Obstetric Practice Research Articles

Principles of treatment of intrahepatic cholestasis of pregnant women

BACKGROUND:Intrahepatic cholestasis of pregnancy occupies a leading place in the structure of hepatoses associated with pregnancy. As with many other diseases that debut during gestation, all the symptoms of intrahepatic cholestasis of pregnancy disappear after delivery and have no consequences for the mother, unlike, for example, acute fatty degeneration of the liver. However, the fetal prognosis remains serious due to the high incidence of preterm birth and the toxic effect of bile components on the developing fetus, which both lead to perinatal complications. Especially fatal is the situation when intrahepatic cholestasis of pregnancy is combined with intrauterine infection, placental insufficiency, severe preeclampsia, diabetes mellitus, or other extragenital pathology. Until recently, it was believed that the only correct solution for intrahepatic cholestasis of pregnancy development was early delivery. Only in recent decades, attempts have been made to therapeutic correction of this pathology in order to prolong pregnancy to full term and reduce the frequency of perinatal complications. So far, tangible results have been achieved with the use of ursodeoxycholic acid preparations and the introduction of efferent methods of therapy into obstetric practice.
 AIM:The aim of this study was to develop optimal schemes for pathogenetic therapy of intrahepatic cholestasis of pregnancy using hepatoprotectors from the ursodeoxycholic acid group, as well as ademetionine, essential phospholipids, and membrane plasmapheresis.
 MATERIALS AND METHODS:This study included 150 pregnant women with intrahepatic cholestasis of pregnancy. Group I (n= 50) comprised patients who were treated only with ursodeoxycholic acid. Group II (n= 50) included individuals who were given combined drug therapy with ursodeoxycholic acid, ademetionine, and essential phospholipids. Group III (n= 50) consisted of women whose treatment included efferent therapies (membrane plasmapheresis) in combination with ursodeoxycholic acid or ademetionine preparations. All pregnant women before the start of therapy were determined the blood levels of bile acids, total and direct bilirubin, and transaminases (alanine aminotransferase, aspartate aminotransferase). Blood parameters were monitored once every seven days. All the patients were also monitored for the condition of the fetus (fetometry, dopplerometry, cardiotocography).
 RESULTS:The use of ursodeoxycholic acid not combined with other hepatoprotectors (group I) was possible only in cases of increased blood levels of bile acids of not more than 40 mmol/L, preparations of ademetionine and essential phospholipids as monotherapy being ineffective. With an increase in the blood levels of bile acids of more than 40 mmol/L and transaminases by two to three or more times from the upper limit of the norm (group II), the most effective was the combined use of ursodeoxycholic acid, ademetionine and essential phospholipid preparations. The most significant decrease in the blood levels of bile acids and hepatic cytolysis parameters (transaminases) was observed when plasmapheresis was used in combination with ursodeoxycholic acid or ademetionine (group III).
 CONCLUSIONS:The choice of treatment regimen depends on the level of increase in bile acids and the severity of cytolytic syndrome. With an increase in the level of bile acids to 40 mmol/L, ursodeoxycholic acid preparations can be used only. With an increase in bile acid level of more than 40 mmol/L, the complex use of the above hepatoprotectors is necessary. The most effective treatment regimen is the use of membrane plasmapheresis in combination with ursodeoxycholic acid or ademetionine.

Bartholin’s gland cyst caused by Sneathia amnii: a case report

BackgroundSneathia amnii is a conditional pathogen of the female genital tract that is involved in bacterial vaginosis and poor reproductive and perinatal outcomes. Few studies have reported subcutaneous cysts following invasive infection caused by S amnii.Case presentationHere we report the case of a 27-year-old woman who presented with Bartholin’s gland cyst due to S amnii infection, and was successfully treated with surgical neostomy and antibiotic agents. The isolate was gram-negative, bacillary, anaerobic, and was identified by polymerase chain reaction (PCR) amplification of the 16 S rRNA.ConclusionsS amni is an important but underappreciated pathogen that needs further investigation. This report describes the microbial and pathogenic characteristics of S amnii and is expected to provide a valuable reference in obstetric and gynecologic clinical practice.

The distal femoral epiphysis used as a fetal maturity marker: Implications of extant medical data for bioarcheological analysis

AbstractThe distal epiphysis of the femur is classically reported as a marker of fetal maturity and is thus identified in a bioarcheological context as an indicator that an individual died at or around the time of birth; it thus provides crucial information in the creation of the biological profile and associated burial practices. The aim of the present study was to re‐evaluate this use by investigating an extant sample to assess (i) the age‐related frequencies of both distal femoral and proximal tibial epiphyses and (ii) the influence of factors such as sex, vitality, and morbidity on the maturation of both epiphyses. The study was conducted on medical CT scans acquired in utero and ex utero between 2008 and 2017 in the hospital of Marseille (France). The final sample included 248 individuals aged between 26 and 42 completed gestational weeks (GW). Based on the results obtained in this study, 11% of the individuals from the sample aged between 26 and 33 completed GW had already developed a distal femoral epiphysis, whereas individuals aged between 38 and 42 GW had already developed both femoral and tibial epiphyses. According to these observations and current obstetrical practice, this maturation indicator cannot therefore be considered a precise estimator of whether a fetus is at term or not in an archeological context. Similarly, no delayed ossification was found among individuals who did not survive to 42 GW, or among those with severe developmental abnormalities, which does not support the hypothesis that delayed epiphysis maturation of the distal femur may be a morbidity marker for this age group in past populations.

Classification of normal and abnormal fetal heart ultrasound images and identification of ventricular septal defects based on deep learning.

Congenital heart defects (CHDs) are the most common birth defects. Recently, artificial intelligence (AI) was used to assist in CHD diagnosis. No comparison has been made among the various types of algorithms that can assist in the prenatal diagnosis. Normal and abnormal fetal ultrasound heart images, including five standard views, were collected according to the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) Practice guidelines. You Only Look Once version 5 (YOLOv5) models were trained and tested. An excellent model was screened out after comparing YOLOv5 with other classic detection methods. On the training set, YOLOv5n performed slightly better than the others. On the validation set, YOLOv5n attained the highest overall accuracy (90.67 %). On the CHD test set, YOLOv5n, which only needed 0.007 s to recognize each image, had the highest overall accuracy (82.93 %), and YOLOv5l achieved the best accuracy on the abnormal dataset (71.93 %). On the VSD test set, YOLOv5l had the best performance, with a 92.79 % overall accuracy rate and 92.59 % accuracy on the abnormal dataset. The YOLOv5 models achieved better performance than the Fast region-based convolutional neural network (RCNN) & ResNet50 model and the Fast RCNN & MobileNetv2 model on the CHD test set (p<0.05) and VSD test set (p<0.01). YOLOv5 models are able to accurately distinguish normal and abnormal fetal heart ultrasound images, especially with respect to the identification of VSD, which have the potential to assist ultrasound in prenatal diagnosis.

Exogenous oxytocin administration during labor and autism spectrum disorder

Oxytocin is a neuropeptide hormone that plays a key role in social behaviour, stress regulation, and mental health. Synthetic oxytocin administration is a common obstetrical practice, and importantly, previous research has suggested that intrapartum exposure may increase the risk of neurodevelopmental disorders, such as autism spectrum disorder (ASD). To examine the association between synthetic oxytocin exposure during labor and ASD diagnosis in the child. This population-based retrospective cohort study compared two cohorts of children: 1) all children born in British Columbia (BC), Canada between April 1, 2000 and December 31, 2014 (n = 414,336 births), and 2) all children delivered at Soroka University Medical Center (SUMC) in Be'er Sheva, Israel between January 1, 2011 and December 31, 2019 (n = 82,892 births). Nine different exposure groups were examined. Cox proportional hazards models were used to estimate crude and adjusted hazard ratios of ASD in both cohorts based on induction and/or augmentation exposures status. To further control for confounding by indication, we conducted sensitivity analyses among a cohort of healthy, uncomplicated deliveries and among a group that was induced only for post-dates. Additionally, we stratified our analyses by infant sex to assess for potential sex differences. In the BC cohort, 170,013 of 414,336 deliveries (41.0%) were not induced or augmented, 107,543 (26.0%) were exposed to oxytocin, and 136,780 (33.0%) were induced or augmented but not exposed to oxytocin. In the Israel cohort, 51,790 of 82,892 deliveries (62.5%) were not induced or augmented, 28,852 (34.8%) were exposed to oxytocin, and 2,250 (2.7%) were induced or augmented but not exposed to oxytocin. Upon adjusting for covariates in the main analysis, significant associations were observed in the Israel cohort, including adjusted hazard ratios (aHRs) of 1.51 (95% CI 1.20, 1.90) for oxytocin augmented births and 2.18 (95% CI 1.32, 3.57) for those induced by means other than oxytocin and not augmented. However, oxytocin induction was not significantly associated with ASD in the Israel cohort. In the Canadian cohort, there were no statistically significant aHRs. Further, no significant sex differences were observed in the fully adjusted models. This study provides support that induction of labor through oxytocin administration does not increase the risk of ASD in the child. Our international comparison of two countries with differences in clinical practice regarding oxytocin administration for induction and/or augmentation suggests that previous studies reporting a significant association were likely confounded by the underlying indication for the induction.

Can transvaginal cervical length and cervical strain elastography predict mid-trimester medical induction to abortion intervals?

Objective Mid-trimester pregnancy terminations are becoming an increasingly common practice in obstetrics. Accurate prediction of delay from induction to abortion may help in planning the optimal time for the medical induction process and optimising the use of healthcare services. Therefore, we aimed to assess whether the transvaginal cervical length and cervical elastography can predict the time interval from medical induction to abortion in cases of medically indicated mid-trimester pregnancy termination. Materials and methods We performed a prospective observational pilot study between January 2022 and October 2022 in patients who have undergone medically indicated mid-trimester pregnancy termination with a non-dilated cervix for foetal morphological, chromosomal abnormalities or preterm premature rupture of membranes. Cervical length (CL) and cervical strain ratio (CSR) were measured by transvaginal sonography. The predictive value of CL and CSR on the induction to abortion interval was calculated after medical induction with misoprostol. Results Fifty-three eligible pregnant women were evaluated. The mean gestational age at abortion was 17.61 ± 2.81 weeks. The mean time interval from induction to abortion was 31.72 ± 16.57 h. In multivariate linear regression analysis, CL and the history of previous vaginal delivery were the significant independent predictors of the induction to abortion interval (all p < 0.01), with no additional significant contribution from CSR. Conclusion Transvaginal CSR is unlikely to be useful in the prediction of induction to abortion interval in the mid-trimester medically indicated termination of pregnancy. SHORT CONDENSATION Transvaginal cervical length is the significant independent predictor of the induction to abortion interval in the mid-trimester medically indicated termination of pregnancy with no additional significant contribution from cervical strain ratio.

Implementation of a Severe Maternal Morbidity Quality Review Process at a Level IV Public Hospital [ID: 1377992

INTRODUCTION: Severe maternal morbidity (SMM) is tracked by national organizations offering opportunities to evaluate, monitor, and address in near real time. Using a multidisciplinary case review committee to analyze all cases of SMM at a level IV inner-city hospital, we hypothesized that case reviews will identify opportunities for improvement in obstetric practices. METHODS: A case review was triggered for any delivery with an SMM ICD-10 code, transfusion of greater than 4 units, readmission within 48 hours of discharge, a patient safety concern by staff, or a severe adverse neonatal outcome. This cohort study included all of the case reviews of cases between 2019 and 2022. Severe maternal morbidity outcomes, demographics, and obstetric practices were analyzed. RESULTS: Of 36,671 deliveries, 296 (0.8%) met criteria and were reviewed. Of these, 80 (27%) had two or more concurrent SMM events. Postpartum hemorrhage was the most common (37%), followed by intensive care unit admission (13%) and hysterectomy (12%). After review, practices done well included interdisciplinary communication and prompt decision-making. Opportunities for improvement included inadequate access to peripartum care due to socioeconomic barriers, communication, and lack of role clarity. CONCLUSION: Social barriers, inadequate communication, and lack of role clarity were identified as the most common areas of improvement in SMM cases. These findings led to the development of an escalation of care pathway for massive transfusion protocol and vital signs thresholds at which to contact anesthesia. The implementation of a standardized SMM surveillance system results in systematic improvements in obstetric practices.

Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611

INTRODUCTION: The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM. METHODS: The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide. RESULTS: Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%. CONCLUSION: Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.

The Effect of the ARRIVE Trial and the COVID-19 Pandemic on Obstetric Practice and Racial Disparities [ID: 1380285

INTRODUCTION: Black birthing people are at increased risk for cesarean delivery (CD) and gestational hypertension (gHTN), compared to their White counterparts. In the ARRIVE trial, labor induction at 39 weeks decreased CD and gHTN in low-risk nulliparous patients. Our aim was to determine whether racial differences in labor induction, CD or gHTN changed after ARRIVE and the COVID-19 pandemic. METHODS: We conducted an IRB-approved, retrospective cohort study using publicly available birth certificate data from three time periods: pre-ARRIVE (January 1, 2015 to August 31, 2018), post-ARRIVE (September 1, 2018 to February 29, 2020), and post-COVID (March 1, 2020 to December 31, 2020). All non-Hispanic Black (NHB) or White (NHW) nulliparous patients with a singleton gestation who delivered at more than 39 weeks of gestation with no documented high-risk conditions were included. Odds of labor induction, gHTN, and CD were compared by time period and race and ethnicity using an interrupted time series analysis adjusted for seasonality and covariates. RESULTS: There were 471,351 NHB and 2,265,018 NHW birth records included in the analysis. Post ARRIVE, the rate of labor induction increased among NHB and NHW birthing people. Non-Hispanic Black patients were less likely to be induced than their White counterparts before and after the publication of ARRIVE and COVID-19. In the adjusted ITS analysis, the odds of induction of labor (IOL) were lower while the odds of gestational hypertension and cesarean birth were higher for NHB compared to NHW in all three time periods. CONCLUSION: It is plausible that the racial difference in 39-week IOL may contribute to racial disparities in gestational hypertension and cesarean delivery. The results of the ARRIVE trial suggest that ensuring equitable access to IOL in the 39th week may be one strategy to reduce obstetric racial disparities.

Implementing a Virtual Collaborative Behavioral Health Care Program in an Obstetrics and Gynecology Practice [ID: 1376661

INTRODUCTION: More women require behavioral health services than exist psychiatrists to treat them. In order to meet this need, the collaborative care model (CoCM) was proposed in the 1990s to extend the reach of behavioral health services. Relatively little is known about the applicability of the CoCM to obstetrics. We instituted a virtual collaborative behavioral health care program in an obstetrics and gynecology practice in our health system. METHODS: This was an IRB-approved retrospective chart review of a collaborative care program using the model initially proposed in the IMPACT study. Patients presenting to an obstetrics and gynecology office were assessed for depression using validated tools (PHQ-9). Women who screened positive were referred to a behavioral health care manager (BHCM) embedded in the practice. The BHCM conducted a behavioral health assessment, provided short-term psychotherapy, coordinated referral to a higher level of care if necessary, maintained a registry of patients, and worked with a supervising psychiatrist who provided medication recommendations. Our primary outcomes were the incidence of screenings completed, the number of contacts with the BHCM, and the number of cases that underwent review by a psychiatrist. RESULTS: Between February 2020 and February 2022, 166 women were enrolled in the CoCM out of 213 referred by the obstetrician–gynecologist (78% enrollment rate); participants were enrolled for an average of 177 days. Ninety participants (n=166, 54%) had at least one PHQ-9 completed and 81 participants (n=166, 49%) had at least one GAD-7 completed. One hundred six (n=166, 64%) patients had therapy for an average of five visits. One hundred four (n=166, 63%) participants participated in care coordination. Thirty-four (n=166, 20%) cases were reviewed by a psychiatrist. CONCLUSION: Our results indicate the high utilization of collaborative care services in this context, and moderate feasibility with only half of enrolled participants receiving validated assessments. Future studies should examine effectiveness and the components of the model that are most beneficial.

Mental Health Care Disparities After Implementation of a Perinatal Depression Intervention [ID: 1377829

INTRODUCTION: Perinatal depression affects upward of 1:7 childbearing individuals and is associated with significant negative intergenerational outcomes, especially when unrecognized and untreated. Our study examined provider perinatal depression screening, assessment, treatment, and follow-up by race and ethnicity, as a proxy for implicit bias or systemic racism, after a perinatal depression intervention was implemented. METHODS: The Program In Support of Moms (PRISM), an obstetric practice intervention, was implemented in November 2017 at the UMass ob-gyn resident clinic. PRISM aims to improve the detection, assessment, treatment, and follow-up of patients with perinatal depression. With IRB approval, we abstracted data from charts of patients having one or greater prenatal or postpartum visits with an Edinburgh Postnatal Depression Screen (EPDS) score equal to or greater than 10 between October 2017 and May 2020. Descriptive statistics were used for comparisons. RESULTS: Seven hundred ninety individuals were included (White n=369, Black n=84, Hispanic n=264, other n=73). There were significant differences by race and ethnicity in the assessment of prior mental health history, interest in treatment engagement, therapy referrals, and medication treatment offered (all P≤.001) with White patients having significantly higher rates than patients who were Black or another race. There were no differences by race and ethnicity in provider positive screen acknowledgement, provision of psychoeducation, or repeat screening after a positive screen. CONCLUSION: Racial disparities in assessment, referral, and medication treatment offerings exist after a perinatal depression intervention. Implementation of PRISM intervention with an anti-racist lens is needed to improve equitable access to mental health care for those marginalized by racism.

Do Clinicians Appropriately Screen for Thyroid Disease in Pregnancy Using Targeted Screening Guidelines? A Real-World Retrospective Study [ID: 1368322

INTRODUCTION: Universal screening for thyroid disease in pregnancy is not currently recommended. Guidelines support targeted screening of high-risk individuals. Prior studies have provided some evidence to the cost-effectiveness of universal screening. We aim to evaluate adherence to targeted screening criteria as well as outcome differences between screened and unscreened patients. METHODS: All patients presenting for new obstetrical visits in 2020 were reviewed. Institutional review board approval was obtained for this study. Risk factors meeting thyroid screening criteria based on American Thyroid Association (ATA) and/or American College of Obstetricians and Gynecologists (ACOG) guidelines, and pregnancy outcomes were extracted. Pregnancy outcomes were compared between patients meeting ATA and/or ACOG criteria who did or did not receive screening via thyroid function testing (TFT). RESULTS: One thousand twenty-five records were included. 87/198 patients meeting ACOG criteria for screening (43.9%) and 108/826 patients meeting ATA criteria (13.1%) had TFT. Patients meeting ATA criteria who underwent TFT had higher live-birth rates and lower miscarriage rates compared to unscreened patients meeting ATA criteria, 92.6% versus 83.26% (P=.006) and 4.63% versus 12.41% (P=.009), respectively. No difference was found between patients meeting ACOG criteria who did or did not receive TFT. No differences were observed in preterm delivery rates. CONCLUSION: In a real-world study of obstetrical practice, less than 50% of patients were appropriately screened for thyroid disease in pregnancy. ATA criteria identified threefold more patients for screening compared to ACOG criteria. Those screened appropriately per ATA criteria had higher live-birth rates and lower miscarriage rates compared to unscreened patients meeting ATA criteria.

Newborn Outcomes After Maternal COVID-19 Infection in Pregnancy and the Potential Role of Infection Severity [ID: 1373946

INTRODUCTION: COVID-19 poses health risks in pregnancy including increased rates of cesarean sections, preeclampsia, and miscarriage. However, less is known about newborn effects and the effect of severity of infection. We evaluated the link between pregnancy COVID-19 infection status and severity, and newborn outcomes. METHODS: Participants in this IRB-approved retrospective chart review study were identified via medical records from a single university-affiliated obstetric practice and grouped as COVID-19 positive during pregnancy (n=69), or COVID-19 negative delivering pre-COVID (n=59). Severity of infection was based on emergency department visit, hospitalization, oxygen treatment, steroids, antibodies, or ventilation. Information on socioeconomic factors, medical history, and birth outcomes was also abstracted. RESULTS: Compared to controls, and after adjustment for background differences, those with COVID-19 infection during pregnancy had newborns 242 g lighter and were 4.3 times more likely to deliver preterm, 2.6 times more likely to have a newborn with a 1-minute Apgar score less than 8, and 2.9 times more likely to remain hospitalized a week or more. Differences were largely driven by earlier delivery. Finally, severe COVID-19 infection (which occurred for 41% of participants with COVID-19) was a strong predictor of preterm delivery, low birth weight, receipt of oxygen, neonatal intensive care unit admission, and longer hospital stay. CONCLUSION: COVID-19 infection during pregnancy predicts adverse newborn outcomes, especially as a result of reduced gestational duration. Additionally, severity of infection may predict worse outcomes. A larger, more diverse sample is needed to confirm findings, and to examine potential effect of vaccination in reducing the effect of COVID-19 infection during pregnancy.

Terlipressin in obstetric and gynecological practice: a case of a missed miscarriage in late pregnancy complicated by bleeding. Case report

A few randomized multicenter studies indicate that prophylactic vasopressin in obstetric and gynecological surgeries is mainly safe and associated with a significant reduction in intraoperative blood loss. This article reviews recent scientific papers describing the use of vasopressin in obstetric and gynecological practice with an assessment of its effectiveness depending on the dose and route of administration. We present a clinical case demonstrating that drugs with a vasopressor effect, in particular terlipressin, in a patient with uterine bleeding after a late induced miscarriage allowed to obtain an excellent hemostatic effect and avoid the need for additional methods of surgical hemostasis.

The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section

Objective To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS). Methods This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups. Results A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay. Conclusions Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.

Variants of system and organ damage in patients with various thrombotic microangiopathy subtypes in obstetric practice

Introduction. All thrombotic microangiopathy (TMA) variants in obstetric practice have a diverse clinical presentation and can manifest as various system and organ damage, which often makes it difficult or interfere with the diagnostic assessment, thus slowing down initiation of the necessary therapy.Aim. To study the clinical presentations of various TMA variants in obstetric practice.Materials and methods. A total of 313 pregnant women were enrolled in the study, of which atypical hemolytic uremic syndrome (aHUS) was diagnosed in 71 women, “HELLP syndrome” in 124 women, and “PE” with varied severity in 70 women. A group of patients with more rare causes of TMA was also identified: TTP and sepsis in 13 patients, and 35 patients without signs of TMA were included in the control group. We assessed and compared the main clinical, laboratory and instrumental findings.Results. The study identified damage to various systems and organs in various TMA types in obstetric practice. The damage to kidneys, liver, nervous system, visual organs was observed in patients with aHUS, HELLP syndrome, TTP, septic TMA and PE, while the damage to skin, cardiovascular system and lungs was detected in patients from all groups except for PE. Small and large vessel thrombotic complications were detected in patients from the former three groups. The patients with aHUS showed the maximum multisystemic presentation severity.Conclusions. The thrombotic microangiopathy in obstetrics is generalized in nature, and various symptoms of organ dysfunction require a multidisciplinary approach to such patients.

Effect of Brief Interpersonal Therapy on Depression During Pregnancy

Prenatal depression is prevalent with negative consequences for both the mother and developing fetus. Brief, effective, and safe interventions to reduce depression during pregnancy are needed. To evaluate depression improvement (symptoms and diagnosis) among pregnant individuals from diverse backgrounds randomized to brief interpersonal psychotherapy (IPT) vs enhanced usual care (EUC). A prospective, evaluator-blinded, randomized clinical trial, the Care Project, was conducted among adult pregnant individuals who reported elevated symptoms during routine obstetric care depression screening in general practice in obstetrics and gynecology (OB/GYN) clinics. Participants were recruited between July 2017 and August 2021. Repeated measures follow-up occurred across pregnancy from baseline (mean [SD], 16.7 [4.2] gestational weeks) through term. Pregnant participants were randomized to IPT or EUC and included in intent-to-treat analyses. Treatment comprised an engagement session and 8 active sessions of brief IPT (MOMCare) during pregnancy. EUC included engagement and maternity support services. Two depression symptom scales, the 20-item Symptom Checklist and the Edinburgh Postnatal Depression Scale, were assessed at baseline and repeatedly across pregnancy. Structured Clinical Interview for DSM-5 ascertained major depressive disorder (MDD) at baseline and the end of gestation. Of 234 participants, 115 were allocated to IPT (mean [SD] age, 29.7 [5.9] years; 57 [49.6%] enrolled in Medicaid; 42 [36.5%] had current MDD; 106 [92.2%] received intervention) and 119 to EUC (mean [SD] age, 30.1 [5.9] years; 62 [52.1%] enrolled in Medicaid; 44 [37%] had MDD). The 20-item Symptom Checklist scores improved from baseline over gestation for IPT but not EUC (d = 0.57; 95% CI, 0.22-0.91; mean [SD] change for IPT vs EUC: 26.7 [1.14] to 13.6 [1.40] vs 27.1 [1.12] to 23.5 [1.34]). IPT participants more rapidly improved on Edinburgh Postnatal Depression Scale compared with EUC (d = 0.40; 95% CI, 0.06-0.74; mean [SD] change for IPT vs EUC: 11.4 [0.38] to 5.4 [0.57] vs 11.5 [0.37] to 7.6 [0.55]). MDD rate by end of gestation had decreased significantly for IPT participants (7 [6.1%]) vs EUC (31 [26.1%]) (odds ratio, 4.99; 95% CI, 2.08-11.97). In this study, brief IPT significantly reduced prenatal depression symptoms and MDD compared with EUC among pregnant individuals from diverse racial, ethnic, and socioeconomic backgrounds recruited from primary OB/GYN clinics. As a safe, effective intervention to relieve depression during pregnancy, brief IPT may positively affect mothers' mental health and the developing fetus. ClinicalTrials.gov Identifier: NCT03011801.

Césariennes « code rouge » : création d’une grille de pertinence par méthode Delphi permettant l’analyse de pratique

ObjectiveIn France, C-sections are classified through a color code according to their degree of urgency. A red-classified C-section is triggered when life of mother or fetus is immediately threatened These cases happen very rarely and represent less than 1% of total deliveries. Many French maternity hospitals are above this rate. This risky procedure should remain an exception. The main purpose of this study is to develop a new tool enabling to determine the relevance of red C-sections in order to improve obstetrical practices. MethodsEleven national obstetrical experts were submitted with relevant-estimated indications of red C-sections. A two-round Delphi methodology was then used to reach a consensus on a new table of relevance. ResultsFive different groups of indications were proposed to the panel of experts. After two rounds, four groups achieved a consensus by being qualified “very relevant” or “relevant” by more than 80% of the 11 experts. ConclusionThe aim of this new consensual table of relevance is to improve quality of care. It allows to evaluate the relevance of red C-sections and determine when red C-sections are non-relevant but it particularly helps teams to identify ways of improvements. Finally, this tool enables a reproductible analysis that can be further intra- or inter-hospitals developed towards harmonization of practices.

Optimization of the cosmetic appearance of skin scar after caesarean section - part I: obstetric practice.

Caesarean section (CS) is a surgical way of child delivery by cutting the abdomen and uterus. Although compared to natural childbirth, it carries a greater risk of complications, the percentage of performed cuts is still increasing. The consequence of this procedure is the surgical skin scar. The appearance of this scar depends on many factors, including appropriate pre- and intraoperative procedure, operator skills and experience. The aim of the work is to present actions aimed at increasing the aesthetics of the skin scar after CS including pre-, intra- and postoperative procedures.

Strengthening midwives' competencies for addressing maternal and newborn mortality in Tanzania: Lessons from Midwifery Emergency Skills Training (MEST) project

IntroductionIn Low- and Middle-Income Countries (LMICs), maternal and infant mortality remains a significant problem. Inadequate healthcare provider competencies, including those of midwives, are cited as one of the major contributors to the high maternal and newborn mortality rates. Thus, enhancing the skills of midwives is a prerequisite for enhancing positive maternal and newborn health outcomes. This study describes the lessons learned from a Midwifery Emergencies Skills Training (MEST) project implemented in Tanzania between 2013 and 2018. MethodsAn exploratory qualitative study was used to purposefully recruit and interview twelve health facility in-charges and eighteen midwives from twelve selected health facilities in six districts of Tanzania mainland to discover their perceptions about the midwifery practice after MEST training. The data were transcribed verbatim and analysed with qualitative content analysis. ResultsFour categories were generated from the analysis (i) enhanced knowledge and skills in the provision of midwifery care and management of obstetric emergencies, (ii) improved midwives’ communication skills, (iii) increased trust and support between midwives and community and (iv) transformed attitudes of midwives toward continued professional development (CPD). ConclusionMEST enhanced the knowledge and skills of midwives in the management of obstetric emergencies and referral protocol practice. However, notable gaps remain in the capacity of midwives to provide human rights-based respectful maternity care. Continued professional development for nurses and midwives through training, mentorship and supervision programs is recommended for improving maternal and newborn health.