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A study published in the journal Paediatric & Perinatal Epidemiology explores the association between hypertensive disorders of pregnancy (HDP) and cardiovascular mortality. The study found that specific subtypes of HDP, such as chronic hypertension, preeclampsia with severe features, and eclampsia, were associated with an increased risk of cardiovascular-related deaths. However, the study may have underestimated the true association due to limitations in data collection and classification of cardiovascular events. The findings highlight the need for extended postpartum care and health insurance coverage for individuals with HDP to prevent maternal cardiovascular deaths. Further research is needed to validate the underlying causes of maternal mortality and improve the quality of epidemiological data for surveillance purposes. [Extracted from the article]

Background: Optimal obstetric management for women with coronavirus disease (COVID-19) is not known. We describe the management of six pregnant women requiring in-hospital care for severe COVID-19. Methods: A retrospective chart review was conducted to identify pregnant women who tested positive for Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) between 15 March and 30 June 2020. A subset of women meeting criteria for severe COVID-19 was included. Results: Four women required non-invasive supplemental oxygen therapy and two required mechanical ventilation. Four women were discharged from hospital undelivered and two required preterm delivery. One woman had a pulmonary embolism, and two required re-admission for worsening symptoms. Conclusion: Management of pregnant women with severe COVID-19 is complex and should involve multidisciplinary expertise. Avoiding early delivery may be a safe option. We recommend an individualized approach to care, including careful consideration of the expected risks and benefits of expectant obstetric management versus delivery. [ABSTRACT FROM AUTHOR]

Since the declaration of coronavirus disease 2019 (COVID-19) as a global pandemic, the medical literature has been inundated with COVID-19-related publications at an unprecedented pace. Coronavirus disease 2019 pandemic and pregnancy and neonatal outcomes in general population: a living systematic review and meta-analysis (updated Aug 14, 2021). [Extracted from the article]

Those who are infected with Severe Acute Respiratory Syndrome-related CoronaVirus-2 are theoretically at increased risk of venous thromboembolism during self-isolation if they have reduced mobility or are dehydrated. Should patients develop coronavirus disease (COVID-19) pneumonia requiring hospital admission for treatment of hypoxia, the risk for thromboembolic complications increases greatly. These thromboembolic events are the result of at least two distinct mechanisms - microvascular thrombosis in the pulmonary system (immunothrombosis) and hospital-associated venous thromboembolism. Since pregnancy is a prothrombotic state, there is concern regarding the potentially increased risk of thrombotic complications among pregnant women with COVID-19. To date, however, pregnant women do not appear to have a substantially increased risk of thrombotic complications related to COVID-19. Nevertheless, several organizations have vigilantly issued pregnancy-specific guidelines for thromboprophylaxis in COVID-19. Discrepancies between these guidelines reflect the altruistic wish to protect patients and lack of high-quality evidence available to inform clinical practice. Low molecular weight heparin (LMWH) is the drug of choice for thromboprophylaxis in pregnant women with COVID-19. However, its utility in non-pregnant patients is only established against venous thromboembolism, as LMWH may have little or no effect on immunothrombosis. Decisions about initiation and duration of prophylactic anticoagulation in the context of pregnancy and COVID-19 must take into consideration disease severity, outpatient vs inpatient status, temporal relation between disease occurrence and timing of childbirth, and the underlying prothrombotic risk conferred by additional comorbidities. There is currently no evidence to recommend the use of intermediate or therapeutic doses of LMWH in thromboprophylaxis, which may increase bleeding risk without reducing thrombotic risk in pregnant patients with COVID-19. Likewise, there is no evidence to comment on the role of low-dose aspirin in thromboprophylaxis or of anti-cytokine and antiviral agents in preventing immunothrombosis. These unanswered questions are being studied within the context of clinical trials. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular severe maternal morbidity (CSMM) is rising and has become the leading cause of maternal mortality. Research using administrative data sets may allow for better understanding of this critical group of diseases.Objective: To validate a composite variable of CSMM for use in epidemiologic studies.Methods: We analysed delivery hospitalisations at an obstetric teaching hospital from 2007 to 2017. We utilised a subset of indicators developed by the Centers for Disease Control and Prevention based on ICD codes to form the composite variable for CSMM. Two expert clinicians manually reviewed all qualifying events using a standardised tool to determine whether these represented true CSMM events. Additionally, we estimated the number of CSMM cases among delivery hospitalisations without qualifying ICD codes by manually reviewing all hospitalisations with severe preeclampsia, a population at high risk of CSMM, and a random sample of 1000 hospitalisations without severe preeclampsia. We estimated validity of the composite variable.Results: Among 91 355 admissions for delivery, we captured 113 potential CSMM cases using qualifying ICD codes. Of these, 65 (57.5%) were true CSMM cases. Indicators for acute myocardial infarction, cardiac arrest, and cardioversion had the highest true-positive rates (100% for all). We found an additional 70 CSMM cases in the 2102 admissions with severe preeclampsia and a single CSMM case in the random sample. Assuming a rate of 1 CSMM case per 1000 deliveries in the remaining cohort, the composite variable had a positive predictive value of 57.5% (95% CI 47,9, 66.8), a negative predictive value of 99.8% (95% CI 99.8, 99.9), a sensitivity of 29.0% (95% CI 23.2, 35.4), and a specificity of 100% (95% CI 99.9, 100.0).Conclusion: A novel composite variable for CSMM had reasonable PPV but limited sensitivity. This composite variable may enable epidemiologic studies geared towards reducing maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]

Fetal tachycardia is a rare complication during pregnancy. After exclusion of maternal and fetal conditions that can result in a secondary fetal tachycardia, supraventricular tachycardia is the most common cause of a primary sustained fetal tachyarrhythmia. In cases of sustained fetal supraventricular tachycardia, maternal administration of digoxin, flecainide, sotalol, and more rarely amiodarone, is considered. As these medications have the potential to cause significant adverse effects, we sought to examine maternal safety during transplacental treatment of fetal supraventricular tachycardia. In this narrative review we summarize the literature addressing pharmacologic properties, monitoring, and adverse reactions associated with medications most commonly prescribed for transplacental therapy of fetal supraventricular tachycardia. We also describe maternal monitoring practices and adverse events currently reported in the literature. In light of our findings, we provide clinicians with a suggested maternal monitoring protocol aimed at optimizing safety. [ABSTRACT FROM AUTHOR]

Hyperemesis gravidarum is a complication of pregnancy associated with severe nausea and vomiting that can lead to fluid-electrolyte imbalances and nutritional deficiencies. Wernicke's encephalopathy is a neurologic manifestation of acute thiamine (vitamin B1) deficiency. We describe a case of hyperemesis gravidarum presenting with gait ataxia and nystagmus which led to a diagnosis of Wernicke's encephalopathy. [ABSTRACT FROM AUTHOR]

Background: In countries with low tuberculosis (TB) incidence, immigrants from higher incidence countries represent the major pool of individuals with latent TB infection (LTBI). The antenatal period represents an opportunity for immigrant women to access the medical system, and hence for potential screening and treatment of LTBI. However, such screening and treatment during pregnancy remains controversial. Objectives: In order to further understand the prevalence, natural history, screening and management of LTBI in pregnancy, we conducted a systematic literature review addressing the screening and treatment of LTBI, in pregnant women without known HIV infection. Methods: A systematic review of 4 databases (Embase, Embase Classic, Medline, Cochrane Library) covering articles published from January 1st 1980 to April 30th 2014. Articles in English, French or Spanish with relevant information on prevalence, natural history, screening tools, screening strategies and treatment of LTBI during pregnancy were eligible for inclusion. Articles were excluded if (1) Full text was not available (2) they were case series or case studies (3) they focused exclusively on prevalence, diagnosis and treatment of active TB (4) the study population was exclusively HIV-infected. Results: Of 4,193 titles initially identified, 208 abstracts were eligible for review. Of these, 30 articles qualified for full text review and 22 were retained: 3 cohort studies, 2 case-control studies, and 17 cross-sectional studies. In the USA, the estimated prevalence of LTBI ranged from 14 to 48% in women tested, and tuberculin skin test (TST) positivity was associated with ethnicity. One study suggested that incidence of active TB was significantly increased during the 180 days postpartum (Incidence rate ratio, 1.95 (95% CI 1.24–3.07). There was a high level of adherence with both skin testing (between 90–100%) and chest radiography (93–100%.). In three studies from low incidence settings, concordance between TST and an interferon-gamma release assay was 77, 88 and 91% with kappa values ranging from 0.26 to 0.45. In low incidence settings, an IGRA may be more specific and less sensitive than TST, and results do not appear to be altered by pregnancy. The proportion of women who attended follow-up visits after positive tuberculin tests varied from 14 to 69%, while 5 to 42% of those who attended follow-up visits completed a minimum of 6 months of isoniazid treatment. One study raised the possibility of an association of pregnancy/post-partum state with INH hepatitis (risk ratio 2,5, 95% CI 0.8–8.2) and fatal hepatotoxicity (rate ratio 4.0, 95% CI 0.2–258). One study deemed INH safe during breastfeeding based on peak concentrations in plasma and breast milk after INH administration. Conclusion: Pregnancy is an opportunity to screen for LTBI. Interferon-gamma release assays are likely comparable to tuberculin skin tests and may be used during pregnancy. Efforts should be made to improve adherence with follow-up and treatment post-partum. Further data are needed with respect to safety and feasibility of antepartum INH therapy, and with respect to alternative treatment regimens. [ABSTRACT FROM AUTHOR]

Background: The preventability of strokes during pregnancy and postpartum is understudied. Methods: We identified patients with ischemic and hemorrhagic strokes in pregnancy or within 12 weeks postpartum between 2009 and 2020 at an obstetric teaching hospital. We described the clinical course of the included cases. A multi-disciplinary panel adjudicated each occurrence of stroke according to a modified classification system for preventability. Results: Fifteen patients experienced a stroke during pregnancy or postpartum. Precisely, 60% presented with a headache, and 47% of events were complicated by severe obstetrical hypertension. Two cases were thought to be "possibly preventable" due to delays in presentation to care and miscommunication regarding hypertension management goals. Conclusion: In a cohort of pregnant and postpartum patients with stroke at a tertiary-care center, strokes may be prevented by future initiatives focusing on patient and provider education regarding early warning signs of pregnancy-associated stroke and hypertension thresholds and management specific to pregnancy. [ABSTRACT FROM AUTHOR]

Background: Low‐dose aspirin prophylaxis is recommended for women at risk of preeclampsia. Capturing aspirin prophylaxis within administrative databases can be challenging since it is an over‐the‐counter medication. The Better Outcome Registry and Network (BORN) database, a perinatal health registry in Ontario, Canada, includes a formal variable that captures aspirin prophylaxis for preeclampsia. This variable has not been formally validated. Objectives: To assess the accuracy of the aspirin prophylaxis variable in the BORN database against an electronic medical record (EMR). Methods: This validation study comprised 200 randomly selected women who had a livebirth at St. Michael's Hospital (SMH) in Toronto, Ontario, from January 2018 to July 2022. Recorded aspirin prophylaxis in pregnancy and maternal sociodemographic characteristics were independently extracted by two abstractors. Accuracy of aspirin prophylaxis use in the BORN database was compared to that in the SMH EMR, expressed as sensitivity, specificity, positive (PPV) and negative predictive values (NPV), Cohen's kappa (κ), and overall percent agreement, with 95% confidence intervals (CI). Sensitivity analyses were performed to account for missing or unclear aspirin prophylaxis use. Results: Among 200 women, 24 (12.0%) received aspirin prophylaxis – 12.5% within the SMH EMR and 8.0% in the BORN database. Women using aspirin were older (37.0 vs 33.0 years) and had higher median gravidity (3 vs. 2). Sensitivity and specificity of the BORN aspirin prophylaxis variable were 62.5% (95% CI 40.6, 81.2) and 100.0% (95% CI 97.3, 100.0), respectively. The corresponding positive and negative predictive values were 100.0% (95% CI 78.2, 100.0), and 93.8% (95% CI 88.6, 97.1), respectively. Cohen's κ was 0.74 (95% CI 0.58, 0.90), and overall percent agreement was 94.4% (95% CI 87.1, 100.0). Conclusions: Aspirin use within the BORN database, based on a standard variable field, appears accurate enough for the potential use in epidemiological studies of aspirin prophylaxis for preeclampsia or as a covariate in related studies. [ABSTRACT FROM AUTHOR]

The effects of lipid metabolism disorders (LMD) on pregnancy outcomes is not well known. The purpose of this study is to evaluate the impact of LMD on maternal and fetal outcomes. Using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States, we carried out a retrospective cohort study of all births between 1999 and 2015 to determine the risks of complications in pregnant women known to have LMDs. All pregnant patients diagnosed with LMDs between 1999 and 2015 were identified using the International Classification of Disease-9 coding, which included all patients with pure hypercholesterolemia, pure hyperglyceridemia, mixed hyperlipidemia, hyperchylomicronemia, and other lipid metabolism disorders. Adjusted effects of LMDs on maternal and newborn outcomes were estimated using unconditional logistic regression analysis. A total of 13,792,544 births were included, 9,666 of which had an underlying diagnosis of LMDs for an overall prevalence of 7.0 per 10,000 births. Women with LMDs were more likely to have pregnancies complicated by diabetes, hypertension, and premature births, and to experience myocardial infarctions, venous thromboembolisms, postpartum hemorrhage, and maternal death. Their infants were at increased risk of congenital anomalies, fetal growth restriction, and fetal demise. Women with LMDs are at significantly higher risk of adverse maternal and newborn outcomes. Prenatal counselling should take into consideration these risks and antenatal care in specialized centres should be considered. [ABSTRACT FROM AUTHOR]

Background: Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission. Objectives: To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48 h, or maternal death. Methods: Chart review of ICU admissions during pregnancy/postpartum (2006–2016); logistic regressions to evaluate the impact of age on outcomes. Results: With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15–14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66–8.02). Conclusion: Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Obtaining granular data on events and circumstances leading to severe maternal morbidity (SMM) could complement large epidemiologic studies and enable targeted interventions to improve maternal health. This study aims to assess the feasibility of gathering such data from maternity units across Canada through a Canadian Obstetric Survey System (CanOSS). METHODS: The study is a sequential explanatory mixed-methods study, the first step of which is a nationwide survey of maternity unit leads. Semistructured qualitative interviews are being conducted with unit leads that expressed interest in response to the survey. Responses are reported using proportions and percentages. Interviews are being thematically analyzed. This study was approved by the Hamilton Integrated Research Ethics Board (HiREB) #14002. RESULTS: As of October 18, 2022, we have identified 306 maternity units nationally, and sent 218 surveys, with 59 maternity units across 8 provinces completing. Among these, 34 (83%) report having a system in place for reviewing SMM, conducted on an as-needed basis in 61% of units, and most commonly involving a multidisciplinary panel of experts with representation from nursing (85%), maternity unit leadership (79%), and hospital management (74%). A written report is prepared following 76% of meetings. Findings are shared with health care professionals involved in the event and formulated into recommendations in 79% and 82% of units, respectively. Importantly, 78% of respondents would be willing to contribute anonymized data on SMM within a centralized reporting system. Interviews have taken place with 14 unit leads. Interviewed participants unanimously agree that an obstetric survey system is needed. Concerns raised include privacy, resources, funding, and having a clear definition of SMM. CONCLUSION: This feasibility study will facilitate future planning, clarify barriers to be addressed, and resource implications for gathering data on SMM at a national level, and lay the foundations for a future CanOSS. [ABSTRACT FROM AUTHOR]

Background: Nausea and vomiting in pregnancy often require pharmacotherapy for symptom management. Serotonin syndrome is a rare clinical entity that can be precipitated by the medications used to treat nausea and vomiting in pregnancy.Case: A 35-year-old pregnant individual with a history of hyperemesis gravidarum in an earlier pregnancy requiring prolonged hospitalization presented with nausea and vomiting at 7 weeks of gestation. She was incidentally found to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection when she was universally screened at the time of admission. She required pharmacotherapy, including prochlorperazine and ondansetron for treatment of nausea as well as sumatriptan for migraine. She developed acute spasticity, autonomic dysfunction, and temperature rise, precipitated by antiemetic therapy, consistent with serotonin syndrome. The syndrome resolved with supportive care and benzodiazepines.Conclusion: Serotonin syndrome is a serious clinical entity that can be provoked by the pharmacotherapy given to treat nausea and vomiting in pregnancy. This medical emergency requires early recognition and prompt management. [ABSTRACT FROM AUTHOR]

Severe complications of infectious diseases can occur during pregnancy. Evidence-based prevention and treatment strategies are critical to improve maternal and neonatal health outcomes. Despite this medical need, pregnant and breastfeeding people have been systematically excluded from biomedical research. The objective of this study was to characterize representation of pregnant and breastfeeding people in randomized controlled trials (RCTs) evaluating a broad range of interventions for infectious diseases. Pregnancy and breastfeeding inclusion criteria were examined in infectious diseases RCTs published between 1 January 2017, and 31 December 2019, in the top five highest impact general medicine and the top three highest impact infectious diseases and HIV journals. Of 376 RCTs, 5.3% and 1.9% included pregnant and breastfeeding people, respectively. Justification for exclusion was documented in 36/271 (13.3%) studies that explicitly excluded pregnant people. Most studies excluding pregnant people (177/271, 65.3%) required at least one form of contraception, abstinence and/or negative pregnancy test(s) as part of participation. Only 11/271 (4.1%) studies excluding pregnant people allowed participants to continue the intervention if unintended pregnancy occurred during the study. When both pregnant and non-pregnant people were eligible, pregnant people made up <3% of participants. Only 2/48 (4.2%) vaccine studies included pregnant people; 13/234 (5.5%) drug studies included pregnant people. All studies of procedures, devices, behaviour/education and supplements/vitamins explicitly excluded or did not address pregnancy eligibility criteria. Only 2/20 (10.0%) RCTs including pregnant people collected pharmacokinetic data. This study demonstrates widespread exclusion of pregnant and breastfeeding people from infectious disease RCTs. [ABSTRACT FROM AUTHOR]

Excluding pregnant people from Covid‐19 clinical trials may lead to unintended harmful consequences. For this study, an online questionnaire was sent to physicians belonging to Canadian professional medical associations in order to evaluate their perspectives on the participation of pregnant women in Covid‐19 clinical trials. The majority of respondents expressed support for including pregnant women in Covid‐19 trials (119/165; 72%), especially those investigating therapies with a prior safety record in pregnancy (139/164; 85%). The main perceived barriers to inclusion identified were unwillingness of pregnant patients to participate and of treating teams to offer participation, the burden of regulatory approval, and a general "culture of exclusion" of pregnant women from trials. We describe why some physicians may be reluctant to include pregnant individuals in trials, and we identify barriers to the appropriate participation of pregnant people in clinical research. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the performance of B-type natriuretic peptide as a diagnostic tool for heart failure in pregnant or postpartum women with singleton gestations.Methods: We conducted a retrospective study of diagnostic accuracy. We identified pregnant and postpartum women with B-type natriuretic peptide and echocardiography performed at an obstetric teaching hospital from 2007 to 2018. Women with known cardiac disease or multiple gestation were excluded. A panel of two cardiovascular disease experts, blinded to B-type natriuretic peptide values, determined the diagnosis of heart failure by consensus. Their judgement was based on detailed clinical features and parameters at the time of presentation with suspected heart failure. Where consensus could not be reached, differences were adjudicated by a third expert. A receiver operating characteristic curve estimated the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of B-type natriuretic peptide at various thresholds.Results: In total, 22 pregnant and 38 postpartum women were included in the cohort. Average age was 32±6.8 years. The most common clinical features at the time of presentation with suspected heart failure included preeclampsia (33/60, 55%), dyspnea (50/60, 83%), chest discomfort (34/60, 58%), and bilateral lower extremity edema (32/60, 53%). In total, 39 (65%) women had heart failure. The median B-type natriuretic peptide level was 326 pg/mL (interquartile range 200.5-390.5) in women with heart failure, as compared with 75.5 pg/mL (interquartile range 19-245) in women without heart failure (P<.01). The estimated optimal B-type natriuretic peptide cutoff was 111 (95% CI 78-291) pg/mL. Using this threshold, 45 (75%) women had an elevated B-type natriuretic peptide, which yielded a 95% sensitivity (95% CI 83-99), 62% specificity (95% CI 38-82), a positive likelihood ratio of 2.5 (95% CI 1.4-4.3), and a negative likelihood ratio of 0.1 (95% CI 0.0-0.3) for heart failure.Conclusions: B-type natriuretic peptide is a useful clinical tool to evaluate pregnant and postpartum women with suspected heart failure. [ABSTRACT FROM AUTHOR]

Background Use of health administrative databases is proposed for screening and monitoring of participants in randomized registry trials. However, access to these databases raises privacy concerns. We assessed patient's preferences regarding use of personal information to link their research records with national health databases, as part of a hypothetical randomized registry trial. Methods and results Cardiology patients were invited to complete an anonymous self-reported survey that ascertained preferences related to the concept of accessing government health databases for research, the type of personal identifiers to be shared and the type of follow-up preferred as participants in a hypothetical trial. A total of 590 responders completed the survey (90% response rate), the majority of which were Caucasians (90.4%), male (70.0%) with a median age of 65 years (interquartile range, 8). The majority responders (80.3%) would grant researchers access to health administrative databases for screening and follow-up. To this end, responders endorsed the recording of their personal identifiers by researchers for future record linkage, including their name (90%), and health insurance number (83.9%), but fewer responders agreed with the recording of their social security number (61.4%, p < 0.05 with date of birth as reference). Prior participation in a trial predicted agreement for granting researchers access to the administrative databases (OR: 1.69, 95% confidence interval: 1.03–2.90; p = 0.04). Conclusion The majority of Cardiology patients surveyed were supportive of use of their personal identifiers to access administrative health databases and conduct long-term monitoring in the context of a randomized registry trial. [ABSTRACT FROM AUTHOR]