COVID-19 vaccination and transmission patterns among pregnant and postnatal women during the fifth wave of COVID-19 in a tertiary hospital in Hong Kong.

INTRODUCTION: Vaccination is a key strategy to control the coronavirus disease 2019 (COVID-19) pandemic. Safety concerns strongly influence vaccine hesitancy. Disease transmission during pregnancy could exacerbate risks of preterm birth and perinatal mortality. This study examined patterns of vaccination and transmission among pregnant and postnatal women during the fifth wave of COVID-19 in Hong Kong. METHODS: The Antenatal Record System and Clinical Management System of the Hospital Authority was used to retrieve information concerning the demographic characteristics, vaccination history, COVID-19 status, and obstetric outcomes of women who were booked for delivery at Queen Mary Hospital in Hong Kong and had attended the booking antenatal visit from 1 July 2021 to 30 June 2022. RESULTS: Among 2396 women in the cohort, 2006 (83.7%), 1843 (76.9%), and 831 (34.7%) had received the first, second, and third doses of COVID-19 vaccine, respectively. Among 1012 women who had received the second dose, 684 (67.6%) women were overdue for their third dose. There were 265 (11.1%) reported COVID-19 cases. Women aged 20 to 29 years had a low vaccination rate but the highest disease rate (19.1%). The disease rate was more than tenfold higher in women who had no (20.3%) or incomplete (18.8%) vaccination, compared with women who had complete vaccination (2.1%; P<0.001). CONCLUSION: Acceptance of COVID-19 vaccination was low in pregnant women. Urgent measures are needed to promote vaccination among pregnant women before the next wave of COVID-19.

Behavioural adaptations and responses to obstetric care among pregnant women during an early stage of the COVID-19 pandemic in Hong Kong: a cross-sectional survey.

INTRODUCTION: This study evaluated behavioural adaptations and responses to obstetric care among pregnant women during an early stage of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This cross-sectional survey included pregnant women who received obstetric care from 27 May 2020 to 16 June 2020 in a university-affiliated hospital in Hong Kong. Responses were collected with respect to obstetric appointment scheduling, workplace changes, mask-wearing practices, travel and quarantine experiences, obstetric service adjustments, and visiting arrangements. Regression analysis was used to compare the effects of patient characteristics on their responses. RESULTS: In total, 1000 surveys were distributed; 733 pregnant women provided complete survey responses. Among obstetric-related appointments in public hospitals, 16% were postponed or cancelled by pregnant women; such changes were most frequent among women beyond 24 weeks of gestation, women who had previous deliveries, and women who had a history of mental illness. The practice of working from home imposed psychological stress and negatively impacted the pregnancy experience in 4.5% of women. Childbirth companionship was regarded as an important service by 88.1% of women; only 4.2% agreed with its suspension. Obstetric service adjustments had the greatest impact on Chinese women and nulliparous women. CONCLUSIONS: The findings provide an overview of how pregnant women adapted during an early stage of the COVID-19 pandemic. Women adjusted obstetric service attendance, began working from home, and wore masks. Women's expectations did not match changes in childbirth companionship and peripartum services. Hospital administrators should consider psychological impacts on pregnant women when implementing service adjustments.

Effect of COVID-19 on delivery plans and postnatal depression scores of pregnant women.

INTRODUCTION: Owing to the coronavirus disease 2019 outbreak Hong Kong hospitals have suspended visiting periods and made mask wearing mandatory. In obstetrics, companionship during childbirth has been suspended and prenatal exercises, antenatal talks, hospital tours, and postnatal classes have been cancelled. The aim of the present study was to investigate the effects of these restrictive measures on delivery plans and risks of postpartum depression. METHODS: We compared pregnancy data and the Edinburgh Postpartum Depression Scale (EPDS) scores of women who delivered between the pre-alert period (1 Jan 2019 to 4 Jan 2020) and post-alert period (5 Jan 2020 to 30 Apr 2020) in a tertiary university public hospital in Hong Kong. Screening for postpartum depression was performed routinely using the EPDS questionnaire 1 day and within 1 week after delivery. RESULTS: There was a 13.1% reduction in the number of deliveries between 1 January and 30 April from 1144 in 2019 to 994 in 2020. The EPDS scores were available for 4357 out of 4531 deliveries (96.2%). A significantly higher proportion of women had EPDS scores of ≥10 1 day after delivery in the post-alert group than the pre-alert group (14.4% vs 11.9%; P<0.05). More women used pethidine (6.2% vs 4.6%) and fewer used a birthing ball (8.5% vs 12.4%) for pain relief during labour in the post-alert group. CONCLUSIONS: Pregnant women reported more depressive symptoms in the postpartum period following the alert announcement regarding coronavirus infection in Hong Kong. This was coupled with a drop in the delivery rate at our public hospital. Suspension of childbirth companionship might have altered the methods of intrapartum pain relief and the overall pregnancy experience.

Acceptance of antiviral treatment and enhanced service model for pregnant patients carrying hepatitis B.

INTRODUCTION: A service model was established for pregnant women with positive screening results for hepatitis B surface antigen (HBsAg) at Queen Mary Hospital in Hong Kong. All women were offered a blood test for hepatitis B virus (HBV) DNA level during the first antenatal visit. Women with HBV DNA levels of ≥200 000 IU/mL received counselling from hepatologists regarding treatment with antenatal tenofovir disoproxil fumarate (TDF) 300 mg daily. METHODS: This retrospective review included women attending our antenatal clinic who exhibited positive HBsAg screening results from 15 May 2017 to 31 December 2019. The proportions of women with positive HBsAg, DNA test acceptance, hepatological review, and TDF acceptance during pregnancy were reviewed. RESULTS: In total, 375 (2.9%) of 13 082 pregnant women had positive HBsAg screening results. Blood tests for HBV DNA and hepatological reviews were offered to 273 women who had not undergone hepatological review prior to pregnancy; the acceptance rate was 97.8%. Sixty (22.6%) pregnant women were hepatitis B carriers with high viral loads of ≥200 000 IU/mL. Among 58 women with high viral loads, 57 received antenatal counselling regarding TDF and 56 (96.6%) agreed to take the drug; 92.9% of these 56 women had commenced TDF at or before 32 weeks of gestation. CONCLUSIONS: This study indicated broad acceptance of HBV DNA tests by pregnant women. Triage allowed early review and commencement of antiviral medication. This service model serves as a framework for enhanced antenatal service to prevent mother-to-child-transmission in public maternity units.

Effect of couple-based cognitive behavioural intervention on prevention of postnatal depression: multisite randomised controlled trial.

OBJECTIVE: To compare a couple-based cognitive behavioural intervention (CBI) for postnatal depression with CBI delivered to women alone and control (standard perinatal care). DESIGN: Multisite randomised controlled trial. SETTING: Antenatal clinics at three regional public hospitals in Hong Kong. SAMPLE: 388 low-risk childbearing couples. METHODS: Childbearing couples were randomly allocated to couple-based CBI (n = 134), women-alone CBI (n = 124) or control (n = 130). The CBI consists of a 3-hour antenatal group session and two 30-minute postnatal telephone follow-up sessions. MAIN OUTCOME MEASURES: The primary outcome was depressive symptoms, measured on the Edinburgh Postnatal Depression Scale (EPDS). Assessments were collected at baseline (during pregnancy), 6 weeks, 6 months, and 12 months postpartum. RESULTS: Depressive symptoms were significantly more improved at 6 weeks postpartum for mothers in couple-based CBI than in women-alone CBI (difference 1.46, 95% CI 0.11-2.81) or control groups (difference 1.71, 95% CI 0.29-3.13). The proportion of mothers with postnatal depression (EPDS score ≥ 10) was significantly lower at 6 weeks postpartum in couple-based CBI than in control (difference 17.8%, 95% CI 3.6-32.0). However, the treatment effect was not maintained at 6 and 12 months. There was no significant intervention effect among fathers. CONCLUSIONS: Couple-based CBI is more effective than CBI delivered to mothers alone and standard perinatal care in reducing the incidence of postnatal depression among Chinese mothers in the early postpartum period. TWEETABLE ABSTRACT: Couple-based cognitive behavioural intervention is effective in reducing postnatal depression among Chinese mothers in the early postpartum period.

Application of transcervical hysterofetoscopy and cord blood collection at first trimester termination of pregnancy for fetal abnormalities.

OBJECTIVE: To examine the applicability of hysterofetoscopy and cord blood collection at first trimester termination of pregnancy for fetal abnormalities. METHODS: From 2004 to 2007, transcervical hysterofetoscopy was performed in seven patients at the same operation setting of surgical termination of pregnancy. The findings were compared with prenatal diagnosis. Feasibility of cord blood collection was also examined. RESULTS: Out of these seven patients, six of them had prenatal ultrasound diagnosis of cystic hygroma. All of them had chromosomal abnormalities. Subcutaneous oedema was confirmed by hysterofetoscopy with good view. Another pregnancy was complicated by homozygous alpha thalassaemia and the diagnosis was confirmed by electrophoresis of fetal haemoglobin collected from umbilical cord vessel. Cord blood collection was also attempted in two other patients yielding fetal blood with minimal maternal contamination. CONCLUSION: Transcervical hysterofetoscopy is a feasible tool in confirming external fetal structural abnormalities before surgical termination of pregnancy. It can be performed under either general anaesthesia or conscious sedation. Umbilical cord blood collection can facilitate confirmation of genetic diseases. It may also allow the potential of isolating fetal mesenchymal stem cell in first trimester.

Nuchal translucency in dichorionic twins conceived after assisted reproduction.

OBJECTIVES: As opposed to biochemical markers of Down syndrome, nuchal translucency (NT) was once thought to be a more reliable screening marker for high order multiple pregnancies and pregnancies conceived after assisted conception. Recent data suggested that NT in singleton fetuses from assisted reproduction technology (ART) was thicker than those from singleton pregnancies. The present study compared the thickness of NT in dichorionic twins from natural conception and assisted reproduction. METHODS: A retrospective analysis for comparison of NT thickness on 3319 spontaneous singletons, 19 pairs of spontaneous twins and 27 pairs of assisted reproduction twins was performed. RESULTS: The median NT multiple of median (MoM) of spontaneous singletons was 1.00. For twins, the median NT MoM for pregnancies after assisted reproduction and natural conception were 1.02 and 1.07 respectively. There was no statistical difference in the NT thickness among the three pregnancy groups. CONCLUSION: Contrary to the observed increase in NT in singleton pregnancies from assisted reproduction, the NT in dichorionic twins was comparable to the spontaneous ones. The mode of conception appears to impose differential influence on singletons and twins.

Nuchal translucency in pregnancies conceived after assisted reproduction technology.

OBJECTIVES: Levels of maternal serum markers of fetal Down syndrome in pregnancies conceived after assisted reproduction are different from those of normal spontaneous pregnancies. The present study examined the effects of conventional in-vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI) and embryo cryopreservation on nuchal translucency (NT) thickness. METHODS: A retrospective analysis on 16 673 spontaneous pregnancies, 119 pregnancies with fresh embryos from IVF, 62 pregnancies with frozen-thawed embryos from IVF, 81 pregnancies with fresh embryos from ICSI and 39 frozen-thawed embryos from ICSI was performed. All were singletons with known normal outcomes. Multiples of the median (MoM) of NT were compared. RESULTS: The median NT MoM of spontaneous pregnancies was 1.01. In the assisted reproduction pregnancies, the median NT MoM were significantly increased to 1.07 (P = 0.003), 1.09 (P = 0.009) and 1.09 (P = 0.001) in pregnancies conceived with fresh embryos from IVF, frozen-thawed embryos from IVF and fresh embryos from ICSI, respectively. A non-significant increase in median NT MoM (1.04; P = 0.489) was also observed in pregnancies with frozen-thawed embryos from ICSI. CONCLUSIONS: Increased NT in assisted reproduction pregnancies is postulated to be due to some delay in fetal development. Another possible reason might be related to adverse antenatal course in these pregnancies.

Amniotic fluid human chorionic gonadotrophin and alpha-fetoprotein levels in pregnancies conceived after assisted reproduction.

OBJECTIVES: To study the alteration in the second-trimester maternal serum levels of human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP) in pregnancies conceived after assisted reproduction. METHODS: We compared the amniotic fluid hCG and AFP concentrations of 45 pregnancies with fresh embryo transfer and 25 pregnancies with frozen-thawed embryo transfer with 269 spontaneous pregnancies. Wilcoxon rank-sum test was used for analysis. RESULTS: The median amniotic fluid hCG MoM in pregnancies conceived after frozen-thawed embryo transfer was significantly increased to 1.41 compared to 1.00 (p = 0.01) in naturally occurring pregnancies and 0.96 (p = 0.049) in pregnancies after fresh embryo transfer. Further analysis showed that this was only observed in frozen embryos fertilized by conventional insemination with MoM of 1.59. The AFP MoMs were similar among the groups. CONCLUSIONS: The observed raised amniotic fluid hCG level in IVF-FET pregnancies may reflect the elevated maternal serum level in these pregnancies. Further studies should be directed towards exploring the underlying pathophysiology.

Maternal serum hCG and alpha-fetoprotein levels in pregnancies conceived after IVF or ICSI with fresh and frozen-thawed embryos.

BACKGROUND: Studies have shown that levels of serum markers of Down's syndrome were altered in pregnancies conceived after IVF, though the reason for this remains unknown. METHODS: Second-trimester maternal serum levels of hCG and alpha-fetoprotein (AFP) in pregnancies conceived with fresh and frozen-thawed embryos after assisted reproduction were compared with those conceived spontaneously. RESULTS: There were 203 pregnancies with fresh embryo transfers (130 IVF cases, 73 ICSI cases) and 98 pregnancies with frozen-thawed embryo transfers (61 IVF cases, 37 ICSI cases). The controls consisted of 17 145 spontaneous pregnancies. The median hCG multiples of the median (MoM) was significantly increased to 1.24 in 98 pregnancies conceived after frozen embryo transfer. This elevation was observed only in the IVF-frozen embryo transfer subgroup (P < 0.001), but not in the ICSI-frozen embryo transfer subgroup. The median AFP MoM for 203 pregnancies after fresh embryo transfer was 0.90. Among the subgroups, the median AFP MoM was significantly reduced to 0.90 and 0.86 in IVF-embryo transfer (P = 0.04) and ICSI-embryo transfer (P = 0.001) pregnancies respectively, and significantly raised to 1.20 in the IVF-frozen embryo transfer subgroup. CONCLUSIONS: The degree of alterations in maternal serum hCG and AFP levels varied between fresh and frozen-thawed embryos, and also between the mode of fertilization. Pregnancies resulting from ICSI or frozen embryo transfer should be regarded as distinct entities from those of IVF-embryo transfer.

Fluid conductance of cancellous bone graft as a predictor for graft-host interface healing.

The aim of this study is to test the hypothesis that the fluid conductance of cancellous bone graft is a deciding factor in graft-host union. Cylindrical cancellous bone specimens were trephined from fresh porcine femoral heads in a direction either parallel or perpendicular to the femoral neck axes. The graft after a defatting and freeze-drying process was placed in a perfusion apparatus. The pressure drop across the bone graft and the induced flow were measured and the conductance to fluid flow was calculated as the slope of the flow-pressure relation. Grafts of different flow conductance were transplanted into 35 rabbits to replace segments of tibiae. Nine weeks after grafting, 29 rabbits which had completed the follow-up without incidents were sacrificed. The decalcified sections of the grafts and the adjacent tibiae were examined microscopically for histological events during graft-host interface healing. Perfusion data indicated that fluid conductance ranged from 0.05 x 10(-10) to 13.4 x 10(-10) m3 s-1 Pa-1 and was higher in the direction parallel to the femoral neck axis, inversely proportional to the length of the graft and directly proportional to the square of porosity. Data from rabbit model supported the hypothesis stated above. A threshold conductance was found to be 1.5 x 10(-10) m3 s-1 Pa-1, below which revascularisation and the formations of osteoblasts and fibrous tissues could not be attained. How the low conductance led to non-union at the graft-host interface was briefly discussed.

Ultrasonographic hip morphometry in infants.

Ultrasonographic study of 463 normal children (926 hips) from birth to 6 months of age with equal sex distribution was performed. Hip morphometry, including Graf's alpha and beta angles. Morin's head coverage percentage, and head size were measured. Using the same technique, a group of 52 babies was measured longitudinally from birth to 6 months of age, with three measurements taken for each hip for a total of 312 measurements. Results showed that the boys had a consistently higher alpha angle, a lower beta angle, better head coverage, and larger head size through the 6 months. Differences between the right and left hips were only noted in the beta angle. The containment of the hip was found to increase rapidly in the first 4 months. Comparing data from the longitudinal versus the cross-sectional group, no statistically significant differences were detectable in all the parameters measured. Intraobserver variations were found to be best with alpha angle measurements, with a standard deviation of 3.22 degrees.

Translation of the radius as a predictor of outcome in distal radial fractures of children.

We conducted a retrospective analysis of 94 children with fractures of the distal third of the radius, with or without ulnar fractures, treated by primary closed reduction and plaster. The overall failure rate of 29% was due mainly to irreducibility, inability to maintain reduction and eventual limitation of forearm rotation. Age, sex and severity of angulation were not significant, but the direction of angulation and the degree of translation at either the radial or the ulnar fracture sites were significant risk factors. Translation of the radius was the single most reliable predictor of outcome (83% correct). The risk of failure in fractures with translation of the radius of more than half the diameter of the bone was 60%, compared with 8% for fractures with less translation.

Partial weight bearing after operations for hip fractures in elderly patients.

Factors affecting a patient's ability to carry out partial weight bearing after operation for hip fracture were studied in 100 patients. Seventy-six were able to do so. Significant factors included the muscle power of the good limbs and the mental state, whereas age, body-weight and type of operation were not significant. Logistical regression analysis showed that it was possible to predict a patient's partial weight bearing potential by simply testing the left hand grip and the 'Set' test score.

Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients.

The Gamma nail was introduced for the treatment of peritrochanteric fractures with the theoretical advantage of a load-sharing femoral component which could be implanted by a closed procedure. We report a randomised prospective study of 186 fractures treated by either the Gamma nail or a dynamic hip screw. Gamma nails were implanted with significantly shorter screening times, smaller incisions, and less intraoperative bleeding. The Gamma nail group had a shorter convalescence and earlier full weight-bearing, but there was no significant difference in mortality within six months, postoperative mobility, or hip function at review. More intra-operative complications were recorded in the Gamma nail group, mainly due to the mismatching of the femoral component of the nail to the small femurs of Chinese people. Use of a smaller modified nail reduced these complications. We conclude that with careful surgical technique and the modified femoral component, the Gamma nail is an advance in the treatment of peritrochanteric fractures.

Joint laxity in children.

Joint laxity was measured clinically in 2,360 normal Chinese children aged 3-13 years with equal sex distribution using the Carter Wilkinson five tests and scoring system. Results showed minimal differences due to gender. The degree of joint laxity diminished with age. The knee extension and ankle extension tests were more sensitive than other tests. Chinese children were far more lax throughout the age range, with 100% "laxity" at age 3, 67% laxity at age 6, and 28% laxity at age 12, in contrast to 50, 5, and 1% laxity in the same age group respectively, in large series of Caucasian children.

Angular and rotational profile of the lower limb in 2,630 Chinese children.

Angular and rotational profile of the lower limbs of 2,630 normal Chinese children from newborn to age 12 years were compiled using tibiofemoral angle, intercondylar, intermalleolar distance, medial and lateral rotation of the hip, and thigh-foot angle. Children with clinical tibiofemoral angles, intercondylar or intermalleolar distances tended to be bowlegged at birth, maximally knock-kneed at age 3 and to have normal lower limbs by age 8. Medial hip rotation increased steadily from birth to a maximum of 56 degrees at age 9, and lateral hip rotation decreased from birth to a minimum of 30 degrees at age 9. Significant differences between Chinese children and children of other races were highlighted.

Abnormal renal and splanchnic arterial Doppler pattern in premature babies with symptomatic patent ductus arteriosus.

The flow velocity pattern in the descending aorta, renal arteries, and celiac and superior mesenteric arteries was studied with pulsed Doppler in eight premature babies with symptomatic ductus arteriosus before and after ductal closure, as compared to nine premature babies without ductus arteriosus. There was a decrease or reversal of flow in diastole in the above arteries in babies with ductus and diastolic flow reappeared after ductal closure. This diastolic steal phenomenon has not been previously demonstrated in the abdominal arteries. It may contribute to proneness to ischemic damage of abdominal organs in premature babies.