SARS-CoV-2 vaccination modelling for safe surgery to save lives : data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.Peer reviewe

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; pPeer reviewe

Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection

Objectives To evaluate the maternal and perinatal outcomes of pregnancies affected by SARS-CoV-2 infection. Methods This was a multinational retrospective cohort study including women with a singleton pregnancy and laboratory-confirmed SARS-CoV-2 infection, conducted in 72 centers in 22 different countries in Europe, the USA, South America, Asia and Australia, between 1 February 2020 and 30 April 2020. Confirmed SARS-CoV-2 infection was defined as a positive result on real-time reverse-transcription polymerase chain reaction (RT-PCR) assay of nasopharyngeal swab specimens. The primary outcome was a composite measure of maternal mortality and morbidity, including admission to the intensive care unit (ICU), use of mechanical ventilation and death. Results In total, 388 women with a singleton pregnancy tested positive for SARS-CoV-2 on RT-PCR of a nasopharyngeal swab and were included in the study. Composite adverse maternal outcome was observed in 47/388 (12.1%) women; 43 (11.1%) women were admitted to the ICU, 36 (9.3%) required mechanical ventilation and three (0.8%) died. Of the 388 women included in the study, 122 (31.4%) were still pregnant at the time of data analysis. Among the other 266 women, six (19.4% of the 31 women with first-trimester infection) had miscarriage, three (1.1%) had termination of pregnancy, six (2.3%) had stillbirth and 251 (94.4%) delivered a liveborn infant. The rate of preterm birth before 37 weeks' gestation was 26.3% (70/266). Of the 251 liveborn infants, 69/251(27.5%) were admitted to the neonatal ICU, and there were five (2.0%) neonatal deaths. The overall rate of perinatal death was 4.1% (11/266). Only one (1/251, 0.4%) infant, born to a mother who tested positive during the third trimester, was found to be positive for SARS-CoV-2 on RT-PCR. Conclusions SARS-CoV-2 infection in pregnant women is associated with a 0.8% rate of maternal mortality, but an 11.1% rate of admission to the ICU. The risk of vertical transmission seems to be negligible. (C) 2020 International Society of Ultrasound in Obstetrics and Gynecology.Peer reviewe

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Role of second trimester ultrasound in prediction of newborns neurologic damage after maternal Cytomegalovirus infection

Objective To find a correlation between cerebral symptoms at birth and abnormalities found at anomaly scan, through the analysis of sensitivity of the anomaly scan in the prediction of severe CMV neonatal disease. Methods - Design, Setting, Population This was a retrospective collection of all cases of primary congenital CMV infection reported in our unit (Obstetrics and Perinatal Medicine, Policlinico di S Orsola, IRCSS, Bologna) over a period of 9 years (2013–2022). Only cases of fetal infection following confirmed maternal primary infection in the first trimester (MPI) and newborns with confirmed CMV infection on blood/saliva or urine were included. Results Between 2014 and 2022, 69 fetuses had an antenatal diagnosis of primary CMV infection. The infection occurred after MPI in the first, second, and third trimester in 63.7% (43/69), 27.5% (19/69), and 10% (7/69) of cases, respectively. Second-trimester assessment by anomaly scan was abnormal in 10/69 (15%) fetuses: 5/69 (7%) had an extracerebral STA and 5/69 (7%) had a cerebral STA. Normal anomaly scan was found in 59/69 (86%) fetuses. When looking at all fetuses infected in the first trimester, 12.5% (5/40) underwent TOP and 45% (18/40) had symptoms at birth. A mean follow-up of 22.4 months (range 12–48 months) was available for 68/69 (99%) live born neonates. Conclusion Anomaly scan results to have a predictive positive value of 67% fetuses infected in the first trimester. Serial assessment by ultrasound is necessary to predict the risk of sequelae occurring in 35% following fetal infection in the first trimester of pregnancy. This combined evaluation by US and trimester of infection should be useful when counselling on the prognosis of cCMV infection

Gravidanza multipla e malformazioni

Il diffondersi delle tecniche di procreazione medicalmente assistita (PMA) ha portato ad un aumento dell’incidenza delle gravidanze gemellari, rendendo necessaria la discussione della maggiore frequenza di malformazioni congenite documentata nei nati da gravidanza plurima. Contrariamente rispetto a quanto siamo abituati a credere, i gemelli non sono necessariamente identici, ma possono differire tra loro per anomalie congenite e/o genetiche: si definiscono concordanti i gemelli che presentano la stessa malformazione, mentre sono discordanti se uno solo dei gemelli presenta un’anomalia congenita, oppure se entrambi hanno anomalie congenite, ma distinguibili sotto il profilo eziopatogenetico. Le anomalie di più comune riscontro nei gemelli sono le anomalie cardiache, del sistema nervoso centrale e dell’apparato gastroenterico. Gli stressi gemelli monocoriali possono presentare cariotipo discordante per anomalie cromosomiche (gemelli eterocarionti) o malattie monogeniche (gemelli eteroallelici). I progressi della chirurgia pediatrica nell’ambito delle tecniche di separazione dei gemelli congiunti, in associazione all’uso estensivo dell’ecografia ostetrica nel primo trimestre, impongono agli ecografisti ostetrici la definizione diagnostica precoce dei casi di gemelli congiunti, così da poter fornire ai futuri genitori gli strumenti più idonei per una scelta consapevole circa la prosecuzione di una gravidanza. Le informazioni disponibili in letteratura circa le anomalie congenite nei gemelli sono, purtroppo, ad oggi, frammentarie. Pertanto gli studiosi esperti hanno il dovere, nei casi di anomalie genetiche o fenotipiche in gravidanza gemellare, di pubblicare, nel medesimo report, i risultati delle analisi genetiche, degli esami istologici delle placente, delle eventuali autopsie o dell’esame clinico postnatale, così da contribuire, in modo concreto, ai futuri studi sulle anomalie nelle gravidanze gemellari

Il DNA fetale

Nel circolo materno è presente materiale genetico di origine fetale sotto forma di una miscela di frammenti di acidi nucleici aventi due distinte origini: materna e fetale. La quantità di DNA fetale rilevata nel campione di plasma analizzato rispetto al DNA plasmatico totale (materno + fetale) viene espressa in termini di frazione fetale (FF). Per poter fornire risultati attendibili è necessaria una frazione fetale di almeno il 4%. Le principali tecniche di sequenziamento utilizzate per l’analisi del cfDNA sono tecniche quantitative di seconda generazione (Next Generation Sequencing - NGS) dell’intero genoma (Massively Parallel Shotgun Sequency - MPSS) o di specifiche regioni (CSS, Chromosome Selective Sequencing). Un approccio alternativo di tipo qualitatitvo è basato sull'analisi dei polimorfismi a singolo nucleotide (Single-nucleotide polymorphysm- SNPs). Nessuna delle tecniche di analisi del cfDNA attualmente in uso è in grado di fornire una percentuale di falsi positivi (FPR) pari a 0% e sensibilità (DR) del 100%, configurandosi, di fatto, come test di screening e non diagnostici. Alcune delle applicazioni del cfDNA riguardano l’indagine non invasiva di microdelezioni e altre malattie monogeniche, tuttavia, allo stato attuale non sono disponibili dati sufficientemente validati per porre indicazione al loro utilizzo nella pratica clinica. Una valutazione ecografica accurata nel primo trimestre dovrebbe essere offerta a tutte le donne che richiedono uno screening prenatale indipendentemente dalla scelta di sottoporsi al test del cfDNA. L’esito del cfDNA test viene espresso in forma di due possibili risultati per ciascuna delle aneuploidie cromosomiche prese in esame: basso rischio (> 1 su 10.000) o alto rischio (> 99%). Un risultato di basso rischio consente di ridurre il rischio a priori di circa 300 volte per la trisomia 21 e di 50 volte per la trisomia 18 e 13. Un risultato di alto rischio prevede una conferma diagnostica mediante villocentesi o amniocentesi. In una percentuale variabile tra l’1% e il 5% delle gravidanze, il test del cfDNA può non fornire alcun risultato al primo prelievo. Tentativi successivi forniscono un risultato nel 60-70% dei casi. Il fallimento della metodica nella maggior parte dei casi è attribuibile ad una bassa frazione fetale. L’implementazione del cfDNA nella pratica clinica può essere realizzata attraverso due possibili percorsi: in sostituzione all’attuale Test Combinato (“screening universale”) oppure come screening di seconda linea dopo Test Combinato (“screening contingente”). Il modello contingente appare il più vantaggioso

Antenatal and Postnatal Sequelae of Oxidative Stress in Preterm Infants: A Narrative Review Targeting Pathophysiological Mechanisms

The detrimental effects of oxidative stress (OS) can start as early as after conception. A growing body of evidence has shown the pivotal role of OS in the development of several pathological conditions during the neonatal period, which have been therefore defined as OS-related neonatal diseases. Due to the physiological immaturity of their antioxidant defenses and to the enhanced antenatal and postnatal exposure to free radicals, preterm infants are particularly susceptible to oxidative damage, and several pathophysiological cascades involved in the development of prematurity-related complications are tightly related to OS. This narrative review aims to provide a detailed overview of the OS-related pathophysiological mechanisms that contribute to the main OS-related diseases during pregnancy and in the early postnatal period in the preterm population. Particularly, focus has been placed on pregnancy disorders typically associated with iatrogenic or spontaneous preterm birth, such as intrauterine growth restriction, pre-eclampsia, gestational diabetes, chorioamnionitis, and on specific postnatal complications for which the role of OS has been largely ascertained (e.g., respiratory distress, bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, necrotizing enterocolitis, neonatal sepsis). Knowledge of the underlying pathophysiological mechanisms may increase awareness on potential strategies aimed at preventing the development of these conditions or at reducing the ensuing clinical burden

Antenatal and Postnatal Sequelae of Oxidative Stress in Preterm Infants: A Narrative Review Targeting Pathophysiological Mechanisms

The detrimental effects of oxidative stress (OS) can start as early as after conception. A growing body of evidence has shown the pivotal role of OS in the development of several pathological conditions during the neonatal period, which have been therefore defined as OS-related neonatal diseases. Due to the physiological immaturity of their antioxidant defenses and to the enhanced antenatal and postnatal exposure to free radicals, preterm infants are particularly susceptible to oxidative damage, and several pathophysiological cascades involved in the development of prematurity-related complications are tightly related to OS. This narrative review aims to provide a detailed overview of the OS-related pathophysiological mechanisms that contribute to the main OS-related diseases during pregnancy and in the early postnatal period in the preterm population. Particularly, focus has been placed on pregnancy disorders typically associated with iatrogenic or spontaneous preterm birth, such as intrauterine growth restriction, pre-eclampsia, gestational diabetes, chorioamnionitis, and on specific postnatal complications for which the role of OS has been largely ascertained (e.g., respiratory distress, bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, necrotizing enterocolitis, neonatal sepsis). Knowledge of the underlying pathophysiological mechanisms may increase awareness on potential strategies aimed at preventing the development of these conditions or at reducing the ensuing clinical burden

Quantification of Posterior Risk Related to Intrapartum FIGO 2015 Criteria for Cardiotocography in the Second Stage of Labor

Introduction: Intrapartum cardiotocography (CTG) was used for several decades to detect a stressed fetus so that delivery can be expedited to prevent birth asphyxia. The main aim of the study was to calculate the risk of neonatal acidemia (pH 64 7.10) according to duration of the 2nd stage of labor and occurrence of the International Federation of Gynecology and Obstetrics (FIGO) 2015 CTG classification parameters. Materials and methods: This was a retrospective case-control study on 552 pregnancies receiving continuous CTG monitoring in labor and immediate hemogasanalysis at birth. Cases with umbilical artery (UA) pH 64 7.10 and controls with UA pH 65 7.10 were matched for parity and gestational age at delivery, with ratio 1:5. Logistic regression analysis, adjusted for the expected risk in the general population, was used to calculate the baseline risk of UA pH 64 7.10 in the absence of any CTG pathological feature and those associated with pathological CTG patterns occurring in the 2nd stage according to FIGO 2015. Results: Seventy-three cases and 387 controls reached 2nd stage and were included in the analysis. For those reaching 2nd stage, the mean adjusted risk of acidemia associated with nonpathological CTG was 1.6%. Stratification of risk according to duration of the 2nd stage yielded risks of neonatal acidemia of 1.23, 2.08, 5.81, and 15.22% at 30, 60, 120, and 180 min, respectively. Bradycardia >10 min was associated with risk of neonatal acidemia of 9.9 and 15.8% for 2nd-stage durations of 30 and 60 min, respectively. Risks associated with 1 prolonged deceleration >5 min were 6.80, 11.08, 27.0, and 51.0% at 30, 60, 120, and 180 min, respectively. Repetitive late or prolonged decelerations >30 min were associated with risk of neonatal acidemia of 2.43, 4.14, 11.17, and 26.45% at 30, 60, 120, and 180 min, respectively. Conclusion: The risk of neonatal acidemia is directly proportional to duration of the 2nd stage, irrespective of the presence of CTG abnormalities, increasing 12-fold (1.2-15.3%) from 30 to 180 min. Occurrence of FIGO 2015 pathological CTG patterns showed a decreasing impact from bradycardia >10 min to decelerations >5 min, recurrent later or prolonged decelerations >30 min, and nonpathological CTG.