Unfolding of maternal-infant bonding amidst the COVID-19 pandemic: Social support as a risk and protective factor.

BACKGROUND: Social, familial, and physiological stressors may put maternal-infant bonding at risk. Therefore, it is plausible that the stressful conditions brought on by COVID-19 could influence maternal-infant bonding. This study aimed to elucidate the contribution of COVID-19-related experience to variance in maternal-infant bonding, beyond that of established risk factors and as moderated by social support. METHODS: This longitudinal, multicenter study examined the relationship of demographic and obstetric variables, social support, postpartum depression, as well as COVID-19-related fear, exposure, and subjective difficulty with mother-infant bonding six months following birth. Participants (N = 246) were women who delivered during the pandemics' strict lockdown period and were recruited 10 weeks after a liveborn delivery and followed up six months later. RESULTS: Relationship between fear of COVID-19 and maternal-infant bonding was moderated by social support: Amongst mothers with high levels of social support, fear of COVID-19 negatively predicted bonding. DISCUSSION: Results indicate that social support, while overall a protective factor for mother-infant bonding, may lose its buffering effect when fear of COVID-19 is high. This relationship was maintained even when early bonding experiences such as forced separation and the risk incurred by postpartum depression were accounted for. Implications for providers are discussed.

Maternal fear of COVID-19 and prevalence of postnatal depression symptoms, risk and protective factors.

This is a multicenter prospective observational study, aimed to evaluate the relations between Fear of COVID-19 and postpartum depression (PPD) symptom, that included a cohort of women who delivered during COVID-19 lockdown between 03 and 05/2020. Participants were approached after delivery and asked to complete an online questionnaire. Data was verified with each center's perinatal database. The validated Fear of COVID-19 Scale was in use. PPD was evaluated using the EPDS questionnaire as a categorical (≥13) and as a continuous scale. Pre-existing maternal disability was defined as any prior physiological/psychological chronic health condition. Continuous medical supervision or stress contributing complications at birth included pregnancy and labor related complications. Regression analysis and ROC statistics were utilized to evaluate associations and control for confounders. Overall, 421 women completed the questionnaires. Of them, 53(12.6%) had a high EPDS score. Fear of COVID-19 was positively correlated with PPD symptoms (r = 0.35,p = 0.000), ROC-AUC 0.73, 95% CI 0.65-0.81, p = 0.000. Following adjustment to confounders (maternal age, nulliparity, ethnicity, marital status, financial difficulties, maternal disability, accessibility to medical services, and continuous medical supervision (, the most important factor that correlated with depression symptoms was maternal disability (aOR 4.61,95% CI 1.96-10.82) followed by Fear of COVID-19 (aOR 1.11,95% CI 1.05-1.17). High accessibility to medical services during pregnancy (aOR 0.62, 95%CI 0.45-0.84) was protective for PPD symptoms. To conclude, during the COVID-19 pandemic, maternal disability and Fear of COVID-19 are positively associated with a high EPDS score. High medical accessibility during pregnancy was found as a protective factor for PPD.

Perioperative noninvasive cardiac output monitoring in parturients with singleton and twin pregnancies undergoing cesarean section under spinal anesthesia with prophylactic phenylephrine drip: a prospective observational cohort study.

Purpose: Spinal anesthesia is considered the gold standard anesthetic technique for cesarean deliveries (CDs) but is associated with a high rate of hypotension. The recent international consensus recommends continuous prophylactic phenylephrine infusion (PPI) administered throughout CD to prevent hypotension. However, little information is available on the hemodynamic profiles of women with twin pregnancies as compared to singleton pregnancies perioperatively. Therefore, in this study, we aim to compare maternal hemodynamic changes both intraoperatively and postoperatively with the use of the NICAS bioimpendence monitor in healthy singleton versus twin parturients undergoing CD deliveries with spinal anesthesia with PPI. Materials and methods: After IRB approval and signed informed consent, healthy term women with either twin or singleton pregnancies undergoing spinal anesthesia for uncomplicated CD were enrolled. The following data were collected - cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), and total peripheral resistance (TPR). Measurements were measured at five time points: (1) before arrival in OR, (2) after spinal anesthesia with PPI, (3) after beginning of oxytocin infusion, (4) in post anesthesia care room, (5) 24 hours postoperatively, and (6) 48 hours postoperatively. All parturients received standardized spinal solution consisting of 12 mg hyperbaric bupivacaine, 20 µg fentanyl and 100-µg preservative-free morphine. PPI administered was titrated to preserve blood pressure to 20% of baseline blood pressure and stopped at the end of surgery. Oxytocin was administered as a continuous infusion (20-units/1000 cm3 Ringer's lactate) at a rate of 100 cm3/h. Results: One hundred and thirty seven parturients with singleton pregnancies and 27 parturients with twin pregnancies completed the study. There were no significant differences between groups in age or BMI. Intraoperatively, there was no difference in any hemodynamic parameter. However, postoperatively at all three times women with twin pregnancies had higher MAP, lower CO and higher TPR compared with parturients with singleton pregnancies. Conclusions: There were significant hemodynamic changes postoperatively but not intraoperatively in parturients with twin pregnancies compared to women with singleton pregnancies. These changes need to be further investigated.

Different formulas, different thresholds and different performance-the prediction of macrosomia by ultrasound.

OBJECTIVE: The sonographic prediction of fetal macrosomia affects obstetrical decision regarding the timing and mode of delivery. We aimed to compare the accuracy of various formulas for prediction of macrosomia at different thresholds. STUDY DESIGN: This was a retrospective cohort study of singleton gestations at term, with fetal biometrical measurements taken up to 7 days prior to delivery (2007 to 2014). Sonographic estimated fetal weight was calculated using 20 previously published formulas. Macrosomia prediction was evaluated for every formula utilizing: (1) measures of accuracy (sensitivity, specificity and so on); (2) comparison of the systematic and random errors (SE and RE), and the proportion of estimates within 10% of actual birth weight for macrosomic and non-macrosomic neonates. Performance measurements were evaluated for different macrosomia thresholds: 4000, 4250 and 4500 g. Best performing formula for every threshold was defined as the one with the lowest Euclidean distance (=SQRT(SE2+RE2)). RESULTS: Out of 7977 women who met the inclusion criteria, 754 (9.4%) delivered a neonate weighing ⩾4000 g, 266 (3.3%) delivered a neonate weighing⩾4250 g and 75 (0.9%) delivered a neonate weighing⩾4500 g. Considerable variability was noted between the accuracy parameters of the different formulas, with Woo's formula integrating Abdominal circumference (AC) and femur length (FL) as the most sensitive formula with the highest negative predictive value for all thresholds and Woo's formula using AC, FL and biparietal diameter (BPD) as the most specific for all thresholds. The same formula also demonstrated the best overall accuracy. Regardless of threshold chosen, 80% or more of formulas demonstrated negative systematic error, meaning lower EFW than actual birthweight. As for the Euclidean distance, Hadlock's formula (AC, FL and BPD) ranked the highest for the 4000 and 4250 g thresholds, whereas Shepard's formula (AC and BPD) ranked the highest for the 4500 g threshold. CONCLUSION: Considerable variability exist between formulas for prediction of neonatal macrosomia. Formulas by Hadlock's and Shepard's utilizing AC, BPD±FL were most accurate for macrosomia prediction at 4000, 4250 and 4500 g thresholds, respectively.

Prediction of large for gestational age by various sonographic fetal weight estimation formulas-which should we use?

OBJECTIVE: As sonographic estimation of fetal weight (EFW) carries substantial impact, especially in large-for-gestational-age (LGA) neonates, we aimed to compare the accuracy of various formulas for prediction of LGA neonates. STUDY DESIGN: Retrospective cohort study of singleton gestations at term, with EFW up to 7 days before delivery (2007 to 2014). Small-for-gestational-age neonates were excluded. LGA prediction for various formulas was evaluated by: (i) measures of performance (sensitivity, specificity, etc.); (ii) systematic and random errors (SE and RE) and the proportion of estimates (POEs) exceeding 10% of actual birth weight. Best performing formula was defined as the one with the lowest Euclidean distance [=square root of (SE2+RE2)]. RESULTS: Out of 62 102 deliveries, 7996 met inclusion criteria, of which 1618 neonates were LGA (22%). There was a considerable variation in sensitivity (74.6±16.3%, 23.5% to 99%), specificity (86.3±10.6%, 51.7% to 99.6%), positive predictive value (64.9±12.4%, 35.6% to 93.8%), positive likelihood ratio (LR; 9.3±10.9, 2.1 to 54.2) and negative LR (0.3±0.16, 0.02 to 0.8), a mild variation in the negative predictive value (92.9±3.7%, 82.3% to 99.5%) and a minimal variation in the area under the curve (94.3%, 93.0 to 95.1; mean±s.d., range for all). Absolute SE was higher for the LGA group in 11/20 formulas (55%). The RE and POE were lower in 19/20 (95%) and 14/20 (70%) for the LGA neonates, respectively. CONCLUSION: There is a wide variation in EFW formulas performance for detecting LGA. Hadlock's formula (1985) combining abdominal circumference, femur length and biparietal diameter ranked highest.

Optimal first trimester preeclampsia prediction: a comparison of multimarker algorithm, risk profiles and their sequential application.

OBJECTIVE: To compare performance of multimarker algorithm, risk profiles and their sequential application in prediction of preeclampsia and determining potential intervention targets. STUDY DESIGN: Maternal characteristics, ultrasound variables and serum biomarkers were collected prospectively at first trimester. Univariate analysis identified preeclampsia associated variables followed by logistic regression analysis to determine the prediction rule. Combined characteristics of the cardiovascular, metabolic and the personal risk factors were compared to the multimarker algorithm and the sequential application of both methods. RESULTS: Out of 2433 women, 108 developed preeclampsia (4.4%). Probability scores considering nulliparity, prior preeclampsia, body mass index, diastolic blood pressure and placental growth factor had an area under the receiver operating characteristic curve 0.784 (95% CI = 0.721-0.847). While the multimarker algorithm had the lowest false negative rate, sequential application of cardiovascular and metabolic risk profiles in screen positives reduced false positives by 26% and identified blood pressure and metabolic risk in 49/54 (91%) women with subsequent preeclampsia as treatable risk factors. CONCLUSION: Sequential application of a multimarker algorithm followed by determination of treatable risk factors in screen positive women is the optimal approach for first trimester preeclampsia prediction and identification of women that may benefit from targeted metabolic or cardiovascular treatment. © 2015 John Wiley & Sons, Ltd.

Predictive value of cervical length in women with twin pregnancy presenting with threatened preterm labor.

OBJECTIVE: To assess the accuracy and determine the optimal threshold of sonographic cervical length (CL) for the prediction of preterm delivery (PTD) in women with twin pregnancies presenting with threatened preterm labor (PTL). METHODS: This was a retrospective study of women with twin pregnancies who presented with threatened PTL and underwent sonographic measurement of CL in a tertiary center. The accuracy of CL in predicting PTD in women with twin pregnancies was compared with that in a control group of women with singleton pregnancies. RESULTS: Overall, 218 women with a twin pregnancy and 1077 women with a singleton pregnancy, who presented with PTL, were included in the study. The performance of CL as a predictive test for PTD was similar in twins and singletons, as reflected by the similar correlation between CL and the examination-to-delivery interval (r, 0.30 vs 0.29; P = 0.9), the similar association of CL with risk of PTD, and the similar areas under the receiver-operating characteristics curves for differing delivery outcomes (range, 0.653-0.724 vs 0.620-0.682, respectively; P = 0.3). The optimal threshold of CL for any given target sensitivity or specificity was lower in twin than in singleton pregnancies. However, in order to achieve a negative predictive value of 95%, a higher threshold (28-30 mm) should be used in twin pregnancies. Using this twin-specific CL threshold, women with twins who present with PTL are more likely to have a positive CL test, and therefore to require subsequent interventions, than are women with singleton pregnancies with PTL (55% vs 4.2%, respectively). CONCLUSION: In women with PTL, the performance of CL as a test for the prediction of PTD is similar in twin and singleton pregnancies. However, the optimal threshold of CL for the prediction of PTD appears to be higher in twin pregnancies, mainly owing to the higher baseline risk for PTD in these pregnancies.