The effect of the COVID-19 pandemic on the mental health of obstetrics and gynaecology trainees: a world-wide literature review

BACKGROUND

Coronavirus (COVID-19) pandemic has affected the training and wellbeing of obstetrics and gynaecology (O&G) trainees. The aim of this review is to offer a worldwide overview on its' impact on the mental health of O&G trainees, so that measures can be put into place to better support trainees during the transition back to the 'new normal'.

METHODS

Key search terms used on PubMed and Google Scholar databases include: mental health, COVID-19, O&G, trainees, residents.

RESULTS

Fifteen articles (cumulative number of respondents = 3230) were identified, of which eight employed validated questionnaires (n = 1807 respondents), while non-validated questionnaires were used in seven (n = 1423 respondents). Studies showed that COVID-19 appeared to exert more of a negative impact on females and on senior trainees' mental health, while protective factors included marriage/partner and having had children. Validated and non-validated questionnaires suggested that trainees were exposed to high levels of anxiety and depression. Their mental health was also affected by insomnia, stress, burnout and fear of passing on the virus.

DISCUSSION

This review analyses the global impact of COVID-19 on O&G trainees' mental health, showing a pervasive negative effect linked to fear of the virus. Limited psychological support has led to prolonged issues, hindering patient safety and increasing sick leave. The study underscores the urgency of comprehensive support, particularly in female-dominated fields. Addressing these challenges is crucial for future pandemics, highlighting the need to learn from past mistakes and prioritise mental health resources for trainee well-being during and beyond pandemics.

How I maximised my training during the COVID-19 pandemic

The COVID-19 pandemic was declared in March 2020 and London maternity units were among the first in the United Kingdom to report maternal infection and vertical transmission. To manage resources, over half of all Obstetrics and Gynaecology trainees were redeployed to support front-line specialities such as Core Medicine and Accident and Emergency. The vignettes in this article illustrate how three trainees maximised their limited training opportunities in the face of exceptional disruption, lack of surgical training opportunities and workload pressures.

Obstetric outcomes in Jehovah's Witnesses: case series over nine years in a London teaching hospital

OBJECTIVES

The aim of the study is to assess obstetric and fetal outcomes of Jehovah's Witnesses (JWs) mothers in an inner city teaching hospital, as well as to examine the acceptance rates of various blood fractions and blood transfusion alternatives.

METHODS

Case series to evaluate the maternal and fetal outcomes of JWs over a nine period between 2013 and 2021.

RESULTS

There were 146 pregnancies extracted from our database, of which 10 were early pregnancy losses. Data from 136 deliveries > 24 weeks' gestation were assessed, with a mean maternal age and gestational age of 30.26 (± 5.4) years and 38.7 (± 5.3) weeks, respectively. 57% had normal vaginal deliveries, 8% had instrumental births and 35% had caesarean births. Mean estimated blood loss at caesarean was 575 (± 305.6) mls, while the overall mean estimated loss was 427.8 (± 299.8) mls. Cell salvage was performed in all caesarean sections but autologous transfusion was only necessary for 26%. Consultant presence was documented in 62% of caesarean births. The mean birthweight and 5-min Apgar scores were 3.31 (± 0.05) kg and 9.1 (± 0.09), respectively. There were no maternal deaths or admissions to the adult intensive care unit and the most serious complication was a uterine rupture following a trial of scar, after which the baby required cooling for hypoxic ischaemic encephalopathy.

CONCLUSIONS

Pregnant JWs received obstetric care led by senior clinicians, with optimisation of haematinics, minimizing of blood loss at delivery and access to technology such as cell salvage.

The Joys of Older Motherhood: A questionnaire-based survey of mothers who delivered over the age of 50 years

OBJECTIVE

It is recognised that advanced maternal age is associated with adverse pregnancy outcomes. It is less known what the psychological impact of having a pregnancy in later maternal age is. This study aimed to establish whether women having children over 50 experience challenges with regards to their mental well-being during the pregnancy and thereafter.

STUDY DESIGN

17 women delivered aged ≥ 50 at our maternity unit in a central London hospital between 2014 and 2020. Of these, one had died of metastatic ampullary carcinoma two years following delivery, one declined taking part, and two we were unable to get hold of, leaving 13 women in the study. Two validated questionnaires were used to survey the women: (i) Warwick-Edinburgh Mental Well-being Scale (WEMWBS), (ii) Parenting Daily Hassles Scale (PDHS). We analysed the questionnaire data using their individual scoring systems.

RESULTS

The WEMWBS showed a median score of 60 out of a possible 70 (range: 45-70), indicating a high level of mental well-being among these women. The PDHS results indicated that reported hassles were overall low in both frequency and intensity for the mothers.

CONCLUSION

Women giving birth over 50 have often experienced long, emotional and financially-burdensome journeys in order to fall pregnant, usually involving assisted reproductive techniques (ART), with multiple antenatal and delivery complications thereafter. As a result, they are extremely happy and grateful to have the child, and are often in better socioeconomic positions that can help with the stress that comes with child-caring.

Retrospective observational RT-PCR analyses on 688 babies born to 843 SARS-CoV-2 positive mothers, placental analyses and diagnostic analyses limitations suggest vertical transmission is possible

Research question

Is there vertical transmission (from mother to baby antenatally or intrapartum) after SARS-CoV-2 (COVID-19) infected pregnancy?

Study design

A systematic search related to SARS-CoV-2 (COVID-19), pregnancy, neonatal complications, viral and vertical transmission. The duration was from December 2019 to May 2020.

Results

A total of 84 studies with 862 COVID positive women were included. Two studies had ongoing pregnancies while 82 studies included 705 babies, 1 miscarriage and 1 medical termination of pregnancy (MTOP). Most publications (50/84, 59.5%), reported small numbers (<5) of positive babies. From 75 studies, 18 babies were COVID-19 positive. The first reverse transcription polymerase chain reaction (RT-PCR) diagnostic test was done in 449 babies and 2 losses, 2nd RT-PCR was done in 82 babies, IgM tests were done in 28 babies, and IgG tests were done in 28 babies. On the first RT-PCR, 47 studies reported time of testing while 28 studies did not. Positive results in the first RT-PCR were seen in 14 babies. Earliest tested at birth and the average time of the result was 22 hours. Three babies with negative first RT-PCR became positive on the second RT-PCR at day 6, day 7 and at 24 hours which continued to be positive at 1 week.

Four studies with a total of 4 placental swabs were positive demonstrating SARS-CoV-2 localised in the placenta. In 2 studies, 10 tests for amniotic fluid were positive for SARS-CoV-2. These 2 babies were found to be positive on RT-PCR on serial testing.

Conclusion

Diagnostic testing combined with incubation period and placental pathology indicate a strong likelihood that intrapartum vertical transmission of SARS-CoV-2 (COVID-19) from mother to baby is possible.

The effects of severe iron-deficiency anaemia on maternal and neonatal outcomes: A case-control study in an inner-city London hospital

This case-control study investigates the effects of severe iron-deficiency anaemia in pregnancy on maternal and neonatal outcomes in a relatively deprived inner-city population in a North London hospital. The study group comprised of 106 women with haemoglobin (Hb) < 8 g/dl at any point during pregnancy, while controls were 106 women with Hb > 11 g/dl throughout pregnancy. The study group lost an average of 80 ml more blood at delivery (p = 0.032) and had higher rates of postpartum haemorrhage than the control group (27 vs 12 patients, p = 0.012). However, anaemia did not appear to influence other maternal or neonatal outcomes; these may have been confounded by antenatal intervention with oral haematinics or blood transfusion.

Pregnancy outcomes in severe hyperemesis gravidarum in a multi-ethnic population

We evaluated pregnancy outcomes among women with hyperemesis gravidarum (HG) in a North London multi-ethnic population. A retrospective case-control study was performed on records of obstetric admissions during a 4-year period, at North Middlesex University Hospital in North London. A total of 208 women with HG were identified according to Fairweather's criteria occurring in the first 20 weeks of pregnancy, which is severe enough to require admission to hospital. The control study group consisted of 208 women without HG, matched for age, ethnicity and parity. Maternal characteristics as well as pregnancy outcomes were compared in the two groups. The incidence of a delivery of a small-for-gestational-age (SGA) neonate below the 10th per centile was significantly higher in the HG group compared with unaffected pregnancies (8.7% vs 16.8%, p = 0.01). Hyperemesis gravidarum in a multi-ethnic population in North London is associated with SGA neonates.

Stem cell therapy for stress urinary incontinence: a systematic review in human subjects

PURPOSE

To systematically evaluate the current evidence on the safety and efficacy of stem cell therapy (SCT) in stress urinary incontinence (SUI) to allow objective comparison with existing surgical techniques.

METHODS

Systematic literature search of Medline from years 1946-2012 using terms: "stem", "cell", "stress", "urinary", and "incontinence". Included studies presented empirical data on the treatment of SUI using SCT.

OUTCOMES

adverse events, incontinence, quality of life, urodynamic, transurethral ultrasound and urethral EMG findings.

RESULTS

Eight studies met inclusion criteria (seven observational and one randomized). Quality score: median 10.75 of 20 (range 2-12.5). Adverse events: one patient had bladder perforation and two procedures could not be completed due to pain. Temporary urinary retention and cystitis were also reported. Incontinence score: Four studies describe significant improvement. Quality of life: significant improvement in four studies. Urodynamic outcomes: four studies show significant improvement in contractility of urethral sphincter; three studies demonstrate no change in bladder capacity and significant reduction in residual volume; significant improvement in urinary flow three studies, although two found no difference; increase in leak point pressure and detrusor pressure in three studies. Urethral ultrasound: three studies found significant increases in rhabdosphincter thickness and contractility. Urethral EMG: two studies found significant increases in the EMG at rest and at contraction.

CONCLUSION

Data suggest that SC treatment for SUI is safe and effective in the short term. However, the quality and maturity of the data are limited. Robust data from better quality studies comparing this to current surgical techniques are needed.

Obstetric outcome of ethnic Turkish women in London: a retrospective case-control study

There is concern that the maternal mortality in ethnic minority women is significantly greater than that of Caucasian British women. The objective of this study was to compare the demographic and obstetric outcomes between these two groups. Data were collected retrospectively over a 2-year period from 148 index and 148 control cases. The study group had statistically similar maternal age, labour duration, blood loss and mode of delivery compared with Caucasian British women (p > 0.05). A total of 68% of Turkish women spoke little or no English; were more likely to be non-smokers and also more likely to be married to unemployed spouses (p = 0.0001). This is the first study comparing obstetric outcomes of immigrant Turkish women with their Caucasian British counterparts. There was no significant difference in maternal or fetal outcomes, which could be attributed to the 'healthy migrant' theory, coupled with increased vigilance in ethnic minority pregnancies.

The relationship of ethnicity, maternal height and shoe size, and method of delivery

In a bid to determine the relationship of ethnicity, maternal height and shoe size as predictors of cephalopelvic disproportion, we conducted a prospective comparative study of primigravidas at term with singleton pregnancies, who had undergone spontaneous labour. A total of 208 primigravidas were studied; 151 (62.9%) achieved vaginal delivery and 57 (37.1%) had emergency caesarean section for failure-to-progress. We found a statistically significant positive correlation between maternal height and vaginal delivery (p = 0.04), but no correlation with maternal shoe size was found (p = 0.24). This study also showed that Caucasian women were significantly more than twice as likely to achieve vaginal delivery compared with Africans (p = 0.02). Maternal height of at least 162.5 cm, has a sensitivity of 74% and a specificity of 43% for predicting vaginal delivery. We concluded that the most predictive anthropometric measurement for vaginal delivery is maternal height.