The effects of low-dose aspirin on preterm birth: a systematic review and meta-analysis of randomized controlled trials.

AIM: To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that evaluated the efficacy of low-dose aspirin (LDA, ≤ 160 mg/day) on preventing preterm birth (PB). METHODS: Five databases were screened from inception until June 25, 2023. The RCTs were assessed for quality according to Cochrane's risk of bias tool. The endpoints were summarized as risk ratio (RR) with 95% confidence interval (CI). RESULTS: Overall, 40 RCTs were analyzed. LDA significantly decreased the risk of PB < 37 weeks (RR: 0.91, 95% CI 0.87, 0.96, p < 0.001, moderate certainty of evidence) with low between-study heterogeneity (I2 = 23.2%, p = 0.11), and PB < 34 weeks (RR: 0.78, 95% CI 0.61, 0.99, p = 0.04, low certainty of evidence) with high between-study heterogeneity (I2 = 58.3%, p = 0.01). There were no significant differences between both groups regarding the risk of spontaneous (RR: 0.94, 95% CI 0.83, 1.07, p = 0.37) and medically indicated (RR: 1.28, 95% CI 0.87, 1.88, p = 0.21) BP < 37 weeks. Sensitivity analysis revealed robustness for all outcomes, except for the risk of PB < 34 weeks. For PB < 37 weeks and PB < 34 weeks, publication bias was detected based on visual inspection of funnel plots for asymmetry and statistical significance for Egger's test (p = 0.009 and p = 0.0012, respectively). CONCLUSION: LDA can significantly reduce the risk of PB < 37 and < 34 weeks. Nevertheless, further high-quality RCTs conducted in diverse populations, while accounting for potential confounding factors, are imperative to elucidate the optimal aspirin dosage, timing of initiation, and treatment duration for preventing preterm birth and to arrive at definitive conclusions.

Parents of Children With Neurodevelopmental Disorders: A Mixed Methods Approach to Understanding Quality of Life, Stress, and Perceived Social Support.

Objective This study aims to investigate the quality of life (QOL), parental stress, and perception of social support in parents of children with neurodevelopmental disorders (NDD) in Saudi Arabia. Background Studies have shown that parenting a child with NDD impacts the QOL, parental stress, and life satisfaction of parents. Those studies, however, assessed those factors separately as well as focusing on autism spectrum disorder (ASD). This study will use a mixed methods approach to gain a deeper understanding of those three factors as they related to parenting a child with NDD. Method Data about parental stress, QOL, and other related sociodemographic variables were collected from parents of children with NDD (N= 63). Next, semi-structured interviews were conducted with four of those parents to gain a deeper understanding of the parents' QOL, parental stress, and perception of social support. Results An analysis of variance (ANOVA) test demonstrated that parents who had children with severe symptoms had poorer QOL and higher levels of parental stress compared to parents who had children who had moderate and mild symptoms. In addition, parents who had children with ASD had poorer QOL compared to all of the other disorders. There was no statistically significant difference in QOL and parental stress between mothers and fathers. The thematic analysis highlighted that the most significant challenges they face are financial, familial, and well-being worries. Conclusion In conclusion, this study shows that parents of children with NDD exhibited higher levels of parental stress and lower levels of QOL depending on the diagnosis and intensity of the child's symptoms. In addition, the interviews highlighted some key challenges that the parents felt affected their QOL and stress levels, as well as their views on family, friends, and community social support. Implications This study can help in developing or improving supportive programs and interventions for parents with children with NDD to enhance their QOL, reduce parental stress, and create a better social support system.

Examining the Association Between Episiotomy and Severe Perineal Tears in a Tertiary Care Center Implementing a Restrictive Episiotomy Policy.

Background Perineal lacerations are feared complications of vaginal delivery, especially the severe types (third- and fourth-degree tears). World Health Organization (WHO) recommended restrictive episiotomy practice after alarming literature linked the increase in severe tears with routine episiotomy. Therefore, this study aimed to measure the association between episiotomy and the incidence of third- and fourth-degree perineal tears and infections in women who underwent episiotomy versus those who did not at a tertiary care center implementing the restrictive episiotomy policy in Jeddah, Saudi Arabia. Methods This retrospective cohort study was conducted in the Department of Obstetrics and Gynecology at King Abdulaziz Medical City (KAMC), Western Region, between May 2016 and May 2018, targeting all pregnant women who underwent normal spontaneous vaginal delivery. The nonprobability convenient sampling technique was used for women who underwent episiotomy. Women without episiotomy (control group) were randomly selected in a 1:1 ratio. The prevalence (incidence) of episiotomy and its association with severe perineal tears were measured. Statistical data were analyzed using SPSS version 27 (IBM Corp., Armonk, NY). A p-value of less than 0.05 was considered significant. Result A total of 7436 deliveries were recorded. At KAMC, episiotomy had a prevalence of 10% and was more common in primipara. The incidence of third-degree tears was 3.3% in the episiotomy group and 0.8% in the control group (odds ratio, 4.1; p = 0.03). None had fourth-degree tears. Furthermore, the infection rate was not significantly different between the two groups (0.1% vs. 0.1%). Using Firth's logistic regression model, primipara emerged as an independent significant risk factor (OR, 3.5 [1.1-11.2]; p = 0.035) while the trend toward increased risk for tear development in the episiotomy group became statistically insignificant (OR, 2.3 [0.7-8.0]; p = 0.19). A post hoc examination to observe the association between episiotomy exposure and BMI using a stepwise logistic regression model showed that parity and age were independent risk factors for episiotomy, with OR values of 2.2 (1.6-3.2) and 0.9 (0.88-0.94), respectively (p < 0.001). The BMI became insignificant, with an OR of 1.0 (0.7-1.4) (p = 0.96). Conclusion The development of severe perineal tears in a center with a restrictive episiotomy policy is rare. Parity has emerged as an independent risk factor for severe perineal tears. Prospective multicenter research with a larger sample size is recommended to validate this study's findings further and investigate other obstetric measures to reduce severe tears in primi mothers.

Comparing pregnancy outcomes between symptomatic and asymptomatic COVID-19 positive unvaccinated women: Multicenter study in Saudi Arabia.

INTRODUCTION: COVID-19 infection in pregnancy ranges from asymptomatic infection to severe disease. However, the maternal and pregnancy outcomes are primarily favorable. Acute Respiratory Illness (ARI) score is a Visual Triage Checklist for Acute Respiratory symptoms created by the ministry of health of Saudi Arabia 12 to screen the patient for acute respiratory infection with MERS-CoV. It has been used during the COVID-19 pandemic to identify suspected cases and place patients in isolation precautions if the score is≥ 4. METHOD: This study is a cross-sectional study of all pregnant women who tested positive for COVID-19 in four medical centers located in four different cities in Saudi Arabia. The study period was from 1/3/2020 until 31/10/2020. Outcomes investigated were the prevalence of COVID infection in pregnant women at the time of delivery. Rate of asymptomatic disease, different maternal and pregnancy outcomes. Women were divided into symptomatic and asymptomatic groups according to the ARI score. The two groups were compared in maternal, perinatal, and neonatal outcomes. Furthermore, the cohort was divided according to maternal age into two groups: women of advanced maternal age ≥ 35 years and younger. The two groups were compared in maternal, perinatal, and neonatal outcomes RESULTS: During the study period, 9573 women gave birth at KAMCs, and 402 pregnant women were identified as COVID positive. Out of all COVID-positive women, only 394 women gave birth at KAMCs. The screening for COVID infection differed between the centers, but the testing was the same by the Nasopharyngeal polymerase chain reaction (PCR) swab. In Riyadh, screening was based on ARI scoring at the beginning of the pandemic. Then, it became universal. In Jeddah, the screening was based on ARI scoring. Any woman who scored four or more was labeled as suspected, and she was tested. Finally, in Madinah and Dammam, the screening was universal throughout the study. The prevalence of COVID-19 infection among women who gave birth at KAMCs was 4.2% (402/9573). (CI 3.8-4.6%). At the time of diagnosis, most women (62%) were asymptomatic. The most common symptoms were cough and shortness of breath. Twenty-two women (5.5%) had Pneumonia, and five women (1.3%) needed admission to Intensive care units (ICU). One woman died due to respiratory failure. When pregnancy outcomes were compared between symptomatic and asymptomatic women, pregnancy in symptomatic women was more likely to be complicated by Abortion (6 versus 2% p-value 0.00), fetal death (3 versus 1.3%), and cesarean delivery (30.8 versus 22.4%, p-value 0.001). COVID-positive pregnant women of advanced maternal age (AMA) were more likely to be symptomatic, have Abortion (5 versus 1%, p-value 0.01), and have Preterm delivery (17 versus 11% p-value 0.01) than younger women. In addition, neonatal death was more common in AMA COVID-positive women than younger (4 versus 0%), regardless of COVID-related symptoms. CONCLUSION: Most of the COVID-infected pregnant women are asymptomatic. Therefore, the ARI scoring system does not help to triage patients. Symptomatic women, especially those older than 35, tend to have a higher maternal and pregnancy complication rate.

Clinical Characteristics of Newborn Infants Delivered to Pregnant Women With Laboratory-Confirmed COVID-19: A Single-Center Experience From Saudi Arabia.

Introduction In Saudi Arabia and countries around the world, clinical health practice has been transformed by the coronavirus 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During the early days of the pandemic, it was a major challenge to care for pregnant women with laboratory-confirmed COVID-19 and their newborn infants. In this article, we share our experience in the management of newborn infants delivered to mothers with laboratory-confirmed COVID-19. Methods A prospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, National Guard Health Affairs, Saudi Arabia. Data collection started in March 2020 and was completed in October 2020. The inclusion criteria included mothers with laboratory-confirmed COVID-19 and their newborn infants. Results A total of 45 pregnant women with polymerase chain reaction (PCR)-confirmed COVID-19 were included in the study. Their mean age was 30.23±5.92 years. The mode of delivery was spontaneous vaginal delivery in 27 women (60%), cesarean section in 15 women (33.3%), and assisted vaginal delivery in three women (6.7%). Three mothers (6.7%) required intensive care unit admission. A total of 45 babies were born and 25 were females (55.6%), 20 males (44.4%). None of the babies had specific symptoms related to COVID-19. All babies were tested negative on the two COVID-19 nasopharyngeal swabs. Babies were initially admitted to the NICU and one baby required prolonged NICU stay due to extreme prematurity (23 weeks), one baby died due to hypoxic-ischemic encephalopathy and respiratory distress syndrome, and the remaining babies were discharged home in a stable condition. Conclusion Our experience suggests that maternal outcomes are generally favorable and no difference between vaginal and cesarean delivery in the risk of virus transmission. With strict implementation of infection prevention measures, mother-to-infant transmission is very unlikely. Early bathing of the newborn infant is preferred to reduce the risk of transmission of infection to newborn infants and the hospital staff. Breastfeeding is safe if performed under strict infection prevention measures.

Examining the Association Between Parental Socioeconomic Status and Preterm Birth Using Multidomain Social Determinants Scale in a Tertiary Care Center in Saudi Arabia.

Objectives Socioeconomic status (SES) plays a conflicting role in preterm birth (PB). This study evaluated the association between SES and PB using, for the first time, a multidomain scale, validated for Saudi Arabia, with a scoring system and examined the effect of each SES domain on PB. The secondary outcome was to determine the effects of SES on birth weight (BW) and the subcategories of PB and BW. Methods This cross-sectional study was conducted between May 2017 and August 2017 at a National Guard tertiary center in Jeddah, Saudi Arabia. A total of 477 parents were interviewed using the Elzahrany R. SES scale. Results The rate of PB was 11.5%, with no significant differences among the high, middle, and low SES classes (13%, 11%, and 12.5%, respectively). There were no patients in the very low SES in this specific population. None of the maternal or neonatal characteristics were significantly different among SES classes except maternal age (p value = 0.03), and antenatal care recorded visits "booking" status (p value = 0.012). Stratified analysis for PB subcategories showed the lower SES classes had higher moderate (3.8%) and extreme (1.6%) PB. For BW subcategories, large for gestational age (LGA) infants were higher in the high SES class (13%). However, the lower SES classes had higher rates of lower BW. The association between SES and PB remained not significant after adjusting for the maternal age and antenatal booking status. Conclusion There was no association between SES and PB at a tertiary center providing universal care to the National Guard using multidomain socioeconomic determinants with a scoring system. However, lower SES was associated with lower BW. The use of the "polysocial risk score" based on locally validated surveys should be considered in any health research that examines the effects of socioeconomic determinants.

Saudi Society of Maternal-Fetal Medicine guidance on pregnancy and coronavirus disease 2019.

[No Abstract Available]    Saudi Med J 2020; Vol. 41 (8): 779-790doi: 10.15537/smj.2020.8.25222 How to cite this article:Yaser A. Faden, Nadia A. Alghilan,  Samiha H. Alawami, Eman S. Alsulmi, Hythem A. Alsum, Yasir A. Katib, Yasser S. Sabr, Fadwah H. Tahir, Nabeel S. Bondagji. Saudi Society of Maternal-Fetal Medicine guidance on pregnancy and coronavirus disease 2019. Saudi Med J 2020; Vol. 41 (8): 779-790. doi: 10.15537/smj.2020.8.25222.

The use of progesterone during pregnancy to prevent preterm birth.

One of the most significant problems facing maternal and children health worldwide is preterm birth (PTB). Although strategies to increase the survival of premature infants have significantly improved in the past few decades, they have yet to be successful. Nine years ago, the use of progesterone in pregnancy was approved by the United States Food and Drug Administration (FDA) for PTB prevention. This paper reviews the recent evidence supporting the use of progesterone in pregnancy for PTB prevention and provides guidelines for its use in daily clinical practice. The guidelines address multiple current controversial areas regarding the prevention of PTB to aid physicians with their clinical decision-making practice, including the use in multifetal gestation, different formulations, safety in pregnancy, dose and route of administration.Saudi Med J 2020; Vol. 41 (4): 333-340doi: 10.15537/smj.2020.4.25036How to cite this article:Alsulmi ES, Alfaraj M, Faden Y, Al Qahtani N. The use of progesterone during pregnancy to prevent preterm birth. Saudi Med J 2020; Vol. 41: 333-340. doi: 10.15537/smj.2020.4.25036.

Association of Antenatal Risk Score With Maternal and Neonatal Mortality and Morbidity.

Introduction/Objectives Women with high-risk pregnancies require careful follow-up, management, and efficient allocation of resources to achieve optimal pregnancy outcomes. This study investigated the association between an updated, validated antenatal risk index score and neonatal mortality and morbidity in a tertiary care center in Saudi Arabia. Methods This retrospective cohort study included pregnant women delivered at King Abdulaziz Medical City, Jeddah, Saudi Arabia, between June 2016 and December 2018. Pregnant women who delivered before arrival, delivered in another hospital, or without an antenatal risk score because of missing data were excluded. The study cohort was recruited by simple random selection. Data of mothers and neonates were extracted from electronic health records. The pregnancy risk was assigned using a validated antenatal risk score index, creating low, moderate, and high-risk pregnancy categories. The association between antenatal risk scores, maternal and neonatal outcomes was investigated. Results A total of 533 pregnant women were included in the analysis, of whom 298 (55.9%) had low antenatal risk scores, 185 (34.7%) had moderate-risk scores, and 50 (9.4%) had high-risk scores. Maternal characteristics showed that high-risk mothers had higher age, gravidity, parity, and abortions than those with low or moderate-risk pregnancies. Newborns of high-risk mothers belonged more often to the male gender and had lower gestational ages, birth weights, and Apgar scores. For maternal outcomes, there was no maternal mortality. High-risk mothers had more cesarean sections and longer lengths of stay as compared to the low and moderate risk group. There was a trend toward increased stillbirths. Neonatal mortality, neonatal intensive care unit (NICU) admission, congenital anomalies, and length of stay were significantly increased in neonates of high-risk mothers. Conclusions An antenatal risk score is a feasible tool in identifying low, moderate, and high-risk pregnancies in a tertiary center outside a North American system. The higher scores were associated with maternal complications as well as neonatal mortality and morbidity. This is the first study to report maternal demographics, mortality, stillbirths, male gender, and congenital anomalies and their associations with categories of pregnancy level of risk. The clinical and economic benefits of antenatal risk screening in Saudi Arabia warrant further large population-based study that includes multi-domain socioeconomic determinants of health specific to our region.

The Role Of Progestogens In Threatened And Idiopathic Recurrent Miscarriage.

It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages, as it is responsible for preparing the endometrium for implantation and maintenance of the gestational sac. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical. Therefore, a group of obstetricians and gynecologists practicing in Saudi Arabia gathered to update the 2014 Saudi guidelines for threatened and recurrent miscarriage management. In preparation, a literature review was conducted to explore the role of oral, vaginal, and injectable progestogens: this was used as a basis to develop position statements to guide and standardize practice across Saudi Arabia.

Antepartum rupture of the intertwin-dividing membrane in monochorionic diamniotic twins: a case report and review of the literature.

We report a case of monochorionic diamniotic twin gestation confirmed by ultrasound visualization of the thin intertwin-dividing membrane at 32 weeks' gestation. Ultrasound at 36 weeks failed to demonstrate the thin dividing membrane. The pregnancy ended a few days later with spontaneous vaginal delivery of the first twin. The second twin was in transverse lie with no membranes that could be felt around. Severe fetal heart rate deceleration developed, prompting delivery by emergency caesarean section. Cord entanglement was noted at the time of delivery, which resulted in severe perinatal morbidity of the second twin. The antepartum rupture of the dividing membrane must have happened some time between 32 and 36 weeks. The etiology for this intrauterine disruption is unknown. A review of the literature about the antepartum rupture of the intertwin-dividing membrane is described, along with its possible causes and complications. In addition, we discuss possible causes of incorrect amnionicity determination, and thus how to minimize these pitfalls. We conclude that antepartum disruption of the intertwin-dividing membrane is more common than previously thought. Moreover, prenatal ultrasonographic visualization of a dividing membrane in a diamniotic twin pregnancy does not rule out future change in this environment to a monoamniotic one, with all its perinatal morbidity and mortality complications, which result mainly from cord entanglement. This suggests a modification in the method and frequency of the prenatal fetal well-being follow-up, as well as the time and mode of delivery.