Maternal and perinatal outcomes in high compared to low risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection (phase 2): the World Association of Perinatal Medicine working group on coronavirus disease 2019

BACKGROUND

It has still to be ascertained whether severe acute respiratory syndrome coronavirus 2 infection in pregnancy is associated with worse maternal and fetal outcomes compared to low risk gestations.

OBJECTIVE

This study aimed to evaluate maternal and perinatal outcomes in high- and low-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection.

STUDY DESIGN

This was a multinational retrospective cohort study involving women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 76 centers from 25 countries in Europe, the United States, South America, Asia, and Australia from April 4, 2020, to October 28, 2020. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit, use of mechanical ventilation, or death. The secondary outcome was a composite measure of adverse perinatal outcome, including miscarriage, fetal loss, neonatal and perinatal death, and admission to the neonatal intensive care unit. All outcomes were assessed in high- and low-risk pregnancies. Pregnancies were considered high risk in case of either preexisting chronic medical conditions in pregnancy or obstetrical disorders occurring in pregnancy. The Fisher exact test and logistic regression analysis were used to analyze the data.

RESULTS

A total of 887 singleton pregnancies who tested positive for severe acute respiratory syndrome coronavirus 2 infection using reverse transcription-polymerase chain reaction of nasal and pharyngeal swab specimens were included in the study. The risk of composite adverse maternal outcomes was higher in high-risk pregnancies than in low-risk pregnancies (odds ratio, 1.52; 95% confidence interval, 1.03-2.24; P=.035). In addition, women carrying high-risk pregnancies were at higher risk of hospital admission (odds ratio, 1.48; 95% confidence interval, 1.07-2.04; P=.002), presence of severe respiratory symptoms (odds ratio, 2.13; 95% confidence interval, 0.41-3.21; P=.001), admission to the intensive care unit (odds ratio, 2.63; 95% confidence interval, 1.42-4.88), and invasive mechanical ventilation (odds ratio, 2.65; 95% confidence interval, 1.19-5.94; P=.002). When exploring perinatal outcomes, high-risk pregnancies were at high risk of adverse perinatal outcomes (odds ratio, 1.78; 95% confidence interval, 0.15-2.72; P=.009). However, such association was mainly because of the higher incidence of miscarriage in high-risk pregnancies compared with that in low-risk pregnancies (5.3% vs 1.6%, P=.008); furthermore, there was no difference in other explored outcomes between the 2 study groups. At logistic regression analysis, maternal age (odds ratio, 1.12; 95% confidence interval, 1.02-1.22; P=.023) and high-risk pregnancy (odds ratio, 4.21; 95% confidence interval, 3.90-5.11; P<.001) were independently associated with adverse maternal outcomes.

CONCLUSION

High-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection were at higher risk of adverse maternal outcomes than low-risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection.

Risk factors associated with adverse fetal outcomes in pregnancies affected by Coronavirus disease 2019 (COVID-19): a secondary analysis of the WAPM study on COVID-19

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6±9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8-0.9 per week increase; p<0.001), birthweight (OR: 1.17, 95% CI 1.09-1.12.7 per 100 g decrease; p=0.012) and maternal ventilatory support, including either need for oxygen or CPAP (OR: 4.12, 95% CI 2.3-7.9; p=0.001) were independently associated with composite adverse fetal outcome. Conclusions Early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection. Conversely, the risk of vertical transmission seems negligible.

Haptic simulation of tissue tearing during surgery

We present a method for the real-time, interactive simulation of tissue tearing during laparoscopic surgery. The method is designed to work at haptic feedback rates (ie, around 1 kHz). Tissue tearing is simulated under the general framework of continuum damage mechanics. The problem is stated as a general, multidimensional parametric problem, which is solved by means of proper generalized decomposition methods. One of the main novelties is the reduction of history-dependent problems, such as damage mechanics, by resorting to an approach in which a reduced-order field of initial damage values is considered as a parameter of the formulation. We focus on the laparoscopic cholecystectomy procedure as a general example of the performance of the method.

Real-time simulation of biological soft tissues: a PGD approach

We introduce here a novel approach for the numerical simulation of nonlinear, hyperelastic soft tissues at kilohertz feedback rates necessary for haptic rendering. This approach is based upon the use of proper generalized decomposition techniques, a generalization of PODs. Proper generalized decomposition techniques can be considered as a means of a priori model order reduction and provides a physics-based meta-model without the need for prior computer experiments. The suggested strategy is thus composed of an offline phase, in which a general meta-model is computed, and an online evaluation phase in which the results are obtained at real time. Results are provided that show the potential of the proposed technique, together with some benchmark test that shows the accuracy of the method.

[Classification of disposable medical plastics and search for alternatives without polyvinyl chloride in the Hospital Virgen de las Nieves (Granada, Spain)]

OBJECTIVES

To identify and classify disposable hospital products containing polyvinyl chloride (PVC), including the search and evaluation of cost-effective sustainable alternative products free of PVC.

METHODS

A descriptive observational analysis was performed, after classifying the latest research in major databases, and disposable products that could contain PVC. These were divided into 5 groups: cannulas, catheters, tubes, bags, and equipment, purchased in the period 2008-2009, differentiating between the technical and economic assessment of the materials.

RESULTS

In the analysis of the composition of 492 articles selected, 234 (47.5%) contained PVC, and 19.4% were considered PVC-free alternatives, with only 11.3% of these being economically viable.

CONCLUSIONS

This study highlights the advantages of the classification of PVC products, by showing that safe and efficient alternatives exist for some product lines that are consistent with patient safety and quality in the work by doctors.

Real-time simulation of surgery by reduced-order modeling and X-FEM techniques

This paper describes a novel approach for the simulation of surgery by a combined technique of model order reduction and extended finite element method (X-FEM) methods. Whereas model order reduction techniques employ globally supported (Ritz) shape functions, a combination with X-FEM methods on a locally superimposed patch is developed for cutting simulation without remeshing. This enables to obtain models with very few degrees of freedom that run under real-time constrains even for highly non-linear tissue constitutive equations. To show the performance of the technique, we studied an application to refractive surgery in the cornea.

Accounting for large deformations in real-time simulations of soft tissues based on reduced-order models

Model reduction techniques have shown to constitute a valuable tool for real-time simulation in surgical environments and other fields. However, some limitations, imposed by real-time constraints, have not yet been overcome. One of such limitations is the severe limitation in time (established in 500Hz of frequency for the resolution) that precludes the employ of Newton-like schemes for solving non-linear models as the ones usually employed for modeling biological tissues. In this work we present a technique able to deal with geometrically non-linear models, based on the employ of model reduction techniques, together with an efficient non-linear solver. Examples of the performance of the technique over some examples will be given.

Real-time deformable models of non-linear tissues by model reduction techniques

In this paper we introduce a new technique for the real-time simulation of non-linear tissue behavior based on a model reduction technique known as proper orthogonal (POD) or Karhunen-Loève decompositions. The technique is based upon the construction of a complete model (using finite element modelling or other numerical technique, for instance, but possibly from experimental data) and the extraction and storage of the relevant information in order to construct a model with very few degrees of freedom, but that takes into account the highly non-linear response of most living tissues. We present its application to the simulation of palpation a human cornea and study the limitations and future needs of the proposed technique.

Teicoplanin pharmacokinetics in critically ill paediatric patients

Twenty-one critically ill children aged between 7 days and 12 years were treated with teicoplanin (three loading dosages of 10 mg/kg at 12 h intervals, followed by a maintenance dosage of 10 mg/kg/day). Serum teicoplanin concentrations were monitored by HPLC. Mean concentrations in plasma 30 min after drug administration were 20 +/- 16.1 mg/L. The volume of distribution was 0.30 L/kg and the terminal half-life was 17.41 h. Only 11% of trough values were >10 mg/L (established as desirable values). In critically ill children a dosage of 10 mg/kg/day does not assure serum trough values >10 mg/L.

Transpyloric enteral feeding in critically ill children

BACKGROUND

Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated.

METHODS

A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF.

RESULTS

The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF.

CONCLUSIONS

Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

Life-threatening effects of discontinuing inhaled nitric oxide in children

We treated 40 children, aged between 15 d and 17 y, diagnosed with acute respiratory distress syndrome and/or pulmonary hypertension, with inhaled nitric oxide. The most frequent underlying diagnosis associated with ARDS were bronchopneumonia (eight), cardiac surgery (five), and sepsis (three). Pulmonary hypertension was secondary to cardiomyopathy in 2 patients and occurred in the postoperative period of cardiac surgery in 17 patients--the most frequent were ventricular septal defect (5), transposition of great arteries (4), and atrioventricular septal defect (3). In 11 patients, sudden discontinuation of nitric oxide induced a decrease in oxygenation associated in some of the patients with an increase in pulmonary artery pressure. In two patients discontinuation of nitric oxide induced severe pulmonary hypertension, extreme bradycardia and hypoxaemia, which required cardiopulmonary resuscitation. When exogenous nitric oxide is abruptly interrupted, hypoxaemia and pulmonary hypertension are found in some patients, due to a decrease in the nitric oxide concentration in the pulmonary circulation. This may be caused by the exogenous nitric oxide administration that may have inhibited endogenous production. We recommend making a progressive withdrawal of inhaled nitric oxide to avoid the side effects observed in the sudden discontinuation.