Search results for: pregnancy outcomes

Authors: Sibusiso Mkwananzi

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The health of mother and child remain at risk among pregnant adolescents. Nevertheless, these are placed in even greater jeopardy when an expectant adolescent experiences violence. This paper sought to explore the levels and determinants of expecting adolescents in five Southern African countries. The study used the most recent (2010/2015) nationally representative demographic health survey (DHS) data from Malawi, Mozambique, Namibia, Zambia, and Zimbabwe. The highest levels of violence during pregnancy occurred amongst adolescent females living in Zimbabwe at 11.4%, followed by Zambia (8.3%) and Namibia (7.7%). Lowest levels were seen in Mozambique at 3.6%. Additionally, the determinants of experiencing violence during pregnancy included educational attainment, marital status, wealth and place of residence. Expectant adolescents that had a higher likelihood of experiencing violence were married and lived predominantly in rural settings. Higher risk was also associated with lower acquisition of education and poverty. These results show a very similar pattern to the risk factors associated with early pregnancy in the region. The predictors point to issues of possible lowered empowerment amongst younger women in their relationships and the structural challenges faced by this fledgling group. Nevertheless, addressing these dynamics could go a long way in not only decreasing the likelihood of unwanted motherhood at this early stage of the life course, but indeed even ensuring the prevention of violence during wanted early pregnancy. This would lead to improved levels of maternal and child health despite younger maternal age and aid in achieving a number of sustainable development goals.

Keywords: adolescents, determinants, Southern Africa, violence during pregnancy

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Authors: Husham Bayazed

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Purpose of presentation: Pregnancy represents the most important period for the conservation of the species. The immune system is one of the most important systems protecting the mother against the environment and preventing damage to the fetus. This presentation aims to review and discuss the role of the immune system during pregnancy, the evolutionary inflammatory process through pregnancy, infectious and environmental exposure influences on the mother and the fetus, and the impacts of sexual dimorphism of the placenta on offspring susceptibility to different disorders. Recent Findings: In 1960, Peter Medawar (Nobel Prize Winner) proposed that the fetus, a semi-allograft, is similar to a tissue graft that escapes rejection through a mechanism involving systemic immune suppression (Graft –Host response). However, recent researchers and studies have documented that implantation means inflammation, and the inflammatory process is considered a breach of tolerance in pregnancy with immune induction, which is necessary for the protection of the mother and the fetus against infections and environmental triggers. This inflammatory process should be maintained during different pregnancy phases till parturition, and any block at any phase will be associated with pregnancy complications, including pregnancy failure or loss, miscarriage, and preterm birth subsequently. Maternal immune activation following any trigger can have a positive effect on the fetus. The old concept of the placenta being asexual is inaccurate, and being with sexual dimorphism with clear differences in susceptibility to different factors that stimulate maternal immunity. Summary: The presence of different immune cells ((i.e., T cells, B cells, NK cells, etc.) at the implantation site is considered proof of a strong maternal immune response to the fetus. Therefore, human pregnancy is considered a unique immunological paradigm requiring maternal immune modulation rather than suppression. So Medawar's postulation of maternal systemic immunosuppression is wrong. Maternal immune system activation triggered by infections, stress, diet, and pollution can have a positive effect on the fetus, with the development of fetal-trained immunity necessary for survival. The sexual dimorphism of the placenta seems to have an impact on the differences in sex susceptible to the environment maternal risk stimuli. This link to why the incidence of autism is increasing more among boys than girls.

Keywords: pregnancy, maternal immunity, implantation and inflammation, placenta sexual dimorphism

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Authors: Agnieszka Rolinska, Marta Makara-Studzinska

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Introduction: In recent years, there has been an intensive development of research into the physiological relationships between the experienced stress and obesity. Moreover, strong chronic stress leads to the disorganization of a person’s activeness on various levels of functioning, including the behavioral and cognitive sphere (also in one’s diet). Aim: The present work addresses the following research questions: Is there a relationship between an increase in stress related to the disease and the need for the cyclicality of diabetologic education in gestational diabetes? Are there any differences in terms of the experienced stress during the last three months of pregnancy in women with gestational diabetes and in normal pregnancy between the patients with normal weight gains and those with abnormal weight gains? Are there any differences in terms of stress coping styles in women with gestational diabetes and in normal pregnancy between the patients with normal weight gains and those with abnormal weight gains? Method: The study involved pregnant women with gestational diabetes (treated with diet, without insulin therapy) and in normal pregnancy – 206 women in total. The following psychometric tools were employed: Perceived Stress Scale (PSS; Cohen, Kamarck, Mermelstein), Coping Inventory for Stressful Situations (CISS; Endler, Parker) and authors’ own questionnaire. Gestational diabetes mellitus was diagnosed on the basis of the results of fasting oral glucose tolerance test (75 g OGTT). Body weight measurements were confirmed in a diagnostic interview, taking into account medical data. Regularities in weight gains in pregnancy were determined according to the recommendations of the Polish Gynecological Society and American norms determined by the Institute of Medicine (IOM). Conclusions: An increase in stress related to the disease varies in patients with differing requirements for the cyclical nature of diabetologic education (i.e. education which is systematically repeated). There are no differences in terms of recently experienced stress and stress coping styles between women with gestational diabetes and those in normal pregnancy. There is a relationship between weight gains in pregnancy and the stress experienced in life as well as stress coping styles – both in pregnancy complicated by diabetes and in physiological pregnancy. In the discussion of the obtained results, the authors refer to scientific reports from English-language magazines of international range.

Keywords: diabetologic education, gestational diabetes, stress, weight gain in pregnancy

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Authors: Maryam Ghavam Sadri, Kimia Moiniafshari

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Objectives: Autism is a neuro-developmental disorder that has negative effects on verbal, mental and behavioral development. Studies have shown the role of a maternal dietary pattern before and during pregnancy. The relation of exerting of nutritional management programs in prevention of Autism has been approved. This review article has been made to investigate the role of nutritional management strategies before and during pregnancy in the prevention of Autism. Methods: This review study was accomplished by using the keywords related to the topic, 67 articles were found (2000-2015) and finally 20 article with criteria such as including maternal lifestyle, nutritional deficiencies and Autism prevention were selected. Results: Maternal dietary pattern and health before and during pregnancy have important roles in the incidence of Autism. Studies have suggested that high dietary fat intake and obesity can increase the risk of Autism in offspring. Maternal metabolic condition specially gestational diabetes (GDM) (p-value < 0.04) and folate deficiency (p-value = 0.04) is associated with risk of Autism. Studies have shown that folate intake in mothers with autistic children is less than mothers who have typically developing children (TYP) (p-value<0.01). As folate is an essential micronutrient for fetus mental development, consumption of average 600 mcg/day especially in P1 phase of pregnancy results in significant reduction in incidence of Autism (OR:1.53, 95%CI=0.42-0.92, p-value = 0.02). furthermore, essential fatty acid deficiency especially omega-3 fatty acid increases the rate of Autism and consumption of supplements and food sources of omega-3 can decrease the risk of Autism up to 34% (RR=1.53, 95%CI=1-2.32). Conclusion: regards to nutritional deficiency and maternal metabolic condition before and during pregnancy in prevalence of Autism, carrying out the appropriate nutritional strategies such as well-timed folate supplementation before pregnancy and healthy lifestyle adherence for prevention of metabolic syndrome (GDM) seems to help Autism prevention.

Keywords: autism, autism prevention, dietary inadequacy, maternal lifestyle

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Authors: M. Illias Kanchan

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The death of a woman during pregnancy and childbirth is not only a health issue, but also a matter of social injustice. This study makes an attempt to explore the association between maternal death and associated factors in West Bengal using the approaches of facility-based and community-based maternal death review. Bivariate and binary logistic regression analysis have been performed to understand the causes and circumstances of maternal deaths in West Bengal. Delay in seeking care was the major contributor in maternal deaths, near about one-third women died due to this factor. The most common cause of maternal death is found to be hypertensive disorders of pregnancy or eclampsia. We believe that these deaths can be averted by reducing hypertensive disorders of pregnancy or eclampsia.

Keywords: maternal death, facility-based, community-based, review, west Bengal, eclampsia

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Authors: Samad Lotfollahzadeh

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To evaluate the effect of intramuscular administration of vitamin A during dry period in pregnant dairy cows, which already received it in their daily ration, on vitamin A status of neonatal calves, a total of 30 cows were randomly selected and divided to two main groups; treatment and control group. Animals in the treatment group were subdivided into two groups. Single intramuscular injection of 2000000 IU vitamin A; was carried in 10 dairy cows at 7 months of pregnancy (group 1). In the second group of treated animals (10 cows) the injection was performed in 8 months of pregnancy (group 2). Ten pregnant dairy cows were received saline injection as placebo and selected as the control group. Blood samples were collected from experimental dairy cows at 7 and 8 months of pregnancy as well as their newborn calves’ pre and after colostrum intake. There was no significant difference between vitamin A and β- carotene concentration of dairy cows of three groups in two last months of pregnancy (P > 0.05). Vitamin A concentration of calves of two treatment groups before and after receiving of colostrum were significantly higher than that in the control group (P < 0.05). There was no significant difference between serum concentrations of vitamin A in calves of two treated groups (P > 0.05). β- Carotene concentration of serum samples of dairy cows and neonatal calves of three groups were not significantly different as compared with together. From results of the present study it can be concluded that daily supplementation of vitamin A in late pregnancy in dairy cows may not compensate the calves need for vitamin A and single injection of this vitamin A during dry either in 7 or 8 months of pregnancy can significantly increase level of vitamin A in their colostrum and neonatal calves.

Keywords: dry cow, beta carotene, newborn calves, vitamin A, dry cows

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Authors: Seyed Mazyar Mortazavi, Masod Memari, Hasan Ali Ahmadi, Zhaleh Abed

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Introduction: VACTERL association is a rare disorder with various congenital malformations. The aetiology remains unknown. Combination of at least three congenital anomalies of the following criteria is required for diagnosis: vertebral defects, anal atresia, cardiac anomalies, tracheo-esophageal fistula, renal anomalies, and limb defects. Case presentation: The first case was 1-day old male neonate with multiple congenital anomalies was bore from 28 years old mother. The mother had history of pregnancy with lymphocyte therapy. His anomalies included: defects in thoracic and lumbar vertebral, anal atresia, bilateral hydronephrosis, atrial septal defect, and lower limb abnormality. Other anomalies were cryptorchidism and nasal canal narrowing. The second case was born with 32 weeks gestational age from mother with history of pregnancy with lymphocyte therapy. He had thoracic vertebral defect, cardiac anomalies and renal defect. Conclusion: diagnosis based on clinical finding is VACTERL association. Early diagnosis is very important to investigation and treatment of other coexistence anomalies. VACTERL association in mothers with history of pregnancy with lymphocyte therapy has suggested possibly of relationship between VACTERL association and this method of pregnancy.

Keywords: anal atresia, tracheo-esophageal fistula, atrial septal defect, lymphocyte therapy

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Authors: Charlotte Bach, Albrecht Jahn, Mahnaz Motamedi, Maryam Karimi-Ghahfarokhi

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Background: Maternal and infant deaths are most prevalent in the first month after birth, emphasizing the critical need for quality healthcare services during this period. Immigrant women, who are more susceptible to adverse pregnancy outcomes, often face neglect in accessing proper healthcare. The lack of adequate postpartum care significantly contributes to mortality rates. Therefore, utilizing maternal health care services and implementing postpartum care is crucial in reducing maternal and child mortality. Aims: This study aims to evaluate the assessment of pre- and postnatal care among women with and without migration background. In addition, the study explores the impact of COVID-19 procedures on women's experiences during pregnancy, birth, and the postpartum period. Methods: This research employs a cross-sectional Mixed-Method design. Data collection was facilitated through structured questionnaires administered to participants, alongside the utilization of patient bases, including Maternity and child medical records. Following the assumption that the investigator aimed to gain comprehensive insights, qualitative sampling focused on individuals with substantial experiences related to COVID-19, regarded as rich cases. Results: our study highlighted the influence of educational level, marital status, and consensual partnerships on the likelihood of Cesarean deliveries. Regarding breastfeeding practices, migrant women exhibited higher rates of breastfeeding initiation and continuation. Contraception utilization revealed interesting patterns, with non-migrants displaying higher odds of contraceptive use. The qualitative component of our research adds depth to the exploration of women's experiences during the COVID-19 pandemic, revealing nuanced challenges related to anxiety, hospital restrictions, breastfeeding support, and postnatal ward routines. Conclusion: Dissimilarity among studies toward cesarean rate between migrants and non-migrants underscores the importance of targeted interventions considering the diverse needs of distinct population groups. It also acknowledges potential cultural, contextual, and healthcare system influences on the association between mode of delivery and infant feeding practices. Studies acknowledge the influence of contextual variables on contraceptive preferences among migrants and non-migrants, emphasizing the need for tailored healthcare policies. The findings contribute to existing research, highlighting the need for a nuanced understanding of the impact of birth preparation courses on maternal and infant outcomes. Furthermore, they emphasize the universality of certain maternity care experiences, regardless of pandemic contexts, reinforcing the importance of patient-centred approaches in healthcare delivery.

Keywords: migration background, pregnancy outcome, covid-19, postpartum

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Authors: Jayeon Kim, Eunjung Yu, Taeki Yoon

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Most spontaneous miscarriage is believed to be a consequence of embryo aneuploidies. Transferring eukaryotic embryos selected by PGS is expected to decrease the miscarriage rate. Current PGS indications include advanced maternal age, recurrent pregnancy loss, repeated implantation failure. Recently, use of PGS for healthy women without above indications for the purpose of improving in vitro fertilization (IVF) outcomes is on the rise. However, it is still controversy about the beneficial effect of PGS in this population, especially, in women with a history of no more than 2 miscarriages or miscarriage of eukaryotic abortus. This study aimed to investigate if karyotyping result of abortus is a good indicator of preimplantation genetic screening (PGS) in subsequent IVF cycle in women with a history of spontaneous abortion. A single-center retrospective cohort study was performed. Women who had spontaneous abortion(s) (less than 3) and dilatation and evacuation, and subsequent IVF from January 2016 to November 2016 were included. Their medical information was extracted from the charts. Clinical pregnancy was defined as presence of a gestational sac with fetal heart beat detected on ultrasound in week 7. Statistical analysis was performed using SPSS software. Total 234 women were included. 121 out of 234 (51.7%) underwent karyotyping of the abortus, and 113 did not have the abortus karyotyped. Embryo biopsy was performed on 3 or 5 days after oocyte retrieval, followed by embryo transfer (ET) on a fresh or frozen cycle. The biopsied materials were subjected to microarray comparative genomic hybridization. Clinical pregnancy rate per ET was compared between PGS and non-PGS group in each study group. Patients were grouped by two criteria: karyotype of the abortus from previous miscarriage (unknown fetal karyotype (n=89, Group 1), eukaryotic abortus (n=36, Group 2) or aneuploidy abortus (n=67, Group 3)), and pursuing PGS in subsequent IVF cycle (pursuing PGS (PGS group, n=105) or not pursuing PGS (non-PGS group, n=87)). The PGS group was significantly older and had higher number of retrieved oocytes and prior miscarriages compared to non-PGS group. There were no differences in BMI and AMH level between those two groups. In PGS group, the mean number of transferable embryos (eukaryotic embryo) was 1.3 ± 0.7, 1.5 ± 0.5 and 1.4 ± 0.5, respectively (p = 0.049). In 42 cases, ET was cancelled because all embryos biopsied turned out to be abnormal. In all three groups (group 1, 2, and 3), clinical pregnancy rates were not statistically different between PGS and non-PGS group (Group 1: 48.8% vs. 52.2% (p=0.858), Group 2: 70% vs. 73.1% (p=0.730), Group 3: 42.3% vs. 46.7% (p=0.640), in PGS and non-PGS group, respectively). In both groups who had miscarriage with eukaryotic and aneuploidy abortus, the clinical pregnancy rate between IVF cycles with and without PGS was not different. When we compare miscarriage and ongoing pregnancy rate, there were no significant differences between PGS and non-PGS group in all three groups. Our results show that the routine application of PGS in women who had less than 3 miscarriages would not be beneficial, even in cases that previous miscarriage had been caused by fetal aneuploidy.

Keywords: preimplantation genetic diagnosis, miscarriage, kpryotyping, in vitro fertilization

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Authors: Mimoza Canga, Irene Malagnino, Vergjini Mulo, Alketa Qafmolla, Vito Antonio Malagnino

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Background: Dental caries is the most common dental disease and pregnancy represents a special process of physical, hormonal and metabolic changes in pregnant women, which is accompanied by an imbalance in the oral cavity. Objective: The objective of this study is to evaluate caries reduction after dental visits, the scaling of teeth, fluoridated water, brushing of the teeth and using fluoride toothpaste before and during pregnancy. Materials and methods: This study was conducted in the time period March 2018- September 2021, the age range of the participants was: 18-41 years old. The sample taken under observation was composed of 84 pregnant women. The questionnaire included the demographic characteristics of the sample, such as age, women's education level was primary, secondary, and higher education. Based on women's education level, our analysis found that 25.9% of pregnant women had completed primary education, 35.2% of them had secondary education and 38.9% of pregnant women had higher education. The descriptive and analytical research analysis is formulated as a longitudinal study. Statistical analysis was performed using IBM SPSS Statistics 23.0. The significance level (α) was set at 0.05, whereas P-value and analysis of variance (ANOVA) were used to analyze the data. Results: In the present study, it was observed that there is a strong relationship between dental visits and the scaling of the teeth with the value of P˂ .0001. While the number of teeth with caries before pregnancy and fluoridated water have a P-value=0.002. If we compare the same factor with the number of teeth with dental caries during pregnancy, the correlation is P-value = 0.0001. The number of teeth with caries before pregnancy and carbohydrates consumption has a strong relation with P-value=0.05. According to the present research, the number of teeth with dental caries before pregnancy in relation to brushing the teeth has a P-value ˂ 0.05. Furthermore, in the actual research, it was established that using fluoride toothpaste doesn’t affect the number of teeth with caries before pregnancy with a P-value= .314. Conclusion: According to the results of the present study performed in Albania, it was found out that the periodical dental visits, scaling of the teeth, fluoridated water, brushing of the teeth influenced caries reduction before and during pregnancy. In comparison, the usage of fluoride toothpaste did not have any effect on dental caries reduction in the same time period. The recommendations are as follows: maintaining oral hygiene, using fluoridated water and brushing the teeth regularly. Healthcare providers should inform pregnant women about the importance of oral health and the implementation of measures to manage dental caries.

Keywords: brushing of the teeth, dental visits, dental scaling, fluoridated water, pregnancy

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Authors: Adaobi Anakwe, Wilson Majee, Kari White, Rhonda BeLue

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Background: Black men in the U.S. have overall poorer health, are more likely to experience unintended pregnancies, and have pregnancies (with their partner) at younger ages than other racial/ethnic groups. These factors increase the likelihood that pregnancies among Black fathers will occur at suboptimal paternal health. Although several community-based programs exist to support low-income Black fathers’ involvement with their families, little is known about the sexual and reproductive health, and family planning needs of fathers enrolled in these programs. The objective of this study was to quantitatively examine the relationship between Black fathers’ fertility desires and pregnancy prevention strategies and qualitatively explore the nuances of this relationship. Methods: A concurrent mixed-methods approach was used to survey 36 and interview 13 Black fathers from low-income backgrounds, who were participating in a community-based fatherhood program in a Midwestern urban area. Fathers in this study were ≥18 years old with at least one child. Differences between groups were compared using Fisher’s Exact tests and thematic analyses to examine the relationship between participants' fertility desires and reproductive planning practices. Results: Participants had a median age of 33 years, and 72% were non-residential biological parents. About 40% of men desired pregnancy, and 69% reported they or their partner always used contraception. In bivariate analysis, participants’ fertility desires were not associated with pregnancy prevention (p=0.251). Although most interview participants desired pregnancies, several factors contributed to their ability to plan for a pregnancy. Men felt that using contraception to prevent pregnancies was dependent on navigating trust with a partner. Health before pregnancy and financial stability were also important. Overall, participants thought that using an adult mindset, in which they considered the consequences of unprotected sex, was key to family planning. Conclusion: Black fathers may not desire pregnancy and consider a variety of factors, but this does not always result in active pregnancy prevention/contraceptive use. Community-based organizations already working with Black fathers can be leveraged to increase reproductive health awareness and facilitate reproductive planning for fathers.

Keywords: reproductive planning, reproductive health, preconception health, Black fathers, fertility desires, pregnancy

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Authors: Zahra BehboodiI-Moghadam, Zohre Khalajinia, Ali Reza Nikbakht Nasrabadi, Minoo Mohraz

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The purpose of our study was to explore and describe the experiences of pregnant women with HIV in Iran. A qualitative exploratory study with conventional content analysis was used. Twelve pregnant women with HIV who referred to perinatal care at the Imam Khomeini Hospital Behavioral Diseases Consultation: Center in Tehran were recruited to participate in in-depth interviews. The average age of the participants was 32.5 years. Four main themes were extracted from the data: “fear and hope, “stigma and discrimination, “marital life stability” and “trust”. The findings reveal the pregnant women living with HIV are vulnerable and need professional support. Improving the knowledge of healthcare professionals especially midwifes on pregnancy complications for women with HIV is crucial in order to provide high-quality care to pregnant women with HIV-positive.

Keywords: HIV, pregnancy, content analysis, experiences, Iran, qualitative research

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Authors: Luisa Windhagen, Atsumi Hirose, Alex Bottle

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Global urbanization has resulted in the expansion of slums, leaving over 10 million Tanzanians in urban poverty and at risk of poor health. Whilst rural residence has historically been associated with an increased risk of adverse pregnancy outcomes, recent studies found higher perinatal mortality rates in urban Tanzania. This study aims to understand to what extent slum neighborhoods may account for the spatial disparities seen in Tanzania. We generated a slum indicator based on UN-HABITAT criteria to identify slum clusters within the 2015-2016 Tanzania Demographic and Health Survey. Descriptive statistics, disaggregated by urban slum, urban non-slum, and rural areas, were produced. Simple and multivariable logistic regression examined the association between cluster residence type and neonatal mortality and stillbirth. For neonatal mortality, we additionally built a multilevel logistic regression model, adjusting for confounding and clustering. The neonatal mortality ratio was highest in slums (38.3 deaths per 1000 live births); the stillbirth rate was three times higher in slums (32.4 deaths per 1000 births) than in urban non-slums. Neonatal death was more likely to occur in slums than in urban non-slums (aOR=2.15, 95% CI=1.02-4.56) and rural areas (aOR=1.78, 95% CI=1.15-2.77). Odds of stillbirth were over five times higher among rural than urban non-slum residents (aOR=5.25, 95% CI=1.31-20.96). The results suggest that slums contribute to the urban disadvantage in Tanzanian neonatal health. Higher neonatal mortality in slums may be attributable to lack of education, lower socioeconomic status, poor healthcare access, and environmental factors, including indoor and outdoor air pollution and unsanitary conditions from inadequate housing. However, further research is required to ascertain specific causalities as well as significant associations between residence type and other pregnancy outcomes. The high neonatal mortality, stillbirth, and slum formation rates in Tanzania signify that considerable change is necessary to achieve international goals for health and human settlements. Disparities in access to adequate housing, safe water and sanitation, high standard antenatal, intrapartum, and neonatal care, and maternal education need to urgently be addressed. This study highlights the spatial neonatal mortality shift from rural settings to urban informal settlements in Tanzania. Importantly, other low- and middle-income countries experiencing overwhelming urbanization and slum expansion may also be at risk of a reversing trend in residential neonatal health differences.

Keywords: urban health, slum residence, neonatal mortality, stillbirth, global urbanisation

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Authors: Yoseph Gela Ali

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Inadequate quality and quantity diet is one of the major reasons for high levels of malnutrition in pregnant women. Across-sectional survey was conducted in Shashemene District, Southern Oromia Region. A two-stage cluster sampling technique was used to select a representative sample of 15190 pregnant women aged 20-50 years from four rural villages Energy and nutrient intakes from foods were calculated from one-day weighed food records on a sub-sample (n = 83). The result of the study showed that the intakes of most nutrients were lower than the recommended intake. The energy intake of the study participants both in 2nd and 3rd trimesters of pregnancy were 2,308 kcal and 1,420.5 kcal compared to the recommended 2,340 kcal and 2,452 kcal, respectively. Except iron, almost all micronutrient intakes were lower than the recommended intake. Vitamin A intake was 3 µg compared with the recommended 800 µg, while protein intake of the study respondents in 2nd and 3rd trimester of pregnancy was 45.9 g and 31.5 g, respectively, compared with the recommended 71 g. Risk factors for under nutrition were multiple pregnancy and no consumption of cereal-based foods. This study revealed that the energy and nutrient intake of the pregnant women in the study area was below the recommended intakes. Furthermore, the situation might be aggravated by the high phytate content food consumption reported. Nutritional status of pregnant women in the study area was not adequate to support the increased energy and nutrient requirement of the participants.

Keywords: nutrition, pregnancy, protein, vitamin, energy

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Authors: Galila Aisyah Latif Amini, Husnul Khatimah, Citra Amelia

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Smoking among women is of particular concern for the maternal and child health community due to the strong association between prenatal smoking and adverse birth outcomes. Pregnancy is perceived to be a unique reason for smoking cessation, as motivation to care for the unborn fetus. This study aimed to find out the determinants of smoking cessation among pregnant women. Method that we use in this study is systematic review. We identified relevant studies by searching on science database online through SAGE journals, Proquest, Scopus, Emerald, JSTOR, and Springerlink. Journals were screened by title and abstract according to the research topic then filtered using the criteria exclusion and inclusion. And then we did critical appraisal. The results of the four studies reviewed were found that the determinant of smoking cessation are parity, the level of education, socioeconomic status, household SHS exposure, smoking habits of both parents, partner smoking status, psychological factors, antenatal care, intervention for health care provider, age smoking duration. The factor most strongly associated with smoking cessation is parity (OR 2,55; Cl 2,34-2,77). The results of this study are expected to give advice for developing future smoking cessation and relapse prevention programs.

Keywords: pregnancy, smoking cessation, tobacco use cessation, smoking

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Authors: Dieudonne Uwizeye, Reuben Muhayiteto

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Teenage pregnancy is a challenging problem for sustainable development due to restrictions it poses to socioeconomic opportunities for young mothers, their children and families. Being unable to take appropriate economic and social responsibilities, teen mothers get trapped into poverty and become economic burden to their family and country. Besides, teenage pregnancy is also a health problem because children born to very young mothers are vulnerable with greater risk of illnesses and deaths, and teenage mothers are more likely to be exposed to greater risk of maternal mortality and to other health and psychological problems. In Kigali city, in Rwanda, teenage pregnancy rate is currently high and its increase in recent years is worrisome. However, only individual factors influencing the teenage pregnancy tend to be the basis of interventions. It is important to understand the important socioeconomic factors at the household level that are associated with teenage pregnancy to help government, parents, and other stakeholders to appropriately address the problem with sustainable measures. This study analyzed secondary data from the Fifth Rwanda Demographic and Health Survey (RDHS-V 2014-2015) conducted by the National Institute of Statistics of Rwanda (NISR). The aim was to examine household socio-economic factors that are associated with incidence of teenage pregnancies in Kigali city. In addition to descriptive analysis, Pearson’s Chi Square and Binary Logistic Regression were used in the analysis. Findings indicate that marital status and age of household head, number of members in a household, number of rooms used for sleeping, educational level of the household head and household's wealth are significantly associated with teenage pregnancy in Rwanda ( p< 0.05). It was found that teenagers living with parents, those having parents with higher education and those from richer families are less likely to become pregnant. Age of household head was pinpointed as factor to teenage pregnancy, with teenage-headed households being more vulnerable. The findings also revealed that household composition correlates with the probability of teenage pregnancy (p < 0.05) with teenagers from households with less number of members being more vulnerable. Regarding the size of the house, the study suggested that the more rooms available in households, the less incidences of teenage pregnancy are likely to be observed (p < 0.05). However, teenage pregnancy was not significantly associated with physical violence among parents (p = 0.65) and sex of household heads (p = 0.52), except in teen-headed households of which female are predominantly heads. The study concludes that teenage pregnancy remains a serious social, economic and health problem in Rwanda. The study informs government officials, parents and other stakeholders to take interventions and preventive measures through community sex education, policies and strategies to foster effective parental guidance, care and control of young girls through meeting their necessary social and financial needs within households.

Keywords: household socio-economic factors, Rwanda, Rwanda demographic and health survey, teenage pregnancy

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Authors: Alessandro Marano

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Aim: The author describes a strategy for choosing between two different rhinoplasty approaches for outcomes treatment. Methods: Series of the case study. There are advantages and disadvantages on both approaches for rhinoplasty. On the side of the open approach, we are be able to better manage the techniques for shaping and restoring nasal structures in rhinoplasty outcomes; on the other side, the closed approach requires more practice and experience to achieve good results. Results: Author’s choice is the closed approach on rhinoplasty outcomes. Anyway, the open approach is most commonly preferred due to superior management and better vision on nasal structures. Conclusions: Both approaches are valid for the treatment of rhinoplasty outcomes, author's preferred approach is closed, with minimally invasive modification focused on restoring outcomes in nasal function and aesthetics.

Keywords: rhinoplasty, aesthetic, face, outcomes

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Authors: Jennifer Reese, Josh Biber, Howard Weeks, Rachel Hess

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Aim: The Edinburgh Postnatal Depression Screen (EPDS) is a mental health screening for pregnant women that has been widely used over the last 30 years. This screen is typically given in clinic on paper to patients throughout pregnancy and postpartum. The screen helps identify patients who may be at risk for pregnancy related depression or postpartum depression. In early 2016, University of Utah Health implemented an electronic version of the EPDS as well as the PROMIS Depression v1.0 instrument for all pregnant and postpartum patients. We asked patients both instruments to understand coverage of patients identified as at risk for each instrument. Methods: The EPDS is currently administered as part of our PRO template for pregnant and postpartum women. We also administer the PROMIS Depression as part of a standard PRO assessment to all patients. Patients are asked to complete an assessment no more often than every eight weeks. PRO assessments are either completed at home or in clinic with a tablet computer. Patients with a PROMIS score of ≥ 65 or a EPDS score of ≥ 10 were identified as at risk for depression Results: From April 2016 to April 2017, 1,330 unique patients were screened at University of Utah Health in OBGYN clinics with both the EPDS and PROMIS depression instrument on the same day. There were 28 (2.1%) patients were identified as at risk for depression using the PROMIS depression screen, while 262 (19.7%) patients were identified as at risk for postpartum depression using the EPDS screen. Overall, 27 (2%) patients were identified as at risk on both instruments. Conclusion: The EPDS identified a higher percent (19.7%) of patients at risk for depression when compared to the PROMIS depression (2.1%). Ninety-six percent of patients who screened positive on the PROMIS depression screen also screened positive on the EPDS screen. Mental health is an important component to a patient’s overall wellbeing. We want to ensure all patients, particularly pregnant or post-partum women, receive screening and treatment when necessary. A combination of screenings may be necessary to provide the overall best care for patients and to identify the highest percentage of patients at risk.

Keywords: patient reported outcomes, mental health, maternal, depression

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Authors: Alexa L. Walsh, Christine Hartl, Juliette Ferdschneider, Lezode Kipoliongo, Eleonora Feketeova

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The investigation of COVID-19 and its effects has been at the forefront of clinical research since its emergence in the United States in 2020. Although the possibility of severe infection in immunocompromised individuals has been documented, within the general population of pregnant individuals, there remains to be vaccine hesitancy and uncertainty regarding how the virus may affect the individual and fetus. To combat this hesitancy, this study aims to evaluate the effects of COVID-19 infection on maternal and neonatal complication rates. This retrospective study was conducted by manual chart review of women who were diagnosed with COVID-19 during pregnancy (n = 78) and women who were not diagnosed with COVID-19 during pregnancy (n = 1,124) that gave birth at Garnet Health Medical Centers between 1/1/2019-1/1/2021. Both the COVID+ and COVID- groups exhibited similar median ages, BMI, and parity. The rates of complications were compared between the groups and statistical significance was determined using Chi-squared analysis. Results demonstrated a statistically higher rate of PROM, polyhydramnios, oligohydramnios, GDM, DVT/PE, preterm birth, and the overall incidence of any birth complication in the population that was infected with COVID-19 during their pregnancy. With this information, obstetrical providers can be better prepared for the management of COVID-19+ pregnancies and continue to educate their patients on the benefits of vaccination.

Keywords: complications, COVID-19, Gynecology, Obstetrics

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Authors: Kim Toyer, Belinda Thompson, Louise Koelmeyer

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Lymphoedema is a chronic condition caused by dysfunction of the lymphatic system, which limits the drainage of fluid and tissue waste from the interstitial space of the affected body part. The normal physiological changes in pregnancy cause an increased load on a normal lymphatic system which can result in a transient lymphatic overload (oedema). The interaction between lymphoedema and pregnancy oedema is unclear. Women with pre-existing lymphoedema require accurate information and additional strategies to manage their lymphoedema during pregnancy. Currently, no resources are available to guide women or their healthcare providers with accurate advice and additional management strategies for coping with lymphoedema during pregnancy until they have recovered postnatally. This study explored the experiences of Australian women with pre-existing lymphoedema during recent pregnancy and the early postnatal period to determine how their usual lymphoedema management strategies were adapted and what were their additional or unmet needs. Interactions with their obstetric care providers, the hospital maternity services, and usual lymphoedema therapy services were detailed. Participants were sourced from several Australian lymphoedema community groups, including therapist networks. Opportunistic sampling is appropriate to explore this topic in a small target population as lymphoedema in women of childbearing age is uncommon, with prevalence data unavailable. Inclusion criteria were aged over 18 years, diagnosed with primary or secondary lymphoedema of the arm or leg, pregnant within the preceding ten years (since 2012), and had their pregnancy and postnatal care in Australia. Exclusion criteria were a diagnosis of lipedema and if unable to read or understand a reasonable level of English. A mixed-method qualitative design was used in two phases. This involved an online survey (REDCap platform) of the participants followed by online semi-structured interviews or focus groups to provide the transcript data for inductive thematic analysis to gain an in-depth understanding of issues raised. Women with well-managed pre-existing lymphoedema coped well with the additional oedema load of pregnancy; however, those with limited access to quality conservative care prior to pregnancy were found to be significantly impacted by pregnancy, including many reporting deterioration of their chronic lymphoedema. Misinformation and a lack of support increased fear and apprehension in planning and enjoying their pregnancy experience. Collaboration between maternity and lymphoedema therapy services did not happen despite study participants suggesting it. Helpful resources and unmet needs were identified in the recent Australian context to inform further research and the development of resources to assist women with lymphoedema who are considering or are pregnant and their supporters, including health care providers.

Keywords: lymphoedema, management strategies, pregnancy, qualitative

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Authors: Genevieve R. Kan, Jolyon Ford

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Background: Caesarean section has become the routine route of delivery for breech fetuses, but breech cesarean deliveries are hypothesized to have poorer immediate neonatal outcomes when compared to cephalic deliveries. In accordance with this, in many Australian hospitals, the pediatric team is routinely required to attend every elective breech cesarean section in case urgent resuscitation is required. Our study aimed to determine whether term elective breech deliveries indeed had worse immediate neonatal outcomes at delivery, which will justify the necessity of pediatric staff presence at every elective breech cesarean delivery and influence the workload for the pediatric team. Objective: Elective breech cesarean deliveries were compared to elective cephalic cesarean deliveries at 37 weeks gestation or above to evaluate the immediate neonatal outcomes (Apgar scores <7 at 5 minutes, and Special Care Nursery admissions on Day 1 of life) of each group. Design: A retrospective cohort study Method: This study examined 2035 elective breech and cephalic singleton cesarean deliveries at term over 5 years from July 2017 to July 2022 at Frankston Hospital, a metropolitan hospital in Melbourne, Australia. There were 260 breech deliveries and 1775 cephalic deliveries. De-identified patient data were collected retrospectively from the hospital’s electronically integrated pregnancy and birth records to assess demographics and neonatal outcomes. Results: Apgar scores <7 at 5 minutes of life were worse in the breech group compared to the cephalic group (3.4% vs 1.6%). Special Care Nursery admissions on Day 1 of life were also higher for the breech cohort compared to the cephalic cohort (9.6% vs 8.7%). Conclusions: Our results support the expected findings that breech deliveries are associated with worse immediate neonatal outcomes. It, therefore, suggests that routine attendance at elective breech cesarean deliveries by the pediatric team is indeed required to assist with potentially higher needs for neonatal resuscitation and special care nursery admission.

Keywords: breech, cesarean section, Apgar scores, special care nursery admission

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Authors: M. Yahia, N. Chaoui, A. Chaouch, Massinissa Yahia

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Our study was designed to determine the metabolic changes of some biochemical parameters (cholesterol, triglyceride, Iron, uric acid, Urea and folic acid) and highlight their changes in 57 women of the region Batna, during the first trimester of pregnancy. This practical work was done with 27 women with missed miscarriage, compared with 30 control subjects of normal pregnant women. The assay results revealed a highly significant difference (P = 0.0006) between the two groups in serum iron (64.00 vs 93.54) and in the rate of folate (6.70 vs 9.22) (P <0.001) but no difference was found regarding the rate of Ca (9.69 vs 10.20), urea (0.19 vs 0.17), UA (33.96 vs 32.76), CH (1.283 vs 1.431), and TG (0.8852 vs 0.8290). The present study indicates that iron deficiency and folate are associated with missed miscarriage, but no direct pathophysiological link has been determined. Further in-depth studies are needed to determine the exact mechanism by which these deficits lead to a missed miscarriage.

Keywords: biochemical parameters, pregnant women, missed miscarriage, Algeria

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Authors: Raj Raghupathy

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Recurrent Spontaneous Miscarriage (RSM) is a common form of pregnancy loss, 50% of which are due to ‘unexplained’ causes. Evidence exists to suggest that RSM may be caused by immunologic factors such as cytokines which are critical molecules of the immune system, with an impressive array of capabilities. An association appears to exist between Th2-type reactivity (mediated by Th2 or anti-inflammatory cytokines) and normal, successful pregnancy, and between unexplained RSM and Th1 cytokine dominance. If pro-inflammatory cytokines are indeed associated with pregnancy loss, the suppression of these cytokines, and thus the ‘redirection’ of maternal reactivity, may help prevent cytokine-mediated pregnancy loss. The objective of this study was to explore the possibility of modulating cytokine production using Dydrogesterone (Duphaston®), an orally-administered progestogen. Peripheral blood mononuclear cells from 34 women with a history of at least 3 unexplained recurrent miscarriages were stimulated in vitro with a mitogen (to elicit cytokine production) in the presence and absence of dydrogesterone. Levels of selected pro- and anti-inflammatory cytokines produced by peripheral blood mononuclear cells were measured after exposure to these progestogens. Dydrogesterone down-regulates the production of pro-inflammatory cytokines and up-regulates the production of anti-inflammatory cytokines. The ratios of Th2 to Th1 cytokines are markedly elevated in the presence of dydrogesterone, indicating a shift from potentially harmful maternal Th1 reactivity to a more pregnancy-conducive Th2 profile. We used a progesterone receptor antagonist to show that this cytokine-modulating effect of dydrogesterone is mediated via the progesterone receptor. Dydrogesterone also induces the production of the Progesterone-Induced Blocking Factor (PIBF); lymphocytes exposed to PIBF produce higher levels of Th2 cytokines, affecting a Th1 → Th2 cytokine shift which could be favourable to the success of pregnancy. We conclude that modulation of maternal cytokine production profiles is possible with dydrogesterone which has the merits that it can be administered orally and that it is safe.

Keywords: cytokines, dydrogesterone, progesterone, recurrent spontaneous miscarriage

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Authors: R. Komsa-Penkova, G. Golemanov, G. Georgieva, K. Popovski, N. Slavov, P. Ivanov, K. Kovacheva, S. Rathee, E. Konova, A. Blajev

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Leptin and PAI-1 are important cytokines and may play a role in the regulation of PCOS development. PCOS is frequently associated with obesity, high BMI index and consequently with increased risk of metabolic disorders. The aim of the present study was to evaluate PAI-1 levels, genetic influence of the carriage of 675 4G/5G polymorphism in PAI-1 gene and leptin as a marker of obesity in the development of PCOS. Methods: Genotyping in 84 patients with PCOS and PCO and 100 healthy control subjects to detect single nucleotide deletion 675 G in the promoter of PAI-1 gene. The present study provides evidence that SNP 4G in the PAI-1 gene is associated with early pregnancy losses in patients with polycystosis. Further to this, there is a correlation between leptin levels, PAI-1 levels and BMI in the patients with PCOS, which confirms the role of obesity as a risk factor for PCOS.

Keywords: carriage of 675 4G/5G polymorphism, PCOS, early pregnancy losses, PAI-1 gene

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Authors: Retno Supriyanti, Ahmad Chuzaeri, Yogi Ramadhani, A. Haris Budi Widodo

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The use of ultrasonography in the medical world has been very popular including the diagnosis of pregnancy. In determining pregnancy, ultrasonography has many roles, such as to check the position of the fetus, abnormal pregnancy, fetal age and others. Unfortunately, all these things still need to analyze the role of the obstetrician in the sense of image raised by ultrasonography. One of the most striking is the determination of gestational age. Usually, it is done by measuring the length of the fetus manually by obstetricians. In this study, we developed a computer-aided diagnosis for the determination of gestational age by measuring the length of the fetus automatically using edge detection method and image morphology. Results showed that the system is sufficiently accurate in determining the gestational age based image processing.

Keywords: computer aided diagnosis, gestational age, and diameter of uterus, length of fetus, edge detection method, morphology image

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Authors: Ronelle Prinsloo

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Teenage pregnancy in South African schools is a growing concern. In South Africa, many young female learners end their schooling permanently, not because they have completed their studies, but due to pregnancy. The admission policy of public schools is determined by the governing body of such a school, and this policy can determine that a pregnant leaner may not attend school during pregnancy and for a certain period after the birth of the child. This can be seen as an infringement of the rights of the teenage mother to be allowed to attend school. It can also be argued that this conflicts with the best interest of the child as well as the rights of the governing body to determine policy in accordance with the mandate as given to them by the parents and community served by the school. A pregnant learner can argue that the admission policy of a school is discriminatory if it does not allow the pregnant learner to continue her schooling. She may also argue that she is being unfairly discriminated against based on gender because in many instances, the baby’s father is still allowed to go to school. The Constitution (Constitution of the Republic of South Africa, Act 108 of 1996), provides in section 9, that everyone is equal before the law; it goes on to provide that equality includes the full and equal enjoyment of all rights and freedoms and provides those grounds on which one may not be discriminated against including, gender, sex, and pregnancy. Schools should be encouraged to re-enroll students if they have a support system available to assist with the necessary childcare when they attend school. To dramatically increase the number of young people enrolled in alternative pathways such as Further Education and Training or Adult Basic Education and Training must be provided. In addition, alternative systems must offer viable exit opportunities for participants by cohering with further education and economic opportunities.

Keywords: admission policy, Constitution of South Africa, human rights, teenage pregnancy

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Authors: Samira Akdader-Oudahmane, Assia Kamel, Lynda Lakabi, Michael Bruce Zimmermann, Zohra Hamouli-Said, Djamila Meskine

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Background: Iodine is a trace element whose adequate intakes are essential during pregnancy to promote the correct growth and development of the fetus. Iodine deficiency is the cause of several disorders in foetal development, and thyroid disorders during pregnancy are associated with an increased risk of miscarriage or premature birth. The aim of this study was to assess the iodine status and thyroid function of pregnant women (PW) in northern Algeria. Methods: Healthy PW were recruited from an urban area (Algiers). Spot urine and venous blood samples were collected to assess iodine status (urinary iodine concentration, UIC) and serum thyroid hormones (TSH, FT4), and anti-thyroid peroxidase antibodies (TPO-Ab) concentrations. Results: The median UIC for the PW (n=172) in Algiers was 246,74µg/L, 244,68 µg/L, and 220,63µg/L, respectively, during the first, second, and third trimesters of pregnancy. Mean TSH and FT4 concentrations were within reference ranges in all groups of women. Among PW, 72.7%, 75.4%, and 75.5% in the first, second and third trimester were TPO-Ab+. Among PW, 14%, 10%, and 10% in the first, second and third trimester, respectively, with TPO -Ab+ had subclinical hypothyroidism. An analysis of the variations in the levels of the serum parameters (FT4, TSH and anti-TPO antibodies) was analyzed according to the UIC intervals admitted and show that these marker are predictive of thyroid function. Conclusion: In northern Algeria, median UICs indicate iodine sufficiency in PW. About 75% of PW are TPO-Ab+ and the prevalence of subclinical hypothyroidism is high.

Keywords: thyroid, pregnant woman, urinary iodine, subclinical hypothyroidism

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Authors: Nautiyal Ruchira, Nautiyal Hemant, Chaudhury Devnanda, Bhargava Surbhi, Chauhan Nidhi

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Introduction: South East Asian region contributes 2.5 million cases of malaria each year to the global burden of 300 to 500 million of which 76% is reported from India. Government of India launched a national program almost half a century ago, still malaria remains a major public health challenge. Pregnant women are more susceptible to severe malaria and its fetomaternal complications. Inadequate surveillance and under-reporting underestimates the problem. Aim: Present study aimed to analyze the clinical course and pattern of malaria during pregnancy and to study the feto-maternal outcome. Methodology: This is a prospective observational study carried out at Himalayan Institute of Medical Sciences – a tertiary care center in the sub-Himalayan state of Uttarakhand, Northern India. All the pregnant women with malaria and its complications were recruited in the study during 2009 to 2014 which included referred cases from the state of western Uttar Pradesh. A thorough history and clinical examination were carried out to assess maternal and fetal condition. Relevant investigations including haemogram, platelet count, LFT, RFT, and USG was done. Blood slides and rapid diagnostic tests were done to diagnose the type of malaria.The primary outcomes measured were the type of malaria infection, maternal complications associated with malaria, outcome of pregnancy and effect on the fetus. Results: 67 antenatal cases with malaria infection were studied. 71% patients were diagnosed with plasmodium vivax infection, 25% cases were plasmodium falciparum positive and in 3% cases mixed infection was found. 38(56%) patients were primigravida and 29(43%) were multiparous. Most of the patients had already received some treatment from their local doctors and presented with severe malaria with the complications. Thrombocytopenia was the commonest manifestation seen in 35(52%) patients, jaundice in 28%, severe anemia in 18%, and severe oligohydramnios in 10% and renal failure in 6% cases. Regarding pregnancy outcome there were 44 % preterm deliveries, 22% had IUFD and abortions in 6% cases.20% of newborn were low birth weight and 6% were IUGR. There was only one maternal death which occurred due to ARDS in falciparum malaria. Although Plasmodium vivax was the main parasite considering the severity of clinical presentation, all the patients received intensive care. As most of the patients had received chloroquine therapy hence they were treated with IV artesunate followed by oral artemesinin combination therapy. Other therapies in the form of packed RBC’s and platelet transfusions, dialysis and ventilator support were provided when required. Conclusion: Even in areas with annual parasite index (API) less than 2 like ours, malaria in pregnancy could be an alarming problem. Vivax malaria cannot be considered benign in pregnancy because of high incidence of morbidity. Prompt diagnosis and aggressive treatment can reduce morbidity and mortality significantly. Increased community level research, integrating ANC checkups with the distribution of insecticide-treated nets in areas of high endemicity, imparting education and awareness will strengthen the existing control strategies.

Keywords: severe malaria, pregnancy, plasmodium vivax, plasmodium falciparum

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Authors: Alejandra Cardenas, Ona Flores, Fabiola Gretzinger

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Since the 1990s, legal strategies for the promotion and protection of maternal health rights have achieved significant gains. Successful litigation in courts around the world have shown that these rights can be judicially enforceable. Governments and international organizations have acknowledged the importance of a human rights-based approach to maternal mortality and morbidity, and obstetric violence has been recognized as a human rights issue. Despite the progress made, maternal mortality has worsened in some regions of the world, while progress has stagnated elsewhere, and mistreatment in maternal care is reported almost universally. In this context, issues of maternal autonomy and decision-making during pregnancy, labor, and delivery as a critical barrier to access quality maternal health have been largely overlooked. Indeed, despite the principles of autonomy and informed consent in medical interventions being well-established in international and regional norms, how they are applied particularly during childbirth and pregnancy remains underdeveloped. National and global legal standards and decisions related to maternal health were reviewed and analyzed to determine how maternal autonomy and decision-making during pregnancy, labor, and delivery have been protected (or not) by international and national courts. The results of this legal research and analysis lead to the conclusion that a few standards have been set by courts regarding pregnant people’s rights to make choices during pregnancy and birth; however, most undermine the agency of pregnant people. These decisions recognize obstetric violence and gender-based discrimination, but fail to protect pregnant people’s autonomy, privacy, and their right to informed consent. As current human rights standards stand today, maternal health is the only field in medicine and law in which informed consent can be overridden, and patients can be forced to submit to treatments against their will. Unconsented treatment and loss of agency during pregnancy and childbirth can have long-term physical and mental impacts, reduce satisfaction and trust in health systems, and may deter future health-seeking behaviors. This research proposes a path forward that focuses on the pregnant person as an independent agent, relying on the doctrine of self-determination during pregnancy and childbirth, which includes access to the necessary conditions to enable autonomy and choice throughout pregnancy and childbirth as a critical step towards our approaches to reduce maternal mortality, morbidity, and mistreatment, and realize the promise of access to quality maternal health as a human right.

Keywords: autonomy in childbirth and pregnancy, choice, informed consent, jurisprudential analysis

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Authors: Thao Nguyen, Maximiliano Hyon, Sany Rajagukguk, Anna Melkonyan

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Introduction: Type 2 Diabetes is a well-established risk factor for severe SARS-CoV-2 infection. Uncontrolled hyperglycemia in patients with established or newly diagnosed diabetes is associated with poor outcomes, including increased mortality and hospital length of stay. Objectives: Our study aims to compare three different glycemic management strategies and their association with clinical outcomes in patients hospitalized for moderate to severe SARS-CoV-2 infection. Identifying optimal glycemic management strategies will improve the quality of patient care and improve their outcomes. Method: This is a retrospective observational study on patients hospitalized at Adventist Health White Memorial with severe SARS-CoV-2 infection from 11/1/2020 to 02/28/2021. The following inclusion criteria were used: positive SARS-CoV-2 PCR test, age >18 yrs old, diabetes or random glucose >200 mg/dL on admission, oxygen requirement >4L/min, and treatment with glucocorticoids. Our exclusion criteria included: ICU admission within 24 hours, discharge within five days, death within five days, and pregnancy. The patients were divided into three glycemic management groups: Group 1, managed solely by the Primary Team, Group 2, by Pharmacy; and Group 3, by Endocrinologist. Primary outcomes were average glucose on Day 5, change in glucose between Days 3 and 5, and average insulin dose on Day 5 among groups. Secondary outcomes would be upgraded to ICU, inpatient mortality, and hospital length of stay. For statistics, we used IBM® SPSS, version 28, 2022. Results: Most studied patients were Hispanic, older than 60, and obese (BMI >30). It was the first CV-19 surge with the Delta variant in an unvaccinated population. Mortality was markedly high (> 40%) with longer LOS (> 13 days) and a high ICU transfer rate (18%). Most patients had markedly elevated inflammatory markers (CRP, Ferritin, and D-Dimer). These, in combination with glucocorticoids, resulted in severe hyperglycemia that was difficult to control. Average glucose on Day 5 was not significantly different between groups primary vs. pharmacy vs. endocrine (220.5 ± 63.4 vs. 240.9 ± 71.1 vs. 208.6 ± 61.7 ; P = 0.105). Change in glucose from days 3 to 5 was not significantly different between groups but trended towards favoring the endocrinologist group (-26.6±73.6 vs. 3.8±69.5 vs. -32.2±84.1; P= 0.052). TDD insulin was not significantly different between groups but trended towards higher TDD for the endocrinologist group (34.6 ± 26.1 vs. 35.2 ± 26.4 vs. 50.5 ± 50.9; P=0.054). The endocrinologist group used significantly more preprandial insulin compared to other groups (91.7% vs. 39.1% vs. 65.9% ; P < 0.001). The pharmacy used more basal insulin than other groups (95.1% vs. 79.5% vs. 79.2; P = 0.047). There were no differences among groups in the clinical outcomes: LOS, ICU upgrade, or mortality. Multivariate regression analysis controlled for age, sex, BMI, HbA1c level, renal function, liver function, CRP, d-dimer, and ferritin showed no difference in outcomes among groups. Conclusion: Given high-risk factors in our population, despite efforts from the glycemic management teams, it’s unsurprising no differences in clinical outcomes in mortality and length of stay.

Keywords: glycemic management, strategies, hospitalized, SARS-CoV-2, outcomes

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