Maternal Survival Research Articles

Health facility preparedness of maternal and neonatal health services: a survey in Jumla, Nepal

BackgroundOver the past 20 years, Nepal has seen major improvements in childhood and maternal survival. In 2015, the Nepalese government introduced a new federal political structure. It is unclear how this has affected the health system, and particularly, maternal and child health care. Hence, this study aims to describe and analyse health facility preparedness in the light of the federalization process with regards to providing appropriate and timely maternal and neonatal health services.MethodsA descriptive cross-sectional study was conducted in Jumla district, Nepal in 2019 covering all 31 state health facilities (HF) to assess the availability of maternal and neonatal health services including appropriate workforce and access to essential medicines. Tests of association between demographic factors and the probability of a facility experiencing a shortage of essential medicine within the last 3 months were also conducted as exploratory procedures.ResultsOut ot 31 HFs, more than 90% of them had all their staff positions filled. Most facilities (n = 21) had experienced shortages of essential medicines within the past 3 months. The most common out of stock medicine were: Amoxicillin (n = 10); paracetamol (n = 10); Vitamin A (n = 7); and Metronidazole (n = 5). Twenty-two HFs had referred maternal and newborn cases to a higher centre within the past 12 months. However, more worryingly, twenty HFs or their catchment communities did not have emergency ambulance transport for women and newborns.ConclusionHFs reported better staffing levels than levels of available drugs. HFs should be supported to meet required minimal standards such as availability of essential medicines and the provision of emergency ambulance transport for women and newborns.

A novel intervention combining supplementary food and infection control measures to improve birth outcomes in undernourished pregnant women in Sierra Leone: A randomized, controlled clinical effectiveness trial.

BackgroundInnovations for undernourished pregnant women that improve newborn survival and anthropometry are needed to achieve the Sustainable Development Goals 1 and 3. This study tested the hypothesis that a combination of a nutritious supplementary food and several proven chemotherapeutic interventions to control common infections would increase newborn weight and length in undernourished pregnant women.Methods and findingsThis was a prospective, randomized, controlled clinical effectiveness trial of a ready-to-use supplementary food (RUSF) plus anti-infective therapies compared to standard therapy in undernourished pregnant women in rural Sierra Leone. Women with a mid-upper arm circumference (MUAC) ≤23.0 cm presenting for antenatal care at one of 43 government health clinics in Western Rural Area and Pujehun districts were eligible for participation. Standard of care included a blended corn/soy flour and intermittent preventive treatment for malaria in pregnancy (IPTp). The intervention replaced the blended flour with RUSF and added azithromycin and testing and treatment for vaginal dysbiosis. Since the study involved different foods and testing procedures for the intervention and control groups, no one except the authors conducting the data analyses were blinded. The primary outcome was birth length. Secondary outcomes included maternal weight gain, birth weight, and neonatal survival. Follow-up continued until 6 months postpartum. Modified intention to treat analyses was undertaken. Participants were enrolled and followed up from February 2017 until February 2020.Of the 1,489 women enrolled, 752 were allocated to the intervention and 737 to the standard of care. The median age of these women was 19.5 years, of which 42% were primigravid. Twenty-nine women receiving the intervention and 42 women receiving the standard of care were lost to follow-up before pregnancy outcomes were obtained. There were 687 singleton live births in the intervention group and 657 in the standard of care group. Newborns receiving the intervention were 0.3 cm longer (95% confidence interval (CI) 0.09 to 0.6; p = 0.007) and weighed 70 g more (95% CI 20 to 120; p = 0.005) than those receiving the standard of care. Those women receiving the intervention had greater weekly weight gain (mean difference 40 g; 95% CI 9.70 to 71.0, p = 0.010) than those receiving the standard of care. There were fewer neonatal deaths in the intervention (n = 13; 1.9%) than in the standard of care (n = 28; 4.3%) group (difference 2.4%; 95% CI 0.3 to 4.4), (HR 0.62 95% CI 0.41 to 0.94, p = 0.026). No differences in adverse events or symptoms between the groups was found, and no serious adverse events occurred. Key limitations of the study are lack of gestational age estimates and unblinded administration of the intervention.ConclusionsIn this study, we observed that the addition of RUSF, azithromycin, more frequent IPTp, and testing/treatment for vaginal dysbiosis in undernourished pregnant women resulted in modest improvements in anthropometric status of mother and child at birth, and a reduction in neonatal death. Implementation of this combined intervention in rural, equatorial Africa may well be an important, practical measure to reduce infant mortality in this context.Trial registrationClinicalTrials.gov NCT03079388.

Coronary Artery Diseases During Pregnancy: Minimizing Adverse Consequences and Improving Clinical Outcome

Coronary artery disease in pregnancy is a catastrophic situation that may endanger the lives of both the mother and the fetus. Cardiac diseases may account for up to 15% of maternal mortality. Pregnancy may increase the risk of acute myocardial infarction up to 4-fold. Various hemodynamic derangements may occur during pregnancy including expansion of plasma and blood volume, compression of inferior vena cava and fall in both systemic and pulmonary vascular resistances. If pregnant women present with acute coronary artery disease, medical management should be attempted first and if any intervention or surgery is needed, efforts must be made to lower the risk. A multidisciplinary approach is essential involving obstetrician, cardiologist, cardiac surgeons, anesthesiologist and neonatologists or pediatrician. Pregnancy is considered to be a relative contraindication to thrombolytic therapy due to some complications. Revascularization may be considered in acute coronary syndrome in pregnant women like other nonpregnant patients. Primary per cutaneous coronary intervention or coronary artery bypass graft have been performed successfully during pregnancy and may be considered as therapeutic option in pregnancy in selective cases. Percutaneous coronary intervention (PCI) is considered to be relatively safe for maternal and fetal survival during pregnancy. Main worry in PCI is radiation exposure and need to dual antiplatelet therapy. Bare metal stent is preferred during pregnancy because of shorter duration of anticoagulation therapy. Early second trimester is the optimum surgical period to coronary artery bypass surgery (CABG) in pregnant women. Coronary artery bypass surgery can be safely done after 28 weeks of gestational age and immediately after cesarean section. Early detection, a multidisciplinary approach and timely interventions must be considered in coronary artery disease in pregnancy for better obstetric outcome. Cardiovasc j 2021; 14(1): 61-69

Ethically designing research to inform multidimensional, rapidly evolving policy decisions: Lessons learned from the PROMISE HIV Perinatal Prevention Trial.

Research in rapidly evolving policy contexts can lead to the following ethical challenges for sponsors and researchers: the study's standard of care can become different than what patients outside the study receive, there may be political or other pressure to move ahead with unproven interventions, and new findings or revised policies may decrease the relevance of ongoing studies. These ethical challenges are considerable, but not unprecedented. In this article, we review the case of a multinational, randomized, controlled perinatal HIV prevention trial, the "PROMISE" (Promoting Maternal Infant Survival Everywhere) study. PROMISE compared the relative efficacy and safety of interventions to prevent mother to child transmission of HIV. The sponsor engaged an independent international ethics panel to address controversy about the study's standard of care and relevance as national and international guidelines changed. This ethics panel concluded that continuing the PROMISE trial as designed was ethically permissible because: (1) participants in all arms received interventions that were effective, and there was insufficient evidence about whether one intervention was more effective or safer than the other, and (2) data from PROMISE could be useful for a diverse range of stakeholders. In general, trials designed to inform rapidly evolving policy issues should develop mechanisms to revisit social value while recognizing that the value of research varies for diverse stakeholders with legitimate reasons to weigh evidence differently. We conclude by providing four reasons that trials may depart from the standard of care after a change in policy, while remaining ethically justifiable, and by suggesting how to improve existing trial oversight mechanisms to address evolving social value.

Incidence of childhood hearing loss after in utero exposure to platinum agents.

When treated for childhood cancers, at least 50% of children exposed to platinum agents have permanent hearing loss. We determined the relative risk of childhood hearing loss after in utero exposure to platinum chemotherapy in our registry cohort. After exposure to platinum chemotherapy in utero, all children undergo routine newborn hearing screening. This consists of Otoacoustic Emissions. Children who failed this screen were evaluated by audiologists. For those children with hearing loss by Automated Auditory Brainstem Response, prenatal and postnatal treatment details were compared to platinum exposed children without hearing loss. Three hundred and seven children were exposed to chemotherapy in utero. Four children were diagnosed with hearing loss, all exposed to platinum agents. Chemotherapy exposures included: Cisplatin/Paclitaxel (2), Etoposide/Cisplatin/Bleomycin (1), Carboplatin/Paclitaxel (1) to treat ovarian (2), or cervical cancer (2). Of the 39 platinum exposed without hearing loss: 11 children were exposed to oxaliplatin, 16 were exposed to cisplatin and 12 to carboplatin in utero. Two hundred and sixty four women received non-platinum based chemotherapy for various cancers during pregnancy. Among these, there were no cases of hearing loss. There was a significant difference in hearing loss based on exposure to platinum agents in utero compared to non-platinum-containing chemotherapy regimens, 4/43 versus 0/264, p=0.0003. There were no statistical differences in prenatal and postnatal treatment details, including: gestational age at diagnosis, at first chemotherapy treatment, at first platinum treatment, at delivery (<32weeks, <35weeks, <37weeks), gender, birthweight, birthweight percentile, rates of intrauterine growth restriction, neonatal complications or use of postnatal antibiotics between the platinum exposed children with and without hearing loss. The only children in the registry exposed to chemotherapy who were diagnosed with hearing loss had been exposed to cisplatin or carboplatin in utero. No hearing loss occurred in children exposed to oxaliplatin, or non-platinum agents. Due to a concern for cisplatin ototoxicity, carboplatin is the preferred platinum agent for use in pregnancy when equivalent maternal survival can be expected for the particular cancer type. For newborns exposed to platinum agents in utero, newborn screening with an auditory emissions test at birth (OES) may not detect sensorineural hearing loss and auditory brainstem response testing is recommended, regardless of the newborn screening result.

Spatial patterns of maternal mortality causes in West Kalimantan, Indonesia

Background: Maternal Mortality Rate (MMR) is one of the health indicators to see maternal survival in general and is a component in the health development index. Maternal Mortality Rate is also an important indicator of the quality of health services and the performance of the Health system.Objective: This study aimed to analyze the spatial patterns of maternal mortality based on the mortality causes in Sambas District, West Kalimantan, Indonesia.Methods: This study used a descriptive and exploratory approach to be able to see the distribution of maternal mortality and the coverage of the distribution of health care facilities. A spatial pattern was carried out to analyze the distribution pattern of maternal mortality cases using the Average Nearest Neighbor.Results: The results showed that most maternal mortality causes include bleeding, pregnancy hypertension, circulation system disorders (heart, stroke), metabolic disorders (diabetes mellitus), and other causes, such as pulmonary embolism. The analysis using a buffer of 3 kilometers and 5 kilometers show that not all the areas are covered by health service facilities in the Sambas district. Analysis of the mean of the nearest neighbors showed that the Nearest Neighbor ratio was 1.039398 with a z-score of 1.022396, which means that the pattern of distribution of maternal death according to the cause of death has a random pattern.Conclusion: The spatial pattern of cases of maternal death according to the cause of death in the Sambas district, West Kalimantan, Indonesia, has a random pattern. This finding can be used as a basis for decreasing the maternal mortality rate.

Pregnancy outcomes after kidney transplantation

BackgroundSome complications are frequently seen in pregnancies with kidney transplantation and graft functions may be impaired. In this study, it was aimed to examine the course and results of pregnancies after transplantation, the effect of pregnancy on graft functions and the risk factors in complications in these pregnancies. MethodsA total of 24 pregnancies conceived after kidney transplantation due to end-stage renal disease between January 2013 and December 2020 and followed up in the Obstetrics and Gynecology clinic of our hospital were included in the study. ResultsThe mean age was 31.8±6.4, the mean time between transplantation and pregnancy was 54±36 months, and the mean newborn weight was 1945±529.5 grams.Of the pregnancies, abortion occurred in one (4.2%), preterm delivery in 17 (70.3%), and intrauterine growth retardation (IUGR) in 10 (41.7%). Immunosuppressant treatment was given to all pregnant women due to transplantation, and all women used tacrolimus. No graft rejection was seen.The median serum creatinine level did not show a significant change during pregnancy according to the prenatal value (p>0.05 for each), and it increased significantly in the 6th month (p=0.006) and 3rd year (p=0.007) measurements. Urine protein level increased significantly in the third trimester compared to pre-pregnancy (p=0.009). ConclusionThe findings show that pregnancy does not have a significant effect on maternal and fetal survival, graft rejection and graft function in pregnancies with kidney transplantation, but that complication rates such as hypertension, preterm delivery and low birth weight are high.

Evolution of Lactase Persistence: Turbo-Charging Adaptation in Growth Under the Selective Pressure of Maternal Mortality?

The emergence of the capacity to digest milk in some populations represents a landmark in human evolution, linking genetic change with a component of niche construction, namely dairying. Alleles promoting continued activity of the enzyme lactase through the life-course (lactase persistence) evolved in several global regions within the last 7,000 years. In some European regions, these alleles underwent rapid selection and must have profoundly affected fertility or mortality. Elsewhere, alleles spread more locally. However, the functional benefits underlying the rapid spread of lactase persistence remain unclear. Here, we set out the hypothesis that lactase persistence promoted skeletal growth, thereby offering a generic rapid solution to childbirth complications arising from exposure to ecological change, or to new environments through migration. Since reduced maternal growth and greater neonatal size both increase the risk of obstructed labour, any ecological exposure impacting these traits may increase maternal mortality risk. Over many generations, maternal skeletal dimensions could adapt to new ecological conditions through genetic change. However, this adaptive strategy would fail if ecological change was rapid, including through migration into new niches. We propose that the combination of consuming milk and lactase persistence could have reduced maternal mortality by promoting growth of the pelvis after weaning, while high calcium intake would reduce risk of pelvic deformities. Our conceptual framework provides locally relevant hypotheses to explain selection for lactase persistence in different global regions. For any given diet and individual genotype, the combination of lactase persistence and milk consumption would divert more energy to skeletal growth, either increasing pelvic dimensions or buffering them from worsening ecological conditions. The emergence of lactase persistence among dairying populations could have helped early European farmers adapt rapidly to northern latitudes, East African pastoralists adapt to sudden climate shifts to drier environments, and Near Eastern populations counteract secular declines in height associated with early agriculture. In each case, we assume that lactase persistence accelerated the timescale over which maternal skeletal dimensions could change, thus promoting both maternal and offspring survival. Where lactase persistence did not emerge, birth weight was constrained at lower levels, and this contributes to contemporary variability in diabetes risk.

Maternal mortality ratio in China from 1990 to 2019: trends, causes and correlations

BackgroundMaternal mortality ratio is an important indicator to evaluate the health status in developing countries. Previous studies on maternal mortality ratio in China were limited to certain areas or short periods of time, and there was a lack of research on correlations with public health funding. This study aimed to assess the trends in the maternal mortality ratio, the causes of maternal death, and the correlations between maternal mortality ratio and total health financing composition in China from 1990 to 2019.MethodsData in this longitudinal study were collected from the China Health Statistics Yearbooks (1991–2020) and China Statistical Yearbook 2020. Linear regression analysis was used to assess the trends in the maternal mortality ratio in China. Pearson correlation analysis was used to assess the correlations between national maternal mortality ratio and total health financing composition.ResultsThe yearly trends of the national, rural and urban maternal mortality ratio were − 2.290 (p < 0.01), − 3.167 (p < 0.01), and − 0.901 (p < 0.01), respectively. The gap in maternal mortality ratio between urban and rural areas has narrowed. Obstetric hemorrhage was the leading cause of maternal death. The mortalities ratios for the main causes of maternal death all decreased in China from 1990 to 2019. The hospital delivery rate in China increased, with almost all pregnant women giving birth in hospitals in 2019. Government health expenditure as a proportion of total health expenditure was negatively correlated with the maternal mortality ratio (r = − 0.667, p < 0.01), and out-of-pocket health expenditure as a proportion of total health expenditure was positively correlated with the maternal mortality ratio (r = 0.516, p < 0.01).ConclusionChina has made remarkable progress in improving maternal survival, especially in rural areas. The maternal mortality ratio in China showed a downward trend over time. To further reduce the maternal mortality ratio, China should take effective measures to prevent obstetric hemorrhage, increase the quality of obstetric care, improve the efficiency and fairness of the government health funding, reduce income inequality, and strengthen the medical security system.

Government revenue, quality of governance and child and maternal survival

ABSTRACT This paper considers the effect of government revenue and the quality of governance on the under-five and maternal survival rates. A non-linear panel data study was undertaken using annual data for every country in the world. The study’s broad conclusion is that while government resources, measured as total revenue received by a country’s government, is essential, the quality of governance is even more critical in determining a good outcome for both mother and child.

Trends in the association between educational assortative mating, infant and child mortality in Nigeria

BackgroundExisting knowledge has established the connection between maternal education and child survival, but little is known about how educational assortative mating (EAM), relates to childhood mortality. We attempt to examine this association in the context of Nigeria.MethodsData was obtained from the 2008, 2013, and 2018 waves of the Nigeria Demographic and Health Survey, which is a cross-sectional study. The sample includes the analysis of 72,527 newborns within the 5 years preceding each survey. The dependent variables include the risk of a newborn dying before 12 months of age (infant mortality), or between the age of 12–59 months (child mortality). From the perspective of the mother, the independent variable, EAM, includes four categories (high-education homogamy, low-education homogamy, hypergamy, and hypogamy). The Cox proportional hazard regression was employed for multivariate analyses, while the estimation of mortality rates across the spectrum of EAM was obtained through the synthetic cohort technique.ResultsThe risk of childhood mortality varied across the spectrum of EAM and was particularly lowest among those with high-education homogamy. Compared to children of mothers in low-education homogamy, children of mothers in high-education homogamy had 25, 31 to 19% significantly less likelihood of infant mortality, and 34, 41, and 57% significantly less likelihood of child mortality in 2008, 2013 and 2018 survey data, respectively. Also, compared to children of mothers in hypergamy, children of mothers in hypogamous unions had 20, 12, and 11% less likelihood of infant mortality, and 27, 36, and 1% less likelihood of child mortality across 2008, 2013 and 2018 surveys, respectively, although not significant at p < 0.05. Both infant and child mortality rates were highest in low-education homogamy, as expected, lowest in high-education homogamy, and lower in hypogamy than in hypergamy. Furthermore, the trends in the rate declined between 2008 and 2018, and were higher in 2018 than in 2013.ConclusionThis indicates that, beyond the absolute level of education, the similarities or dissimilarities in partners’ education may have consequences for child survival, alluding to the family system theory. Future studies could investigate how this association varies when marital status is put into consideration.

Warm Springs Are Associated with Early Births in Three Montane Rattlesnake Species

A warming climate is correlated with phenological shifts in many taxa. We analyzed data from two long-term field studies of three viviparous viperid snakes to examine correlations between temperature and parturition dates. We studied Rock Rattlesnakes (Crotalus lepidus) and Ridge-Nosed Rattlesnakes (Crotalus willardi) over a 31-yr period and Twin-Spotted Rattlesnakes (Crotalus pricei) over a 23-yr period. On average, a 1°C increase in mean daily maximum temperature during mid-April to June, the probable gestation period, was associated with C. lepidus litters being found 6.0 ± 0.84 days earlier and C. willardi litters being found 5.7 ± 1.79 days earlier. We were more likely to find C. pricei neonates during surveys in late July following warm springs and pregnant females in late July following cool springs. Although earlier parturitions could potentially increase maternal survival and improve lifetime reproductive output, warmer temperatures during embryo development could cause unviability or neonate abnormalities. Neonate survival would probably be negatively affected if births occurred before the onset of the summer monsoon rains. Populations of these species that inhabit the highest elevations of mountain ranges will be unable to shift their distributions to maintain the thermal conditions under which they evolved.

Improving global maternal and newborn survival via innovation: Stakeholder perspectives on the Saving Lives at Birth Grand Challenge.

The Saving Lives at Birth (SL@B) funding partners joined in 2011 to source, support, and scale maternal and newborn health (MNH) innovations to improve maternal and newborn survival by focusing on the 24 hours around the time of birth. A multi-methods, retrospective portfolio evaluation was conducted to determine SL@B’s impact. Forty semi-structured, key informant interviews (KIIs) were conducted with experts in global MNH based in low- and middle-income and in high-income countries to assess the SL@B program. KIIs were conducted with global MNH technical experts, innovators, government officials in low- and middle-income countries, donors, private investors, and implementing partners to include the full spectrum of voices involved in identifying and scaling innovations. Data were analyzed using thematic analysis. Stakeholders believe the SL@B program has been successful in changing the way maternal and newborn health programs are delivered with a focus on doing things differently through innovation. The open approach to sourcing innovation was seen as positive to the extent that it brought more interdisciplinary stakeholders to think about the problem of maternal and newborn survival. However, a demand-driven approach that aims to source innovations that address MNH priority needs and takes into account the needs of end users (e.g. individuals and governments) was suggested as a strategy for ensuring that more innovations go to scale.

Effects of Scaling Up Family Planning on Maternal Survival in Ethiopia: Spectrum Modeling.

BackgroundEthiopia has made great strides on under-five and maternal mortality reduction as demonstrated by achieving the millennium development target of child mortality reduction by the start of 2015. According to a recent demographic and health survey report, Ethiopia has a 67 per 1000 under-five mortality rate and a 412 per 100,000 live births maternal mortality ratio. The current trend of maternal and child mortality reduction is not enough to meet sustainable development goal three (SDG3) of maternal and child mortality reduction target which is set to reduce the maternal mortality ratio to below 70/100,000 live births in all countries. This paper aimed to model the effect of scaling up family planning on pregnancies, live births, stillbirths, abortions and maternal mortality in Ethiopia.MethodsWe used the Spectrum software package to model the impact of family planning on maternal survival and other maternal health metrics. Spectrum has different modules consisting of demproj module (demographic projection), famplan module (family planning), LiST (life saved tool), and AIM (aids impact model). We used Demproj, Famplan and LiST modules for this particular paper. Baseline national data were taken from findings of the Ethiopian demographic and health survey 2016, and World Bank and World Health Organization country specific reports.ResultsTotal fertility rate will decline to 2.3 children per women by the year 2030 when contraceptive prevalence is scaled up by 2% annually from 2016 to 2030. As a result of continuous scaling up of contraceptive use, around 3.17 million unintended pregnancies can be averted. Unmet need for family planning will significantly decline to 11.7% by 2030. Ninety-four thousand unsafe abortions could be averted and 1233 additional maternal lives could be saved by the end of 2030 in Ethiopia.ConclusionScaling up family planning has shown a significant effect to meet the SDG3 maternal mortality reduction target. A considerable proportion of unintended pregnancies and unsafe abortions can be averted by scaling up contraceptive prevalence by 2% annually until 2030. Family planning is effective and a less costly intervention to reduce maternal mortality in countries with high fertility; hence, it is highly recommended to rampup all efforts to scale up contraceptive use for improving maternal health status in Ethiopia.

Acute Myeloid Leukemia in Pregnancy

Introduction: The management of acute myeloid leukemia (AML) in pregnancy remains a daunting clinical challenge for oncologists, obstetricians, patients, and their families. Although the incidence of AML in pregnancy is low at 1 in 75,000 pregnancies, cancer represents the second most common cause of maternal death behind gestation-related vascular complications. Due to the small number of patients diagnosed during this time, there are only retrospective reviews and case series to guide complex management decisions. Case Report: A 26-year-old Caucasian woman presented to our institution at 17 weeks gestation after she was found to have an absolute monocytosis, neutropenia, and anemia on routine prenatal evaluation. The bone marrow aspirate demonstrated a diagnosis of AML. The blast population compromised 14% of cellular elements, and fluorescence in situ hybridization (FISH) karyotyping was positive for inversion 16. She and her husband were extensively counseled regarding the diagnosis and wished to proceed with the pregnancy. She received standard dose induction chemotherapy with daunorubicin and cytarabine and achieved a complete remission. Starting at 22 weeks gestation, we proceeded with consolidation chemotherapy using intermediate-dose cytarabine 1.5 grams/m2 every 12 hours on days 1, 3, and 5 of the 6 day cycle. Fetal status was monitored with serial growth ultrasounds and daily tocographic assessment. She tolerated the first cycle well and starting at 28 weeks gestation she began the second cycle of consolidation. She was induced at 35 weeks gestation and delivered a morphologically normal male in good health weighing 5 pounds and 9 ounces. She received her final two cycles of consolidation post-partum, and cytarabine dose was increased to 3 grams/m2 for the standard high-dose regimen. Throughout pregnancy, her care was managed by a multidisciplinary team which included neonatology, maternal fetal medicine, and oncology. Expert opinion was solicited from top medical centers across the country for guidance on consolidation therapy. Discussion: Our case highlights the complexities of AML management in pregnancy. There are no formal management guidelines and sparse data on consolidation during this period. The appropriate dosing of chemotherapy, fetal monitoring, and timing of delivery all represent challenges in providing optimal care and improving maternal and fetal overall survival. In a recent meta-analysis, the maternal median overall survival rate for 87 women with AML in pregnancy was found to be 30%. The live birth rate in this study for chemotherapy-exposed neonates was 87%, and the complication rate was 16%. These complications included unspecified deformations, patent ductus arteriosus, hydrocephalus, ventricular septal defect, cytopenias, intracranial hemorrhage, and respiratory compromise. Management recommendations from experts in the field showed significant heterogeneity underscoring the need for consensus guidelines. Conclusion: There is a critical need of management guidelines to address timing and dosing of anthracycline/cytarabine based regimens, potential drug toxicity to the mother and fetus, and transplant considerations in intermediate and high-risk patients. A national registry for leukemia patients treated in pregnancy could be formed to help answer these questions and improve maternal and fetal overall survival rates. Delays in chemotherapy should be avoided, and a multidisciplinary team is needed to provide comprehensive care to patients and their families. Follow Up: The end of treatment bone marrow examination was negative for leukemia by morphology, cytogenetics, and FISH. The patient and child are in good health now more than two years after completion of chemotherapy. Disclosures Powell: Rafael Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Epidemiology of pregnant patients with major trauma in Victoria.

Trauma is one of the most common contributors to maternal and foetal morbidity and mortality. The aim of the present study was to describe the characteristics and outcomes of major trauma in pregnant patients using a population-based registry. Registry-based study using data from the Victorian State Trauma Registry (VSTR), a population-based database of all hospitalised major trauma (death due to injury, Injury Severity Score [ISS] ≥12, admission to an intensive care unit [ICU] for more than 24 h and requiring mechanical ventilation for at least part of their ICU stay or urgent surgery) in Victoria, Australia, from 1 July 2007 to 30 June 2019. Pregnant patients with major trauma were identified on the VSTR. We summarised patient data using descriptive statistics. Over the 12-year study period, there were 63 pregnant major trauma patients. Fifty-two (82.5%) patients sustained injuries resulting from road transport collisions. The maternal survival rate was 98.4% and the foetal survival rate was 88.9%. Thoracic injury was the most common injury (25/63), followed by abdominal injury (23/63). Eighty-six percent of the third trimester patients (19/22) were transported directly to a major trauma service with capacity for definitive care of the pregnancy. The present study demonstrated road transport injury was the most common mechanism of injury and both maternal survival rates and foetal survival rates were high. This information is essential for trauma care system planning and public health initiatives to improve the clinical management and outcomes of pregnant women with major trauma.

Retrospective evaluation of feline dystocia: clinicopathologic findings and neonatal outcomes in 35 cases (2009-2020).

The aim of this study was to describe the characteristics of cases of feline dystocia presenting to a university emergency service. The medical records of queens presenting for dystocia between January 2009 and September 2020 were reviewed. Data collected included queen signalment, presenting complaints, treatments, and maternal and neonatal outcomes. Clinicopathologic data included serum ionized calcium concentration, blood glucose level, packed cell volume and total solids. Owing to the small sample size, descriptive statistics were used and data presented as median (range). Thirty-five cases were reviewed. Dystocia was attributed to maternal factors in 69% (n = 24) and fetal factors in 31% (n = 11). Venous blood gas data from 19 queens in stage 2 labor revealed that no queens were hypocalcemic (median ionized calcium 5.4 mg/dl [range 4.9-5.8]) or hypoglycemic (median glucose 143 mg/dl [range 78-183]). Medical management was attempted in 21/35 queens. Successful medical management was achieved in 29% (n = 6/21). Thirteen queens underwent surgical management, six of these after failing medical management. Seven queens received no treatment. Fifteen queens were discharged and one queen was euthanized while still in labor. The remaining 19 queens delivered all fetuses with medical (n = 6) or surgical management (n = 13). Maternal survival was 94% (n = 33/35). A total of 136 kittens were born to all queens, with 58% (n = 79/136) born prior to initiation of treatment, 16% (n = 22/136) after medical management and 26% (n = 35/136) after surgical management. Overall neonatal survival to discharge was 66% (n = 90/136). Feline dystocia is an emergent condition that can result in up to 34% neonatal mortality for kittens delivered via both medical and surgical means. Hypoglycemia and hypocalcemia were not precipitating causes of feline dystocia in this population.

The impact of kin proximity on net marital fertility and maternal survival in Sweden 1900-1910-Evidence for cooperative breeding in a societal context of nuclear families, or just contextual correlations?

We investigate the association between the geographic proximity of the grandparents on net marital fertility and maternal survival in Sweden, 1900-1910, within the framework of the cooperative-breeding-hypothesis. Data were derived from Swedish full-count censuses (1880-1910) and the Swedish Death Index. Married couples were linked to their parental households. Poisson and logistic regression analyses were used to investigate the association between the geographical proximity of the grandparents on net marital fertility, which we measured as the number of surviving children born between 1900 and 1910, and the mother's survival. Models were fitted with and without fixed effects to assess the effects of unobserved characteristics shared at the parish and the family level. The results indicate that net fertility and maternal survival increased with the husband's parents' geographic proximity. In contrast, we found no evidence that the geographic proximity of the wife's parents was associated with increased fertility or maternal survival. Rather, the presence of the mother's parents in the household lowered net fertility and reduced maternal survival. This study provides evidence that kin proximity was associated with fertility and mortality of married women, and that the associations differed for paternal and maternal kin in the societal context of Swedish nuclear families (1900-1910). However, the patterns of kin proximity that we identified were correlated with characteristics such as socioeconomic status, occupation, and wealth, which also exhibited strong correlations with fertility and survival. Future research assessing the effects of kinship on demographic developments must therefore carefully consider the socio-environmental context.

Effect of mass deworming with antihelminthics for soil-transmitted helminths during pregnancy.

Helminthiasis is an infestation of the human body with parasitic worms. It is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hookworm infestation) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries (LMIC) suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hookworm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious, but evidence of their beneficial effect and safety when given during pregnancy has not been established. This is an update of a Cochrane Review last published in 2015. To determine the effects of mass deworming with antihelminthics for soil-transmitted helminths (STH) during the second or third trimester of pregnancy on maternal and pregnancy outcomes. For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (8 March 2021) and reference lists of retrieved studies. We included all prospective randomised controlled trials evaluating the effect of administration of antihelminthics versus placebo or no treatment during the second or third trimester of pregnancy; both individual-randomised and cluster-randomised trials were eligible. We excluded quasi-randomised trials and studies that were only available as abstracts with insufficient information. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, checked accuracy and assessed the certainty of the evidence using the GRADE approach. We included a total of six trials (24 reports) that randomised 7873 pregnant women. All of the included trials were conducted in antenatal clinics within hospitals in LMICs (Uganda, Nigeria, Peru, India, Sierra Leone and Tanzania). Among primary outcomes, five trials reported maternal anaemia, one trial reported preterm birth and three trials reported perinatal mortality. Among secondary outcomes, included trials reported maternal worm prevalence, low birthweight (LBW) and birthweight. None of the included studies reported maternal anthropometric measures or infant survival at six months. Overall, we judged the included trials to be generally at low risk of bias for most domains, while the certainty of evidence ranged from low to moderate. Analysis suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia by 15% (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.72 to 1.00; I²= 86%; 5 trials, 5745 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on preterm birth (RR 0.84, 95% CI 0.38 to 1.86; 1 trial, 1042 participants; low-certainty evidence) or perinatal mortality (RR 1.01, 95% CI 0.67 to 1.52; 3 trials, 3356 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on hookworm (average RR 0.31, 95% CI 0.05 to 1.93; Tau² = 1.76, I² = 99%; 2 trials, 2488 participants; low-certainty evidence). Among other secondary outcomes, findings suggest that administration of antihelminthics during pregnancy may reduce the prevalence of trichuris (average RR 0.68, 95% CI 0.48 to 0.98; I²=75%; 2 trials, 2488 participants; low-certainty evidence) and ascaris (RR 0.24, 95% CI 0.19 to 0.29; I²= 0%; 2 trials, 2488 participants; moderate-certainty evidence). Antihelminthics during pregnancy probably make little or no difference to LBW (RR 0.89, 95% CI 0.69 to 1.16; 3 trials, 2960 participants; moderate-certainty evidence) and birthweight (mean difference 0.00 kg, 95% CI -0.03 kg to 0.04 kg; 3 trials, 2960 participants; moderate-certainty evidence). The evidence suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia and worm prevalence when used in settings with high prevalence of maternal helminthiasis. Further data is needed to establish the benefit of antihelminthic treatment on other maternal and pregnancy outcomes. Future research should focus on evaluating the effect of these antihelminthics among various subgroups in order to assess whether the effect varies. Future studies could also assess the effectiveness of co-interventions and health education along with antihelminthics for maternal and pregnancy outcomes.

Successful management of perimortem cesarian section with two types of pelvic packing; a case report

Perimortem cesarean is rare and one of the worst possible scenarios in obstetrics. Multidisciplinary approach and speed are extremely important. Pelvic packing in massive postpartum hemorrhages is a method which obstetricians do not commonly use. The patient who had cardiac arrest during travail was successfully managed with a peripartum hysterectomy and two different types of pelvic packing after perimortem cesarean. The mother and baby were healthily discharged. Fetal and maternal survival after perimortem cesarean is quite low. The most important factor determining survival is speed. Pelvic packing is effective in postpartum unstoppable bleeding.