Impact of Dengue Fever on Pregnancy and Its Outcome

BACKGROUND Dengue fever is a vector-borne disease common in the tropics. It is known to have an adverse effect on pregnant women with unfavourable foetal outcomes. However, only a few studies are addressing this problem. Many of the studies had confounding factors such as the simultaneous occurrence of other vector-borne diseases and maternal health conditions. Therefore, the actual impact of dengue fever on pregnancy and pregnancy outcome is not clear. We wanted to study maternal and foetal outcomes in dengue positive pregnant females. METHODS This is a retrospective study done over 6 months in a tertiary care institute. Data regarding demography, obstetric history, biochemical parameters / blood investigation and pregnancy outcomes were collected and analysed. RESULTS Most of the dengue positive women presented with fever and thrombocytopenia in 44 % of cases. Obstetric complications such as preterm labour, abruption and postpartum haemorrhage (PPH) were common. Caesarean section rate was increased and the most common indication was foetal distress. The need for new-born intensive care unit (NICU) admission for new-born and foetal death was also increased. No evidence of congenital anomaly was found in the study. CONCLUSIONS Antenatal complications like preeclampsia, oligohydramnios; intrapartum complications like abruption, DIC, foetal distress and immediate postpartum complications like postpartum haemorrhage, need for blood, platelet transfusion were common in women with a history of dengue fever especially more in the low platelet group. The maternal and foetal outcomes were compromised and both required intensive care. A high index of clinical suspicion is essential in pregnant women presenting with fever and thrombocytopenia. Early diagnosis and management are essential. KEY WORDS Dengue Fever, Dengue in Pregnancy, Complications of Dengue Fever in Pregnancy

Rhabdomyolysis and Obstetric Correlates: Literature Perspectives for the Obstetric Anesthesiologist

Rhabdomyolysis complicating the antepartum or peripartum period is not a commonly reported finding and where they occur, it can be life-threatening. The problem with rhabdomyolysis during pregnancy or labour is the potential harmful systemic and local effects it can cause. These includes cardiac arrhythmias, acute kidney injury, clotting problems in severe cases [1]. To the fetus, foetal distress or foetal demise could be the end-result where timely management is not initiated [2].

Clinical significance of ultrasonic placental grading during third trimester in hypertensive disorders in pregnancy and its correlation with fetal outcome in tertiary care centre

Background: Hypertension is one of the common complications in pregnancy and contributes significantly to maternal and perinatal morbidity and mortality. The aim of the present study was to study placental grading by grading by ultrasonography in pregnancy complicated with hypertension and normotensive gravidas. To compare the foetal outcome regarding placental grading and its correlation pattern of placental grade distribution, type of delivery, foetal distress, birth asphyxia, foetal maturity, perinatal morbidity and mortality.Methods: The present study was conducted for a period of 12 months, which included 200 patients who attended OPD at PDRMC, Udaipur. Inclusion criteria was hypertensive pregnant women with BP >140/90 mmHg. Exclusion criteria was Pregnancy associated with other medical disorders, twin gestation, renal and cardiovascular disease and diabetes mellitus.Results: 100 pregnant women with preeclampsia as study group. The most common age group in study group is 22-23 Years. The grade III placenta was found early third trimester in study group. Caesarean delivery was more common mode of delivery in grade III placenta. In foetal outcome small for gestational age was more among the grade III placenta. Foetal distress, birth asphyxia, perinatal mortality, morbidity more among the grade III placenta among the study group.Conclusions: Foetal complications were significantly more in study group compared to control group. Ultrasound placental grade III was statistically significant in correlating with foetal complications like foetal distress, birth asphyxia, perinatal morbidity and mortality.

Unique Severe COVID-19 Placental Signature Independent of Severity of Clinical Maternal Symptoms

Background: Although the risk for transplacental transmission of SARS-CoV-2 is rare, placental infections with adverse functional consequences have been reported. This study aims to analyse histological placental findings in pregnancies complicated by SARS-CoV-2 infection and investigate its correlation with clinical symptoms and perinatal outcomes. We want to determine which pregnancies are at-risk to prevent adverse pregnancy outcomes related to COVID-19 in the future. Methods: A prospective, longitudinal, multicentre, cohort study. All pregnant women presenting between April 2020 and March 2021 with a nasopharyngeal RT-PCR-confirmed SARS-CoV-2 infection were included. Around delivery, maternal, foetal and placental PCR samples were collected. Placental pathology was correlated with clinical maternal characteristics of COVID-19. Results: Thirty-six patients were included, 33 singleton pregnancies (n = 33, 92%) and three twin pregnancies (n = 3, 8%). Twenty-four (62%) placentas showed at least one abnormality. Four placentas (4/39, 10%) showed placental staining positive for the presence of SARS-CoV-2 accompanied by a unique combination of diffuse, severe inflammatory placental changes with massive perivillous fibrin depositions, necrosis of syncytiotrophoblast, diffuse chronic intervillositis, and a specific, unprecedented CD20+ B-cell infiltration. This SARS-CoV-2 placental signature seems to correlate with foetal distress (75% vs. 15.6%, p = 0.007) but not with the severity of maternal COVID-19 disease. Conclusion: We describe a unique placental signature in pregnant patients with COVID-19, which has not been reported in a historical cohort. We show that the foetal environment can be seriously compromised by disruption of placental function due to local, devastating SARS-CoV-2 infection. Maternal clinical symptoms did not predict the severity of the SARS-CoV-2-related placental signature, resulting in a lack of adequate identification of maternal criteria for pregnancies at risk. Close foetal monitoring and pregnancy termination in case of foetal distress can prevent adverse pregnancy outcomes due to COVID-19 related placental disease.

Fetomaternal outcome and effect of ursodeoxycholic acid in patients of obstetric cholestasis

Background: The objective of this study was to determine fetomaternal outcome and effect of ursodeoxycholic acid in patients of obstetric cholestasis.Methods: This study was prospective observational descriptive study of 130 women, which was conducted in the department of obstetrics and gynaecology, Deen Dayal Upadhayay Hospital, New Delhi. Statistical analysis was performed using the z test when appropriate. A p value of <0.05 will be considered statistically significant.Results: Spontaneous onset of labour was present in 48.5% of patients, induction was done in 31.5% of patients and in rest 20% of patients LSCS was indicated. Normal vaginal delivery occurred in 97 of 130 patients while emergency LSCS done 33 of 130 patients. Emergency LSCS was done in 16 of 33 patients due to foetal distress. Pre-term delivery and PROM occurred in 8.5% and 9.2% of patients respectively while PPH occurred in 12.3% of patients. Among the 130 cases included in present study 34 patients (27.2%) had fetal distress, 41 patients (31.5%) had MSL and 40 neonates (32.0%) required NICU. 16 neonates out of 130 (12.8%) had birth weight below 2.5 kg. Apgar score was <7 after 5 min in 31 neonates.Conclusions: Ursodeoxycholic acid (UDCA) is useful in relieving symptoms and decreasing the biochemical markers.

Analysis of Caesarean Section Rates by Robson’s Classification

BACKGROUND A standard and comprehensive classification system is needed to maintain appropriate Caesarean section (CS) rates like Robson Ten Group Classification System. The present study was conducted to analyse Caesarean section rate and its distribution according to Robson’s classification. METHODS A descriptive study was conducted in the Department of Obstetrics and Gynaecology, Deen Dayal Upadhyay Hospital, Hari Nagar, New Delhi, from August 2018 to May 2019 on pregnant women of more than 28 weeks of gestation admitted for delivery. RESULTS Out of 8099 deliveries, 2924 required Caesarean section. The overall Caesarean section rate was 36.11 %, 1616 (55.27 %) were primary Caesarean section and 1308 (44.73 %) were repeat Caesarean section. Preterm delivery by Caesarean section was in 7.49 %. Majority of Caesarean section were in 37- 40 weeks of gestation (79.42 %). Out of 2924 cases 90.62 %, 8.21 % and 1.17 % were cephalic presentation, breech and other presentations respectively. 32 Caesarean section cases were twin pregnancy, 20.83 % was induced whereas 23.91 % was in spontaneous labour. Previous Caesarean section (44.74 %) was the commonest cause followed by foetal distress (16.82 %). Commonest cause for repeat Caesarean section was foetal distress (25.76 %). Major contributor to overall Caesarean section rate was Robson’s group 5 (38.72 %) followed by group 2 and group 1 i.e 21.64 % and 11.79 % respectively. Least contributor was group 8 (1.09 %). CONCLUSIONS Robson’s classification can help to identify broad categories of women to be targeted to decrease Caesarean section rates. Caesarean section rate can be reduced by decreasing primary Caesarean section, offering trial of labour (TOLAC), strict induction protocols implementation and precise interpretation of foetal heart rate tracings. KEYWORDS Caesarean Section, Robson’s Classification, Malpresentation

Pattern of primary caesarean deliveries in a Nigerian tertiary hospital

Background: Primary caesarean section (CS) has become a major driver of the steadily rising total caesarean rate. This study determined the primary CS rate, pattern and associated factors.Methods: It was a retrospective, hospital-based cross-sectional study of 645 pregnant women who had primary caesarean section over a 3-year period in Lagos state university teaching hospital, Lagos, Nigeria. Data obtained were expressed in frequency and percentages.Results: Primary CS accounted for more than 50% of all the CS done during the study period with a primary CS rate of 16.7% and total CS rate was 30.6%. Primary CS was commonest among women of age group 30-39years (50.1%) and women with no prior parous experience (58.6%). The commonest indication for primary CS was poor progress in labour due to cephalopelvic disproportion, which occurred in 170 women (26.4%), followed by suspected foetal distress in 94 women (14.6%) and hypertensive disease in pregnancy in 91 women (14.1%). Post-operative wound infection and/or dehiscence was the most prevalent post-operative complication occurring in 12.1% of women who had primary CS.Conclusions: Primary CS rate is increasing and relatively more common among primiparous women. Cephalopelvic disproportion, suspected foetal distress and hypertensive disorders of pregnancy are the leading indications for primary CS.

General versus regional anaesthesia for caesarean section indicated for acute foetal distress: a retrospective cohort study

Background Acute foetal distress (AFD) is a life-threatening foetal condition complicating 2% of all pregnancies and accounting for 8.9% of caesarean sections (CS) especially in developing nations. Despite the severity of the problem, no evidence exists as to the safest anaesthetic technique for the mother and foetus couple undergoing CS for AFD. We aimed to compare general anaesthesia (GA) versus regional (spinal and epidural) anaesthesia in terms of their perioperative maternal and foetal outcomes. Methods We carried out a retrospective cohort study by reviewing the medical records of all women who underwent CS indicated for AFD between 2015 to 2018 at the Douala General Hospital, Cameroon. Medical records of neonates were also reviewed. We sought to investigate the association between GA, and regional anaesthesia administered during CS for AFD and foetal and maternal outcomes. The threshold of statistical significance was set at 0.05. Results We enrolled the medical records of 117 pregnant women who underwent CS indicated for AFD. Their mean age and mean gestational age were 30.5 ± 4.8 years and 40 weeks respectively. Eighty-three (70.9%), 29 (24.8%) and 05 (4.3%) pregnant women underwent CS under SA, GA and EA respectively. Neonates delivered by CS under GA were more likely to have a significantly low APGAR score at both the 1st (RR = 1.93, p = 0.014) and third-minute (RR = 2.52, p = 0.012) and to be resuscitated at birth (RR = 2.15, p = 0.015). Past CS, FHR pattern on CTG didn’t affect these results in multivariate analysis. Adverse maternal outcomes are shown to be higher following SA when compared to GA. Conclusion The study infers an association between CS performed for AFD under GA and foetal morbidity. This, however, failed to translate into a difference in perinatal mortality when comparing GA vs RA. This finding does not discount the role of GA, but we emphasize the need for specific precautions like adequate anticipation for neonatal resuscitation to reduce neonatal complications associated with CS performed for AFD under GA.

Health care workers’ experiences of managing foetal distress and birth asphyxia at health facilities in Northern Uganda

Background Birth asphyxia is one of the leading causes of intrapartum stillbirth and neonatal mortality worldwide. We sought to explore the experiences of health care workers in managing foetal distress and birth asphyxia to gain an understanding of the challenges in a low-income setting. Methods We conducted in-depth interviews with 12 midwives and 4 doctors working in maternity units from different health facilities in Northern Uganda in 2018. We used a semi-structured interview guide which included questions related to; health care workers’ experiences of maternity care, care for foetal distress and birth asphyxia, views on possible preventive actions and perspectives of the community. Audio recorded interviews were transcribed verbatim and analysed using inductive content analysis. Results Four categories emerged: (i) Understanding of and actions for foetal distress and birth asphyxia including knowledge, misconception and interventions; (ii) Challenges of managing foetal distress and birth asphyxia such as complexities of the referral system, refusal of referral, lack of equipment, and human resource problems, (iii) Expectations and blame from the community, and finally (iv) Health care worker’ insights into prevention of foetal distress and birth asphyxia. Conclusion Health care workers described management of foetal distress and birth asphyxia as complex and challenging. Thus, guidelines to manage foetal distress and birth asphyxia that are specifically tailored to the different levels of health facilities to ensure high quality of care and reduction of need for referral are called for. Innovative ways to operationalise transportation for referral and community dialogues could lead to improved birth experiences and outcomes.

Association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes: a cohort study

ObjectivesThe secondary impacts of the COVID-19 pandemic on adverse maternal and neonatal outcomes remain unclear. In this study, we aimed to evaluate the association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes.DesignWe conduced retrospective analyses on two cohorts comprising 7699 pregnant women in Beijing, China, and compared pregnancy outcomes between the pre-COVID-2019 cohort (women who delivered from 20 May 2019 to 30 November 2019) and the COVID-2019 cohort (women who delivered from 20 January 2020 to 31 July 2020). The secondary impacts of the COVID-2019 pandemic on pregnancy outcomes were assessed by using multivariate log-binomial regression models, and we used interrupted time-series (ITS) regression analysis to further control the effects of time-trends.SettingOne tertiary-level centre in Beijing, ChinaParticipants7699 pregnant women.ResultsCompared with women in the pre-COVID-19 pandemic group, pregnant women during the COVID-2019 pandemic were more likely to be of advanced age, exhibit insufficient or excessive gestational weight gain and show a family history of chronic disease (all p<0.05). After controlling for other confounding factors, the risk of premature rupture of membranes and foetal distress was increased by 11% (95% CI, 1.04 to 1.18; p<0.01) and 14% (95% CI, 1.01 to 1.29; p<0.05), respectively, during the COVID-2019 pandemic. The association still remained in the ITS analysis after additionally controlling for time-trends (all p<0.01). We uncovered no other associations between the COVID-19 pandemic and other pregnancy outcomes (p>0.05).ConclusionsDuring the COVID-19 pandemic, more women manifested either insufficient or excessive gestational weight gain; and the risk of premature rupture of membranes and foetal distress was also higher during the pandemic.