Preterm Cesarean Research Articles

Effect of SARS-CoV-2 Infection in Pregnancy on Maternal and Neonatal Outcomes in Africa: An AFREhealth Call for Evidence through Multicountry Research Collaboration.

.In the African context, there is a paucity of data on SARS-CoV-2 infection and associated COVID-19 in pregnancy. Given the endemicity of infections such as malaria, HIV, and tuberculosis (TB) in sub-Saharan Africa (SSA), it is important to evaluate coinfections with SARS-CoV-2 and their impact on maternal/infant outcomes. Robust research is critically needed to evaluate the effects of the added burden of COVID-19 in pregnancy, to help develop evidence-based policies toward improving maternal and infant outcomes. In this perspective, we briefly review current knowledge on the clinical features of COVID-19 in pregnancy; the risks of preterm birth and cesarean delivery secondary to comorbid severity; the effects of maternal SARS-CoV-2 infection on the fetus/neonate; and in utero mother-to-child SARS-CoV-2 transmission. We further highlight the need to conduct multicountry surveillance as well as retrospective and prospective cohort studies across SSA. This will enable assessments of SARS-CoV-2 burden among pregnant African women and improve the understanding of the spectrum of COVID-19 manifestations in this population, which may be living with or without HIV, TB, and/or other coinfections/comorbidities. In addition, multicountry studies will allow a better understanding of risk factors and outcomes to be compared across countries and subregions. Such an approach will encourage and strengthen much-needed intra-African, south-to-south multidisciplinary and interprofessional research collaborations. The African Forum for Research and Education in Health’s COVID-19 Research Working Group has embarked upon such a collaboration across Western, Central, Eastern and Southern Africa.

Large Oropharyngeal Teratoma Diagnosed Ante-Natally Using Foetal 3D Ultrasound Scan and MRI: a Case Report

A case presentation of a rare condition of foetal oropharyngeal teratoma suspected by antenatal 3D ultrasound scan and foetal MRI at 30 weeks gestation. The tumour originated in the oropharynx and grew through the open jaw into the amniotic fluid causing obstruction and polyhydramnios. The baby was delivered through a pre-term emergency Caesarean section at 31 weeks gestation followed by postnatal MRI that confirmed the diagnosis. The outcome was early neonatal death as a consequence of respiratory distress and neonatal sepsis.

Previous preterm cesarean delivery and risk of uterine rupture in subsequent trial of labor—a national cohort study

Previous cesarean delivery is the major risk factor for uterine rupture in subsequent trial of labor. It has been suggested that a previous preterm cesarean delivery is associated with an increased risk of uterine rupture compared with a previous term cesarean delivery. However, the proposed association has only been investigated in a few studies and never in a study based on unselected contemporary prospectively collected data. This study aimed to investigate the risk of uterine rupture among women attempting trial of labor after 1 previous preterm cesarean delivery compared with women with 1 previous term cesarean delivery. In this population-based cohort study, we used the Swedish Medical Birth Register between 1983 and 2016 and identified 9300 women with 1 previous preterm index cesarean delivery, 57,168 women with 1 previous term index cesarean delivery, and a second outcome delivery defined as trial of labor after 1 previous cesarean delivery. The risk of the main outcome uterine rupture and secondary outcomes placental abruption; placenta accreta spectrum; postpartum hemorrhage; blood transfusion; appearance, pulse, grimace, activity, and respiration of <7 at 5 minutes; neonatal cerebral dysfunction; and neonatal seizures were assessed using multivariate logistic regression models adjusted for potential confounders. Among women with a preterm index cesarean delivery, 102 (1.1%) had uterine rupture in the outcome delivery compared with 759 of women (1.4%) with term index cesarean delivery. This corresponded to a decreased risk of uterine rupture for women with preterm index cesarean delivery (odds ratio, 0.79; 95% confidence interval, 0.64-0.97), which did not remain significant in the analysis adjusted for maternal age, interdelivery interval, maternal body mass index, maternal height, induction of labor, postoperative infection after index cesarean delivery, and birthweight (odds ratio, 0.94; 95% confidence interval, 0.74-1.18). Stratifying by gestational week at index cesarean delivery (32+0 to 36+6 and <32+0 weeks' gestation) did not alter the main result. Stratifying by interdelivery interval revealed that women with a preterm index cesarean delivery were at a decreased risk of uterine rupture (odds ratio, 0.55 [95% confidence interval, 0.39-0.78]; adjusted odds ratio, 0.74 [95% confidence interval, 0.51-1.07]) in interdelivery intervals of >36 months whereas there were no significant differences within other time intervals. Of the secondary outcomes, 89 women (1.0%) with preterm index cesarean delivery were diagnosed as having placental abruption compared with 331 women (0.6%) with term index cesarean delivery, which corresponded to an approximately 60% increased risk (odds ratio, 1.66; 95% confidence interval, 1.31-2.10), which remained significant after adjusting for confounders (odds ratio, 1.49; 95% confidence interval, 1.13-1.96). Likewise, there was a slightly increased risk of postpartum hemorrhage for women with preterm index cesarean delivery (adjusted odds ratio, 1.12; 95% confidence interval, 1.02-1.24). There were no significant differences in the remaining secondary outcomes. The findings of this study suggest that preterm cesarean delivery is not associated with an increased risk of uterine rupture. Hence, women with 1 previous preterm cesarean delivery (with lower uterine segment incision) should receive medical management and counseling similar to women with previous term cesarean delivery before trial of labor after cesarean delivery.

Trends in cesarean birth rates in Iceland over a 19-year period.

Cesarean birth (CB) rates have increased in high-resource countries during the past two decades, yet it is not known whether CB rates have changed according to maternal age and/or gestational age. All singleton live births in Iceland between 1997 and 2015 were identified from the Icelandic Medical Birth Registry (80130). Rates of cesarean births (intrapartum and prelabor) were calculated overall and separately for maternal age groups and gestational age groups and by parity. Logit binomial regression was used to calculate odds ratios (ORs) and confidence intervals (CIs) for annual change in cesarean birth rates adjusted for maternal characteristics and clinical indication groups. The overall CB rate was 15.7% in 1997 and 15.8% in 2015; the CB rate did not change significantly during the study period. The overall CB rate for early-term deliveries (37-38weeks) decreased for multiparas (annual aOR=0.99 [95% CI=0.98-0.99]), and the preterm (<37weeks) prelabor cesarean rate increased significantly (1.11 [1.09-1.14]) for both primiparas and multiparas. For multiparas only, the intrapartum CB rate decreased (0.97 [0.97-0.98]), whereas the prelabor CB rate increased, predominantly for women aged over 35years (1.03 [1.02-1.04]). Adjustment for clinical indication groups did not change these results. Findings indicate a rise in prelabor cesarean for preterm births and women aged over 35years (multiparas only). As adjustment for clinical indications did not affect these results, changes in obstetric practice are more likely to have affected these rate changes rather than changes in clinical indications.

Clinical characteristics, prognostic factors, and maternal and neonatal outcomes of SARS-CoV-2 infection among hospitalized pregnant women: A systematic review.

BackgroundPregnant women represent a potentially high‐risk population in the COVID‐19 pandemic.ObjectiveTo summarize clinical characteristics and outcomes among pregnant women hospitalized with COVID‐19.Search strategyRelevant databases were searched up until May 29, 2020.Selection criteriaCase series/reports of hospitalized pregnant women with laboratory‐confirmed COVID‐19.Data collection and analysisPRISMA guidelines were followed. Methodologic quality was assessed via NIH assessment tools.Main resultsOverall, 63 observational studies of 637 women (84.6% in third trimester) with laboratory‐confirmed SARS‐CoV‐2 infection were included. Most (76.5%) women experienced mild disease. Maternal fatality, stillbirth, and neonatal fatality rates were 1.6%, 1.4%, and 1.0%, respectively. Older age, obesity, diabetes mellitus, and raised serum D‐dimer and interleukin‐6 were predictive of poor outcomes. Overall, 33.7% of live births were preterm, of which half were iatrogenic among women with mild COVID‐19 and no complications. Most women underwent cesarean despite lacking a clear indication. Eight (2.0%) neonates had positive nasopharyngeal swabs after delivery and developed chest infection within 48 hours.ConclusionsAdvanced gestation, maternal age, obesity, diabetes mellitus, and a combination of elevated D‐dimer and interleukin‐6 levels are predictive of poor pregnancy outcomes in COVID‐19. The rate of iatrogenic preterm birth and cesarean delivery is high; vertical transmission may be possible but has not been proved.

Rate of gestational weight gain trajectory is associated with adverse pregnancy outcomes.

To examine the gestational weight gain (GWG) trajectory and its possible association with pregnancy outcomes. GWG trajectories were identified using the latent class growth model. Binary logistic regression was performed to examine the associations between adverse pregnancy outcomes and these trajectories. Negeri Sembilan, Malaysia. Two thousand one hundred ninety-three pregnant women. Three GWG trajectories were identified: 'Group 1 - slow initial GWG but followed by drastic GWG', 'Group 2 - maintaining rate of GWG at 0·58 kg/week' and 'Group 3 - maintaining rate of GWG at 0·38 kg/week'. Group 1 had higher risk of postpartum weight retention (PWR) (adjusted OR (AOR) 1·02, 95 % CI 1·01, 1·04), caesarean delivery (AOR 1·03, 95 % CI 1·01, 1·04) and having low birth weight (AOR 1·04, 95 % CI 1·02, 1·05) compared with group 3. Group 2 was at higher risk of PWR (AOR 1·18, 95 % CI 1·16, 1·21), preterm delivery (AOR 1·03, 95 % CI 1·01, 1·05) and caesarean delivery (AOR 1·02, 95 % CI 1·01, 1·03), but at lower risk of having small-for-gestational-age infants (AOR 0·97, 95 % CI 0·96, 0·99) compared with group 3. The significant associations between group 1 and PWR were observed among non-overweight/obese women; between group 1 and caesarean delivery among overweight/obese women; group 2 with preterm delivery and caesarean delivery were only found among overweight/obese women. Higher GWG as well as increasing GWG trajectories was associated with higher risk of adverse pregnancy outcomes. Promoting GWG within the recommended range should be emphasised in antenatal care to prevent the risk of adverse pregnancy outcomes.

Is mode of first birth a risk factor for subsequent preterm birth?

Previous preterm birth is a strong predictor of subsequent preterm birth, but less is known about the causes of preterm birth following a full-term first pregnancy. Recent research has highlighted previous caesarean section as a potential risk factor. To examine the relationship between mode of first birth and the risk of subsequent preterm birth in New South Wales (NSW), Australia. A population-based record-linkage study of NSW women who had a live singleton first birth at ≥37weeks gestation, followed by a singleton second birth between 2005 and 2017. Relative risk (RR) and 95% CI of preterm birth in the subsequent pregnancy was calculated using modified Poisson regression, with mode of first birth as the exposure. Spontaneous preterm birth and preterm prelabour caesarean were secondary outcomes. Women who had either an intrapartum (RR: 1.26, 95% CI 1.19-1.32) or prelabour caesarean (RR: 1.26, 95% CI 1.18-1.35) first birth had a higher risk of subsequent preterm birth (any birth <37weeks gestation), than those who birthed vaginally. Women who had a previous instrumental birth (RR: 0.85, 95% CI 0.79-0.91) or prelabour caesarean (RR: 0.74, 95% CI 0.67-0.82) had lower risks of subsequent spontaneous preterm birth. However, prior prelabour caesarean also greatly increased risk of subsequent preterm prelabour caesarean (RR: 5.25, 95% CI 4.65-5.93). The mode of first birth has differing effects on the risk of subsequent spontaneous preterm birth and preterm prelabour caesarean. Awareness of the risk of subsequent preterm birth following caesarean section may help inform clinical decisions around mode of first birth.

All we know about COVID-19 in pregnancy: from perinatal to ethical and psychological perspective

The Novel Coronavirus (SARS-CoV-2), also known as Wuhan coronavirus, causes the 2019-nCoV acute respiratory disease or COVID-19. While coronavirus infection is a common and usually self-limiting infection, in a specific population like pregnant women, complications of the disease appear to be more relevant, and pregnant women are particularly susceptible to morbidity and mortality, especially in case of high pathogenicity virus. Most common complications associated with COVID-19 in pregnancy include preterm birth, cesarean delivery, and perinatal deaths. The risk of vertical transmission seems to be negligible.

SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes.

BackgroundPerform a systematic review and meta-analysis of SARS-CoV-2 infection and pregnancy.MethodsDatabases (Medline, Embase, Clinicaltrials.gov, Cochrane Library) were searched electronically on 6th April and updated regularly until 8th June 2020. Reports of pregnant women with reverse transcription PCR (RT-PCR) confirmed COVID-19 were included. Meta-analytical proportion summaries and meta-regression analyses for key clinical outcomes are provided.Findings86 studies were included, 17 studies (2567 pregnancies) in the quantitative synthesis; other small case series and case reports were used to extract rarely-reported events and outcome. Most women (73.9%) were in the third trimester; 52.4% have delivered, half by caesarean section (48.3%). The proportion of Black, Asian or minority ethnic group membership (50.8%); obesity (38.2%), and chronic co-morbidities (32.5%) were high. The most commonly reported clinical symptoms were fever (63.3%), cough (71.4%) and dyspnoea (34.4%). The commonest laboratory abnormalities were raised CRP or procalcitonin (54.0%), lymphopenia (34.2%) and elevated transaminases (16.0%). Preterm birth before 37 weeks’ gestation was common (21.8%), usually medically-indicated (18.4%). Maternal intensive care unit admission was required in 7.0%, with intubation in 3.4%. Maternal mortality was uncommon (~1%). Maternal intensive care admission was higher in cohorts with higher rates of co-morbidities (beta=0.007, p<0.05) and maternal age over 35 years (beta=0.007, p<0.01). Maternal mortality was higher in cohorts with higher rates of antiviral drug use (beta=0.03, p<0.001), likely due to residual confounding. Neonatal nasopharyngeal swab RT-PCR was positive in 1.4%.InterpretationThe risk of iatrogenic preterm birth and caesarean delivery was increased. The available evidence is reassuring, suggesting that maternal morbidity is similar to that of women of reproductive age. Vertical transmission of the virus probably occurs, albeit in a small proportion of cases.FundingN/A

Clinical Presentation and Outcomes of Pregnant Women With Coronavirus Disease 2019: A Systematic Review and Meta-analysis.

BackgroundDescriptions of coronavirus disease 2019 (COVID-19) have focused on the nonpregnant adult population. This study aims to describe the clinical characteristics and perinatal outcomes of COVID-19 in pregnancy.MethodsWe searched databases from December 2019 to 30 April 2020. Eligible studies reported clinical characteristics, radiological findings, and/or laboratory testing of pregnant women during infection. Data were pooled across studies using a random-effects model.ResultsTwenty-four studies (136 women) were included. The most common symptoms were fever (62.9%) and cough (36.8%). Laboratory findings included elevated C-reactive protein (57%) and lymphocytopenia (50%). Ground-glass opacity was the most common radiological finding (81.7%). Preterm birth rate was 37.7% and cesarean delivery rate was 76%. There was 1 maternal death. There were 2 fetal COVID-19 cases.ConclusionsThe clinical picture in pregnant women with COVID-19 did not differ from the nonpregnant population; however, the rate of preterm birth and cesarean delivery are considerably higher than international averages.

Rates of Maternal and Perinatal Mortality and Vertical Transmission in Pregnancies Complicated by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Co-V-2) Infection: A Systematic Review.

To ascertain the frequency of maternal and neonatal complications, as well as maternal disease severity, in pregnancies affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MEDLINE, Ovid, ClinicalTrials.gov, MedRxiv, and Scopus were searched from their inception until April 29, 2020. The analysis was limited to reports with at least 10 pregnant patients with SARS-CoV-2 infection that reported on maternal and neonatal outcomes. Inclusion criteria were pregnant women with a confirmed diagnosis of SARS-CoV-2 infection. A systematic search of the selected databases was performed by implementing a strategy that included the MeSH terms, key words, and word variants for "coronavirus," "SARS-CoV-2," "COVID-19," and "pregnancy.r The primary outcomes were maternal admission to the intensive care unit (ICU), critical disease, and death. Secondary outcomes included rate of preterm birth, cesarean delivery, vertical transmission, and neonatal death. Categorical variables were expressed as percentages with number of cases and 95% CIs. Of the 99 articles identified, 13 included 538 pregnancies complicated by SARS-CoV-2 infection, with reported outcomes on 435 (80.9%) deliveries. Maternal ICU admission occurred in 3.0% of cases (8/263, 95% CI 1.6-5.9) and maternal critical disease in 1.4% (3/209, 95% CI 0.5-4.1). No maternal deaths were reported (0/348, 95% CI 0.0-1.1). The preterm birth rate was 20.1% (57/284, 95% CI 15.8-25.1), the cesarean delivery rate was 84.7% (332/392, 95% CI 80.8-87.9), the vertical transmission rate was 0.0% (0/310, 95% CI 0.0-1.2), and the neonatal death rate was 0.3% (1/313, 95% CI 0.1-1.8). With data from early in the pandemic, it is reassuring that there are low rates of maternal and neonatal mortality and vertical transmission with SARS-CoV-2. The preterm birth rate of 20% and the cesarean delivery rate exceeding 80% seems related to geographic practice patterns. PROSPERO, CRD42020181497.

The adverse maternal and perinatal outcomes of adolescent pregnancy: a cross sectional study in Hebei, China

BackgroundThe adverse pregnancy outcomes caused by teenage pregnancy are major public health problems with significant social impact. While China is the most populous country in the world, and 8.5% of the women aged 10–50 years are adolescent women, we aimed to analyze the adverse maternal and perinatal outcomes of the adolescent pregnancy in Hebei Province, China.MethodsThere were 238,598 singleton pregnant women aged 10–34 years from January 1, 2013 to December 31, 2017 in the database of Hebei Province Maternal Near Miss Surveillance System (HBMNMSS). The 238,598 pregnant women were divided into two groups: adolescent group (aged 10–19 years) and adult group (aged 20–34 years). The adolescent group was divided into two subgroups (aged 10–17 years, aged 18–19 years), the adult group was divided into two subgroups (aged 20–24 years, aged 25–34 years). We compared the risk of adverse pregnancy outcomes using univariate and multivariate logistic regression. We also made a stratified analysis of nulliparous and multiparous adolescent pregnancy.ResultsCompared with women aged 20–34 years, women aged 10–19 years had lower risk of cesarean delivery [adjusted risk ratio (aRR): 0.75, 95% confidence interval (CI): 0.70–0.80], gestational diabetes mellitus (GDM) (aRR: 0.55, 95%CI: 0.41–0.73). Women aged 10–19 years had higher risk of preterm delivery (aRR: 1.76, 95%CI: 1.54–2.01), small for gestational age (SGA) (aRR: 1.19, 95%CI: 1.08–1.30), stillbirth (aRR: 2.58, 95%CI: 1.83–3.62), neonatal death (aRR: 2.63, 95%CI: 1.60–4.32). The adolescent women aged 10–17 years had significantly higher risk of stillbirth (aRR: 5.69, 95%CI: 3.36–9.65) and neonatal death (aRR: 7.57, 95%CI: 3.74–15.33) compared with the women aged 25–34 years. Younger adults (20–24 years) also had higher risks of preterm delivery (aRR: 1.26, 95%CI: 1.20–1.32), stillbirth (aRR: 1.45, 95%CI: 1.23–1.72), and neonatal death (aRR: 1.51, 95%CI: 1.21–1.90) compared with women aged 25–34 years. The structural equation model showed that preterm delivery and cesarean delivery had an indirect effect on neonatal death in adolescent pregnancy.ConclusionsThe adolescent pregnancy was related to adverse perinatal (fetal and neonatal) outcomes, such as preterm delivery, stillbirth and neonatal death, especially in younger adolescent pregnancies.

Diet Modulates the High Sensitivity to Systemic Infection in Newborn Preterm Pigs.

Background: Preterm infants are born with an immature immune system, limited passive immunity, and are at risk of developing bacteremia and sepsis in the postnatal period. We hypothesized that enteral feeding, with or without added immunoglobulins, improves the clinical response to systemic infection by coagulase negative staphylococci.Methods: Using preterm cesarean delivered pigs as models for preterm infants, we infused live Staphylococcus epidermidis (SE, 5 × 109 colony forming units per kg) systemically 0–3 days after birth across five different experiments. SE infection responses were assessed following different gestational age at birth (preterm vs. term), enteral milk diets (bovine colostrum, infant formula with or without added porcine plasma) and with/without systemic immunoglobulins. Pigs infected with SE were assessed 12–48 h for clinical variables, blood bacteriology, chemistry, hematology, and gut dysfunction (intestinal permeability, necrotizing enterocolitis lesions).Results: Adverse clinical responses and increased mortality were observed in preterm vs. term pigs, when infected with SE just after birth. Feeding bovine colostrum just after birth improved blood SE clearance and clinical status (improved physical activity and intestinal structure, fewer bone marrow bacteria), relative to pigs fed infant formula. A few days later, clinical responses to SE bacteremia (hematology, neutrophil phagocytic capacity, T cell subsets) were less severe, and less affected by different milk diets, with or without added immunoglobulins.Conclusion: Prematurity increases the sensitivity of newborn pigs to SE bacteremia, potentially causing sepsis. Sensitivity to systemic SE infection decreases rapidly in the days after preterm birth. Both age and diet (parenteral nutrition, colostrum, milk, formula) may influence gut inflammation, bacterial translocation and systemic immune development in the days after birth in preterm newborns.

Comparison of Maternal and Neonatal Outcome Following Cesarean Section at 38-40 Weeks

Background: The rate of Cesarean section is increasing which may be due to maternal and neonatal issues. Preterm Cesarean (at 38-39 weeks) has several morbidities and leads to maternal problems. The goal of this study was to compare neonatal and maternal complications following the performance of the Cesarean section after 38 weeks.Methods: This cross-sectional study evaluated 1010 subjects with term Cesarean section that referred to Yas hospital, in Tehran, Iran during 2015-7. The participants were divided into three groups based on the week of delivery. Afterward, they were studied for different neonatal and maternal complications.Results: According to the findings, the risk of adverse neonatal outcomes had a statistically negative relationship with the progress of gestational age. Moreover, the rate of hypoglycemia and hyperbilirubinemia and stillbirth was higher in neonates delivered before 38 weeks. Among the maternal complications, the rate of massive bleeding during cesarean section or in the postpartum period was significantly higher in deliveries before 39 weeks, whereas the rate of pelvic infection was higher in deliveries after 40 weeks.Conclusion: Based on the results of this study, the best time for the Cesarean section is the 39th week of pregnancy which led to the elimination of maternal and neonatal complications.

The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study.

To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.

Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery

ObjectiveTo evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks). Material and methodsWe performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death). ResultsAmong the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78−0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20−0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25−5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age < 28 weeks and SMM (aOR, 1.80; 95 % CI, 0.99−3.27, p = 0.05). ConclusionLower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.

Mediation of Adverse Pregnancy Outcomes in Autoimmune Conditions by Pregnancy Complications: A Mediation Analysis of Autoimmune Conditions and Adverse Pregnancy Outcomes.

Autoimmune conditions are associated with an increased risk of adverse pregnancy complications and outcomes, suggesting that pregnancy complications may mediate the excess risk. We performed a causal mediation analysis to quantify the mediated effects of autoimmune conditions on adverse pregnancy outcomes. We queried a California birth cohort created from linked birth certificates and hospital discharge summaries. From 2,963,888 births, we identified women with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriasis, and inflammatory bowel disease (IBD). Pregnancy complications included preeclampsia/hypertension, gestational diabetes mellitus, and infection in pregnancy. Adverse pregnancy outcomes were preterm birth, cesarean delivery, and small for gestational age. We performed a mediation analysis to estimate the total effects of each autoimmune condition and adverse pregnancy outcome and the indirect effects through pregnancy complications. All 4 autoimmune conditions were associated with preterm birth and cesarean delivery, and RA, SLE, and IBD were associated with offspring that were small for gestational age. The strongest mediator of RA, SLE, and psoriasis was preeclampsia/hypertension, accounting for 20-33% of the excess risk of preterm births and 10-19% of excess cesarean deliveries. Gestational diabetes mellitus and infections generally mediated <10% of excess adverse pregnancy outcomes. Of the 4 autoimmune conditions, selected pregnancy complications mediated the least number of adverse pregnancy outcomes among women with IBD. We found evidence that some excess risk of adverse pregnancy outcomes is mediated through pregnancy complications, particularly preeclampsia/hypertension. Quantifying excess risk and associated pathways provides insight into the underlying etiologies of adverse pregnancy outcomes and can inform intervention strategies.

COVID-19 Management in Newborn Babies in the Light of Recent Data: Breastfeeding, Rooming-in and Clinical Symptoms.

COVID-19 infection proceeds to spread rapidly, it has affected approximately 22 million people and resulted in 770.000 deaths worldwide so far (18 August 2020). The effect of COVID-19 infection on newborn babies still remains unclear. There is limited data regarding the effect of the virus in fetal life and among neonates after birth. Due to insufficient data, an ideal management method or treatment and follow-up guideline for disease in newborn babies cannot be established. In the recent three studies with the highest number of cases, it is reported that mothers who had COVID-19 infection in the last trimester, can breastfeed their babies if they comply with the appropriate hygiene and transmission prevention rules. It is also reported that pregnant women who got infected during pregnancy, have higher rates of maternal mortality, preterm birth frequency and cesarean delivery. Moreover it is asserted that vertical transmisson of the virus is possible and the babies who have community-acquired COVID-19 infection after birth often have symptoms of fever, hypoxemia, cough, tachypnea, less frequently feeding difficulty, retraction, ral, nasal congestion and exanthema. Topics as; its transmission via vaginal secretions during vaginal delivery, presence of the virus in breast milk and whether it has a teratogenic effect in intrauterine period, have not been fully explained. In this study, it is aimed to review the studies on newborn babies with COVID-19 infection and to compile the epidemic data, clinical findings, diagnosis and current information recommended for treatment. Although there is a limited number of published data on babies of mothers who had COVID-19 infection in the last period of pregnancy and babies who had infection in the neonatal period, the effects of the virus on the fetus in the early period of pregnancy and the long-term problems of newborn babies remain unknown.

1022: Association between extremely preterm cesarean delivery and maternal depressive symptoms: a national population-based cohort study

The aim of this study was to evaluate whether cesarean delivery before 26 weeks was associated with depressive and anxiety symptoms of mothers of preterm infants in comparison with cesarean deliveries between 26 and 34 weeks. The Etude Epidémiologique sur les petits ages gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm birth in 2011. We included mothers who delivered between 22 and 34 weeks and whom mothers' self-reported depressive symptoms (Center for Epidemiologic Studies Depression Scale: CES-D) and state anxiety (State-Trait Anxiety Inventory: STAI) symptoms were assessed at the moment of neonatal discharge. To assess the association of cesarean delivery before 26 weeks with depression (CES-D ≥ 16) and anxiety symptoms (STAI ≥ 45), we used univariate and cluster (to take into account a potential center effect) multivariate logistic regression analysis. Among 2270 women completing CES-D and STAI questionnaires at the moment of neonatal discharge, 38 (0.6%) had cesarean delivery and 61 (0.9%) had vaginal delivery before 26 weeks whereas 1415 (62.7%) women had cesarean delivery after 26 weeks and 744 (40.1%) had vaginal delivery after 26 weeks. Depression symptoms occurred in 25 (65.8%) women having cesarean delivery before 26 weeks versus in 748 (50.6%) women having cesarean delivery after 26 weeks (p=0.03). Cluster multivariate logistic regression showed significant association of cesarean delivery before 26 weeks and depression symptoms compared with cesarean delivery after 26 weeks (adjusted odd ratio [aOR], 2.61 ; 95% confidence interval [CI], 1.13-6.02) whatever neonatal birth weight and severe neonatal morbidity. Univariate and cluster multivariate analysis did not show significant association between preterm mode of delivery and anxiety symptoms. Cesarean delivery before 26 weeks is an independent factor of depressive symptoms in mothers of preterm infants. Perinatal professionals should be aware of maternal psychological morbidity and take special preventive care to these women.

Maternal characteristics and pregnancy outcomes of women with chronic hypertension: a population-based study.

Background We aimed to study the maternal characteristics and obstetric and neonatal outcomes in pregnant mothers with chronic hypertension (CHTN) compared to non-CHTN. Methods The study was a population-based cohort study, and a PEARL-Peristat Study (PPS) for the year of 2017. There were 20,210 total births including 19,762 singleton and 448 multiple births. We excluded multiple gestations from the analysis as they differ in fetal growth, duration of gestation and have a higher rate of obstetric and neonatal complications. We compared the maternal characteristics of mothers with pre-existing HTN with non-hypertensive mothers and studied the obstetric and neonatal outcomes including cesarean section, stillbirths, prematurity, macrosomia and postpartum hemorrhage (PPH). Results We identified 223 births of mothers with essential HTN. The overall prevalence of CHTN in our population was 1.1% (223/20,210). In regard to maternal characteristics, women with CHTN were at or above 35 years of age at the time of delivery 58.9% compared to non-CHTN women 18.7%, P-value <0.001. Pre-existing diabetes was found more in women with CHTN 15.1% compared to non-CHTN women 1.9%, P-value <0.001; while obesity was found in 64% of women with CHTN compared to 32.5% in non-CHTN women, P-value <0.001. Preterm birth was noted in 26% compared to 8% in CHTN compared to non-CHTN women, respectively, P-value <0.001. The rate of stillbirth was similar between the two groups, 0.9% compared to 0.6% in CHTN compared to non-CHTN women, respectively, P-value 0.369. Conclusion Hypertensive mothers have multiple other comorbidities. When compared to the general population, they are older, parous, diabetic and obese with an increased risk of preterm birth and cesarean deliveries. Lifestyle modification, extensive pre-conceptional counseling and multidisciplinary antenatal care are required for such a high-risk group.