Ashraf Nabhan

BACKGROUND: Clinical presentation and outcomes of COVID-19 infection during pregnancy remain limited and fragmented. OBJECTIVES: To summarize the existing literature on COVID-19 infection during pregnancy and childbirth, particularly concerning clinical presentation and outcomes. SEARCH STRATEGY: A systematic search of LitCovid, EBSCO MEDLINE, CENTRAL, CINAHL, Web of Science, and Scopus electronic databases. The references of relevant studies were also searched. SELECTION CRITERIA: Identified titles and abstracts were screened to select original reports and cross-checked for overlap of cases. DATA COLLECTION AND ANALYSIS: A descriptive summary organized by aspects of clinical presentations (symptoms, imaging, and laboratory) and outcomes (maternal and perinatal). MAIN RESULTS: We identified 33 studies reporting 385 pregnant women with COVID-19 infection: 368 (95.6%) mild; 14 (3.6%) severe; and 3 (0.8%) critical. Seventeen women were admitted to intensive care, including six who were mechanically ventilated and one maternal mortality. A total of 252 women gave birth, comprising 175 (69.4%) cesarean and 77 (30.6%) vaginal births. Outcomes for 256 newborns included four RT-PCR positive neonates, two stillbirths, and one neonatal death. CONCLUSION: COVID-19 infection during pregnancy probably has a clinical presentation and severity resembling that in non-pregnant adults. It is probably not associated with poor maternal or perinatal outcomes.

BACKGROUND: Amniotic fluid volume is an important parameter in the assessment of fetal well-being. Oligohydramnios occurs in many high-risk conditions and is associated with poor perinatal outcomes. Many caregivers practice planned delivery by induction of labor or caesarean section after diagnosis of decreased amniotic fluid volume at term. There is no clear consensus on the best method to assess amniotic fluid adequacy. OBJECTIVES: To compare the use of the amniotic fluid index with the single deepest vertical pocket measurement as a screening tool for decreased amniotic fluid volume in preventing adverse pregnancy outcome. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to May 2007) and the metaRegister of Controlled Trials (May 2007). We handsearched the citation lists of relevant publications, review articles, and included studies. SELECTION CRITERIA: Randomised controlled trials involving women with a singleton pregnancy, whether at low or high risk, undergoing ultrasound measurement of amniotic fluid volume as part of antepartum assessment of fetal well-being that compared the amniotic fluid index and the single deepest vertical pocket measurement. DATA COLLECTION AND ANALYSIS: Both authors independently assessed eligibility and quality, and extracted the data. MAIN RESULTS: Four trials (3125 women) met the inclusion criteria. There is no evidence that one method is superior to the other in the prevention of poor peripartum outcomes, including: admission to a neonatal intensive care unit; an umbilical artery pH of less than 7.1; the presence of meconium; an Apgar score of less than 7 at five minutes; or caesarean delivery. When the amniotic fluid index was used, significantly more cases of oligohydramnios were diagnosed (risk ratio (RR, random) 2.33, 95% CI 1.67 to 3.24), and more women had inductions of labor (RR (fixed) 2.10, 95% CI 1.60 to 2.76) and caesarean delivery for fetal distress (RR (fixed) 1.45, 95% CI 1.07 to 1.97). AUTHORS' CONCLUSIONS: The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of induction of labor without improvement in peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required.

BACKGROUND: Cardiovascular disease (CVD) is the major cause of mortality worldwide. Coronary artery disease (CAD) contributes to half of mortalities caused by CVD. The mainstay of management of CAD is medical therapy and revascularisation. Revascularisation can be achieved via coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Peripheral arteries, such as the femoral or radial artery, provide the access to the coronary arteries to perform diagnostic or therapeutic (or both) procedures. OBJECTIVES: To assess the benefits and harms of the transradial compared to the transfemoral approach in people with CAD undergoing diagnostic coronary angiography (CA) or PCI (or both). SEARCH METHODS: We searched the following databases for randomised controlled trials on 10 October 2017: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in August 2017. There were no language restrictions. Reference lists were also checked and we contacted authors of included studies for further information. SELECTION CRITERIA: We included randomised controlled trials that compared transradial and transfemoral approaches in adults (18 years of age or older) undergoing diagnostic CA or PCI (or both) for CAD. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. At least two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We contacted trial authors for missing information. We used risk ratio (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). All analyses were checked by another author. MAIN RESULTS: We identified 31 studies (44 reports) including 27,071 participants and two ongoing studies. The risk of bias in the studies was low or unclear for several domains. Compared to the transfemoral approach, the transradial approach reduced short-term net adverse clinical events (NACE) (i.e. assessed during hospitalisation and up to 30 days of follow-up) (RR 0.76, 95% CI 0.61 to 0.94; 17,133 participants; 4 studies; moderate quality evidence), cardiac death (RR 0.69, 95% CI 0.54 to 0.88; 11,170 participants; 11 studies; moderate quality evidence). However, short-term myocardial infarction was similar between both groups (RR 0.91, 95% CI 0.81 to 1.02; 19,430 participants; 11 studies; high quality evidence). The transradial approach had a lower procedural success rate (RR 0.97, 95% CI 0.96 to 0.98; 25,920 participants; 28 studies; moderate quality evidence), but was associated with a lower risk of all-cause mortality (RR 0.77, 95% CI 0.62 to 0.95; 18,955 participants; 10 studies; high quality evidence), bleeding (RR 0.54, 95% CI 0.40 to 0.74; 23,043 participants; 20 studies; low quality evidence), and access site complications (RR 0.36, 95% CI 0.22 to 0.59; 16,112 participants; 24 studies; low quality evidence). AUTHORS' CONCLUSIONS: Transradial approach for diagnostic CA or PCI (or both) in CAD may reduce short-term NACE, cardiac death, all-cause mortality, bleeding, and access site complications. There is insufficient evidence regarding the long-term clinical outcomes (i.e. beyond 30 days of follow-up).

BACKGROUND: Maternal infections are an important cause of maternal mortality and severe maternal morbidity. We report the main findings of the WHO Global Maternal Sepsis Study, which aimed to assess the frequency of maternal infections in health facilities, according to maternal characteristics and outcomes, and coverage of core practices for early identification and management. METHODS: We did a facility-based, prospective, 1-week inception cohort study in 713 health facilities providing obstetric, midwifery, or abortion care, or where women could be admitted because of complications of pregnancy, childbirth, post-partum, or post-abortion, in 52 low-income and middle-income countries (LMICs) and high-income countries (HICs). We obtained data from hospital records for all pregnant or recently pregnant women hospitalised with suspected or confirmed infection. We calculated ratios of infection and infection-related severe maternal outcomes (ie, death or near-miss) per 1000 livebirths and the proportion of intrahospital fatalities across country income groups, as well as the distribution of demographic, obstetric, clinical characteristics and outcomes, and coverage of a set of core practices for identification and management across infection severity groups. FINDINGS: Between Nov 28, 2017, and Dec 4, 2017, of 2965 women assessed for eligibility, 2850 pregnant or recently pregnant women with suspected or confirmed infection were included. 70·4 (95% CI 67·7-73·1) hospitalised women per 1000 livebirths had a maternal infection, and 10·9 (9·8-12·0) women per 1000 livebirths presented with infection-related (underlying or contributing cause) severe maternal outcomes. Highest ratios were observed in LMICs and the lowest in HICs. The proportion of intrahospital fatalities was 6·8% among women with severe maternal outcomes, with the highest proportion in low-income countries. Infection-related maternal deaths represented more than half of the intrahospital deaths. Around two-thirds (63·9%, n=1821) of the women had a complete set of vital signs recorded, or received antimicrobials the day of suspicion or diagnosis of the infection (70·2%, n=1875), without marked differences across severity groups. INTERPRETATION: The frequency of maternal infections requiring management in health facilities is high. Our results suggest that contribution of direct (obstetric) and indirect (non-obstetric) infections to overall maternal deaths is greater than previously thought. Improvement of early identification is urgently needed, as well as prompt management of women with infections in health facilities by implementing effective evidence-based practices. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and United States Agency for International Development.

ISBN 978 92 4 154936 3.