BJOG Exchange

Objective: To evaluate the relation between peripartum infection at first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. Design: Retrospective case-control study from March 2014 to October 2020. Setting: University-affiliated medical centre. Sample: Women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who had a successful vaginal birth after Cesarean section without evidence of dehiscence or uterine rupture. Methods: We compared the rate of peripartum infection during the first Cesarean delivery and other relevant variables, between the two groups. We also analysed the type of infection correlated with uterine rupture or dehiscence. Main Outcome Measures: Rate of peripartum infection. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful vaginal birth after Cesarean section as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p=0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk-factor for uterine rupture at the subsequent trial of labour after Cesarean delivery (95% CI, P=0.018). We also found that endometritis had the highest correlation to uterine rupture (9.8% vs. 0%, p=0.02) Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery. Compared to other infections, endometritis may pose the greatest risk for uterine rupture or dehiscence.

Objective: To identify the association between cervical length (CL) and gestational age at birth. Design: Prospective cohort study. Setting: Seventeen Brazilian reference hospitals. Population: A cohort of 3139 asymptomatic singleton pregnant women who participated in the screening phase of a Brazilian multicenter randomized controlled trial (P5 trial). Methods: Transvaginal ultrasound (TVU) to measure CL was performed from 18 to 22+6 weeks. Women with CL ≤ 30 mm received vaginal progesterone (200 mg/day) until 36 weeks’ gestation. Main Outcome Measures: Area under receive operating characteristic curve (AUC), sensitivity, specificity, Kaplan-Meier curves for preterm birth (PTB), number needed to screen (NNS). Results: CL ≤25mm was associated with extremely severe, severe, moderate and late PTB, whereas a CL 25–30mm was directly associated with late sPTB. The AUC to predict sPTB<28 weeks was 0.82 and for sPTB<34 weeks was 0.67. Almost half of the sPTB occurred in nulliparous women and CL ≤30mm was associated with sPTB <37 weeks (OR = 7.84; 95%CI = 5.5–11.1). The NNS to detect one sPTB <34 weeks in women with CL ≤25mm is 121 and 248 screening tests are necessary to prevent one sPTB <34 weeks using vaginal progesterone prophylaxis. Conclusions: CL measured by TVU is associated with sPTB <34 weeks. Women with CL ≤30mm are at increased risk for late sPTB. Funding: Bill & Melinda Gates Foundation [OPP1107597], the Brazilian Ministry of Health, and the Brazilian National Council for Scientific and Technological Development (CNPq) [401615/20138]. Keywords: cervical length; number needed to screen; preterm birth; short cervix.

A novel over-the-peritoneum aorta clamp enabled a senior obstetrician, backed by a urologist, to manage 33 women with histopathology-confirmed Placenta Accreta spectrum, with no maternal mortality, relatively low incidence of blood transfusion and urological injuries in a limited resource setting. Easily applied by the obstetricians themselves, this clamp can be an effective and relatively safer alternative to intra-aortic balloon occlusion and aortic-cross clamping. We anticipate, obstetricians in low-resource settings can easily adapt our methods and contribute further prospective evidence.

Gestational diabetes: False dichotomy and slippery slope

Objectives: Our primary objective to determine the cumulative retention of Ob/Gyns since the inception of the program, to determine the demographic and practice characteristics of all Ob/Gyns who have been trained by the Ghana postgraduate Ob/Gyn programs, and to compare the geographic distribution of Ob/Gyns throughout Ghana between 2010 when a prior study was conducted and the current practice locations of all graduates in 2017. Design: Cross-sectional, Quantitative Investigation Setting: Fieldwork for this study was conducted in Ghana between June 21, 2017, and August 20, 2017. Methods: A roster of certified Ob/Gyns, year certified, and email contact information was obtained from the Ghana College of Physicians and Surgeons, a roster of practice locations was obtained from Ghana Medical Board. Main Outcome Measures: retention of Ob/Gyns, geographic distribution of providers, fand comparisons between 2010 and 2017 Results: Significant geographic spread and increase in in-country medical programs have occurred over the seven-year period. In recent years, the Ghana College of Physicians and Surgeons surpassed that of the West African College of Surgeons. Conclusion: Establishing an Ob/gyn training program with national certification provides a cadre of certified Ob/Gyns that can be trained and retained in low-income settings. Moreover, this allows for long term commitment in multiple relevant sectors that may serve to establish a comprehensive obstetric and gynecology capacity beyond urban centers.

Objective : To study changes in caesarean delivery (CD) rates between maternity wards in a perinatal network after implementation of the Ten Group Classification System (TGCS) in an audit with feedback. Design A retrospective pre–post study of all births from 1 January 2012 to 31 December 2018. Setting A French perinatal network of 10 maternity wards in the Yvelines district of France. Population All live births of gestational age ≥24 weeks in the network. Methods During the pre-period (1 January 2012 to 31 December 2014), the audit and feedback provided only overall CD rates. During the post-period (1 January 2015 to 31 December 2018), CD rates for each TGCS group were provided. Regression models, adjusted for maternal characteristics and maternity ward, were used to compare CD rates globally and for each TGCS group. Variability of CD rates between maternity wards was analysed using the coefficients of variation. Main outcome measure CD rates. Results There were 51 082 women who delivered during the pre-period and 63 964 during the post-period. The overall CD rate did not decrease (24.5% during the pre-period versus 25.1% during the post-period). There were no significant differences in CD rates for any TGCS group after adjustment for maternity, maternal age and socio-demographic characteristics. Nor did audit implementation decrease CD rate variability between maternity wards or within TGCS groups. Conclusion Implementation of an audit-and-feedback cycle using the TGCS did not decrease either CD rates or variability between maternity wards.

Coronavirus Disease 2019 and messenger RNA Vaccination in Pregnant Women.Paulino Vigil-De Gracia, MD.Complejo Hospitalario Dr. AAM Caja de Seguro Social. Investigador distinguido del Sistema Nacional de Investigación, SENACYT Panamá, e-mail: pvigild@hotmail.comIntroductionSince its appearance in December of 2019, the SARS-CoV-2 infection has been associated with greater severity in patients with pre-existing pathologies. With the progression of the disease and adequate studies in pregnant women, it has been shown that this group of the population is associated with a higher risk and severity of the disease1. About 10% of pregnant women evolve severely, there is a higher risk of admission to the intensive care unit (ICU), the need for mechanical ventilation, maternal deaths, a higher risk of pre-eclampsia, premature births, and neonatal complications2-4. Vaccines based on an mRNA platform have become one of the safest and most widely used alternatives for combatting SARS-CoV-2 5 infections.Pregnant women with SARS-CoV-2Pregnant women with COVID-19 are 3-5 times more likely to enter the ICU compared to non-pregnant women of reproductive age or pregnant women without the disease. In addition, there is a fatality percentage between 0.6 to 1.6%, which is highly significant 2,3. Another finding that worsens the prognosis is the association between COVID-19 and pre-eclampsia. This association has been observed in a longitudinal study 3 and in a systematic review4. Pregnant women infected with SARS-CoV-2 have a significant 62% greater likelihood of developing pre-eclampsia than those without infection, including a higher risk of presenting the worst conditions of pre-eclampsia in its severe form, HELLP syndrome and eclampsia, according to the findings of a systematic review4.As pregnant women are at high risk when infected with SARS-CoV-2, said prognosis worsens, as it is associated with pre-eclampsia/eclampsia. They are two diseases with poor maternal and perinatal prognosis.Neonatal complications, prematurity, and NICU stay are higher in those born to mothers with COVID-19 1,3. In addition to these findings, the frequency of cesarean sections is significantly higher in pregnant women with severe COVID-19. Therefore, neonatal results seem to be influenced more by the diagnosis of disease severity than the presence of the maternal infection itself.Vaccination before pregnancy and in the first weeks of pregnancyMessenger RNA vaccines are not live, attenuated, inactivated virus vaccines, nor do they use an adjuvant. These vaccines do not enter the nucleus and do not alter human DNA. As a result, mRNA vaccines cannot cause any genetic changes. Animal studies performed with the Moderna vaccine, evaluating perinatal and postnatal toxicity, show no alterations to embryonic, fetal or postnatal development after use of this type of vaccine. Pregnant women were not included in the original studies where the usefulness of these vaccines was confirmed. Therefore, there are no randomized studies that show benefits (or complications) in pregnant women.After the acceptance of the emergency use of the COVID-19 vaccine, several studies have been completed that show results associated with pregnancy. A report in the UK shows us that in the vaccinated women who were part of the original randomized studies, the number of unplanned pregnancies was the same in both groups (vaccine or placebo); furthermore, there were no differences in loss percentages in the first trimester of pregnancy 6.More recently, a preprint 5 vaccination report from the United States shows us the results of 2,456 pregnant women and the risk of spontaneous abortion between 6 and 19 weeks when these women were vaccinated in the pre-conception period or before the first 20 weeks of pregnancy. This study does not show a higher incidence of spontaneous abortions in the population vaccinated with mRNA vaccines, compared to the reference standard.Vaccination according to trimester of pregnancyThere are no randomized controlled studies proving the benefit of SARS-CoV-2 vaccines in pregnant women, however, there are several reports on its benefits and safety regardless of the trimester of pregnancy in which it has been used. A large cohort 7shows us that of 3,958 vaccinated pregnant women, 28.6% were vaccinated in the first trimester of pregnancy and 43.3% in the second trimester. According to the findings of this study in the United States7 and another in Israel 8, mass vaccination of the population occurs in all trimesters of pregnancy and the follow-up study of the population that has finished their pregnancy shows that there was no evidence of an increase in: abortions, malformations, fetal or neonatal death, premature birth, or restricted growth. In addition, there is a series of cases that shows that vaccination in the third trimester does not cause placental disorders9.Evidence of protectionTwo large retrospective cohorts have evaluated the effect of mRNA vaccines in vaccinated pregnant women. The study carried out in the USA7 with 3,958 pregnant women shows us that the possibility of infection 14 days after the first dose is 0.3%. Furthermore, the study carried out in 7,530 vaccinated pregnant women in Israel 8 compared to 7,530 unvaccinated (paired) women shows that between 11 and 28 days after the first dose, there is a significant decrease in infection when compared to the unvaccinated group. This difference becomes greater with the increase of the number of days post vaccination until a follow-up of 70 days.Another important finding with maternal vaccination is the possible fetal and neonatal protection. Breast milk was tested in a cohort of 84 vaccinated mothers with at least two doses of mRNA vaccine10. This study found a robust secretion of specific IgG and IgA antibodies against SARS-CoV-2 in breast milk for 6 weeks after vaccination. These results suggest the potential protective effect against SARS-CoV-2 in infants of vaccinated or infected breastfeeding mothers.On the other hand, the transplacental transfer of IgG antibodies has been evaluated in mothers who have received mRNA vaccine in the third trimester 11. The studies show that if 16-21 days have passed since the first dose by the time of birth, there will already be a large amount of IgG antibodies present in the umbilical cord and the greatest amount of passive immunity will be obtained 3-4 weeks after the first dose of mRNA vaccine administered to the mother. By that time, the amount of antibodies in the umbilical cord are similar to those existing in maternal blood 11.Other studies 12 have performed analyzes on both pregnant and lactating women and their results show that maternal antibodies generated by vaccines are transported to the child through umbilical cord blood and breast milk.SummaryPregnant women represent a group at high risk of infection by SARS-CoV-2. There are greater levels of admission to ICU, more death, more pre-eclampsia and prematurity,Vaccines with the mRNA platform have been shown to be effective and safe in pregnant women and there is no evidence of fetal or neonatal damage in any trimester of pregnancy.Vaccination against COVID-19 in pregnant women has been delayed in the world due to the non-inclusion in the original randomized studies; despite the absence of valid scientific elements demanding their exclusion. This experience should be used in the future and especially with this type of vaccine.ReferencesVouga M, Favre G, Martinez-Perez O, Pomar L, Acebal LF, Abascal-Saiz A, Hernandez MRV, Hcini N, Lambert V, Carles G, Sichitiu J, Salomon L, Stirnemann J, Ville Y, de Tejada BM, Goncé A, Hawkins-Villarreal A, Castillo K, Solsona EG, Trigo L, Cleary B, Geary M, Bartels H, Al-Kharouf F, Malone F, Higgins M, Keating N, Knowles S, Poncelet C, Ribeiro-do-Valle CC, Surita F, Dantas-Silva A, Borrelli C, Luz AG, Fuenzalida J, Carvajal J, Canales MG, Hernandez O, Grechukhina O, Ko AI, Reddy U, Figueiredo R, Moucho M, Pinto PV, De Luca C, De Santis M, de Campos DA, Martins I, Garabedian C, Subtil D, Bohrer B, Da Rocha Oppermann ML, Wender MCO, Schuler-Faccini L, Sanseverino MTV, Giugliani C, Friedrich L, Scherer MH, Mottet N, Ducarme G, Pelerin H, Moreau C, Breton B, Quibel T, Rozenberg P, Giannoni E, Granado C, Monod C, Mueller D, Hoesli I, Bassler D, Heldstab S, Kölble NO, Sentilhes L, Charvet M, Deprest J, Richter J, Van der Veeken L, Eggel-Hort B, Plantefeve G, Derouich M, Calvache AJN, Lopez-Giron MC, Burgos-Luna JM, Escobar-Vidarte MF, Hecher K, Tallarek AC, Hadar E, Haratz KK, Amikam U, Malinger G, Maymon R, Yogev Y, Schäffer L, Toussaint A, Rossier MC, De Sa RAM, Grawe C, Aebi-Popp K, Radan AP, Raio L, Surbek D, Böckenhoff P, Strizek B, Kaufmann M, Bloch A, Boulvain M, Johann S, Heldstab SA, Bernasconi MT, Grant G, Feki A, Brochut AM, Giral M, Sedille L, Papadia A, Brugger RC, Weber B, Fischer T, Kahlert C, Saines KN, Cambou M, Kanellos P, Chen X, Yin M, Haessig A, Ackermann S, Baud D, Panchaud A. Maternal outcomes and risk factors for COVID-19 severity among pregnant women. Sci Rep. 2021 Jul 6;11(1):13898. Doi: 10.1038/s41598-021-92357.Zambrano LD, Ellington S, Strid P, et al. Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–October 3, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1641–1647. DOI: http://dx.doi.org/10.15585/mmwr.mm6944e3external iconPapageorghiou AT, Deruelle P, Gunier RB, Rauch S, García-May PK, Mhatre M, Usman MA, Abd-Elsalam S, Etuk S, Simmons LE, Napolitano R, Deantoni S, Liu B, Prefumo F, Savasi V, do Vale MS, Baafi E, Zainab G, Nieto R, Maiz N, Aminu MB, Cardona-Perez JA, Craik R, Winsey A, Tavchioska G, Bako B, Oros D, Rego A, Benski AC, Hassan-Hanga F, Savorani M, Giuliani F, Sentilhes L, Risso M, Takahashi K, Vecchiarelli C, Ikenoue S, Thiruvengadam R, Soto Conti CP, Ferrazzi E, Cetin I, Nachinab VB, Ernawati E, Duro EA, Kholin A, Firlit ML, Easter SR, Sichitiu J, Bowale A, Casale R, Cerbo RM, Cavoretto PI, Eskenazi B, Thornton JG, Bhutta ZA, Kennedy SH, Villar J. Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study. Am J Obstet Gynecol. 2021 Jun 26:S0002-9378(21)00561-5. Doi: 10.1016/j.ajog.2021.05.014.Conde-Agudelo A, Romero R. SARS-COV-2 infection during pregnancy and risk of preeclampsia: a systematic review and meta-analysis. Am J Obstet Gynecol. 2021 Jul 21:S0002-9378(21)00795-X. doi: 10.1016/j.ajog.2021.07.009.Zauche LH, Wallace B, Smoots AN, Olson CK, Oduyebo T, Kim SY et all. Receipt of mRNA COVID-19 vaccines preconception and during pregnancy and risk of self-report spontaneous abortions, CDC v-safe COVID-19 vaccine pregnancy registry 2020-21. Preprint DOI:10.21203/rs.3.rs-798175/v1Male V. Are COVID-19 vaccines safe in pregnancy? Nat Rev Immunol. 2021 Apr;21(4):200-201. Doi: 10.1038/s41577-021-00525-y. Erratum in: Nat Rev Immunol. 2021 Mar 12.Shimabukuro TT, Kim SY, Myers TR, Moro PL, Oduyebo T, Panagiotakopoulos L, Marquez PL, Olson CK, Liu R, Chang KT, Ellington SR, Burkel VK, Smoots AN, Green CJ, Licata C, Zhang BC, Alimchandani M, Mba-Jonas A, Martin SW, Gee JM, Meaney-Delman DM; CDC v-safe COVID-19 Pregnancy Registry Team. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons. 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Objective: Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. Design: State-wide retrospective cohort study. Setting: Victoria, Australia. Population: All births (455,000) between 2009-2014. Methods: The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites. Results: Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3rd or 4th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 – 1.38)). Conclusions: Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3rd or 4th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.

Objective: Compare maternal and perinatal outcomes between emergency and elective caesarean-hysterectomy for placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team. Design and setting: Single-centre retrospective cohort study Population: 125 cases of antenatally suspected and pathologically confirmed PAS disorder. Methods: Maternal and perinatal outcomes were analyzed. Multivariate logistic regression was used to test associations, adjusting for potential confounders. Survival curves exploring risk factors for emergency delivery were sought. Main Outcome Measures: Maternal outcomes including hemorrhagic morbidity, operative complications. Perinatal outcomes included gestational age at delivery, birthweight, Apgar scores and perinatal death. Results: 25 (20%) and 100 (80%) patients had emergency and elective delivery, respectively. Emergency delivery had a higher estimated blood loss (median IQR 2772 [2256.75] vs. 1561.19 [1152.95], p<0.001), with a higher rate of coagulopathy (40 vs. 6%; p<0.001) and bladder injury (44 vs. 13%; p<0.001). Emergency delivery was associated with increased rates of blood transfusion (aOR 4.9, CI95% 1.3-17.5, p=0.01), coagulopathy (aOR 16.4, CI95% 2.6-101.4, p=0.002) and urinary tract injury (aOR 6.96, CI95% 1.5-30.7, p=0.01). Gestational age at delivery was lower in the emergency group (mean SD 35.19 [2.77] vs. 31.55 [4.75], p=0.001), no difference in perinatal mortality was found (aOR 0.01, CI95% <0.001-17.5, p=0.53). A sonographically short cervix and/or history of APH had an increased cumulative risk of emergency delivery with advancing gestational age. Conclusions: Patients with PAS disorders managed in a tertiary centre by a multidisciplinary team requiring emergency delivery have increased maternal morbidity and poorer perinatal outcomes than those with elective delivery.

Objective: To determine the association between placental lesions and lifetime cardiovascular disease (CVD) risk screening at 6 months postpartum following preeclampsia (PE). Design: Observational cohort study. Setting: Tertiary care centres in Ottawa and Kingston, Ontario, Canada. Population: Women diagnosed with PE who received cardiovascular screening at 6 months postpartum. Methods: Placentas from women diagnosed with PE were evaluated for histopathological lesions according to a standardised synoptic data collection form with blinding to clinical outcomes apart from gestational age at delivery. At 6 months postpartum, each participant was screened for cardiovascular risk factors and a lifetime cardiovascular risk score was calculated. A risk score >35% was deemed high risk for lifetime CVD. Main Outcome Measures: The association between placental lesions and lifetime CVD risk was assessed using odds ratios (OR, 95% confidence intervals). Results: Of the 85 participants, 53 (62.4%) screened high-risk for lifetime CVD. High-risk women had more severe lesions of maternal vascular malperfusion (MVM). MVM lesions with a severity score >2 resulted in a 3-fold increased risk of screening high risk for lifetime CVD (OR 3.10 [1.20-7.92]). MVM lesion score >2 was moderately predictive of high-risk screening (AUC 0.63 [0.51,0.75]; sensitivity: 71.8% [54.6,84.4]; specificity: 54.7% [41.5,67.3]). When clinical data was added, the model’s predictive performance improved (AUC 0.73 [0.62,0.84] sensitivity 78.4% [65.4,87.5]; specificity 51.6% [34.8,68.0]). Conclusions: PE women with MVM are more likely to screen high-risk for lifetime CVD compared to women without these lesions. Placenta pathology may provide a unique modality to identify women for postpartum cardiovascular screening.

Abstract Objective. To evaluate the efficacy and safety of parallel loop binding suture of the lower uterus during cesarean section in pernicious placenta previa complicated with placenta increta. Design. A retrospective study Setting. Qilu Hospital of Shandong University Population. Patients with pernicious placenta previa between November 2014 and December 2020 at the Qilu Hospital of Shandong University were eligible. Methods. The degree of placental invasion was evaluated using preoperative color Doppler ultrasonography and/or magnetic resonance imaging (MRI). Main outcome measures. Postpartum hemorrhage was evaluated as the primary outcome. Additionally, neonatal outcomes were evaluated. Results. Of the 38 patients, only 3 (7.89%) underwent hysterectomy due to massive blood loss. With parallel loop binding compression suture, the volume of blood lost ranged from 500 - 6000 (mean: 2152.63±1169.37) mL and the volume of blood transfused was between 400 - 3200 (1431.58±699.85) mL. The mean gestational age was 36 weeks and 2 days (range: 32+6 to39+6 weeks). The average operation time was 109.78 ± 33.49 min, and the average fetal childbirth time was 14.05±5.60 min. The rate of NICU admission was 36.84% (14/38). The postoperative menstrual cycle and menstrual flow both returned to normal levels. All infants at our hospital were safely discharged after treatment. Conclusion. Parallel loop binding compression suture is an effective, swift, practical, and safe method to reduce postpartum bleeding in women with pernicious placenta previa, complicated with placenta increta.

Background Antenatal Care (ANC) is one of the key care-packages required to reduce global maternal and perinatal mortality and morbidity Objectives To identify the essential components of ANC and develop signal functions Search strategy MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science Selection Criteria Papers and reports on content of ANC published from 2000-2020 Data collection and Analysis Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders Main Results A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions adress monitoring of foetal growth and wellbeing and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC. Conclusions New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Background: The ectopic pregnancy(EP) patients requires the closely monitor. However, there is no international consensus through which method to select EP patients from the pregnancy of unknown location (PUL) patients. Objective: To summarize and review the protocols of screening patients with EP when being diagnosed with PUL. Search strategy: We searched MEDLINE, web of science and Embase from inception to May 2020. All the articles were dual-reviewed based on predetermined selection criteria. Selection criteria: Studies exploring PUL outcomes can be included. Data collection and analysis: Prediction results, final diagnosis, and expense depending on patient’s visits and examination were analyzed by R. version 3.6.3 and Revman version 5.4. Results: 29 studies were included. M6 model had the areas under the curve(AUC) of 0.944, the progesterone cut-offs an AUC of 0.725, and the M4 model an AUC of 0.871 respectively. When the sum of visits and examinations of the protocols increased from 3 to 5, the rate of lost to follow-up patients increased from 11.19% to 18.63%. The average production utility of progesterone cut-offs is 0.242, the M4 is 0.174, and the M6 is 0.157. Conclusions: The M6 model had the best performance to predict EP among the PUL patients. The progesterone cut-offs is the most cost-effective method to predict the final outcome of EP. Fundings: Project supported by National Natural Science Foundation of China (82073323) and the Joint Funds of the National Natural Science Foundation of China (U20A20368). Keywords: ectopic pregnancy, pregnancy of unknown location, predictive protocol，hCG，progesterone.

Letter to the Editor, BJOG Title:Prophylactic negative wound pressure dressing (NWPD) after caesarean – an extended debate to include surgical aspectsRe: Hyldig N, Joergensen JS, Lamont RF, Moller S, Vinter CA. Prophylactic negative pressure wound therapy in obese women undergoing caesarean section: a commentary on new evidence that fuels the debate. BJOG 2021; https://doi.org/10.1111/1471-0528.16750.Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKEmail: s.sholapurkar@nhs.netTel: 07906620662Word count: 500Corresponding Author: Mr. Shashikant L SHOLAPURKARMD, DNB, MRCOGDept of Obstetrics & Gynaecology,Royal United Hospital, Bath, BA1 3NG, UKStatement of interest: The author has no conflict of interest or funding to declare.

Mini commentary on BJOG-21-0235.R1The Project Appropriate Birth: significance of the Robson classification in confronting the caesarean section

Commentary

Objective To determine the prevalence and type of anaemia and its association with pre-eclampsia (PE) in pregnant South Africans of African ancestry. Design Cross-sectional study design Setting A regional hospital in KwaZulu-Natal, South Africa. Sample 671 women seeking antenatal care. Methods Participants had haemoglobin(Hb), anthropometric measurements, HIV status, blood pressure levels(BP) and proteinuria measured to determine PE. Iron studies and transferrin receptor levels were assessed in a subset and chi-square tests of association between normotensive and pre-eclampsia sub-groups and blood parameters were conducted. Results No difference in Hb concentration amongst the 4 groups (F (3,621)=0.981, p< .001, η2=.014) was observed. A chi-square test of association (χ2(3)=6.674, p=.083) showed no associations between study groups and having anaemia. The severity of anaemia did not vary amongst study groups (χ2(12) =10.756, p=.550). Using ferritin, there was an association between the study groups having an iron deficiency, anaemia, both or neither (χ2(3)=12.559, p=.045) with a positive association between normotensive term and iron deficiency (adjusted residual(AR) 2.2) and positive association between early-onset PE(AR 2.4). Similar trends were found for transferrin and soluble transferrin receptor ferritin index. Twenty-two percent of the participants were not iron deficient. Conclusion Early-onset PE is associated with high iron status and not anaemia. Normotensive term pregnancies were associated with iron deficiency anaemia. Broad iron supplementation without adequate determination of iron deficiency in pregnant women needs to be revisited. Funding National Research Foundation (TTK170508230162), University of KwaZulu-Natal UCPD and Medical Research Council of South Africa(SIR Grant UNS14197). Keywords Anaemia, iron deficiency, pre-eclampsia

Background: Postpartum Haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. Objectives: To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. Search strategy: MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms including ‘postpartum haemorrhage’, ‘prognostic model’, and ‘risk factors’ that were developed from a scoping review. Selection Criteria: Observational or experimental studies describing a prognostic model for risk of PPH, published in English. Data Collection and Analysis: The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and Prediction Model Risk of Bias Assessment Tool guided analysis. Main Results: 16 studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from 8 different countries. Models were developed for women who experienced vaginal birth (n=7), caesarean birth(n=2), any type of birth(n=2), hypertensive disorders(n=1) and those with placental abnormalities(n=4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. Conclusions: No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice. Funding: This study received no funding. Keywords: Postpartum haemorrhage, prognostic model, prediction tool.

Objective: To identify the clinical characteristics of pregnancy associated group A streptococcus (GAS) infection and predictors for intensive care unit (ICU) admission. Design: A retrospective cohort study of culture-proven pregnancy-related GAS infections. Setting and population: a tertiary university-affiliated hospital between 1/2008-7/2020. Methods: Review patient’s electronic records of patients. Main outcome measures: Incidence of pregnancy associated GAS, proportion given prophylaxis and admission to ICU. Results: Of the 143,750 who delivered during the study period, 66 (0.04%) were diagnosed as having a pregnancy associated GAS infection. Fifty-seven of them (86.3%) presented postpartum, and nine (13.6%) had septic abortions. The most common presenting signs and symptoms among puerperal GAS, were postpartum pyrexia (72%), abdominal pain and/or tenderness (33%), and tachycardia (>100 bpm, 22%). Thirteen women (19.6%) developed streptococcal toxic shock syndrome (STSS): 10 of them delivered vaginally, two had caesarean deliveries. Predictors for STSS and ICU admission were: antibiotic administration >24 hours from presentation postpartum, tachycardia, and a C-reactive protein level >200 mg/L. Women that received antibiotic prophylaxis during labour had a significantly lower rate of STSS (0 vs 10, 22.7%; P = 0.04), as evidenced by the delayed interval from delivery to the first presentation of infection among those who received prophylaxis during labour (8 ± 4.8 vs 4.8 ± 4.2 hours, P = 0.008). Conclusion: Deferral of medical intervention >24 hours from the first registered abnormal sign had the most important impact on deterioration of women with invasive puerperal GAS. Antibiotic prophylaxis during labour in women with GAS may reduce complications

Objective To determine the prevalence of genital mycoplasma infection and the risk of spontaneous preterm birth (sPTB) in asymptomatic pregnant women. Design Prospective cohort. Setting Public and private health services in Ribeirão Preto-SP, Brazil. Population 1.349 asymptomatic women with a singleton pregnancy at 20-25 weeks of gestation (WG) recruited between 2010 and 2011. Methods Baseline data was assessed using a questionnaire, in addition to cervicovaginal fluid and blood samples, to analyze lower reproductive tract infections (RTIs) and immune mediators, respectively. The association between variables and the risk of sPTB was evaluated using logistic regression analysis to estimate the odds ratios (ORs). Main outcome measures Genital mycoplasma infection and prematurity. Results The prevalence of the sPTB and genital mycoplasma was 6.8% and 18%, respectively. The infection was not a risk factor for sPTB (aOR 0.66; 95% CI 0.32-1.35), even when associated with bacterial vaginosis (BV). However, it was associated with a low socioeconomic status (p=0.0470), cigarette use (p=0.0009), number of sexual partners (p=0.0019), and BV (p<.0001). Regarding the risk factors associated with sPTB, previous history of PTB (aOR 12.06; 95% CI 6.21-23.43) and a cervical length ≤ 2.5 cm (aOR 3.97; 95% CI 1.67-9.47) were significant. Conclusions The risk of sPTB was independently associated with the history of PTB and the cervical length but not with the genital mycoplasma infection. Funding: This work was founded by CNPq, FAPESP and CAPES. Keywords: Preterm birth, pregnancy, genital mycoplasma, bacterial vaginosis, risk factor

Background The global effect of the COVID-19 pandemic has had an impact on pregnancy and outcomes. There has been recently some conflicting evidence on the stillbirths during the COVID-19 pandemic. This meta-analysis attempts to resolve this through a systematic approach. Objectives To analyse and determine the impact of COVID-19 on the stillbirth rate. Search strategy We searched PubMed, Embase, Cochrane library, ClinicalTrials.gov and Web of Science from inception to 05 March 2021 with no language restriction for this meta-analysis. Selection criteria Publications (a) with stillbirth data on pregnant women with COVID-19 (b) comparing stillbirth rates in pregnant women with and without COVID-19 and (c), comparing stillbirth rates before and during the pandemic. Data collection and Analysis The included studies were all observational studies, and we used the Newcastle Ottawa score for risk of bias. We performed the meta-analysis using Comprehensive meta-analysis software, version 3. Main results A total of 29 studies were included in the meta-analysis; from 17 of these, the SB rate was 7 per 1000 in pregnant women with COVID-19. This rate was much higher (34/1000) in low- and middle-income countries. The odds ratio of stillbirth in pregnant women with COVID-19 compared to those without was 1.89. However, there was no significant difference in population SB rates before and during the pandemic. Conclusions There is some evidence that the stillbirth rate has increased during the COVID-19 pandemic, but this is mainly in low- and middle-income countries. Inadequate access to healthcare during the pandemic could be a contributing factor.

Objective To describe the characteristics and outcomes of women with inherited bleeding disorder during pregnancy and birth. Design Retrospective cohort study. Setting Tertiary care hospitals, NSW and Victoria Australia. Population 100 women with inherited bleeding disorders, who birthed 134 live infants from 132 pregnancies. Methods Data was retrospectively obtained from the patient and neonatal medical records. Descriptive analysis was used to report maternal and pregnancy characteristics, birth and neonatal outcomes. Main outcome measures Factor replacement, neuraxial analgesia use and complications, post-partum haemorrhage and neonatal complications. Results PPH occurred in 22% of deliveries with primary PPH occurring in 20% and secondary PPH in 4% of births. 48% of PPHs were classified as major. PPHs occurred across the spectrum of IBD and was evenly distributed between women who had “normalised” their factor levels in pregnancy compared to those requiring factor at the time of birth. An obstetric cause was identified in more than half of PPHs. Conclusions Women with inherited bleeding disorders can deliver safely and receive neuraxial analgesia without complication when best practices are adhered to. PPH appears to occur at higher rates than the general population despite adequate factor levels or planned replacement. Whilst an obstetric cause was demonstrable in the many cases, these findings raise concern over the current definition of “adequate” factor levels at the time of birth.

Objective: To estimate the association between maternal origin and obstetric anal sphincter injury (OASI), and assess if associations differed by length of residence. Design: Population-based cohort study. Setting: The Medical Birth Registry of Norway. Population: Primiparous women with vaginal livebirth of a singleton cephalic fetus between 2008 and 2017 (n=188 658). Methods: Multivariable logistic regression models estimated aORs for OASI with 95% CI by maternal region of origin and birthplace. We stratified models on length of residence and paternal birthplace. Main outcome measures: OASI. Results: Overall 6 373 cases of OASI were identified (3.4% of total cohort). Women from South Asia were most likely to experience OASI (6.2%; aOR 2.24, 95% CI 1.93–2.60), followed by those from Southeast/East Asian/Pacific (5.7%; 1.83, 1.64–2.04), and Sub-Saharan Africa (5.2%; 1.97, 1.72–2.26), compared to women originating from Norway. Among women born in the same region, those with short length of residence in Norway (0–4 years), showed higher odds of OASI. Migrant women across most regions of origin had reduced risk of OASI if they had a Norwegian compared to foreign-born partner. Conclusions: Primiparous women from Asian regions and Sub-Saharan Africa had up to two-fold risk of OASI, compared to women originating from Norway. Migrants with short residence and those with a foreign-born partner had higher risk of OASI, implying that some of the risk differential is due to sociocultural factors. Some migrants, especially new arrivals, may benefit from special attention during labour to reduce morbidity and achieve equitable outcomes.