Obstetric interventions and pregnancy outcomes during the COVID-19 pandemic in England: A nationwide cohort study

Background The COVID-19 pandemic has disrupted maternity services worldwide and imposed restrictions on societal behaviours. This national study aimed to compare obstetric intervention and pregnancy outcome rates in England during the pandemic and corresponding pre-pandemic calendar periods, and to assess whether differences in these rates varied according to ethnic and socioeconomic background. Methods and findings We conducted a national study of singleton births in English National Health Service hospitals. We compared births during the COVID-19 pandemic period (23 March 2020 to 22 February 2021) with births during the corresponding calendar period 1 year earlier. The Hospital Episode Statistics database provided administrative hospital data about maternal characteristics, obstetric inventions (induction of labour, elective or emergency cesarean section, and instrumental birth), and outcomes (stillbirth, preterm birth, small for gestational age [SGA; birthweight < 10th centile], prolonged maternal length of stay (≥3 days), and maternal 42-day readmission). Multi-level logistic regression models were used to compare intervention and outcome rates between the corresponding pre-pandemic and pandemic calendar periods and to test for interactions between pandemic period and ethnic and socioeconomic background. All models were adjusted for maternal characteristics including age, obstetric history, comorbidities, and COVID-19 status at birth. The study included 948,020 singleton births (maternal characteristics: median age 30 years, 41.6% primiparous, 8.3% with gestational diabetes, 2.4% with preeclampsia, and 1.6% with pre-existing diabetes or hypertension); 451,727 births occurred during the defined pandemic period. Maternal characteristics were similar in the pre-pandemic and pandemic periods. Compared to the pre-pandemic period, stillbirth rates remained similar (0.36% pandemic versus 0.37% pre-pandemic, p = 0.16). Preterm birth and SGA birth rates were slightly lower during the pandemic (6.0% versus 6.1% for preterm births, adjusted odds ratio [aOR] 0.96, 95% CI 0.94–0.97; 5.6% versus 5.8% for SGA births, aOR 0.95, 95% CI 0.93–0.96; both p < 0.001). Slightly higher rates of obstetric intervention were observed during the pandemic (40.4% versus 39.1% for induction of labour, aOR 1.04, 95% CI 1.03–1.05; 13.9% versus 12.9% for elective cesarean section, aOR 1.13, 95% CI 1.11–1.14; 18.4% versus 17.0% for emergency cesarean section, aOR 1.07, 95% CI 1.06–1.08; all p < 0.001). Lower rates of prolonged maternal length of stay (16.7% versus 20.2%, aOR 0.77, 95% CI 0.76–0.78, p < 0.001) and maternal readmission (3.0% versus 3.3%, aOR 0.88, 95% CI 0.86–0.90, p < 0.001) were observed during the pandemic period. There was some evidence that differences in the rates of preterm birth, emergency cesarean section, and unassisted vaginal birth varied according to the mother’s ethnic background but not according to her socioeconomic background. A key limitation is that multiple comparisons were made, increasing the chance of false-positive results. Conclusions In this study, we found very small decreases in preterm birth and SGA birth rates and very small increases in induction of labour and elective and emergency cesarean section during the COVID-19 pandemic, with some evidence of a slightly different pattern of results in women from ethnic minority backgrounds. These changes in obstetric intervention rates and pregnancy outcomes may be linked to women’s behaviour, environmental exposure, changes in maternity practice, or reduced staffing levels.

Acute Endovascular Management of a Ruptured Choroidal Artery Arteriovenous Malformation in a Peripartum COVID-19-Positive Patient

Coronavirus disease 2019 (COVID-19) pandemic has led to significant reduction in specialty care causing delayed presentations and decreased resources for elective procedures. We present here a case of a 29-year-old female, 34 weeks primigravida who presented with a twice ruptured right choroidal artery arteriovenous malformation (AVM). She underwent an immediate external ventricular drain placement followed by an emergency cesarean. She underwent a diagnostic angiogram showing a right choroidal AVM with a feeder artery aneurysm along with small supply to its cortical component by the M4 segment of right middle cerebral artery, draining into the basal vein of Rosenthal and vein of Labbe. The patient underwent embolization of the aneurysm and the choroidal feeders. She improved symptomatically following the procedure with external cerebrospinal fluid diversion for 5 days. At follow-up magnetic resonance imaging, the residual AVM remained stable and is planned for Gamma knife radiosurgery. The newborn was taken care at a neonatal intensive care unit and was started on breastfeed on 16th day of birth once the mother had a negative COVID-19 reverse transcription polymerase chain reaction. In this study, we highlight our experience with the above-mentioned patient profile, the multidisciplinary effort during the pandemic, and the measures taken (isolation ward, COVID-19 dedicated Cath-lab and personal precautions) and advised for tackling COVID-19 patients for endovascular procedures.

Estimating the Mode of Delivery through Cause Analysis A Systematic Literature Review on the context of Reducing Cesarean

In developing countries, many health workers force pregnant women in private hospitals having baby through cesarean delivery, even though most pregnant mothers are skeptical about the risk of going under such operations. Doctors often encourage pregnant mothers to have a cesarean on the basis of their physical condition and medical reports. Emergency cesarean patient cannot be prepared in advance but on real time, If a system can be developed that can forecast whether a woman need natural or cesarean delivery, then rate of the risk of the pregnant women get reduce. To design such system, we need to know what factors influences the doctors to choose cesarean over normal delivery. We have conducted a systematic review in well-known databases to understand the various factors of pregnant mothers. A total of 19 studies were selected among 2512 studies based on the relevancy to the research objective. The objective of this study is to predict the mode of delivery based on 10 specific parameters identified separately from 180 parameters present in various test reports.

Puerperal Complications in a Tertiary Hospital

Postnatal period is considered as an important part in reproductive life of women. Even though the antenatal phase and labour are utmost important, puerperal phase of pregnancy cannot be overlooked. Puerperal complication can sometime lead to diabilities for lifelong of women. For the prevention of postnatal complication, antenatal prepadareness is needed. The objective of this study was to find out the incidence of puerperal complications and associated risk factors. This is a retrospective, descriptive study conducted at Tribhuvan University Teaching Hospital, Department of Obstetrics and Gynaecology from April 2019 to March 2020. The cases of puerperal complications were noted from the record book from ward. The individual files were collected from record section. Data was collected from record files and analysed. Total number of deliveries were 4932 in one year. Out of which, 84 cases (1.7%) were admitted due to various puerperal complications. Majority of the women admitted with puerperal complications were between 21-29 years, 59.5%. Sixty-four percent (n=54) were primipara and 35.7%(n=30) were multipara. Seventy-six (90.5%) were term deliveries, 6(7%) were preterm and 2(2.4%) were post term deliveries. Sixty-two (74%) had emergency cesarean section as mode of delivery. Major indication of emergency cesarean section was fetal distress (29.8%, n=25). Surgical site infection (53/84,63%) was the commonest puerperal complication followed by puerperal sepsis (8/84,9.5%). Fifty- three cases of surgical site infection (SSI) were observed in patients who had undergone emergency cesarean section. Associated medical condition like hypertension, diabeties, anemia, obesity was seen in 33.5% (n=33) of the cases. Surgical Site Infection is the most common puerperal complication and commonly seen in women who had undergone emergency cesarean section.

Perioperative Outcomes in COVID-19 Obstetric Patients Undergoing Spinal Anesthesia for Cesarean Section: A Prospective Observational Study

Coronavirus disease 2019 (COVID-19) adds more challenges to the perioperative management of parturients. The aim of this study is to examine perioperative adverse events and hemodynamic stability among COVID-19 positive parturients undergoing spinal anesthesia. This prospective observational investigation was conducted at a tertiary teaching hospital in Jordan between January and June 2021, during which 31 COVID-19 positive parturients were identified. Each COVID-19 positive parturient was matched with a COVID-19 negative parturient who received anesthesia under similar operating conditions as a control group. Of the 31 COVID-19 patients, 22 (71%) were otherwise medically free, 8 (25.8%) were emergency cesarean sections. The sensory level of spinal block after 10 min was T8 (T6–T10) among COVID-19 positive group, compared to T4 (T4–T6) among control group (p = 0.001). There were no significant differences in heart rate, SBP, DBP, and MAP intraoperatively (p > 0.05). Twelve (36.4%) neonates born to COVID-19 positive patients were admitted to NICU, compared to four (11.8%) among control group (p = 0.018). There was no statistically significant difference in postoperative complications. In conclusion, spinal anesthesia is considered a safe anesthetic technique in COVID-19 parturients, and therefore it is the anesthetic method of choice for cesarean deliveries among COVID-19 patients.

Compliance with venous thromboembolism guideline after delivery at Maternity Teaching Hospital, Erbil city, Iraq

Background and objective: Venous thromboembolism is a leading cause of maternal morbidity and mortality. Few published articles have evaluated obstetricians' compliance with thromboprophylaxis guidelines, especially after vaginal delivery. This study aimed to assess obstetricians’ adherence to postpartum thromboprophylaxis guidelines and correlate adherence with the risk factors for venous thromboembolism after vaginal and cesarean delivery. Methods: A cross-sectional study involving 981 women delivered at the Maternity Teaching Hospital, Erbil city, Kurdistan Region, Iraq, was conducted. Obstetricians' compliance with the thromboprophylaxis guideline regarding dose, duration, and indications were recorded. We assessed the risk factors for thromboembolism using the 2015 Royal College of Obstetricians and Gynecologists guideline. Results: Medical thromboprophylaxis was required but not given to 93.2% of the women who delivered vaginally compared with 6.7% of the women who delivered by cesarean section. Women who delivered vaginally had a higher rate of age ˃ 36 years, parity of 3 and more, varicose vein, and current infection (P <0.001). The rates of preeclampsia, preterm labor, and prolonged labor were highest in the emergency cesarean section group (P <0.001). Factors associated with making a wrong decision were having no preeclampsia (odds ratio=15.4; 95% confidence interval=3.4–68.6), post-partum hemorrhage (odds ratio=15.3; 95% confidence interval=2.0–114.2), and vaginal delivery (odds ratio=250.2; 95% confidence interval=110.6–566.0). Conclusion: Obstetricians' compliance with postpartum thromboprophylaxis in the hospital was low, especially after vaginal delivery. Keywords: Thromboprophylaxis; Postpartum; Compliance; Venous thromboembolism; Guideline.

Umbilical Cord Thrombosis: A Rare but Life-threatening Occurrence

Background: Thrombosis of umbilical vessels is a rare but life-threatening pregnancy complication. The correct diagnosis and clinical management of umbilical cord thrombosis remain a challenge. This study aimed to evaluate the meaningful clinical manifestations and features of umbilical cord thrombosis and its optimal management options.Methods: This retrospective study analyzed umbilical cord thrombosis cases enrolled from January 1, 2011, to May 31, 2021. Data were collected from medical archives where the diagnoses of all patients were established by histopathology.Results: A total of 66 patients with umbilical cord thrombosis were enrolled, including 20 patients with intrauterine fetal death and 6 with fatal labor induction in the second trimester. The overall incidence of umbilical cord thrombosis was 0.05% (66/123,746), and the incidence increased significantly in the last 2 years, reaching 0.19% in 2021. The chief complaint was decreased fetal movement (25/60) or nonreactive nonstress test (NST) (19/40). In the 20 patients with intrauterine stillbirth, 8 patients had ignored fetal movement and were referred to the hospital because of ultrasound findings of intrauterine stillbirth. Five patients were misdiagnosed with a single umbilical artery on prenatal ultrasound. Twenty patients underwent emergency cesarean section due to decreased fetal movement and unresponsive fetal monitoring; all neonates were alive. The gross examination of the placenta and cord revealed umbilical cord abnormalities in 26 patients (39.4%, 26/66). The pathological examination revealed venous, venous and arterial, and arterial thrombosis in 74.2%, 12.1%, and 13.6% of patients, respectively.Conclusions: The main manifestation of umbilical cord thrombosis was decreased or disappeared fetal movement. The importance of self-counting fetal movement should be emphasized to patients. The abnormalities in the umbilical cord are the main cause of this phenomenon. Focus on counting fetal movements, electronic fetal monitoring, and specific signs during a prenatal ultrasound can help early identification of umbilical cord thrombi. Emergency cesarean section is recommended to reduce the risk of interrupting the umbilical cord blood flow.

UTERUS DIDELPHYS IN NULLIPAROUS AND MULTIPAROUS WOMEN – A RARE ENTITY

Uterus didelphys is a rare congenital uterine abnormality in which the embryogenetic fusion of the Mullerian ducts fails to occur. It will lead to the formation of a double uterus with two separate cervices and most often a double vagina with a longitudinal septum as well. Here, we present two different cases of uterus didelphys with varied presentations. The first case is a nulliparous woman presented with post-coital bleeding. On examination, two cervical openings with a longitudinal complete vaginal septum were found, conservative management was done. Findings of didelphys uterus were confirmed on USG. The patient was counseled and discharged. The second case is a multiparous woman with previous cesarean delivery, rupture of membranes, and meconium in this pregnancy with term pregnancy taken up for emergency cesarean section. Dense adhesions and a mass on the right side of uterus were found intraoperatively, which on further inspection confirmed to be patent right horn of uterus. Diagnosis of uterus didelphys was made after doing per speculum and per vaginal examination post-cesarean.

Transporting an Artificial Intelligence Model to Predict Emergency Cesarean Delivery: Overcoming Challenges Posed by Interfacility Variation

Research using artificial intelligence (AI) in medicine is expected to significantly influence the practice of medicine and the delivery of health care in the near future. However, for successful deployment, the results must be transported across health care facilities. We present a cross-facilities application of an AI model that predicts the need for an emergency caesarean during birth. The transported model showed benefit; however, there can be challenges associated with interfacility variation in reporting practices.