Preeclampsia and Severe Maternal Morbidity During the COVID-19 Pandemic: A Population-Based Cohort Study in Ontario, Canada

Strategies to support maternal and early childhood wellness: insight from parent and provider qualitative interviews during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic resulted in rapid changes to the delivery of maternal and newborn care. Our aim was to gain an understanding from parents and healthcare professionals (HCPs) of how the pandemic and associated public health restrictions impacted the peripartum and postpartum experience, as well as longer-term health and well-being of families.

DESIGN

Qualitative study through focus groups.

SETTING

Ontario, Canada.

PARTICIPANTS

HCPs and parents who had a child born during the COVID-19 pandemic.

INTERVENTIONS

Semistructured interview guide, with questions focused on how the pandemic impacted their care/their ability to provide care, and strategies to improve care and support now or in future situations with similar healthcare restrictions.

OUTCOME MEASURES

Thematic analysis was used to describe participant experiences and recommendations.

RESULTS

We included 11 HCPs and 15 parents in 6 focus groups. Participants described their experiences as 'traumatic', with difficulties in accessing prenatal and postpartum services, and feelings of distress and isolation. They also noted delays in speech and development in children born during the pandemic. Key recommendations included the provision of partner accompaniment throughout the course of care, expansion of available services for young families (particularly postpartum), and special considerations for marginalised groups, including access to technology for virtual care or the option of in-person visits.

CONCLUSIONS

Our findings may inform the development of healthcare system and organisational policies to ensure the provision of maternal and newborn care in the event of future public health emergencies. Of primary importance to the participants was the accommodation of antenatal, intrapartum and postpartum partner accompaniment, and the provision of postpartum services.

Hospitalizations for Obstetrical Conditions During and After the Covid-19 Pandemic

BACKGROUND

During the Covid-19 pandemic there have been a drastic decrease in hospitalizations for non-Covid conditions. The aim of this study was to evaluate the trend in hospitalizations for obstetrical conditions during and after the Covid-19 pandemic.

METHODS

For this study there we used electronical data base in order to search for all the obstetrical patients that were hospitalized in a tertiary maternity, Clinical Emergency County Hospital Craiova, during the pre-pandemic period (between March - December 2019), during pandemics (2020 March - December, 2021 March - December) and post pandemics (2022 March - December).

RESULTS

The total number of hospitalizations during 2020 dropped by 28% compared to the pre-pandemic year - 2019, and further by 30% in 2021, and by 26% in 2022. In terms of day admissions, a decreasing trend can be observed, with a total of 3230 admissions, from which, 208 in 2020 showing a decrease of 93%, 695 in 2021 with a decrease of 78% and 941 in 2022 with a decrease of 70% compared to 2019.We experienced a significant increase of vaginal birth rate during the pandemic (2020-2021) of 24% that can be attributed to the unavailability of many surrounding low-risk birth units during the pandemic.

CONCLUSION

The obstetrical conditions hospitalizations dramatically dropped during the COVID-19 pandemic and have not yet recovered to the pre-pandemic level.

COVID-19 and Hypertensive Disorders of Pregnancy (HDP): A Portuguese Multicentric Retrospective Cohort Study of HDP in SARS-CoV-2 Infected Patients

BACKGROUND

 An increased incidence of hypertensive disorders of pregnancy (HDP) has been reported among pregnant women infected by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the pathogen behind coronavirus disease-19 (COVID-19). Although it is primarily a respiratory infection, the extra-pulmonary manifestations of COVID-19 mimic those found in preeclampsia (PE). Moreover, the two conditions share common risk factors and pathological mechanisms, hindering the ability to understand the interaction between them. Current literature on this topic is controversial and as there is an overlap of clinical and laboratory findings, HDP can be an overreported outcome in pregnant women with COVID-19. The aim of our study is to assess whether there is an association between maternal SARS-CoV-2 infection and HDP.

METHODS

We designed a multicenter retrospective cohort study with data collected from five maternity hospitals in Almada, Porto, Lisboa, Penafiel and Coimbra, Portugal, between March 2020 and March 2021. We obtained a sample of 789 pregnant women who were followed up or delivered their babies in one of the participating centers. Each pregnant woman who tested positive for SARS-CoV-2 on a real-time polymerase chain reaction test -- exposure group (n= 263), was paired with two negative pregnant women (1:2), who received the same antenatal care and had similar gestational age and parity -- control group (n=526). Data were collected on maternal characteristics, medical history, obstetric outcomes, and delivery.  Outcomes: The primary outcome of our study is to assess the incidence of HDP in pregnant women infected and not infected by SARS-CoV-2. The secondary outcomes of our study are to assess the incidence of HDP across all COVID-19 severity subgroups and to assess whether SARS-CoV-2 infection in pregnancy modified the odds of a set of risk factors developing HDP.  Results: There was a slightly increased, but not statistically significant, incidence of PE (relative risk, RR, 1.33; 95% confidence interval, CI 0.68-2.57) in the SARS-CoV-2 positive group. There was no statistically significant association between having COVID-19 in pregnancy and developing PE/eclampsia/ hemolysis, elevated liver enzymes, and low platelets, HELLP syndrome [X2(1) = 0.732; p = 0.392] as well as developing gestational hypertension (GH) [X2(1) = 0.039; p = 1]. There was no statistically significant association [X²(2) = 0.402; p = 0.875), [X²(2) = 1.529; p = 0.435] between COVID-19 severity and incidence of HDP. The SARS-CoV-2 infection did not modify the odds of each maternal risk factor causing HDP.  Conclusion: Our study did not demonstrate an association between maternal COVID-19 and HDP. We did not observe a significantly increased incidence of HDP in pregnant women infected by SARS-CoV-2. As current literature is controversial on this topic, clinicians should be aware that HDP is a possible complication of maternal SARS-CoV-2 infection and further research studies urge to better assess the association between COVID-19 in pregnancy and HDP.

Pre-eclampsia

Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.

COVID-19 and hemolysis, elevated liver enzymes and thrombocytopenia syndrome in pregnant women - association or causation?

Pregnant women are among the high-risk population for severe coronavirus disease 2019 (COVID-19) with unfavorable peripartum outcomes and increased incidence of preterm births. Hemolysis, the elevation of liver enzymes, and low platelet count (HELLP) syndrome and severe preeclampsia are among the leading causes of maternal mortality. Evidence supports a higher odd of pre-eclampsia in women with COVID-19, given overlapping pathophysiology. Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system. The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation, which may be another common link between COVID-19 and HELLP syndrome. On PubMed search from January 1, 2020, to July 30, 2022, we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome. Most of these studies are case reports or series, did not perform histopathology analysis of the placenta, or measured biomarkers linked to pre-eclampsia/HELLP syndrome. Hence, the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies. We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation, and gaps in the current evidence and propose an area of future research.