-70.0). We found BNT162b2 was effective for all outcomes in the entire population of subjects above 40 years of age, significantly declining for subjects ≥80 years. Interpretation: Two doses of either CoronaVac in population between 40 and 79 years of age, or BNT162b2 among vaccinated above 40 years old significantly reduced deaths of confirmed COVID-19 in a cohort of individuals from Colombia. Vaccine effectiveness for CoronaVac and BNT162b2 declined with increasing age. Funding: UK National Institute for Health Research, the European Union's Horizon 2020 research and innovation programme, and the Bill & Melinda Gates Foundation.

Maternal mortality linked to COVID-19 in Latin America: Results from a multi-country collaborative database of 447 deaths.

Background: This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database. Methods: This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges. Findings: We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight. Interpretation: This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays. Funding: Latin American Center for Perinatology, Women and Reproductive Health.

Antecedentes: Este estudio tuvo el objetivo de describir las características clínicas de las muertes maternas asociadas a COVID-19 registradas en una base de datos latinoamericana multipaís. Métodos: Se implementó un estudio observacional descriptivo en el que participaron ochos países Latinoamericanos desde el 1ero de marzo 2020 al 29 de noviembre 2021. La información se obtuvo del Sistema Informático Perinatal del Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva. Presentamos las variables categóricas como frecuencias y porcentajes y las variables continuas en medianas con rangos inter cuartiles. Resultados: Identificamos un total de 447 muertes. La mediana de edad materna fue de 31 años. 86·4% de las mujeres se infectaron ante del parto, siendo la mayoría de los casos detectados en el tercer trimestre del embarazo (60·3%). Los síntomas más frecuentes en la primera consulta y la admisión fueron disnea (73·0%), fiebre (69·0%), y tos (59·0%). Se reportaron disfunciones orgánicas en 90·4% de las mujeres durante la admisión. Un total de 64·8% de las mujeres fueron ingresadas a cuidados críticos por una mediana de ocho días de estadía. En la mayoría de los casos la muerte ocurrió durante el puerperio, con una media de siete días entre el parto y su ocurrencia. El parto prematuro fue la complicación perinatal más frecuente (76·9%) y 59·9% tuvo bajo peso al nacer. Interpretación: Este estudio describe las características de las muertes maternas durante la pandemia por COVID-19 a partir de una base colaborativa multipaís. Se observaron barreras para el acceso a cuidados intensivos. Los tomadores de decisión deberían trabajar en el fortalecimiento de la conciencia de gravedad, y en estrategias de referencia para evitar potenciales demoras. Financiamiento: Centro Latino Americano de Perinatología, Salud de la Mujer y Reproductiva.

Residual liver stiffness in the postpartum period in women with preeclampsia and healthy women: A case-control study.

OBJECTIVE: We aimed to assess the presence of residual liver stiffness in preeclampsia 45 days after delivery. STUDY DESIGN: This was a longitudinal case-control study to assess the association between residual liver stiffness, measured 45 days postpartum, and hypertensive disorders of pregnancy. Cases were obstetric patients admitted with hypertension during pregnancy (preeclampsia with and without severe features, or HELLP syndrome) between June 2019 and September 2021. Controls were obstetric patients with similar ages, social status, gestational age (assessed by the first-trimester ultrasound), and geographical areas between the same period. A 2:1 case-control match was considered. MAIN OUTCOME MEASURES: We recorded blood pressure and laboratory tests during the hospital stay. We measured the residual liver stiffness in preeclampsia participants and controls 45 days after delivery. RESULTS: We recruited 99 hypertensive patients and 46 control patients. The residual liver stiffness was higher in hypertensive cases than controls (4.6 [3.9-5.3] kPa vs. 4.0 [3.2-5.2] kPa; p = 0.039). Linear regression results showed that systolic and diastolic blood pressures and alanine aminotransferase positively correlated with liver stiffness values (p < 0.01). CONCLUSIONS: Preeclampsia and disease severity were associated with residual liver stiffness. Prospective studies should further evaluate the clinical implications of these findings.

Changes in Oxygenation and Clinical Outcomes with Awake Prone Positioning in Patients with Suspected COVID-19 In Low-Resource Settings: A Retrospective Cohort Study.

INTRODUCTION: This study aimed to describe the use of awake prone positioning (APP) and conventional oxygen therapy (COT) in patients with suspected coronavirus disease (COVID-19) and respiratory failure in a limited-resource setting. METHODS: This was a retrospective cohort study of hospitalized patients aged ≥18 years old who were placed in an awake prone position due to hypoxemic respiratory failure and suspected COVID-19. The patients were selected from a tertiary center in Cartagena, Colombia, between March 1, 2020, and August 31, 2020. Demographic, clinical, and laboratory variables were collated, and all the variables were compared between the groups. RESULTS: The median age of the participants was 63 (IQR, 48.8-73) years (survivors: 59 [IQR, 43.568] years vs. non-survivors: 70 [IQR, 63-78] years, P ≤ .001). Of the 1470 patients admitted for respiratory symptoms, 732 (49.8%) were hospitalized for more than 24 h, and 212 patients developed respiratory failure and required COT and APP (overall hospital mortality, 34% [73/212]). The mean rank difference in PaO2/FiO2 before and after APP was higher in the survivors than in the non-survivors (201.1-252.6, mean rank difference = 51.5, P = .001 vs. 134.1-172.4, mean rank difference = 38.28, P = .24, respectively). CONCLUSION: While using COT in conjunction with APP can improve respiratory failure in patients with suspected COVID-19 in low-resource settings, persistent hypoxemia after APP can identify patients with higher mortality risk. More evidence is needed to establish the role of this strategy.

New obstetric systemic inflammatory response syndrome criteria for early identification of high-risk of sepsis in obstetric patients.

OBJECTIVES: We aimed to establish new cut-off values for SIRS (Systemic Inflammatory Response Syndrome) variables in the obstetric population. METHODS: A prospective cohort study in pregnant and postpartum women admitted with systemic infections between December 2017 and January 2019. Patients were divided into three cohorts: Group A, patients with infection but without severe maternal outcomes (SMO); Group B, patients with infection and SMO or admission to the intensive care unit (ICU); and Group C, a control group. Outcome measures were ICU admission and SMO. The relationship between SIRS criteria and SMO was expressed as the area under the receiver operating characteristics curve (AUROC), selecting the best cut-off for each SIRS criterion. RESULTS: A total of 541 obstetric patients were enrolled, including 341 with infections and 200 enrolled as the reference group (Group C). The patients with infections included 313 (91.7%) in Group A and 28 (8.2%) in Group B. There were significant differences for all SIRS variables in Group B, compared with Groups A and C, but there were no significant differences between Groups A and C. The best cut-off values were the following: temperature 38.2 °C, OR 4.1 (1.8-9.0); heart rate 120 bpm, OR 2.9 (1.2-7.4); respiratory rate 22 bpm, OR 4.1 (1.6-10.1); and leukocyte count 16,100 per mcl, OR 3.5 (1.6-7.6). CONCLUSIONS: The cut-off values for SIRS variables did not differ between healthy and infected obstetric patients. However, a higher cut-off may help predict the population with a higher risk of severe maternal outcomes.

Enfermedad por coronavirus (COVID-19) en embarazo, parto y lactancia / Coronavirus disease 2019 (COVID-19) in pregnancy, childbirth, and lactation

Resumen La pandemia de COVID-19 ha generado múltiples interrogantes respecto a su comportamiento en la población gestante y en los resultados peri- natales. Los datos disponibles sobre la infección por SARS-CoV-2 en el embarazo son limitados. Se realizó una búsqueda de artículos publicados en las bases de datos PubMed, Scopus y Embase utilizando los términos asociados a COVID-19 y embarazo, hasta el 4 de abril de 2020. En la revisión de 43 artículos se tuvieron en cuenta 25, que corresponden a reportes y series de casos, revisiones y guías de manejo. No se encontró evidencia concluyente respecto a transmisión vertical o a mal resultado perinatal en enfermedad leve o moderada. Los síntomas clínicos de COVID-19 en el embarazo no varían de los de la población general. Existe controversia en cuanto a lactancia materna. En conclusión, existe escasa evidencia de calidad sobre el efecto de COVID-19 en el embarazo. Dada la ausencia de evidencia concluyente se plantea la realización de un registro nacional de COVID-19 y embarazo para Colombia y la región.

Abstract The COVID-19 pandemic has raised a number of questions regarding its behavior in the pregnant population and perinatal outcomes. Currently, data available on the COVID-19 infection during pregnancy is limited. A search was conducted of all the articles published in the PubMed, Scopus, and Embase databases, using terms associated with COVID-19 and pregnancy from January 2017 to 04 April 2020, and including all the types of articles published on COVID-19 and pregnancy. The review of 43 articles, of which 23 were considered, demonstrated that all refer to case reports, case series and reviews and management guides. No conclusive evidence was found with respect to vertical transmission or poor perinatal outcome in mild-moderate disease. The clinical symptoms of COVID-19 during pregnancy do not vary from those in the general population. Controversy exists with regards to breastfeeding. In conclusion, quality evidence is scarce on the effect of COVID-19 during pregnancy. Given the lack of conclusive evidence, a national registry is proposed on COVID-19 and pregnancy for Colombia.

The impact of maternal anemia and labor on the obstetric Shock Index in women in a developing country.

BACKGROUND: The Shock Index is a clinical tool to evaluate the hemodynamic status during hemorrhage. The impact of labor and pre-existing anaemia is unknown. The objective was to describe and discuss its clinical utility in this context. METHODS: This was a prospective cross-sectional study. The Shock Index (ratio between heart rate and systolic blood pressure) was measured in pregnant women at term, before or during labor. They were stratified according to the presence of anemia. RESULTS: The median Shock Index was significantly lower in women in labor than in those not in labor (0.72 (IQR: 0.64-0.83) vs. 0.85 (IQR: 0.80-0.94); p < 0.001). In women in labor, the Shock Index was not significantly different if anemia was present (0.72 (0.63-0.83) vs. 0.73 (0.65-0.82); p = 0.67). CONCLUSIONS: Values of the Shock Index are affected by labor, which may hinder its utility in identifying hemorrhage during this period. However, the values were not altered by maternal anaemia. Therefore, an abnormal postpartum Shock Index should not be attributed to an abnormal antepartum Shock Index due to mild/moderate anemia.

Association of plasma lactate concentration at admission of severe preeclampsia to maternal complications.

OBJECTIVE: To evaluate in women with severe preeclampsia the association of lactate concentration at admission with maternal complications. METHODS: A prospective cohort was created of women with severe preeclampsia consecutively admitted to an Obstetrical High-Dependency Unit. Plasma lactate concentration was measured at admission and its association to maternal complication was evaluated. RESULTS: A total of 100 women were included, of which 30 (30%) had a maternal complication. The mean lactate plasma concentration in this group was significantly higher than in those uncomplicated cases (2.38 vs 3.1 mmol/L; p < 0.01). A total of 37 (37%) women had lactate concentrations at >3 mmol/L, which was associated to higher incidence of maternal complications (19% vs. 48.6%; p = 0.002; OR 4.03 [95% CI 1.64-9.9]). This association remained independent of other standard severity criteria (OR 3.89; 95%CI 1.22-12.4; p = 0.022). CONCLUSION: Increased plasma lactate concentrations at admission in women with severe preeclampsia are independently associated to maternal complications.

Reversible pulmonary hypertension and high-output heart failure triggered by pregnancy in a patient with congenital arteriovenous malformation: A case report.

BACKGROUND: Arteriovenous malformations rarely cause congestive heart failure. Pregnancy may in theory trigger heart failure associated with congenital arteriovenous malformations leading to secondary pulmonary hypertension, but no cases have been reported proving that condition. METHODS AND RESULTS: We report a 23-year-old pregnant woman at 36 + 5 weeks of gestation requiring urgent medical care because of shortness of breath. High-output heart failure was suspected, and a congenital arteriovenous malformation on the right scapular region was considered as the possible origin. The patient required urgent caesarean delivery because of ongoing cardiac failure, which improved soon after delivery. Postpartum angiography of the right subclavian artery revealed an arteriovenous malformation on the deltoid region with venous drainage through the subclavian vein and increased flow to the superior cava vein and right atrium. CONCLUSION: A high index of suspicion of arteriovenous malformations should be maintained in pregnant women with cutaneous vascular malformation-like lesions, if symptoms of heart failure are present.

Síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) y embarazo / Obstructive sleep apnea-hypopnea syndrome (OSAHS) and pregnancy

Resumen El embarazo es una condición temporal de la vida en la que ocurren importantes cambios en la fisiología de la mujer, los cuales se resuelven, en gran medida, después del parto. Hay cambios físicos, hormonales y psicológicos, con un aumento progresivo de peso. Estos factores pueden predisponer a un trastorno respiratorio del sueño o a exacerbar alguno ya existente. La literatura científica sugiere una mayor prevalencia de ronquido en las mujeres embarazadas. Las bases de datos demuestran que en menos del 1% de los embarazos aparece el código del diagnóstico de apnea de sueño. Se ha relacionado la presencia tanto de ronquido como de apnea durante el embarazo con algunos desenlaces adversos que se tratan en este artículo, el cual busca sensibilizar a los médicos para que consideren este diagnóstico durante el embarazo.

Abstract Pregnancy is a temporary condition of life during which important changes in the physiology of women occur; such changes are resolved, to a large extent, after childbirth. Physical, hormonal and psychological changes can be observed as weight increases progressively. These factors may predispose to a respiratory sleep disorder or exacerbate an existing sleep disorder. The scientific literature suggests a higher prevalence of snoring in pregnant women, although databases show the diagnosis code of sleep apnea in less than 1% of pregnancies. The presence of both snoring and apnea during pregnancy has been associated with some adverse outcomes discussed in this article, which seeks to sensitize physicians to consider this diagnosis during pregnancy.

Predictors of Maternal Mortality and Prognostic Models in Obstetric Patients.

The use of predictive models has been proposed as a potential tool to reduce maternal morbidity and mortality, by aiding in the timely identification of potential high-risk patients. Prognostic models in critical care have been used to characterize the severity of illness of specific diseases. Physiological changes in pregnancy may result in general critical illness prediction models overestimating mortality in obstetric patients. Models that specifically reflect the unique characteristics of obstetric patients may have better prognostic value. Recently developed tools have focused on identifying at-risk patients before they require intensive care unit (ICU) admission to target early interventions and prevent acute clinical decompensation. The aim of the newest scoring systems, specifically designed for groups of obstetric patients receiving non-ICU care, is to reduce maternal morbidity and mortality by identifying early high-risk patients and initiating prompt effective medical responses.