Maternal and Fetal Outcome of Pregnancy with COVID- 19 in A Tertiary Level Hospital, Bangladesh

Introduction: Pregnant women have long been recognized as a vulnerable population during infectious disease pandemics due to physiological changes in the immune, pulmonary, cardiac and coagulation systems. It is essential to acquire knowledge of pregnancy outcomes, potential complications and neonatal health conditions born to an infected mother with COVID-19. Material and methods: This cross-sectional observational study was conducted in Combined Military Hospital (CMH), Jashore from June 2020 to July 2021 among 100 hospitalized laboratory-confirmed COVID-19 positive pregnant women, patients who had clinical symptoms of COVID but RT PCR negative were excluded. The aim of the study was to evaluate the clinical profile and maternal and fetal outcome of pregnancy. Relevant data were recorded in a preformed data collection sheet and analyzed by SPSS version 20. Results: Among 100 COVID-19 positive hospitalized pregnant women, the mean age of participants was 27years (range 19-40 years), Maximum infection rate observed during 12 to 28 weeks of gestation among the participants, 21% got infected at 37 to 40 weeks of gestation and 20% got infected at 32 to 36 weeks. Seventy-four percent patients underwent delivery during the study & 23% of them continued with ongoing pregnancy; 67 of the participants underwent LUCS and 7 vaginal deliveries were done, 3% had abortion and IUFD 1% ,61% were multipara and 39% were Primipara, associated co-morbidities were subclinical hypothyroidism(15%), pregnancy induced HTN(12%) and GDM(8%); 36% participants were asymptomatic and 44% had mild symptoms, rate of LUCS was higher than (90.64%) vaginal delivery. Among the 73 live births, 80.82% were term and 10.18% were preterm of neonates, small for gestational was seen in the case of 20.55% neonates. Testing for SARS-CoV-2 was performed in all neonatal throat swabs and found positive in one case only. Eighty-six percent neonates were well-baby and 9.58% neonates required NICU admission. There were 2 neonatal deaths due to severe prematurity and 2 babies were found to have congenital cardiac anomaly and cleft lip, cleft palate. Though 36% of patients were asymptomatic but 10% were severe and in the critical stage. HDU support needed for 8% of patients and ICU support for 6%. Conclusion: This cross-sectional study supports that pregnant women with COVID-19 infection are at increased risk of adverse pregnancy and birth outcomes and a low risk of congenital transmission. Availability of ICU in critical conditions is needed for better pregnancy outcomes. J Bangladesh Coll Phys Surg 2022; 40: 10-16

Maternal suicide attempts and deaths in the first year after cesarean delivery

Background Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally. Method All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models. Results Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32–1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88–2.36). Conclusions Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.

Neonatal Intra-Ventricular-Hemorrhage Prevention in Premature at < 30 Weeks Gestational Age

Introduction: Intraventricular Hemorrhage (IVH) is a devastating condition mostly in preterm infants at &lt; 30 weeks GA with large morbidities and mortality usually in the first 72 hours after birth. Prevention seems to be the only way to completely deal with this problem. The IVH prevention in this age group has been studied and includes some strategies such as prenatal corticosteroids, cesarean delivery, careful extraction among others, but still, it has an unacceptably high incidence in this population.Objective: To measure the application of a quality improvement project develop from the "Drive to Zero IVH Prevention Project" presented in a Epiclatino lecture in our unit.Material and method: We design a before and after observational study and measured the incidence of IVH before and after October 2017 when a minimum manipulation protocol was implemented at the Cl&iacute;nica del Country (CDC) unit. We also compare these findings to those of other units in the EpicLatino network. All patients born &lt;30 weeks GA with less than 2 days of age, who survived at least 3 days, and had a neuroimaging taken were included. We compared demographics, diagnosis, and frequency of IVH cases, before Nov 2017 and after from CDC and the from 2018-2019 EpicLatino registry using a bivariate analysis. Results: We collected data from 46 cases before, 40 after implementation, and 203 cases from the EpicLatino registry. Demographic characteristics were very similar in the post-intervention with few statistically significant differences in antenatal steroid use (97.5% post, 96% before and 79.3% Epilatino, p=0.016), prolonged rupture of membranes (15% post, 4% before and 15% EpicLatino, p &lt;0.001), vaginal deliveries (7.5% post, 10.9% before and 24.1% Epilatino, p=0.01), suspended chorioamnionitis (12.5% post, 6% before and 20.2% Epiclatino). We found a significant reduction in IVH after the protocol was implemented with only 5 (7.5%) cases post-intervention compared to 19 (29.4%) case before, and when compared to the 81 (39.1%) cases in the registry, p&lt; 0.001. Most of the cases that occurred in the post-intervention occurred before admission to the unit due to obstetric trauma.Discussion: If a well-controlled delivery minimizing obstetric trauma is achieved, a minimal manipulation protocol appears to significantly decrease the incidence of HIV. Controlled, multicenter studies are still required to confirm these findings.

The relation between head circumference and mid pelvic circumference: A simple index for cephalo-pelvic disproportion evaluation

Introduction: Cephalo-pelvic-disproportion (CPD) is one of the most common obstetric complications. Since CPD is the disproportion between the fetal head and maternal bony pelvis, evaluation of the head-circumference (HC) relative to maternal bony pelvis may be a useful adjunct to pre-labor CPD evaluation. The aim of the present study was a proof-of-concept evaluation of the ratio between HC to pelvic circumference (PC) as a predictor of CPD. Methods: Of 11,822 deliveries, 104 cases that underwent an abdomino-pelvic CT for any medical indication and who underwent normal vaginal deliveries (NVD) (n=84) or cesarean deliveries (CD) due to CPD (n=20) were included retrospectively. Maternal pelvis dimensions were reconstructed and neonatal HC, as a proxy for fetal HC, were measured. The correlation between cases of CPD and Cephalo-Pelvic Circumference Index (CPCI), which represents the ratio between the HC and PC in percent (HC/PC *100) was evaluated. Results: The mid-pelvis cephalo-pelvic circumference index (MP-CPCI) was larger in CD groups as compared to the NVD group: 103±11 vs. 97±8% respectively (p=0.0003). In logistic regression analysis, the MP-CPCI was found to be independently associated with CD due to CPD: each 1% increase in MP-CPCI increased the likelihood of CD for CPD by 11% (aOR 1.11, CI 95% 1.03-1.19, p=0.004). The adjusted odds ratio for CD due to CPD increased incrementally as the MP-CPCI increased, from 3.56 (95%CI, 1.01-12.6) at MP-CPCI of 100, to 5.6 (95%CI, 1.63-19.45) at 105, 21.44 (95%CI, 3.05-150.84) at 110, and 28.88 (95%CI, 2.3-362.27) at MP-CPCI of 115 Conclusions: The MP-CPCI, representing the relative dimensions of the fetal HC and maternal PC, is a simple tool that can potentially distinguish between parturients at lower and higher risk of CPD. Prospective randomized studies are required to evaluate the feasibility of prenatal pelvimetry and MP-CPCI to predict the risk of CPD during labor.

Episiotomy: Evolution of a Common Obstetric Practice at a Public Hospital

Objective This study aimed to evaluate the rate and impact of episiotomy on maternal and newborn outcomes before and after restricted use of episiotomy. Study Design This population-based observational study used an obstetric database of all deliveries since 1990 that has been maintained with quality checks. Inclusion criteria were vaginal deliveries at ≥37 weeks. Exclusion criteria included fetal malformations, multifetal gestations, or fetal deaths known on arrival to Labor and Delivery. The primary outcomes of interest were episiotomy, perineal lacerations, and newborn outcomes. To evaluate the impact of restrictive episiotomy, data from 1990 to 1997 (35% overall episiotomy rate) were compared with data from 2010 to 2017 (2.5% overall episiotomy rate). Univariable analysis of maternal and infant outcomes were performed comparing the two-time epochs with the Pearson's Chi-squared test. Results Overall, 268,415 women met inclusion criteria and 49,089 (18.2%) had an episiotomy. The rate of episiotomy decreased from 37% of deliveries in 1990 to 2% in 2017. A total of 82,082 deliveries occurred in the 1990 to 1997 epoch and 57,183 in 2010 to 2017. Indicated use of episiotomy was associated with a significant decrease in third and fourth degree lacerations. Immediate newborn condition (5-minute Apgar's score ≤3 and umbilical artery pH <7.1) and neonatal outcomes (intraventricular hemorrhage [IVH] grade 3/4, positive culture sepsis, neonatal seizures, and neonatal demise) were not significantly different. Conclusion Selective, indicated use of episiotomy compared with routine was associated with lower rates of third/fourth-degree lacerations with no change in neonatal outcomes. The common obstetric practice of routinely performing episiotomy, presumably to prevent perineal trauma, proved untrue when analyzed over almost three decades. Key Points

Intermittent versus Continuous Catheterization and Differences in the Evolution of Labor: Systematic Review and Meta-analysis

Objective To evaluate the differences between bladder emptying options (permanent catheterization and intermittent bladder emptying/spontaneous urination) regarding the effects on labor length, need of operative vaginal deliveries, and cesarean section rate. Data Sources The search was conducted in MEDLINE, Scopus, Web of Science, and The Cochrane Central Register of Controlled Trials databases. Selection of Studies The survey returned 964 studies. A total of 719 studies were evaluated by title and abstract, of which 4 were selected for inclusion. Data Collection All references were inserted in the Rayyan QCRI tool (Rayyan Systems Inc., Cambridge, MA, USA). The full text of the selected articles was obtained so we could later decide whether or not to include them in this systematic review. Data Synthesis No differences were found in the number of instrumented deliveries or in cesarean section rate between groups. Conclusions After evaluating the studies performed on the topic, we concluded that there is no clear advantage to either method, although continuous catheterization was associated with a greater occurrence of eutocic births. In the remaining outcomes, there were no differences between catheterization types.

Assisted Vaginal Delivery - Preference of Vacuum or Forceps among Obstetricians

Objective: To determine the instrument preference among obstetricians practicing operative vaginal deliveries and to determine the prevalence and risks of vacuum or forceps Assisted Vaginal Delivery (AVD). Methods: This cross-sectional study was carried out in ACS Medical and Hospital, Chennai. A total of 520 obstetricians were included in the study. An online questionnaire was sent to all obstetricians in Chennai. The choice of procedure for specific circumstances, instrument preference [use of vacuum or forceps] and views on the complications encountered in both vacuum and forceps use at vaginal delivery were explored. For the replies, we computed means and percentages for the entire group and distinct subgroups. Risk assessment of outcome with exposure as suitable p-value was included in the statistical analysis. Results: Response rate for the questionnaire was 97% (504/520). The findings suggest that obstetricians preference was more towards vacuum due to their ease of usage. Baseline characteristics were similar between the two groups. Failed vacuum due to slipping of the cup was the most common complication faced - 62%, followed by caput succedaneum 25%, both were statistically significant. The most significant finding was that maternal injuries in the vacuum group were only 2% which was way less than those who had forceps delivery (68%) with a p-value of < 0.001. Conclusion: In this research, physician instrument choice is a significant predictor of results that should be taken into account. Use of vacuum for delivery seemed to be the choice of majority of obstetricians [334 (66%)]. Vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity, whereas neonatal injuries were more common in newborns delivered by vacuum. The choice of instrument should be personalized based on the patient's condition and the obstetrician's experience and expertise.