The variety of placental morphological findings with SARS-CoV-2 maternal infections has raised the issue of poor agreement in histopathological evaluation. The aims of this study were: to describe ...the histopathological placental features of a large sample of SARS-CoV-2-positive women who gave birth in Italy during the COVID-19 pandemic, to analyse the factors underlying these lesions, and to analyse the impact of placental impairment on perinatal outcomes. From 25 February 2020 to 30 June 2021, experienced perinatal pathologists examined 975 placentas of SARS-CoV-2-positive mothers enrolled in a national prospective study, adopting the Amsterdam Consensus Statement protocol. The main results included the absence of specific pathological findings for SARS-CoV-2 infections, even though a high proportion of placentas showed signs of inflammation, possibly related to a cytokine storm induced by the virus, without significant perinatal consequences. Further research is needed to better define the clinical implications of placental morphology in SARS-CoV-2 infections, but the results of this large cohort suggest that placentas do not seem to be a preferential target for the new Coronavirus infection.
Translating evidence-based guidelines into clinical practice is a complex challenge. This observational study aimed to assess the adherence to the Italian national guidelines on postpartum ...haemorrhage (PPH) and describe the clinical management of haemorrhagic events in a selection of maternity units (MUs) in six Italian regions, between January 2019 and October 2020. A twofold study design was adopted: (i) a before-after observational study was used to assess the adherence to national clinical and organisational key recommendations on PPH management, and (ii) a cross-sectional study enrolling prospectively 1100 women with PPH ≥ 1000 mL was used to verify the results of the before-after study. The post-test detected an improved adherence to 16/17 key recommendations of the guidelines, with clinical governance and communication with family members emerging as critical areas. Overall, PPH management emerged as appropriate except for three recommended procedures that emphasise different results between the practices adopted and the difference between what is considered acquired and what is actually practised in daily care. The methodology adopted by the MOVIE project and the adopted training materials and tools have proved effective in improving adherence to the recommended procedures for appropriate PPH management and could be adopted in similar care settings in order to move evidence into practice.
Evidence on the effects of the SARS-CoV-2 Omicron variant on vaccinated and unvaccinated pregnant women is sparse. This study aimed to compare maternal and perinatal outcomes of women infected with ...SARS-CoV-2 during the Omicron wave in Italy, according to their vaccine protection.
This national prospective cohort study enrolled pregnant women with a positive SARS-CoV-2 nasopharyngeal swab within 7 days of hospital admission between 1 January and 31 May, 2022. Women who received at least one dose of vaccine during pregnancy and those who completed the vaccine cycle with the first booster were considered protected against moderate or severe COVID-19 (MSCD). A multivariable logistic regression model evaluated the association between vaccine protection and disease severity. Maternal age, educational level, citizenship, area of birth, previous comorbidities, and obesity were analysed as potential risk factors.
MSCD was rare (41/2147, 1.9%; 95% CI, 1.4–2.6), and the odds of developing it were significantly higher among unprotected women (OR, 2.78; 95% CI, 1.39–5.57). Compared with protected women (n = 1069), the unprotected (n = 1078) were more often younger, with lower educational degrees, and foreigners. A higher probability of MSCD was found among women with previous comorbidities (OR, 2.86; 95% CI, 1.34–6.12) and those born in Asian countries (OR, 3.05; 95% CI, 1.23–7.56). The percentage of preterm birth was higher among women with MSCD compared with milder cases (32.0% 8/25 versus 8.4% 161/1917, p < 0.001) as well as the percentage of caesarean section (52.0% 13/25 versus 31.6% 606/1919, p 0.029).
Although severe maternal and perinatal outcomes were rare, their prevalence was significantly higher among women without vaccine protection. Vaccination during pregnancy has the potential to protect both the mother and the baby, and it is therefore strongly recommended.
Maternal sepsis represents a leading cause of mortality and severe morbidity worldwide. In Italy, it is the second cause of direct maternal mortality. Delay in recognition and treatment initiation ...are the drivers of sepsis-associated adverse outcomes. Between November 2017 and October 2019, the Italian Obstetric Surveillance System coordinated a prospective population-based study on maternal sepsis occurring before or after childbirth from 22 weeks' gestation onward and up to 42 days following the end of pregnancy. A nested 1:2 matched case-control study on postpartum sepsis was also performed. Maternal sepsis was diagnosed for the presence of suspected or confirmed infection alongside signs or symptoms of organ failure. The aim of this study was to assess maternal sepsis incidence and its associated risk factors, management, and perinatal outcomes. Six Italian regions, covering 48.2% of the national births, participated in the project. We identified an incidence rate of 5.5 per 10,000 maternities (95% CI 4.80-6.28). Seventy percent of patients had a low education level and one third were foreigners with a language barrier. Genital, respiratory, and urinary tract infections were the predominant sources of infection; the majority of cases was caused by
and polymicrobial infections. The presence of vascular and indwelling bladder catheters was associated with a nine-fold increased risk of postpartum sepsis. There were no maternal deaths, but one fourth of women experienced a serious adverse event and 28.3% required intensive care; 1.8% of newborns died. Targeted interventions to increase awareness of maternal sepsis and its risk factors and management should be promoted.
Introduction
Spontaneous hemoperitoneum in pregnancy is defined as a sudden non‐traumatic intraperitoneal bleeding in pregnancy and up to 42 days postpartum. In the present study we aim to estimate ...the incidence and investigate the risk factors, the management and the outcomes of spontaneous hemoperitoneum in pregnancy in order to improve its clinical identification and reduce avoidable maternal deaths.
Material and methods
This is a prospective population‐based cohort study, set in maternity units from nine Italian regions covering 75% of the national births. The study population comprises all women admitted for spontaneous intraperitoneal hemorrhage during pregnancy and up to 42 days postpartum between November 2017 and March 2020. Incident cases were reported by trained clinicians through electronic data collection forms. Descriptive statistics were performed. The main outcome measures included incidence rate of spontaneous hemoperitoneum in pregnancy, association with potential risk factors, clinical management and maternal and perinatal outcomes.
Results
Twenty‐nine cases met the adopted definition of spontaneous hemoperitoneum in pregnancy with an estimated incidence rate of 0.04 per 1000 births. An increased risk ratio (RR) of this condition was observed in pregnancies conceived by assisted reproductive technology (RR = 6.60, 95% CI 2.52–17.29), in the case of multiple pregnancies (RR = 6.57, 95% CI 1.99–21.69) and maternal age ≥35 years (RR 2.10, 95% CI 1.01–4.35). In 17/29 cases the bleeding site was intra‐pelvic (23.5% in the posterior uterine wall and 35.2% in the left hemipelvis). Laparotomy represented the surgical treatment in 27 cases (93%), and most women underwent a cesarean delivery (92.6%). Median blood loss was 1900 mL, one hysterectomy was necessary, and two women died. Twenty‐two preterm births were recorded.
Conclusions
Spontaneous hemoperitoneum in pregnancy is a rare, life‐threatening condition associated with high perinatal morbidity and mortality. Maternal age ≥35 years, multiple pregnancies and assisted reproductive technology were associated to a higher risk of the condition. Two women of 29 died and 70% of births occurred preterm.
Spontaneous hemoperitoneum in pregnancy is a rare life‐threatening event. This study provides valuable knowledge for the improvement of clinical appropriateness to avoid near miss cases that can lead to severe maternal and perinatal outcomes.
Objective
The primary aim of this article was to describe SARS‐CoV‐2 infection among pregnant women during the wild‐type and Alpha‐variant periods in Italy. The secondary aim was to compare the ...impact of the virus variants on the severity of maternal and perinatal outcomes.
Design
National population‐based prospective cohort study.
Setting
A total of 315 Italian maternity hospitals.
Sample
A cohort of 3306 women with SARS‐CoV‐2 infection confirmed within 7 days of hospital admission.
Methods
Cases were prospectively reported by trained clinicians for each participating maternity unit. Data were described by univariate and multivariate analyses.
Main outcome measures
COVID‐19 pneumonia, ventilatory support, intensive care unit (ICU) admission, mode of delivery, preterm birth, stillbirth, and maternal and neonatal mortality.
Results
We found that 64.3% of the cohort was asymptomatic, 12.8% developed COVID‐19 pneumonia and 3.3% required ventilatory support and/or ICU admission. Maternal age of 30–34 years (OR 1.43, 95% CI 1.09–1.87) and ≥35 years (OR 1.62, 95% CI 1.23–2.13), citizenship of countries with high migration pressure (OR 1.75, 95% CI 1.36–2.25), previous comorbidities (OR 1.49, 95% CI 1.13–1.98) and obesity (OR 1.72, 95% CI 1.29–2.27) were all associated with a higher occurrence of pneumonia. The preterm birth rate was 11.1%. In comparison with the pre‐pandemic period, stillbirths and maternal and neonatal deaths remained stable. The need for ventilatory support and/or ICU admission among women with pneumonia increased during the Alpha‐variant period compared with the wild‐type period (OR 3.24, 95% CI 1.99–5.28).
Conclusions
Our results are consistent with a low risk of severe COVID‐19 disease among pregnant women and with rare adverse perinatal outcomes. During the Alpha‐variant period there was a significant increase of severe COVID‐19 illness. Further research is needed to describe the impact of different SARS‐CoV‐2 viral strains on maternal and perinatal outcomes.
Tweetable
The rate of severe COVID‐19 disease increased during the Alpha‐variant period compared with the wild‐type period.
Linked article This article is commented on by J G Thornton, p. 232 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16981.
•Women migrant to western European countries are at higher risk of GDM.•Ethnicity increases the risk of adverse outcomes commonly associated to GDM.•Adding GDM and ethnicity in predictive models ...reversed the risk of adverse outcomes.•Targeting GDM is associated, in migrants, with a global reduction in adverse outcomes.
To evaluate the risk of gestational diabetes (GDM) and of neonatal/maternal complications (macrosomia, large for gestational age (LGA), cesarean sections, preterm deliveries, neonatal distress and fetal malformations) among women coming from High Migration Pressure Countries (HMPC), compared to native (Italian) mothers.
Risks of GDM and related neonatal/maternal complications were evaluated in a cohort of 581,073 Italian compared with 105,111 HMPC women of age 15–45 yr, resident in Tuscany, Italy along years 2012–2017, delivering 122,652 singleton live births (18,596 from HMPC mothers).
HMPC women, compared to Italian ones, were at higher risk of GDM (OR: 1.586; 1.509–1.666;p < 0.0001), peaking for women originating from South Asia (OR:3.0.49; 2.618–3.553;p < 0.0001). GDM was associated with increased risk of preterm delivery and cesarean sections, while migrants, regardless of GDM, were burdened by a higher risk of all considered complications. The rise in all these risks, including macrosomia or LGA however, disappeared, after addition of interaction term GDM × HMPC ethnicity.
Compared to Italian mothers, HMPC women had higher risk of GDM and of all considered adverse events. The addiction of the interaction term GDM × HMPC ethnicity in the predictive model, however reversed the rise in risk of all HMPC associated adverse outcomes.
Objective
To compare the estimates of preterm birth (PTB; 22–36 weeks' gestational age, GA) and stillbirth rates during COVID‐19 pandemic in Italy with those recorded in the three previous years.
...Design
A population‐based cohort study of live‐ and stillborn infants was conducted using data from Regional Health Systems and comparing the pandemic period (1 March 2020–31 March 2021, n = 362 129) to an historical period (January 2017–February 2020, n = 1 117 172). The cohort covered 84.3% of the births in Italy.
Methods
Poisson regressions were run in each Region and meta‐analyses were performed centrally. We used an interrupted time series regression analysis to study the trend of preterm births from 2017 to 2021.
Main outcome measures
The primary outcomes were PTB and stillbirths. Secondary outcomes were late PTB (32–36 weeks' GA), very PTB (<32 weeks' GA), and extremely PTB (<28 weeks' GA), overall and stratified into singleton and multiples.
Results
The pandemic period compared with the historical one was associated with a reduced risk for PTB (risk ratio RR 0.91, 95% confidence interval CI 0.88–0.93), late PTB (RR 0.91, 95% CI 0.88–0.94), very PTB (RR 0.88, 95% CI 0.84–0.91) and extremely PTB (RR 0.88, 95% CI 0.82–0.95). In multiples, point estimates were not very different, but had wider CIs. No association was found for stillbirths (RR 1.01, 95% CI 0.90–1.13). A linear decreasing trend in PTB rate was present in the historical period, with a further reduction after the lockdown.
Conclusions
We demonstrated a decrease in PTB rate after the introduction of COVID‐19 restriction measures, without an increase in stillbirths.
Linked article: This article is commented on by Giovanni Sisti and Julie T. Joseph, pp. 285 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471‐0528.17312
This paper aims to describe the Italian obstetric surveillance system (ItOSS) preparedness as an element for a timely response to the new Coronavirus pandemic. ItOSS is a surveillance network that ...has been collecting data on maternal mortality and conducting population studies on obstetric near misses since 2013. At the beginning of the pandemic, ItOSS launched a new population-based project to monitor SARS-CoV-2 infection during pregnancy and post-partum and promptly give back information useful to clinicians and decision-makers. All the regions and autonomous provinces, for a total of 289 birth units (PN), joined the study. Data relating to pregnant or post-partum women with a confirmed SARS-CoV-2 infection diagnosis addressing the maternities for outpatient visits or hospitalization were collected. The project methodology entails that each participating maternity reports the cases to ItOSS uploading data through an open-source platform. The on-line form includes sociodemographic and clinical data and maternal-neonatal outcomes. Biological samples to detect possible vertical transmission are also collected voluntarily. A total of 534 incident cases were reported from February 25th to July 10th 2020; 7 regions also collected biological samples for 227 cases; data collection is still ongoing.A preliminary analysis of the first 146 SARS-CoV-2 positive women who gave birth between February 25th to April 22nd shows an incidence rate of the infection equal to 2.1/1,000 in Italy and 6.9/1,000 in the Lombardy Region (Northern Italy). The brief time needed to setting up and operating the project, the national coverage, the adoption of shared tools for data collection, the quality and completeness of the information collected show how the availability of active networks like ItOSS represents a crucial element to hold a high level of preparedness in case of a health emergency.
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