Volume 48, Issue 5

The new acute respiratory disease severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is highly contagious. It has caused many deaths, despite a relatively low general case fatality rate (CFR). The most common early manifestations of infection are fever, cough, fatigue and myalgia. The diagnosis is based on the exposure history, clinical manifestation, laboratory test results, chest computed tomography (CT) findings and a positive reverse transcription-polymerase chain reaction (RT-PCR) result for coronavirus disease 2019 (COVID-19). The effect of SARS-CoV-2 on pregnancy is not already clear. There is no evidence that pregnant women are more susceptible than the general population. In the third trimester, COVID-19 can cause premature rupture of membranes, premature labour and fetal distress. There are no data on complications of SARS-CoV-2 infection before the third trimester. COVID-19 infection is an indication for delivery if necessary to improve maternal oxygenation. Decision on delivery mode should be individualised. Vertical transmission of coronavirus from the pregnant woman to the fetus has not been proven. As the virus is absent in breast milk, the experts encourage breastfeeding for neonatal acquisition of protective antibodies.

The coronavirus disease 2019 (COVID-19) pandemic has placed great demands on many hospitals to maximize their capacity to care for affected patients. The requirement to reassign space has created challenges for obstetric services. We describe the nature of that challenge for an obstetric service in New York City. This experience raised an ethical challenge: whether it would be consistent with professional integrity to respond to a public health emergency with a plan for obstetric services that would create an increased risk of rare maternal mortality. We answered this question using the conceptual tools of professional ethics in obstetrics, especially the professional virtue of integrity. A public health emergency requires frameshifting from an individual-patient perspective to a population-based perspective. We show that an individual-patient-based, beneficence-based deliberative clinical judgment is not an adequate basis for organizational policy in response to a public health emergency. Instead, physicians, especially those in leadership positions, must frameshift to population-based clinical ethical judgment that focuses on reduction of mortality as much as possible in the entire population of patients served by a healthcare organization.

The novel coronavirus disease 2019 (COVID-19) pandemic is causing concern also for the management and outcome of COVID-19-positive pregnant women and their offspring, as reported cases are rare. Current evidence suggests the association of COVID-19 infection in pregnancy with both severe maternal morbidity requiring intensive care and perinatal complications (preterm birth with consequent neonatal morbidity and even perinatal death). Most of the reported cases focused specifically on the maternal outcomes and possible vertical transmission, but less attention has been paid to fetus as a patient in such pregnancies. The use of antenatal steroids and fetal neuroprotection with magnesium sulfate is clearly underreported. Several recently issued guidelines suggest lowering the upper gestational age for antenatal steroid administration and also advocate extreme caution or even restraining from the use of magnesium sulfate. Also, the rate of cesarean deliveries among COVID-19 women is unacceptably high. Here we provide arguments for NOT changing the existing guidelines and caution against cesarean delivery that was the prevalent delivery mode in the reported cases and case series.

Background The pandemic caused by the new coronavirus SARS-CoV-2 (Covid-19) is quite a challenging experience for the world. At the moment of birth, the fetus is prepared to face the challenge of labor and the exposure to the outside world, meaning that labor and birth represent the first extrauterine major exposure to a complex microbiota. The vagina, which is a canal for reproduction, is by evolution separated (but not far) from the anus and urethra. Passing through the birthing canal is a mechanism for intergenerational transmission of vaginal and gut microorganisms for the vertical transmission of microbiota not only from our mothers and grandmothers but also from earlier ancestors. Methods Many national and international instructions have been developed since the beginning of the Covid-19 outbreak in January 2020 in Wuhan in China. All of them pointed out hygiene measures, social distancing and avoidance of social contacts as the most important epidemiological preventive measures. Pregnancy and neonatal periods are considered as high risk for Covid-19 infection. Results The instructions defined the care for pregnant women in the delivery room, during a hospital stay and after discharge. The controversial procedures in the care of Covid-19-suspected or -positive asymptomatic women in labor were: mode of delivery, companion during birth and labor, skin-to-skin contact, breastfeeding, and visits during a hospital stay. Conclusion There is a hope that instruction on coping with the coronavirus (Covid-19) infection in pregnancy with all proposed interventions affecting mothers, babies and families, besides saving lives, are beneficial and efficient by exerting no harm.

The novel coronavirus disease 2019 (COVID-19) has caused a rapid and massive transition to online education. We describe the response of our Office of Faculty Development at Texas Tech University Health Sciences Center El Paso (TTUHSC EP) to this unprecedented challenge during and after this post-pandemic crisis. The initiatives for emergency transition to eLearning and faculty development described in this paper may serve as a model for other academic health centers, schools, colleges and universities.

If the worries about the coronavirus disease 2019 (COVID-19) pandemic are not already enough, some pregnant women have been questioning whether the hospital is a safe or safe enough place to deliver their babies and therefore whether they should deliver out-of-hospital during the pandemic. In the United States, planned out-of-hospital births are associated with significantly increased risks of neonatal morbidity and death. In addition, there are obstetric emergencies during out-of-hospital births that can lead to adverse outcomes, partly because of the delay in transporting the woman to the hospital. In other countries with well-integrated obstetric services and well-trained midwives, the differences in outcomes of planned hospital birth and planned home birth are smaller. Women are empowered to make informed decisions when the obstetrician makes ethically justified recommendations, which is known as directive counseling. Recommendations are ethically justified when the outcomes of one form of management is clinically superior to another. The outcomes of morbidity and mortality and of infection control and prevention of planned hospital birth are clinically superior to those of out-of-hospital birth. The obstetrician therefore should recommend planned hospital birth and recommend against planned out-of-hospital birth during the COVID-19 pandemic. The COVID-19 pandemic has increased stress levels for all patients and even more so for pregnant patients and their families. The response in this difficult time should be to mitigate this stress and empower women to make informed decisions by routinely providing counseling that is evidence-based and directive.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Background Mother-infant bonding is an emerging perinatal issue. While emergency cesarean deliveries are associated with a risk of bonding disorders, the mode of anesthesia used for emergency cesarean deliveries has never been studied in this context. We aimed to investigate the impact of administering general anesthesia and neuraxial anesthesia to women undergoing cesarean deliveries on mother-infant bonding. Methods This was a retrospective, propensity score-matched multivariable analysis of 457 patients who underwent emergency cesarean deliveries between February 2016 and January 2019 at a single teaching hospital in Japan. The Mother-Infant Bonding Scale (MIBS) scores at hospital discharge and the 1-month postpartum outpatient visit were evaluated in the general anesthesia and the neuraxial anesthesia groups. A high score on the MIBS indicates impaired mother-infant bonding. Results The primary outcome was the MIBS score at hospital discharge in propensity score-matched women. After propensity score matching, the median [interquartile range (IQR)] MIBS scores were significantly higher in the general anesthesia group than those in the neuraxial anesthesia group at hospital discharge [2 (1–4) vs. 2 (0–2); P = 0.015] and at the 1-month postpartum outpatient visit [1 (1–3) vs. 1 (0–2); P = 0.046]. In linear regression analysis of matched populations, general anesthesia showed a significant and positive association with the MIBS scores at hospital discharge [beta coefficient 0.867 (95% confidence interval [CI] 0.147–1.59); P = 0.019] but not at the 1-month postpartum outpatient visit [0.455 (−0.134 to 1.044); P = 0.129]. Conclusion General anesthesia for emergency cesarean delivery is an independent risk factor associated with impaired mother-infant bonding.

Background The primary objective of this study was to compare the fetal cardiac performance index (Tei index) between the fetuses of gestational diabetes mellitus (GDM) mothers and non-GDM mothers; and the secondary objective was to compare various other parameters of fetal cardiac function as well as maternal oxidative stress levels between the groups of GDM and non-GDM mothers. Methods A cross-sectional study was conducted on pregnant women at 24–28 weeks of gestation. All of the participants underwent 100 g, 3-h oral glucose tolerance test (OGTT) as a diagnostic test for GDM and were categorized as non-GDM and GDM group. All participants had fetal echocardiography performed for cardiac function, and then maternal blood samples were collected for biomarker measurements. Results A total of 80 pregnant women, including 43 in the GDM group and 37 in the non-GDM group, were included in the study. The maternal serum 8-isoprostane (8IsoP), tumor necrosis factor-α (TNF-α) and interleukin (IL)-10 levels were significantly higher in the GDM group than those in the non-GDM group (P: 0.028, P: 0.019 and P: 0.031, respectively). The fetal cardiac function parameters were not significantly different between the two groups. Regardless of the GDM status, the fetuses with high levels of oxidative stress (8Isop ≥1000 pg/mg protein) had a significantly higher rate of impaired shortening fraction (SF) of the left ventricle (P: 0.001). Conclusion GDM is significantly associated with an increase in the oxidative stress process, and a high level of oxidative stress was significantly associated with left ventricular (LV) function impairment. Though a correlation between GDM and fetal cardiac function impairment was not clearly demonstrated in this study, this study suggests that GDM patients with a high level of oxidative stress should be evaluated for fetal cardiac function.

Background The aim of the current study is the longitudinal epidemiological study of pregnancies, their outcome and the changes in their treatment, in patients with hemoglobinopathies, during 30 years at a Thalassemia and Sickle Cell Department. Methods The data of a total of 47 pregnancies of 40 women with hemoglobinopathies monitored in the Thalassemia and Sickle Cell Department of Hippokrateio General Hospital of Athens were retrospectively collected. The data were divided and evaluated in two time periods, the first before 2000 and the second between 2000 and 2017. Results There were four miscarriages and 43 completed pregnancies. The mean pregnancy duration was 34.92 weeks. Thalassemia major and thalassemia intermedia patients had higher percentages of in vitro fertilization (IVF) pregnancies and IVF attempts, with the majority of IVF attempts and pregnancies in the time period after 2000. During the period 2000–2017, more women received transfusions and iron chelation therapy both before and during pregnancy compared to the period before 2000. During the period 2000–2017, three women presented hemorrhagic complications. Placental abruption occurred in two cases, while one woman suffered a stroke. Six women had liver disease and two cardiac problems. Conclusion The rate of pregnancies in women with hemoglobinopathies has increased after the year 2000 due to the increased use of IVF technique. Pregnancy planning, close collaboration between gynecologists and hematologists and appropriate pregnancy monitoring are essential for an optimal pregnancy outcome.

Objective To examine the utility of the Healthy Start Screen (HSS), which is an assessment of health, environment, and behavioral risk factors offered to all pregnant women in the state of Florida, in identifying women at risk for developing postpartum depression (PPD). Methods The sample for this Institutional Review Board (IRB)-approved, retrospective study consisted of patients who presented to a women’s clinic for a new prenatal visit. Those patients who completed both the HSS at their prenatal visit and the Edinburgh Postnatal Depression Scale (EPDS) at their postpartum visit were included. We focused on items 1–10 of the HSS, where patients could respond with either “yes” or “no”, and identified a positive EPDS as any score greater than or equal to 12. Results Women who identified as feeling down, depressed or hopeless, feeling alone when facing problems, to having ever received mental health services, or to having any trouble paying bills were more likely to have an EPDS score greater than or equal to 12. Conclusion The HSS, currently mandated by the state of Florida to be offered to all pregnant women, is a useful tool for identifying women at increased risk of developing PPD.

Objective To compare the safety of misoprostol vaginal insert (MVI) for labor induction using standard and adjusted criteria. Methods This was a single-center, comparative cohort study of 138 pregnant women ≥37/0 weeks undergoing labor induction with MVI using standard (69 women; administration for up to 24 h; MVI-24) or adjusted (69 women; administration for up to 10 h; MVI-10) criteria in a tertiary academic center in Germany. The main maternal safety outcomes were the rate of tachysystole and rate of tachysystole requiring tocolysis. Neonatal safety assessments included Apgar score at 5 min and postpartum arterial fetal pH. Results Uterine tachysystole occurred in more women in the MVI-24 group compared with the MVI-10 group [47.8% vs. 25.5%; P = 0.001; relative risk (RR) 2.36 (95% confidence interval [CI]: 1.39–4.00)] and as did uterine tachysystole requiring tocolysis [MVI-24: 26.1% vs. MVI-10: 11.6%; P  =  0.049; RR 2.25 (95% CI: 1.05–4.83)]. The mean 5-min Apgar scores were 9.64 for the MVI-24 group and 9.87 for the MVI-10 (P = 0.016). Low postpartum umbilical arterial pH values occurred more often in the MVI-24 compared with the MVI-10 group (pH 7.10–7.19: 26.1% vs. 20.3% and pH <7.10: 4.4% vs. 0.0%, respectively). Conclusion Adjusted retrieval criteria for MVI of up to 10 h exposure instead of the standard 24 h reduced uterine tachysystole and improved the neonatal outcome.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012–November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28–0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22–0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36–0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01–0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Objective To observe Doppler ultrasound changes in the two segments of the posterior cerebral artery (PCA) in fetuses with transposition of the great arteries (TGA). Methods The peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and velocity-time integral (VTI) of the two segments of PCA (the first segment: PCAS1, the second segment: PCAS2) and of the middle cerebral artery (MCA) were compared in TGA fetuses and normal fetuses. The abnormality rate between the PCAS1-PI and MCA-PI was compared in TGA fetuses. Results The PCAS1-PI and MCA-PI were smaller in the TGA fetuses than in the controls (all P < 0.05), but the PCAS2-PI was unchanged (P > 0.05). The MCA-VTI, PCAS1-VTI, and PCAS2-VTI were larger in the TGA fetuses (all P < 0.05). In the TGA fetuses, the abnormality rate of the PCAS1-PI was significantly higher than that of the MCA-PI (P < 0.05). Conclusion In fetuses with TGA, there were hemodynamic differences between the two segments of the posterior cerebral arteries. Moreover, PCAS1 exhibited signs of vasodilatation more obviously than did the MCA in fetuses with TGA.

Background Group B Streptococcus (GBS) is a common cause of neonatal sepsis. GBS colonization of the newborn gastrointestinal tract (GIT) may be a critical precursor for late-onset infection. Assessment of the rate of neonatal GBS intestinal colonization has generally relied upon culture-based methods. We used polymerase chain reaction (PCR) and culture to determine the rate of GBS transmission to neonates. We hypothesized that PCR may enhance the detection of neonatal GBS colonization of the GIT, and that the rate will be higher when evaluated with PCR as compared to culture. Methods This was a cross-sectional study, in which mothers who were positive for GBS on routine screening and their healthy infants were eligible for recruitment. Newborn stool was collected after 24 h of life and before hospital discharge, and stored at −80°C for culture and PCR targeting the GBS-specific surface immunogenic protein ( sip ) gene. Results A total of 94 mother-infant pairs were enrolled; of these pairs, stool was collected from 83 infants. Based on PCR, the overall GBS transmission rate was 3.6% (3/83). The transmission rate was 2.4% (1/41) among vaginal deliveries and 4.8% (2/42) among cesarean deliveries. The results of culture-based transmission detection were identical. Conclusion These results indicate that the rate of GBS transmission is low and that detection may not be enhanced by PCR methods.

Background Metabolic acidosis, measured in arterial umbilical cord blood at birth, is the most accepted definition of birth asphyxia. The aim of the study was to investigate the rates of metabolic acidosis across the entire range of Apgar score values (0–10) at 1, 5, and 10 min in term infants. Methods In a population-based Swedish cohort of births between 2008 and 2013, we included 85,076 term (≥37 weeks) non-malformed infants with information from umbilical arterial blood gas analyses and complete information on Apgar scores (0–10) at 1, 5, and 10 min. Results Rates of metabolic acidosis generally decreased with increasing Apgar score values. For Apgar score at 1 min, this decrease was consistent from Apgar score 0 (35%) to Apgar score 10 (0%). For Apgar scores at 5 and 10 min, the decrease was consistent for Apgar score values from 6 to 10. Conclusion Although there is a close association between Apgar score values and rates of metabolic acidosis, Apgar score is not and should not be used as a measure of birth asphyxia.

Background Normal development of the human placenta, referred to as villous tree maturation, entails formation of the vasculosyncytial membranes. These structures develop by the approximation of syncytiotrophoblasts with the villous capillary endothelium and constitute the most efficient sites of gaseous exchange in the placenta. Defective maturation of the villous tree can lead to deficient vasculosyncytial membranes, implicated in the high incidence of hypoxic complications. Hypoxia, in turn, can stimulate production of erythropoietin, whereby increased fetal plasma or amniotic fluid concentrations of this hormone reflect fetal hypoxemia. The current study was undertaken to determine whether delayed villous maturation is associated with changes in amniotic fluid erythropoietin concentrations. Methods Placental histologic examination was performed using hematoxylin and eosin. Subsequent to histologic assessment of delayed villous maturation, the diagnosis was confirmed with CD-15 immunohistochemistry. The controls (n = 61) were pregnancies without villous maturation abnormalities, and cases (n = 5) were pregnancies with delayed villous maturation. Amniotic fluid erythropoietin concentrations were measured using a specific immunoassay. Results Concentrations of erythropoietin in the amniotic fluid (1) of controls were less than the limit of detection and (2) of cases with delayed villous maturation were significantly higher than those of controls (P-value = 0.048). Conclusion Delayed villous maturation is associated with higher concentrations of amniotic fluid erythropoietin.