The association between SARS-CoV-2 infection and preterm delivery: a prospective study with a multivariable analysis.

BACKGROUND: To determine whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the cause of COVID-19 disease) exposure in pregnancy, compared to non-exposure, is associated with infection-related obstetric morbidity. METHODS: We conducted a multicentre prospective study in pregnancy based on a universal antenatal screening program for SARS-CoV-2 infection. Throughout Spain 45 hospitals tested all women at admission on delivery ward using polymerase-chain-reaction (PCR) for COVID-19 since late March 2020. The cohort of positive mothers and the concurrent sample of negative mothers was followed up until 6-weeks post-partum. Multivariable logistic regression analysis, adjusting for known confounding variables, determined the adjusted odds ratio (aOR) with 95% confidence intervals (95% CI) of the association of SARS-CoV-2 infection and obstetric outcomes. MAIN OUTCOME MEASURES: Preterm delivery (primary), premature rupture of membranes and neonatal intensive care unit admissions. RESULTS: Among 1009 screened pregnancies, 246 were SARS-CoV-2 positive. Compared to negative mothers (763 cases), SARS-CoV-2 infection increased the odds of preterm birth (34 vs 51, 13.8% vs 6.7%, aOR 2.12, 95% CI 1.32-3.36, p = 0.002); iatrogenic preterm delivery was more frequent in infected women (4.9% vs 1.3%, p = 0.001), while the occurrence of spontaneous preterm deliveries was statistically similar (6.1% vs 4.7%). An increased risk of premature rupture of membranes at term (39 vs 75, 15.8% vs 9.8%, aOR 1.70, 95% CI 1.11-2.57, p = 0.013) and neonatal intensive care unit admissions (23 vs 18, 9.3% vs 2.4%, aOR 4.62, 95% CI 2.43-8.94, p <  0.001) was also observed in positive mothers. CONCLUSION: This prospective multicentre study demonstrated that pregnant women infected with SARS-CoV-2 have more infection-related obstetric morbidity. This hypothesis merits evaluation of a causal association in further research.

Obstetric Outcomes of SARS-CoV-2 Infection in Asymptomatic Pregnant Women.

Around two percent of asymptomatic women in labor test positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Spain. Families and care providers face childbirth with uncertainty. We determined if SARS-CoV-2 infection at delivery among asymptomatic mothers had different obstetric outcomes compared to negative patients. This was a multicenter prospective study based on universal antenatal screening for SARS-CoV-2 infection. A total of 42 hospitals tested women admitted for delivery using polymerase chain reaction, from March to May 2020. We included positive mothers and a sample of negative mothers asymptomatic throughout the antenatal period, with 6-week postpartum follow-up. Association between SARS-CoV-2 and obstetric outcomes was evaluated by multivariate logistic regression analyses. In total, 174 asymptomatic SARS-CoV-2 positive pregnancies were compared with 430 asymptomatic negative pregnancies. No differences were observed between both groups in key maternal and neonatal outcomes at delivery and follow-up, with the exception of prelabor rupture of membranes at term (adjusted odds ratio 1.88, 95% confidence interval 1.13-3.11; p = 0.015). Asymptomatic SARS-CoV-2 positive mothers have higher odds of prelabor rupture of membranes at term, without an increase in perinatal complications, compared to negative mothers. Pregnant women testing positive for SARS-CoV-2 at admission for delivery should be reassured by their healthcare workers in the absence of symptoms.

Éxito en el manejo conservador del acretismo placentario mediante embolización y metotrexato / Successful conservative management of placenta accreta via embolization and methotrexate

Introducción. La incidencia del acretismo placentario ha aumentado, y esta patología puede ser causa de hemorragia posparto subsidiaria de histerectomía. Existen sin embargo tratamientos conservadores alternativos a la cirugía. Caso clínico. Mujer de 38 años de edad, primigesta. Tras el parto, la placenta es extraída mediante desprendimiento manual y legrado. El diagnóstico es confirmado mediante ecografía y resonancia magnética. Se realiza embolización selectiva del vaso nutricio y administración de metotrexato. Tres días después de la embolización se produce la expulsión de la masa placentaria. Conclusiones. La embolización selectiva del vaso nutricio y el tratamiento coadyuvante con metotrexato constituyen una técnica conservadora que permite preservar el útero y así conservar la fertilidad. El caso que presentamos es, según lo descrito hasta ahora en la literatura, uno de los manejados conservadoramente que ha conseguido un intervalo de tiempo menor entre el parto y la expulsión placentaria definitiva (AU)

Introduction. The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery. Case report. A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional vessel was performed and methotrexate was administered. Three days after the embolization, the placental mass was expelled. Conclusions. Selective embolization of a nutritional vessel and adjuvant treatment with methotrexate are conservative techniques that allow preservation of both the uterus and fertility. According to previous reports in the literature, the time interval between delivery and definitive placental expulsion was lower in our case than in other conservatively managed cases (AU)

Cesárea en isquemia-histerectomía: nueva técnica para finalizar la gestación en pacientes con hipertensión arterial pulmonar / Cesarean section in ischemia-hysterectomy: A new technique to terminate pregnancy in patients with serious pulmonary hypertension

La asociación de hipertensión arterial pulmonar (HAP) y embarazo sigue presentando unos índices de mortalidad materna muy elevados. Las nuevas terapias y el abordaje multidisciplinario han conseguido mejorar el curso del embarazo y el pronóstico fetal, pero no el materno. La observación de que la evacuación del feto e involución uterina coincide con un empeoramiento marcado de la función cardíaca materna sugiere como causa desencadenante el paso súbito de la sangre contenida en el músculo uterino a la circulación general, que al comportarse como una autotransfusión eleva a límites insostenibles las presiones en el corazón derecho. Para evitarlo se ha diseñado una nueva técnica quirúrgica, la cesárea en isquemia-histerectomía, que cierra la circulación uterina antes de la extracción fetal. Se describe la técnica quirúrgica y se aportan 4 casos clínicos ilustrativos (AU)

The association of pulmonary hypertension (PH) and pregnancy still leads to high maternal mortality. New treatments and a multidisciplinary approach have improved the course of pregnancies and fetal outcomes but not maternal prognosis. We observed that fetal evacuation and uterine involution coincides with marked worsening of maternal cardiac function, suggesting that the trigger is blood flow from the uterine muscle to the general circulation. This process acts as an autotransfusion and increases the pressure in the right heart to unsustainable limits. A new surgical technique, cesarean section in ischemia-hysterectomy, has been designed to prevent this event. This technique blocks uterine circulation before fetal extraction. We describe this technique and four cases (AU)