Maternal and Perinatal Outcomes During the COVID-19 Epidemic in Pregnancies Complicated by Gestational Diabetes.

Introduction: Gestational diabetes (GDM) is one of the most common complications in pregnancy, with a prevalence that continues to rise. At the time of the COVID-19 epidemic, immediate reorganisation and adjustment of the system was needed. Telemedicine support was offered in order to provide high-quality treatment to pregnant women. However, the success of the treatment is unknown. We therefore aimed to evaluate COVID-19 epidemic effects on pregnancy outcomes in GDM. Methods: The maternal outcomes (insulin treatment, gestational weight gain, caesarean section, hypertensive disorders) and perinatal outcomes (rates of large and small for gestational age, preterm birth and a composite child outcome) of women visiting a university hospital diabetes clinic from March to December 2020 were compared with those treated in the same period in 2019. Results: Women diagnosed with GDM during the COVID-19 epidemic (n=417), were diagnosed earlier (23.9 [11.7-26.0] vs. 25.1 [21.8-26.7] gestational week), had higher fasting glucose (5.2 [5.0-5.4] vs. 5.1 [4.8-5.3] mmol/l) and earlier pharmacological therapy initiation, and had achieved lower HbA1c by the end of followup (5.1% (32.2 mmol/mol) [4.9% (30.1 mmol/mol)-5.4% (35.0 mmol/mol)] vs. 5.2% (33.3 mmol/mol) [5.0% (31.1 mmol/mol) - 5.4%·(35.5 mmol/mol)], p<0.001) compared to a year before (n=430). No significant differences in perinatal outcomes were found. Conclusions: Although GDM was diagnosed at an earlier gestational age and higher fasting glucose concentration was present at the time of diagnosis, the COVID-19 epidemic did not result in worse glucose control during pregnancy or worse pregnancy outcomes in Slovenia.

Perinatal outcomes in women with severe acute respiratory syndrome coronavirus 2 infection: comparison with contemporary and matched pre-COVID-19 controls.

OBJECTIVES: To compare perinatal outcomes in women with vs. without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: Perinatal outcomes in SARS-CoV-2 positive pregnant women who delivered at our institution between October 27th 2020 and January 31st 2021 were compared to SARS-CoV-2 negative pregnancies (contemporary controls) and historical 2019 controls matched by maternal age, pre-pregnancy body mass index and parity. Testing was performed based on symptoms or close contact at any time during pregnancy and as part of universal screening at hospital admission. Multivariable log-linear regression models were used adjusting for potential confounders (p < 0.05 statistically significant). RESULTS: One thousand three hundred seventeen women delivered at our institution during the study period. 1,124 (85%) tested negative and 193 (15%) positive for SARS-CoV-2. 189 (98%) were infected during third trimester. 19 (10%) were asymptomatic, 171 (89%) had mild to moderate coronavirus disease 2019 (COVID-19), and 3 (2%) were critically ill with one case of maternal death. There were no significant differences in preterm birth, small-for-gestational-age birth weight, congenital anomalies, operative delivery, intrapartum hypoxia, and perinatal mortality in SARS-CoV-2 positive pregnancies compared to contemporary reference group or historical controls from pre-COVID-19 period. Labor was more commonly induced in SARS-CoV-2 positive women compared to reference SARS-CoV-2 negative group (68 [35%] vs. 278 [25%], adjusted odds ratio 1.62; 95% confidence interval 1.14-2.28). CONCLUSIONS: SARS-CoV-2 infection in pregnancy was not strongly associated with adverse perinatal outcomes. While the majority of SARS-CoV-2 positive women had no or mild/moderate symptoms, 2% were critically ill, with one case of maternal death.

Pregnancy After Kidney Transplantation.

BACKGROUND: Pregnancy after kidney transplantation is an uncommon event. In addition to the risk to the child and the mother, pregnancy has a certain risk for the transplanted kidney. METHODS: We made a retrospective analysis of pregnancy and kidney function over a 49-year period in women with transplanted kidneys monitored at the National Transplant Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia. RESULTS: We analyzed 22 pregnancies in 18 women (26-39 years old) 78 ± 37 months after transplantation. Serum creatinine before conception was 92 ± 26 µmol/L; 3 years after delivery, it was 117 ± 67 µmol/L. There were no rejections during pregnancy. Three rejections occurred in the first 9 months after delivery. The median duration of pregnancies was 37 weeks. Preeclampsia occurred in 4 women and severe eclampsia occurred in 2 women. In 19 cases, delivery was by caesarean section. One child was born with trisomy of chromosome 21 and 3 children were born with minor congenital anomalies. CONCLUSIONS: Renal function and proteinuria did not deteriorate 3 years after pregnancy, even after 2 pregnancies. Rejections in the early post-pregnancy period were common. Preeclampsia was more frequent than in the average population. The incidence of major congenital anomalies was comparable to that seen in pregnant women without immunosuppression.

Usefulness of COVID-19 screen-and-test approach in pregnant women: an experience from a country with low COVID-19 burden.

OBJECTIVES: Information on the usefulness of screen-and-test strategies of pregnant women for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is lacking. METHODS: We retrospectively reviewed the Ljubljana Maternity Hospital database and searched for pregnant women, who were admitted to the hospital between March 15 and May 16, 2020, for a planned procedure or hospitalization. Their medical records were examined and SARS-CoV-2 test results were retrieved. RESULTS: During the two-month period analyzed, there were a total of 265 scheduled admissions of pregnant women to our hospital. Two hundred two (76.2%) were tested for SARS-CoV-2 1 day prior to admission. All tested negative for SARS-CoV-2 RNA, regardless of having coronavirus disease 2019 (COVID-19)-compatible signs or symptoms (n=28) or not (n=174). CONCLUSIONS: In a population with a low SARS-CoV-2 burden, usefulness of universal testing of pregnant women before admission to the hospital is limited. We recommend that obstetric units in regions with low SARS-CoV-2 burden enforce rational use of personal protective equipment and diligent screening protocols using targeted questionnaires, whereas SARS-CoV-2 laboratory testing should be performed only in screen-positives: those with high clinical suspicion of COVID-19 and/or suspected epidemiological history.

Changes in perinatal outcomes after implementation of IADPSG criteria for screening and diagnosis of gestational diabetes mellitus: A national survey.

OBJECTIVE: To compare perinatal outcomes before and after implementation of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria for testing of gestational diabetes mellitus (GDM). METHODS: A national, perinatal, registry-based cohort study of prospectively collected data was conducted. Patients with diabetes type 1 or 2 were excluded. Outcomes of 135 786 pregnancies before (January 1, 2004 to May 31, 2010) and 140 524 after (June 1, 2011 to December 31, 2017) the introduction of IADPSG criteria were compared using Student t test and χ2 test (P<0.05 was significant). Multivariable logistic regression was used to compare outcomes controlling for potential confounders. RESULTS: Prevalence of GDM increased from 2.6% to 9.7% (adjusted odds ratio 3.92; 95% confidence interval 3.78-4.08). Incidence of large-for-gestational age (LGA), macrosomia (birth weight >4500 g), Erb's palsy, and hypertensive disorders in pregnancy decreased despite increasing maternal age and pre-pregnancy obesity. Rates of cesarean delivery increased in both GDM and non-GDM groups, with a less pronounced increase in GDM mothers. Incidence of small-for-gestational age (SGA) increased in GDM but not in non-GDM group. CONCLUSION: Implementation of IADPSG criteria in a country with a relatively low prevalence of GDM did not result in higher rates of cesarean delivery and was associated with reductions in LGA and hypertensive disorders in pregnancy.

Planned home birth in Slovenia-Are we ready?

Nowadays, women want a more intimate and familiar atmosphere during labour, which results in increased planned home birth rates. Every woman has the autonomy to decide where she will give birth; however, it is important that she is informed of risks and advantages beforehand. Home births can be distinguished between planned and unplanned home births. Planned home births can be conducted by professional birth attendants (licensed midwives) or birth assistants (doulas, etc). The rates of Slovenian women who decided to deliver at home are increasing year by year. Researches on home births still present discordant data about home birth safety. Their findings have shown that the main advantage of home birth is a spontaneous birth without medical interventions, especially in multiparous low-risk women. The main disadvantage, however, is a higher risk for neonatal death, in particular on occurrence of complications requiring a transfer to hospital and surgical intervention. Global guidelines emphasize careful selection of candidates suitable for home birth, well-informed pregnant women, education of birth attendants, and strict formation of transfer indications.

Preoperative autologous blood donation in placenta previa patients.

OBJECTIVE: The aim of this study was to evaluate the usability of preoperative autologous blood donation (PAD) in pregnant women with placenta previa. STUDY DESIGN: We retrospectively reviewed 142 pregnancies with placenta previa from completed 32 weeks of gestation who underwent a caesarean delivery in University clinical centre Ljubljana, over a five-year period. RESULT: Although more than two thirds of pregnant women met the criteria for PAD, it was justified for approximately 13.6% of them. The decrease in haemoglobin level after PAD was only 4.5 ± 6.7 g/l on average and did not induce anaemia. CONCLUSION: Although our study shows that PAD is not reasonable for the majority of all pregnant women with placenta previa who met the criteria for PAD from our study, we believe that with the implementation of Patient Blood Management it still has its prospects of clinical application. However, further prospective studies are needed to find risk factors for increased surgical bleeding to make a proper patient selection for PAD.

Infant mortality and causes of death by birth weight for gestational age in non-malformed singleton infants: a 2002-2012 population-based study.

OBJECTIVE: To explore the associations between birth weight for gestational age (GA) and infant mortality as well as causes of infant death. STUDY DESIGN: A population-based observational study conducted between 2002 and 2012 included 203,620 non-malformed singleton live births from Slovenia. Poisson regression analyses were performed to estimate the crude relative risk (RR) and adjusted RR (aRR) for infant mortality by birth weight percentiles stratified by the GA subgroups term, moderate-to-late preterm, very preterm and extremely preterm. RESULTS: Compared with appropriate for GA (AGA) term infants (referent-AGA), infant mortality was significantly higher in small for GA (SGA) term infants [aRR=2.79 (1.41-5.50)], with significant cause-specific infant mortality risk for neuromuscular disorders [RR=10.48 (2.62-41.91)]. The differences in infant mortality and cause-specific infant mortality in preterm subgroups between referent-AGA and SGA were insignificant. CONCLUSIONS: In the Slovenian population, birth weight for GA is significantly associated with infant mortality only in infants born at term.

Neonatal respiratory morbidity in late-preterm births in pregnancies with and without gestational diabetes mellitus.

OBJECTIVE: To evaluate neonatal respiratory morbidity in infants born late-preterm to mothers with or without gestational diabetes mellitus (GDM). METHODS: Analysis of a population-based cohort of all live-born singletons, born at 34 0/7 to 36 6/7 weeks to mothers with and without GDM, focusing on transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS). RESULTS: The study group comprised 363 (4.7%) singletons born to mothers with GDM and the controls were 7400 born to mothers without GDM. Mothers with GDM were older (31.4 ± 5.1 versus 29.5 ± 5.1 years, p < 0.001) and were more likely to be hypertensive (OR 1.5, 95% CI 1.1-2.1). Neonates of GDM mothers were heavier at birth (2769 ± 539 versus 2636 ± 473 g, p < 0.001). We found a similar incidence of RDS and TTN in both groups. The multiple regression analysis showed cesarean delivery and lower gestational age were independently associated with RDS and TTN. CONCLUSION: GDM, per se, is not a major contributor to RDS in late pre-term infants. Rather, the combination of prematurity and cesarean birth act independently to increase the risk of respiratory morbidity.

Do tall women beget larger babies?

OBJECTIVE: To evaluate the possible relationship between maternal height and fetal size. PATIENTS AND METHODS: We used a population-based cohort of apparently healthy mothers of singletons to evaluate quartiles of the maternal height distribution for parity, being overweight or obese, and for gestational age and birth weight parameters. We also generated birth weight by gestational age curves for each quartile. RESULTS: We analyzed data of 198,745 mothers. Mother from the four quartiles had similar parity, pre-gravid BMI, and gestational age at birth. Short mothers had a significantly higher rate of VLBW and LBW and 2501-4000 g infants, for an OR = 1.38 (95% CI: 1.17-1.62), OR = 2.2 (95% CI: 2.05-2.37) and OR = 1.82 (95% CI: 1.73-1.87) between the shortest and tallest mothers, respectively. By contrast, the opposite trend was noticed for birth weights >4000 g, for an OR = 2.77 (95% CI: 2.65-2.89) between the tallest and shortest mothers. A very similar "growth curve" was apparent until 33 weeks, when a slower growth velocity was observed for shorter compared with taller women. CONCLUSIONS: Maternal stature does not appear to be associated with gestational age but significantly influences birth weight. Height-related differences between mothers appears to begin after 33 weeks' gestation.

Independent factors influencing large-for-gestation birth weight in singletons born after in vitro fertilization.

PURPOSE: Higher risk for birth of singletons being large for gestational age (LGA) has been revealed after in vitro fertilization (IVF) frozen-thawed embryo-transfer (FET). This phenomenon is now being investigated, since there is a speculation that these neonates could suffer from underlying epigenetic disturbances. The aim of the study was to expose independent LGA risk factors and to identify those connected to the IVF techniques. METHODS: Altogether, 4508 singleton pregnancies and births were included in the cohort case-matched study. Two hundred eleven singleton pregnancies and births after FET and 916 after fresh embryo transfer (ET) were included into two study groups. The IVF procedures were performed at the University Medical Centre Ljubljana between 2004 and 2011. For each IVF pregnancy, three matched consecutive controls after natural conception were included. Using logistic regression models, we observed LGA connection to maternal parameters (smoking, hypertension, parity, BMI, gestational diabetes, IVF conception, FET, double ET, and ICSI procedure). RESULTS: Singletons born after FET had a significantly higher risk for being LGA (p = 0.032; OR 1.697; 95 % CI 1.047-2.752). BMI 25-30 was a significant independent risk factor for LGA in the IVF groups (FET p = 0.041, OR 2.460, 95 % CI 1.030-5.857 and fresh ET p = 0.003; OR 2.188, 95 % CI 1.297-3.691). ICSI and double ET had no significant effect on LGA occurrence. CONCLUSIONS: Besides maternal BMI, FET is a significant independent LGA risk factor in IVF patients. Other observed factors (smoking, hypertension, multiparity, GDM, ICSI procedure, or number of embryos transferred) do not influence LGA risk significantly.

A population-based comparison between actual maternal weight gain and the Institute of Medicine weight gain recommendations in singleton pregnancies.

OBJECTIVE: To compare the actual maternal weight gain to that recommended by the Institute of Medicine (IOM) in term singleton gestations. METHODS: We used data from the Slovenian National Perinatal Information System to select singleton pregnancies born at ≥38 weeks during the period from 2003 to 2012. We calculated the frequencies of mothers who gained less than, more than, and as recommended by the IOM according to their pregravid body mass index (BMI). We also compared the fetal size parameters in under- and over-gainer to those who gained weight as recommended by the IOM. RESULTS: We selected 173,715 patients who delivered at ≥38 weeks. Of these patients, the recommended weight gain was achieved by 56,868 (32.7%, 95% CI 32.5, 32.9) only, 82,617 (47.6%, 95% CI 47.3, 47.8) were over-gainers, and 34,230 (19.7%, 95% CI 19.5, 19.8) gained less than recommended. Neither undergaining nor overgaining were always synonymous with adverse fetal outcomes. CONCLUSIONS: Roughly two-thirds of singleton mothers did not gain weight during pregnancy according to the IOM recommendations. Inappropriate maternal weight gain, however, was not always associated with adverse fetal outcomes and this implies that a tailored approach rather than strict adherence to the IOM recommendations may be more practical.

The relationship between cesarean section rate in term singleton pregnancies, maternal weight, and weight gain during pregnancy.

OBJECTIVE: Pregravid maternal weight and appropriate weight gain during pregnancy might be associated with increased cesarean section rate. STUDY DESIGN: We used data from the Slovenian National Perinatal Information System to select singleton pregnancies born at ≥38 weeks, during the period between 2003 and 2012. We calculated the frequencies of urgent and elective cesarean sections (UCS and ECS, respectively) in mothers who gained less than, more than, and as recommended by the Institute of Medicine (IOM) according to their pregravid body mass index (BMI). RESULTS: The analysis included 170,121 women who delivered singletons ≥38 weeks. A total of 24,327 (14.3%) women underwent cesarean section: 14,692 (8.6%) UCS and 9635 (5.7%) ECS. The frequency of cesareans, both UCS and ECS, increases as BMI increases irrespective of weight gain pattern. The frequency of urgent cesareans in all women increases and that of elective cesareans among obese women decreases as the level of weight gain increases from undergainers to overgainers. CONCLUSION: The combination of pregravid BMI and weight gain pattern is an important determinant of cesarean section rates at term.

Changes in incidence of iatrogenic and spontaneous preterm births over time: a population-based study.

OBJECTIVE: To examine the proportion of iatrogenic births among all preterm births over a 26-year period. PATIENTS AND METHODS: A registry-based survey of preterm deliveries between 1987 and 2012 analyzed by the onset of labor: spontaneous with intact membranes, preterm premature rupture of membranes (PPROM) or iatrogenic. Stratification into categories by gestation (22 weeks to 27 weeks and 6 days, 28 weeks to 31 weeks and 6 days, 32 weeks to 33 weeks and 6 days, 34 weeks to 36 weeks and 6 days) was performed. Preterm birth rates were analyzed using the Mantel-Haenszel linear-by-linear association χ2-test (P<0.05 significant). Logistic regression was used to account for potential confounders. RESULTS: Overall preterm birth rate was 5.9% (31328 deliveries) including 2358 (0.4%) before 28 completed weeks, 3388 (0.6%) between 28 weeks and 31 weeks 6 days, 3970 (0.8%) between 32 weeks and 33 weeks and 6 days, and 21611 (4.1%) between 34 weeks and 36 weeks and 6 days There was an increase in overall preterm birth rate (P<0.001). The rate of iatrogenic preterm births and PPROM increased over time (P<0.001 and P<0.014, respectively). Rates of spontaneous preterm birth decreased (P<0.001). After accounting for potential confounders, year of birth remained an independent risk factor for iatrogenic preterm delivery in all four gestational age categories (P<0.001). CONCLUSION: The incidence of iatrogenic preterm birth is increasing with a concomitant decrease in the incidence of spontaneous preterm birth. Attempts to analyze, interpret and decrease preterm birth rates should consider spontaneous and iatrogenic preterm births separately.

A case of avoidable heterotopic pregnancy after single embryo transfer.

A rare case of a heterotopic pregnancy after single embryo and blastocyst transfer is presented. A couple suffered from idiopathic infertility and underwent assisted reproduction techniques in a university hospital. Intercourse on the day of HCG administration was the probable cause for an in vivo fertilization of an oocyte that was not collected during the oocyte retrieval. The patient accessed a regional hospital with a massive haemoperitoneum in the 11th week of pregnancy with the confusing information that only one embryo had been transferred during the assisted reproduction treatment. After tubal pregnancy removal, the in-utero pregnancy proceeded normally but, at the time of the second trimester scan, a caudal regression syndrome was diagnosed and the patient decided to terminate the pregnancy.

Early prediction of spontaneous twin very preterm birth: a population based study 2002-2012.

OBJECTIVE: The aim of this study was to establish early pregnancy risk indicators for spontaneous twin very preterm birth. METHODS: We conducted a retrospective observational population-based study. Twenty-one potential early pregnancy risk factors were analyzed using multivariable logistic regression to determine which of them was independently associated with spontaneous twin very preterm birth. RESULTS: Of 1815 spontaneous twin births 15.3% (277) occurred before 32 weeks. Previous preterm delivery (aOR 3.73; 95% CI, 2.52-5.52), nulliparity (aOR 2.94; 95% CI, 2.09-4.14), body mass index <18.5 (aOR 1.86; 95% CI, 1.12-3.10), body mass index ≥30 (aOR 1.87; 95% CI, 1.21-2.89), hysteroscopic metroplasty (aOR 1.63; 1.07-2.49), conization (aOR 2.05; 95% CI, 1.07-3.94) and monochorionicity (aOR 1.83; 95% CI, 1.28-2.63) were significantly associated with twin very preterm birth. CONCLUSIONS: Pending verification in other populations, twin pregnancies at significant risk for spontaneous very preterm birth can be identified in early pregnancy using several risk indicators.

Impact of pre-gravid body mass index and body mass index change on preeclampsia and gestational diabetes in singleton and twin pregnancies.

OBJECTIVE: To examine pre-gravid body mass index (BMI) and gestational BMI change impact on preeclampsia and gestational diabetes mellitus (GDM). METHODS: Retrospective population-based cohort study. Data from Slovenian National Perinatal Information System were analyzed for the period 2002-2011. Three singleton controls were matched by parity and maternal age to each twin pregnancy delivered at >36 weeks. Student's t test was used to compare pre-gravid BMI and gestational BMI change in different groups (p < 0.05 significant). RESULTS: 2046 twin and 6138 singleton pregnancies were included. Twin and singleton patients with preeclampsia or GDM had higher pre-gravid BMI (p < 0.001). Gestational BMI change was smaller in twins with GDM (p < 0.001), and not associated with preeclampsia (p = 0.07). Smaller gestational BMI change in singleton pregnancies was associated with GDM (p < 0.001), and greater BMI change with preeclampsia (p = 0.004). CONCLUSIONS: Pre-gravid BMI is more strongly associated with preeclampsia and GDM in twin and singleton pregnancies than gestational BMI change. Smaller gestational BMI change in GDM pregnancies reflect the importance of dietary counseling.