Ability of an obstetric hemorrhage risk assessment tool to predict quantitative peripartum blood loss.

OBJECTIVES: Hemorrhage risk assessment tools have been studied using estimated blood loss. We study the association between peripartum hemorrhage risk assessment score and peripartum quantified blood loss (QBL) in term vaginal and cesarean deliveries. METHODS: This is a retrospective analysis conducted on 3,657 patients who underwent term vaginal and cesarean deliveries at a public hospital in New York City. Utilizing the risk assessment tool developed by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), patients were categorized into low-, medium-, or high-risk groups for postpartum hemorrhage. RESULTS: Medium-risk (B=0.08, SE=0.01, p<0.001) and high-risk (B=0.12, SE=0.02, p<0.001) AWHONN scores were associated with significantly higher QBL as compared to low-risk AWHONN score. Medium-risk approached significance (OR: 1.67, 95 % CI: 1.00, 2.79, p=0.050) and high-risk AWHONN score was significantly associated (OR: 1.95, 95 % CI: 1.09, 3.48, p=0.02) with increased odds for postpartum hemorrhage (≥1,000 mL). Each individual factor comprising the AWHONN score whose percentage in our sample was seen in greater than 2.7 % of patients was independently significantly associated with increased QBL (six of nine factors) and postpartum hemorrhage (four of nine factors). CONCLUSIONS: The AWHONN measure previously validated with estimated blood loss predicted obstetric blood loss with QBL. Although not on the basis of the data shown in our study, we believe that QBL should be routinely used to measure obstetric blood loss.

Risk factors for and pregnancy outcomes after SARS-CoV-2 in pregnancy according to disease severity: A nationwide cohort study with validation of the SARS-CoV-2 diagnosis.

INTRODUCTION: We identified risk factors and outcomes associated with SARS-CoV-2 infection in pregnancy in a universally tested population according to disease severity and validated information on SARS-CoV-2 during pregnancy in national health registers in Denmark. MATERIAL AND METHODS: Cohort study using data from national registers and medical records including all pregnancies between March 1, 2020 and February 28, 2021. We compared women with a validated positive SARS-CoV-2 test during pregnancy with non-infected pregnant women. Risk factors and pregnancy outcomes were assessed by Poisson and Cox regression models and stratified according to disease severity defined by hospital admission status and admission reason (COVID-19 symptoms or other). Using medical record data on actual period of pregnancy, we calculated predictive values of the SARS-CoV-2 diagnosis in pregnancy in the registers. RESULTS: SARS-CoV-2 infection was detected in 1819 (1.6%) of 111 185 pregnancies. Asthma was associated with infection (relative risk [RR] 1.63, 95% confidence interval [CI] 1.28-2.07). Risk factors for severe COVID-19 disease requiring hospital admission were high body mass index (median ratio 1.06, 95% CI 1.04-1.09), asthma (RR 7.47, 95% CI 3.51-15.90) and gestational age at the time of infection (gestational age 28-36 vs < 22: RR 3.53, 95% CI 1.75-7.10). SARS-CoV-2-infected women more frequently had hypertensive disorders in pregnancy (adjusted hazard ratio [aHR] 1.31, 95% CI 1.04-1.64), early pregnancy loss (aHR 1.37, 95% CI 1.00-1.88), preterm delivery before gestational age 28 (aHR 2.31, 95% CI 1.01-5.26), iatrogenically preterm delivery before gestational age 37 (aHR 1.49, 95% CI 1.01-2.19) and small-for-gestational age children (aHR 1.28, 95% CI 1.05-1.54). The associations were stronger among women admitted to hospital for any reason. The validity of the SARS-CoV-2 diagnosis in relation to pregnancy in the registers compared with medical records showed a negative predictive value of 99.9 (95% CI 99.9-100.0) and a positive predictive value of 82.1 (95% CI 80.4-83.7). CONCLUSIONS: Women infected with SARS-CoV-2 during pregnancy were at increased risk of hypertensive disorders in pregnancy, early pregnancy loss, preterm delivery and having children small for gestational age. The validity of Danish national registers was acceptable for identification of SARS-CoV-2 infection during pregnancy.

From "disappointing" to "fantastic": Women's experiences with labor induction in a U.S. tertiary hospital.

OBJECTIVE: The series of interventions that comprise labor induction shape patient experiences; however, patient perceptions are not always considered when structuring the process of care. Through qualitative interviews, we elucidated women's expectations and experiences regarding labor induction. METHODS: Labor induction patients were recruited from a United States tertiary care hospital's postpartum mother-baby unit and invited to participate in semi-structured qualitative interviews. Interview questions included expectations and experiences of the labor induction process, side effects and health outcomes of concern, reflections on personal tolerance of different interventions, and thoughts about an ideal process. RESULTS: Between April and September 2018, 36 women were interviewed. The labor induction process involved a wide range of experiences; when asked to characterize labor induction in one word, responses ranged from horrible, frustrating, and terrifying to simple, fast, and smooth. Inductions were often described as longer than what was expected. The most polarizing induction method was the Foley balloon catheter. Women's concerns regarding side effects largely centered on the health of their baby, and an ideal induction involved fewer interventions. CONCLUSIONS: Experiences with labor induction vary greatly and are related to expectations. The way interventions are introduced influences women's perceptions of control and their ultimate level of contentment with the birthing process. Attention to experiences and preferences has the potential to improve quality of care through communication, shared decision-making, and education.

Health facilities preparedness to deliver maternal and newborn health care in Kilifi and Kisii Counties, Kenya.

INTRODUCTION: Health facility preparedness is essential for delivering quality maternal and newborn care, minimizing morbidity and mortality by addressing delays in seeking skilled care, reaching appropriate facilities, and receiving emergency care. A rapid assessment of 23 government health facilities in Kilifi and Kisii counties identified poor maternal and newborn indicators in 16 facilities. The Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project supported these facilities with training, equipment, and referral linkages. This study focuses on facility preparedness of the 16 facilities to deliver maternal and newborn health services, specifically delays two and three at the end of the project implementation. METHODS: A descriptive cross-sectional study was carried-out on behalf of AQCESS project team by respective county ministry of health in-charge of reproductive maternal newborn and child health programs and trained nurses and medical doctors from Aga Khan health services in December 2019. The study evaluated the accessibility and reliability of drugs, commodities, equipment, personnel, basic necessities (such as water and electricity), and guidelines using validated World Health Organization service availability and readiness assessment tool. The findings of the assessment are presented through frequency and percentage analysis, along with a comparative analysis between the two counties. RESULTS: All the 16 facilities assessed offered routine antenatal care (ANC) and normal delivery, but only two provided comprehensive emergency obstetric and newborn care (CEmONC). Most essential medicines, commodities, and required equipment were available. BEmONC and CEmONC guidelines were present in Kilifi, not in Kisii. One staff member was available 24/7 for cesarean section (CS) in each county, with one anesthetist in Kilifi. Electricity was accessible in all facilities, but only half had secondary power supply. Facilities offering CS had backup generators. CONCLUSION: The Facilities assessed had necessary drugs, commodities, equipment, and requirements, but staffing and guidelines were limited. Kilifi outperformed Kisii in most indicators. Additional support is needed for infrastructure and human resources to deliver quality maternal and newborn health services. Continuous monitoring will facilitate resource allocation based on facility needs.

Severe neonatal birth injury: Observational study of associations with operative, cesarean, and spontaneous vaginal delivery.

AIM: To determine the association of successful and unsuccessful operative vaginal delivery attempts with risk of severe neonatal birth injury. METHODS: We conducted a population-based observational study of 1 080 503 births between 2006 and 2019 in Quebec, Canada. The main exposure was operative vaginal delivery with forceps or vacuum, elective or emergency cesarean with or without an operative vaginal attempt, and spontaneous delivery. The outcome was severe birth injury, including intracranial hemorrhage, brain and spinal damage, Erb's paralysis and other brachial plexus injuries, epicranial subaponeurotic hemorrhage, skull and long bone fractures, and liver, spleen, and other neonatal body injuries. We determined the association of delivery mode with risk of severe birth injury using adjusted risk ratios (RR) and 95% confidence intervals (CI). RESULTS: A total of 8194 infants (0.8%) had severe birth injuries. Compared with spontaneous delivery, vacuum (RR 2.98, 95% CI 2.80-3.16) and forceps (RR 3.35, 95% CI 3.07-3.66) were both associated with risk of severe injury. Forceps was associated with intracranial hemorrhage (RR 16.4, 95% CI 10.1-26.6) and brain and spinal damage (RR 13.5, 95% CI 5.72-32.0), while vacuum was associated with epicranial subaponeurotic hemorrhage (RR 27.5, 95% CI 20.8-36.4) and skull fractures (RR 2.04, 95% CI 1.86-2.25). Emergency cesarean after an unsuccessful operative attempt was associated with intracranial and epicranial subaponeurotic hemorrhage, but elective and other emergency cesareans were not associated with severe injury. CONCLUSIONS: Operative vaginal delivery and unsuccessful operative attempts that result in an emergency cesarean are associated with elevated risks of severe birth injury.

A step towards better audit: The Robson Ten Group classification system for outcomes other than cesarean section.

INTRODUCTION: The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. MATERIAL AND METHODS: All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score <7 at 5 minuteutes. Rates of each outcome and contribution of each group to the total outcome rate were calculated. RESULTS: The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score <7 at 5 minute were observed in preterm deliveries, multiple pregnancies, transverse lie and breech presentation. The largest contribution to the total CS rate was made by women with previous CS delivered by prelabor CS, and nulliparous women with induced or spontaneous labor. The largest contribution to all other outcomes was made by nulliparous women with spontaneous or induced labor and, notably, multiparous women with spontaneous labor and unscarred uterus. CONCLUSIONS: The Robson classification provides a useful framework for analyzing CS rates along with rates of operative vaginal delivery, OASIS, postpartum hemorrhage and low Apgar score. Parallel interpretation of several outcomes allows a systematic and multidimensional audit, helpful for families and healthcare professionals, and can be used for comparisons, assessment of trends and subpopulations.

Obstetric anal sphincter injuries-Maternal, fetal and sociodemographic risk factors: A retrospective register-based study.

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potentially serious long-term consequences and large impact on quality of life. The aim was to determine risk and protective factors for OASIS. MATERIAL AND METHODS: We performed a retrospective register-based observational study. A cohort of 988 988 singleton term deliveries 2005-2016 in Sweden were included. Data from the Swedish Medical Birth Registry and Statistics Sweden were extracted to identify cases of OASIS and maternal and fetal characteristics. Modified Poisson Regression analyses were performed to assess risk factors. RESULTS: The rate of OASIS was 3.5% (n = 34 583). Primiparity (adjusted risk ratio [aRR] 3.13, 95% CI 3.05-3.21), vacuum extraction (aRR 2.79, 95% CI 2.73-2.86), forceps (aRR 4.27, 95% CI 3.86-4.72), and high birthweight (aRR 2.61, 95% CI 2.50-2.72) were associated with a significantly increased risk of OASIS. Increasing maternal age and decreasing maternal height also increased the risk of OASIS. Obesity increased the risk of OASIS (aRR 1.04, 95% CI 1.04-1.08), if fetal birthweight was not adjusted for. Smoking (aRR 0.74, 95% CI 0.70-0.79) and low maternal education (aRR 0.87, 95% CI 0.83-0.92) were associated with a decreased frequency of reported OASIS. Previous cesarean section increased the risk of OASIS (aRR 1.41, 95% CI 1.36-1.47). CONCLUSIONS: Primiparity, instrumental delivery, and high birthweight significantly increased the risk of OASIS. Obesity, low height, increasing age, and previous cesarean section also increased the risk whereas smoking and low maternal educational level were associated with a lower OASIS rate.

Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock.

OBJECTIVE: This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. TARGET POPULATION: All pregnant patients. BENEFITS, HARMS, AND COSTS: Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. EVIDENCE: Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

Impact of Planned Delivery on the Perinatal Outcome of Term Fetuses with Isolated Heart Defects.

OBJECTIVE: Pregnancies complicated by fetal heart defects often undergo a planned delivery prior to term by either induction of labour or cesarean delivery to ensure optimal availability of neonatal care. We aimed to assess whether such planned deliveries achieve their goal of better perinatal care. METHODS: We conducted a retrospective case-control study of pregnancies complicated by isolated fetal cardiac defects, without other fetal comorbidities, managed at a single fetal medicine unit over a 10-year period. Only pregnancies delivered past 37 weeks gestation were included. Patients undergoing elective delivery for care planning reasons only were compared with patients in whom planned delivery was clinically indicated and patients who laboured spontaneously. Obstetric and perinatal outcomes were recorded. RESULTS: Of the 180 pregnancies included in the study, 59 (32.8%) were in the elective group, 49 (27.2%), in the indicated group, and 72 (40%), in the spontaneous group. Mean gestational age at delivery was 39.0 ± 1.1 weeks overall and did not differ between the groups. For the elective group, only 35.6% of deliveries occurred during office hours, which was similar to the 2 other groups. The rate of adverse obstetric or postnatal outcomes was not statistically significantly different between groups. CONCLUSION: Timed delivery at term does not seem to be associated with an increased risk of poor perinatal outcomes. It may improve perinatal care by providing proximity to a neonatal intensive care unit and convenience for patients and providers.

[Impact of prolonged second stage of labor on perinatal morbidity : what is our experience ?] / Impact d'un second stade de travail prolongé sur la morbidité périnatale : quelle est notre expérience?

OBJECTIVE: the management of the second stage of labor and its optimal duration are controversial, particularly for nulliparous women. Our aim is to analyze the impact of a prolonged second stage on perinatal morbidity in our institution. MATERIAL AND METHODS: this is a retrospective study conducted in the University Hospital of Liège (Belgium) from January to July 2019. The 160 patients included were divided into two groups according to the duration of the second stage and compared in terms of mode of delivery, maternal and neonatal morbidity. RESULTS: group 1 (85 %) had a second stage of labor inferior to 3 hours and group 2 (15 %) ? 3 hours. The cesarean deliveries for non-engagement of the fetus were significantly higher in group 2. No significant difference was observed in terms of maternal morbidity. The median Apgar score at 5 minutes was higher in group 1. The proportion of babies transferred to neonatal intensive care and to the neonatology department was higher in group 2. CONCLUSION: we mainly noted an increase in neonatal morbidity when the second stage exceeded 3 hours, which is consistent with literature where an increase in maternal morbidity is also described. Prolonging the second stage therefore seems inappropriate to us in the current state of knowledge.

OBJECTIFS: la gestion du second stade de travail et sa durée optimale sont controversées, particulièrement pour les patientes nullipares. Notre objectif est d'étudier l'impact d'un second stade prolongé sur la morbidité périnatale dans notre institution. Matériel et méthodes : il s'agit d'une étude rétrospective menée au CHU de Liège de janvier à juillet 2019. Les 160 patientes incluses ont été réparties en deux groupes en fonction de la durée du second stade et comparées en termes de mode d'accouchement, morbidité maternelle et néonatale. Résultats : le groupe 1 (85 %) présentait un second stade inf�rieur a 3 heures et le groupe 2 (15 %) ? 3 heures. Les césariennes pour non-engagement étaient significativement plus élevées dans le groupe 2. Aucune différence significative n'a été observée en termes de morbidité maternelle. Le score d'Apgar médian à 5 minutes était plus élevé dans le groupe 1. La proportion de bébés transférés au NIC («Neonatal Intensive Care¼) et en néonatologie était plus élevée dans le groupe 2. CONCLUSION: nous avons principalement noté une majoration de la morbidité néonatale lorsque le second stade dépassait 3 heures, ce qui rejoint la littérature où l'on décrit, également, une majoration de la morbidité maternelle. Prolonger le second stade nous semble, dès lors, inapproprié dans l'état actuel des connaissances.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery. METHODS: A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6-12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model. RESULTS: Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07-2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses. CONCLUSION: Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Rates and indications of caesarean section deliveries in Bhutan 2015-2019: a national review.

BACKGROUND: Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. METHODS: This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. RESULTS: For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). CONCLUSION: Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Value-based care in obstetrics: comparison between vaginal birth and caesarean section.

BACKGROUND: Healthcare costs have substantially increased in recent years, threatening the population health. Obstetric care is a significant contributor to this scenario since it represents 20% of healthcare. The rate of cesarean sections (C-sections) has escalated worldwide. Evidence shows that cesarean delivery is not only more expensive, but it is also linked to poorer maternal and neonatal outcomes. This study assesses which type of delivery is associated with a higher healthcare value in low-risk pregnancies. RESULTS: A total of 9345 deliveries were analyzed. The C-section group had significantly worse rates of breastfeeding in the first hour after delivery (92.57% vs 88.43%, p < 0.001), a higher rate of intensive unit care (ICU) admission both for the mother and the newborn (0.8% vs 0.3%, p = 0.001; 6.7% vs 4.5%, p = 0.0078 respectively), and a higher average cost of hospitalization (BRL14,342.04 vs BRL12,230.03 considering mothers and babies). CONCLUSION: Cesarean deliveries in low-risk pregnancies were associated with a lower value delivery because in addition to being more expensive, they had worse perinatal outcomes.

COVID-19 in pregnancy-characteristics and outcomes of pregnant women admitted to hospital because of SARS-CoV-2 infection in the Nordic countries.

INTRODUCTION: Population-based studies about the consequences of SARS-CoV-2 infection (COVID-19) in pregnancy are few and have limited generalizability to the Nordic population and healthcare systems. MATERIAL AND METHODS: This study examines pregnant women with COVID-19 in the five Nordic countries. Pregnant women were included if they were admitted to hospital between 1 March and 30 June 2020 and had a positive SARS-CoV-2 PCR test ≤14 days prior to admission. Cause of admission was classified as obstetric or COVID-19-related. RESULTS: In the study areas, 214 pregnant women with a positive test were admitted to hospital, of which 56 women required hospital care due to COVID-19. The risk of admission due to COVID-19 was 0.4/1000 deliveries in Denmark, Finland and Norway, and 3.8/1000 deliveries in the Swedish regions. Women hospitalized because of COVID-19 were more frequently obese (p < 0.001) and had a migrant background (p < 0.001) compared with the total population of women who delivered in 2018. Twelve women (21.4%) needed intensive care. Among the 56 women admitted due to COVID-19, 48 women delivered 51 infants. Preterm delivery (n = 12, 25%, p < 0.001) and cesarean delivery (n = 21, 43.8%, p < 0.001) were more frequent in women with COVID-19 compared with women who delivered in 2018. No maternal deaths, stillbirths or neonatal deaths were reported. CONCLUSIONS: The risk of admission due to COVID-19 disease in pregnancy was low in the Nordic countries. A fifth of the women required intensive care and we observed higher rates of preterm and cesarean deliveries. National public health policies appear to have had an impact on the risk of admission due to severe COVID-19 disease in pregnancy. Nordic collaboration is important in collecting robust data and assessing rare outcomes.

SARS-CoV-2 infection in pregnancy in Denmark-characteristics and outcomes after confirmed infection in pregnancy: A nationwide, prospective, population-based cohort study.

INTRODUCTION: Assessing the risk factors for and consequences of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy is essential to guide clinical care. Previous studies on SARS-CoV-2 infection in pregnancy have been among hospitalized patients, which may have exaggerated risk estimates of severe outcomes because all cases of SARS-CoV-2 infection in the pregnant population were not included. The objectives of this study were to identify risk factors for and outcomes after SARS-CoV-2 infection in pregnancy independent of severity of infection in a universally tested population, and to identify risk factors for and outcomes after severe infection requiring hospital admission. MATERIAL AND METHODS: This was a prospective population-based cohort study in Denmark using data from the Danish National Patient Register and Danish Microbiology Database and prospectively registered data from medical records. We included all pregnancies between March 1 and October 31, 2020 and compared women with a positive SARS-CoV-2 test during pregnancy to non-infected pregnant women. Cases of SARS-CoV-2 infection in pregnancy were both identified prospectively and through register linkage to ensure that all cases were identified and that cases were pregnant during infection. Main outcome measures were pregnancy, delivery, maternal, and neonatal outcomes. Severe infection was defined as hospital admission due to coronavirus disease 2019 (COVID-19) symptoms. RESULTS: Among 82 682 pregnancies, 418 women had SARS-CoV-2 infection during pregnancy, corresponding to an incidence of 5.1 per 1000 pregnancies, 23 (5.5%) of which required hospital admission due to COVID-19. Risk factors for infection were asthma (odds ratio [OR] 2.19, 95% CI 1.41-3.41) and being foreign born (OR 2.12, 95% CI 1.70-2.64). Risk factors for hospital admission due to COVID-19 included obesity (OR 2.74, 95% CI 1.00-7.51), smoking (OR 4.69, 95% CI 1.58-13.90), infection after gestational age (GA) 22 weeks (GA 22-27 weeks: OR 3.77, 95% CI 1.16-12.29; GA 28-36 weeks: OR 4.76, 95% CI 1.60-14.12), and having asthma (OR 4.53, 95% CI 1.39-14.79). We found no difference in any obstetrical or neonatal outcomes. CONCLUSIONS: Only 1 in 20 women with SARS-CoV-2 infection during pregnancy required admission to hospital due to COVID-19. Risk factors for admission comprised obesity, smoking, asthma, and infection after GA 22 weeks. Severe adverse outcomes of SARS-CoV-2 infection in pregnancy were rare.

A prospective cohort study of confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy evaluating SARS-CoV-2 antibodies in maternal and umbilical cord blood and SARS-CoV-2 in vaginal swabs.

INTRODUCTION: Evidence about the consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy is rapidly increasing; however, data on antibody response and risk of transmission during pregnancy and delivery are still limited. The aim of this study was to evaluate if SARS-CoV-2 is detectable in vaginal swabs and whether antibodies against SARS-CoV-2 are present in maternal and umbilical cord blood of pregnant women with confirmed SARS-CoV-2. MATERIAL AND METHODS: A single-unit prospective cohort study in Denmark including pregnant women with SARS-CoV-2 infection confirmed by a pharyngeal swab between August 20, 2020, and March 1, 2021, who gave birth during the same period. All patients admitted to the maternity ward and antepartum clinic were screened for SARS-CoV-2 infection. A maternal blood sample and vaginal swabs were collected at inclusion. If included antepartum, these samples were repeated intrapartum when an umbilical cord blood sample was also collected. Swabs were analyzed for SARS-CoV-2 and blood samples were analyzed for SARS-CoV-2 total antibodies. Placental and neonatal swabs as well as placental histopathological examinations were performed on clinical indications. RESULTS: We included 28 women, of whom four had serious maternal or fetal outcomes including one case of neonatal death. Within the first 8 days after confirmed SARS-CoV-2 infection, SARS-CoV-2 was detectable in two vaginal swabs (2/28) and SARS-CoV-2 antibodies were detected in 1 of 13 women. From 16 days after confirmed infection, antibodies were observed in 19 of 21 of women. Antibodies in cord blood were not detected during the first 16 days after confirmed infection (n = 7). However, from 26 days, antibodies were present in 16 of 17 cord blood samples of seropositive mothers. Placental examination in two cases of severe fetal outcomes preceded by reduced fetal movements revealed SARS-CoV-2 in swabs and severe histopathological abnormalities. CONCLUSIONS: SARS-CoV-2 was detected in only 2 of 28 vaginal swabs within 8 days after confirmed infection in pregnant women. Our data suggest that maternal seroconversion occurs between days 8 and 16, whereas antibodies in cord blood of seropositive mothers were present in the majority from 26 days after confirmed infection. Additional data are needed regarding timing of seroconversion for the mother and appearance of antibodies in cord blood.

Residual Defects of the Anal Sphincter Complex Following Primary Repair of Obstetrical Anal Sphincter Injuries at a Large Canadian Obstetrical Centre.

OBJECTIVES: To determine the rates of residual anal sphincter defect following primary repair of obstetrical anal sphincter injury (OASIS), and to assess symptomatology in these patients. METHODS: A retrospective observational study of patients who underwent primary repair of an OASIS sustained at Mount Sinai Hospital from January 2016 to June 2017. Records were reviewed for demographic and obstetrical data, symptoms of anal incontinence (AI), and the results of endoanal ultrasonography (EA-US). RESULTS: One hundred and one women sustained an OASIS during the study period, of whom 53 had EA-US performed at Mount Sinai Hospital; 4 women were excluded from this analysis. There were 42 third-degree tears and 7 fourth-degree tears. EA-US revealed residual defects in 22 patients with third-degree tears and 5 patients with fourth-degree tears (52% vs. 71%; P = 0.44).  Twelve patients with third-degree tears and 4 patients with fourth-degree tears reported AI (29% vs. 57%; P = 0.20). EA-US revealed no evidence of a tear in 14 patients clinically diagnosed with third-degree tears and 1 patient clinically diagnosed with a fourth-degree tear (33% vs. 14%). CONCLUSION: These data demonstrate deficiencies in diagnosis and repair of OASIS. Continued training for health care providers on identification and effective repair of OASIS may improve outcomes for women who experience this complication.

Prevalence-pattern and risk factors of Cesarean section in a multiethnic cohort.

OBJECTIVE: This study was aimed to elucidate the prevalence-pattern and determinant of cesarean section (CS) in a multiethnic cohort from Pakistan. METHODS: Through a cross-sectional study design, women delivering at a tertiary care center were recruited during 2013-2017. Data on socio-demographic variables, obstetric complications and birth outcome were obtained. Descriptive statistics, bivariate and multivariate logistic regression analyses were performed. RESULTS: A total of 5,275 pregnant women were recruited and 43% of the deliveries underwent CS. Odds of CS were significantly higher in subjects originating from Azad JammuKashmir and Sindh regions, speaking Potohari and Pahari languages, women in advance ages, and those who were housewives. CS had significantly lower odds of prenatal mortality but increased odds of postnatal mortality. Obstetric factors that appeared to be significant predictors of CS were multiparity, breech position, fetal distress, oligohydroamniosis, preeclampsia, and previous scar. CONCLUSION: This study revealed high variability in CS in various socio-demographic strata of study population. The obstetric complications highlighted in this study may be reduced by proper perinatal counseling and pregnancy monitoring and should be the focus of intervention programs as suggested in the Millennium Development Goals.

Childbirth after mid-urethral sling surgery: effects on long-term success and complications.

INTRODUCTION AND HYPOTHESIS: To evaluate long-term outcomes in women with one or more childbirths after mid-urethral sling (MUS) surgery and potential differences in outcomes based on mode of delivery. METHODS: A population-based cohort study using data from two national registries. Women registered with childbirth after MUS (case group) or without childbirth after MUS (control group), with equal follow-up time, underwent a structured telephone interview using a validated short-form urinary disease-specific questionnaire. Primary outcomes were current stress urinary incontinence (SUI) rate and change in cure rate. Secondary outcomes were effect of delivery mode, rates of repeat operations for SUI, complications, treatment satisfaction and urgency urinary incontinence rate. Childbirth as an independent risk factor for SUI recurrence was also evaluated. RESULTS: Seventy-two women with and 156 women without childbirth after MUS were included. Median follow-up time was 10 years for both groups. Subjective SUI cure rates were 82% (cases) and 75% (controls), respectively (p = 0.31). A significantly lower SUI cure rate was seen in the women with more than one childbirth after MUS (50% vs. 88% p = 0.006). No differences in primary or secondary outcomes were found between groups at follow-up, nor did mode of delivery affect outcomes. Childbirth after MUS was not an independent risk factor for subjective SUI recurrence (OR 0.8 CI 0.3-1.7). CONCLUSIONS: No differences in outcomes were seen between groups at follow-up independently of delivery mode. However, having more than one delivery after MUS seems to impact the continence status.

Timing of delivery in women with diabetes: A population-based study.

INTRODUCTION: Women with diabetes, and their infants, have an increased risk of adverse events due to excess fetal growth. Earlier delivery, when fetuses are smaller, may reduce these risks. This study aimed to evaluate the week-specific risks of maternal and neonatal morbidity/mortality to assist with obstetrical decision making. MATERIAL AND METHODS: In this population-based cohort study, women with type 1 diabetes (n = 5889), type 2 diabetes (n = 9422) and gestational diabetes (n = 138 917) and a comparison group without diabetes (n = 2 553 243) who delivered a singleton infant at ≥36 completed weeks of gestation between 2004 and 2014 were identified from the Canadian Institute of Health Information Discharge Abstract Database. Multivariate logistic regression was used to determine the week-specific rates of severe maternal and neonatal morbidity/mortality among women delivered iatrogenically vs those undergoing expectant management. RESULTS: For all women, the absolute risk of severe maternal morbidity/mortality was low, typically impacting less than 1% of women, and there was no significant difference in gestational age-specific severe maternal morbidity/mortality between iatrogenic delivery and expectant management among women with any form of diabetes. Among women with gestational diabetes, iatrogenic delivery was associated with an increased risk of neonatal morbidity/mortality compared with expectant management at 36 and 37 weeks' gestation (76.7 and 27.8 excess cases per 1000 deliveries, respectively) and a lower risk of neonatal morbidity/mortality at 38, 39 and 40 weeks' gestation (7.9, 27.3 and 15.9 fewer cases per 1000 deliveries, respectively). Increased risks of severe neonatal morbidity following iatrogenic delivery compared with expectant management were also observed for women with type 1 diabetes at 36 (98.3 excess cases per 1000 deliveries) and 37 weeks' gestation (44.5 excess cases per 1000 deliveries) and for women with type 2 diabetes at 36 weeks' gestation (77.9 excess cases per 1000 deliveries) weeks. CONCLUSIONS: The clinical decision regarding timing of delivery is complex and contingent on maternal-fetal wellbeing, including adequate glycemic control. This study suggests that delivery at 38, 39 or 40 weeks' gestation may optimize neonatal outcomes among women with diabetes.