Placenta accreta spectrum and placenta praevia are a significant cause of obstetric haemorrhage, maternal morbidity and mortality worldwide. We report a novel surgical technique, which pre-emptively and prophylactically reduces intrapartum bleeding during caesarean sections for these conditions and hence reducing the risk for a caesarean hysterectomy. This technique is particularly useful in low resource healthcare settings where interventional radiology is not readily available and where the woman is keen on uterine preservation. In this report we present the surgical and clinical outcomes of a case series of 16 patients on whom this technique was piloted demonstrating its feasibility and safety.

BJOG-20-0640.R1 The evolving definition of pre-eclampsia

Objective: To demonstrate that a double balloon catheter combined with oxytocin decreases time between induction of labour and delivery (TID) as compared to a vaginal dinoprostone insert in cases of PROM at term. Design: Prospective, randomized, controlled trial. Setting: French university hospital Population: Patients undergoing labour induction for PROM at term with unfavorable cervix. Methods: We compared the double balloon catheter over a period of 12 hours with adjunction of oxytocin 6 hours after catheter insertion, versus dinoprostone vaginal insert. After device ablation, cervical ripening continued only with oxytocin. Main outcome measures: The primary outcome was TID. Secondary outcomes concerned delivery mode, maternal and fetal outcome and were adjusted for parity. Results: 40 patients per group were randomized. Each group had similar baseline characteristics. The study failed to demonstrate reduced TID (16.2 vs 20.2 hours, ES = 0.16 (-0.27 to 0.60), p=0.12) in catheter group versus dinoprostone except in nulliparous women (17.0 vs 26.5 hours, ES = 0.62 (0.10 to 1.14), p=0.006). The rate of vaginal delivery <24h significantly increased with combined induction (88.5% vs 66.6%, p=0.03). No statistical difference was observed concerning caesarean rate (12.5% vs 17.5%, p>0.05), chorioamnionitis (0% vs 2.5%, p=1), postpartum endometritis, maternal or neonatal outcomes. Procedure-related pain and tolerance to devices were found to be similar for the two methods. Conclusion: The double balloon catheter combined with oxytocin is an alternative for cervical ripening in case of PROM at term, and may reduce TID in nulliparous women.

Objective: To investigate the effect of delayed umbilical cord clamping on neonatal outcomes following caesarean delivery under general anaesthesia. Design: Prospective cohort study. Setting: West China Second University Hospital Sample: Neonates born by caesarean delivery under general anaesthesia after 35 gestational weeks. Methods: Neonates were assigned to Groups A or B if they received early or delayed cord clamping, respectively. Main Outcome Measures: Umbilical arterial blood gas analysis indicators, Apgar scores, resuscitation procedure incidence, peak bilirubin, and neonatal morbidity were compared between the two groups. Results: Group A had 29 and Group B had 21 participants. There were no significant differences in any of the outcome measures between the two groups. We classified five periods during caesarean delivery: aesthetic induction (Period 1), skin incision (Period 2), myometrium incision (Period 3), delivery of the neonate (Period 4), and time of cord clamping (Period 5). One-minute Apgar scores were negatively correlated with cord-clamping time (r=-0.426, P=0.002). Peak bilirubin value was correlated with Periods 2, 3, and 5 (r=0.347, P=0.014; r=0.411, P=0.003; r=-0.289, P=0.042, respectively). The remaining secondary outcomes were not correlated with any of the five periods. The peak bilirubin value was(9.712+0.006 × Period 2+0.006 × Period 3-0.026 × Period 5) (R2=0.313). . Conclusions: In caesarean delivery under general anaesthesia, delayed cord clamping within a certain period may partially prolong the duration of neonatal exposure to general anaesthesia drugs. However, delayed cord clamping is a safe and feasible technique for clinical application.

Aim: To develop clinical algorithms for the assessment and management of slow progress of labour. Population: Low-risk singleton, term, pregnant women in labour. Setting: Institutional births in low- and middle-income countries. Search Strategy: We systematically reviewed the literature on normal labour progression, and guidance on clinical management of abnormally slow progression from 1 December 2015 to 1 December 2020. Case scenarios: We developed two clinical algorithms: one for abnormally slow labour progression and arrest during first and one for second stage. Conclusions: Identifying abnormal progress of labour is often challenging. These algorithms may help to reduce misdiagnosis.

Background: There is variation in the reported incidence of levator avulsion (LA). Objective: Explore incidence of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. Search strategy: We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. Study eligibility criteria: A study was included if LA was assessed by an imaging modality after the first vaginal birth or if only delivered by caesarean section. Case series and reports were not included. Data collection and analysis: RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages for type and timing of imaging analyses. . Results: We included 37 primary non-randomized studies from 17 countries and involving 5594 women. Incidence of LA was 1%, 15%, 21%, 38.5% and 52% following caesarean, spontaneous, vacuum, spatula and forceps births respectively, with no differences by imaging modality. OR of LA following spontaneous birth vs. caesarean was 10.69. While the OR for LA following vacuum and forceps compared to the spontaneous birth were 1.66 and 6.32 respectively. LA was more likely to occur on the right side following spontaneous birth (p = 0.02) and unilaterally vs. bilaterally following spontaneous (P < .0001) and vacuum-assisted births (P = 0.0103) only. Incidence was higher if assessment was performed in the first 4 weeks postpartum. Conclusions: Forceps significantly increases incidence and severity of LA. Ultrasound and MRI are comparable diagnostic tools but early postpartum imaging may lead to over diagnosis of LA.

Objective To evaluate factors affecting cesarean section (CS) rates in groups 1, 2A, 3, 4A, 5 and 10 of the “Ten Group Classification System” (TGCS). Design Retrospective analysis of deliveries occurred from January 1996 to December 2019. Setting A single hospital in Milan. Population Pregnant women belonging to groups 1, 2A, 3, 4A, 5 and 10 of the TGCS. Methods A binary logistic regression analysis was conducted. Included independent variables were maternal age, neonatal birthweight, immigrant status, use of obstetric analgesia, presence of diabetes, hypertension and obesity. Main outcome measures The effect of independent variables on CS rate was expressed as odds ratio. Results A total of 30591 deliveries were recorded. Advanced maternal age was an independent risk factor (RF) in groups 1, 2A, 3, and 4A; diabetes was a risk factor in groups 1 and 5; obesity was a RF in groups 1 and 2A and a protective one in group 5; hypertension was a RF in groups 2A, 5 and 10; macrosomia was a RF in groups 1, 2A and 3; use of obstetric analgesia was either a RF in group 1, and a protective factor in groups 2A, 5 and 10; immigrant status was either a protective factor in groups 1 and 10, and a RF in group 4A. Conclusion The TGCS is a well-established method to compare CS rates between institutions; however, inside each group, many factors can influence the CS rate and they have to be taken into consideration when comparing CS rates.

Coronavirus disease 2019 (COVID-19) has a microembolic pathogenesis. We reviewed the incidence of microembolic complications of pregnancy during the COVID-19 pandemic period compared to the pre-pandemic period, specifically in-utero death (IUD) and placental abruption. Design A retrospective case review. Setting Patients were identified from the Datix reporting system and anonymised data was collected from the electronic health records. Population or Sample Women suffering an IUD or placental abruption during the review periods. Methods A retrospective review of the frequency and clinical characteristics of cases of IUD and placental abruption between 1st Jan 2020 – 30th June 2020 was compared to those from the 1st Jan 2019 – 30th June 2019. Main Outcome Measures To evaluate the frequency and clinical characteristics of women suffering IUD and placental abruption during the pandemic period in 2020, and compare them to the pre pandemic period in 2019. Results There was a increase in the rates of IUD from 2019 to 2020, 1.22/1000 births compared to 2.85/1000 births (p= 0.10). There was no difference in the rates of placental abruption (p= 0.03). Conclusions Our review has demonstrated a non-significant rise in the frequency of IUD in the pandemic period in 2020 compared to those in 2019. Additionally, there was a significantly lower lymphocyte count during the pandemic period- a marker known to be associated with COVID-19. This warrants further investigation to explore the link between COVID-19 and disorders of poor placental perfusion, particularly the rates of IUD.

This study includes 11 cases of PPH seen during Caesarean section by a single surgeon Dr. Sadhna Mathur during the last 7years where this hemostatic suture was used to control PPH from placental site in uterine cavity after the medical measures failed to control the bleeding from placental site(uterine cavity). The bleeding point was localized and a haemostatic suture in the overlying uterine musculature was applied. It was found to be completely effective hence it is being shared through this paper.

Objective: To study the relation between platelet parameters and severe postpartum haemorrhage (SPPH). Design: Retrospective cohort study. Setting: Birth centre of the University Medical Centre Utrecht. Population: 23,205 deliveries between 2009 and 2017. Methods: The predictors platelet count, mean platelet volume (MPV), plateletcrit, platelet distribution width (PDW), and immature platelet fraction (IPF) were measured within 72 hours prior to delivery. Multiple imputation was performed for missing data. Odds ratios were adjusted (aOR’s) for maternal age, multiple gestation, macrosomia, induction of labour, and preeclampsia. Main outcome measures: Severe postpartum haemorrhage (≥1,000mL of blood loss within 24 hours after delivery) Results: Of the 2,402 (10.4%) women with thrombocytopenia (<150*109/L), 10.3% developed SPPH, compared to 7.6% of women with a normal platelet count (aOR: 1.34, 95%-CI: 1.14–1.57). Women with a platelet count of <50*109/L were most at risk (aOR of 2.19 (1.01-4.72)) compared to the reference group with normal platelet counts; the aOR was 1.20 (0.77-1.87) for the 50-99*109/L platelet count group, and 1.30 (1.09-1.55) for the 100-149*109/L platelet count group. Plateletcrit was associated with SPPH (aOR 1.15 (1.08-1.21) per 0.05% decrease), and, although rarely present, a PDW ≥23% (n=22) also increased the odds of SPPH (aOR 6.13 (2.29-16.4)). Conclusions: Low platelet count, low plateletcrit, and a PDW ≥23% were associated with the occurrence of SPPH, independent of common PPH risk factors.

Objectives To estimate the prevalence of latent iron deficiency (LID) among pregnant women, assess LID in relation to parity, age, education, and household income, and to determine correlations between LID and red cell indices, red cell distribution width (RDW), and red cell morphology. Design Cross-sectional design Setting North Colombo Teaching Hospital, Sri Lanka. Sample Participants comprised 355 pregnant women with normal haemoglobin levels seeking antenatal care within < 20 weeks of gestation. Method Data were obtained from interviews and antenatal records. Participant full blood count (FBC), serum ferritin levels, and blood films were analysed. Main Outcome Measures Prevalence of LID, demographic data (age, parity, period of gestation, gap between pregnancies, income, and education), and blood film morphology. Results LID prevalence was 54%. Statistical significance for the gap between pregnancies being < 2 years was observed but not for participant’s age, parity, income, and education. Blood film morphology depicted statistically significant presence of hypochromic microcytic red cells and pencil cells. RDW was significant in indicating the presence of LID. Among those with LID, 25% had ferritin level in the iron deficiency range. Conclusions LID is highly prevalent in early pregnancy and 25% of participants had ferritin levels in the iron deficiency range. Presence of raised RDW, hypochromic microcytic red cells, pencil cells, and <2 years’ gap between pregnancies were indicators of LID. To identify pregnant women with LID, blood film, haemoglobin, and RDW could be recommended as basic tests, and ferritin test as an affirmative one.

Mini-commentary on BJOG-20-1459.R1: Caesarean birth and risk of subsequent preterm birth: retrospective cohort studyDeclarative title to be addedBradley de VriesSchool of Public HealthUniversity of SydneySydneyNew South WalesAustraliaWorldwide, preterm birth occurs in 11% of pregnancies and is the leading cause of childhood mortality. Complications from preterm birth are the most common cause of neonatal death in the United Kingdom, yet the incidence of preterm birth is not falling.In this issue of BJOG, Williams et al (BJOG xxxx) report on an observational study which identifies previous second stage caesarean birth as a risk factor for spontaneous preterm birth, confirming the results of other observational cohorts. Among women with one previous term birth, the adjusted odds ratio was 2.1 (95% confidence interval [CI] 1.3 to 3.1) for preterm birth before 37 weeks gestational age and 7.5 (95% CI 3.4 to 15) for preterm birth before 34 weeks, for previous second stage caesarean birth compared with previous vaginal birth. They adjusted for confounders not addressed in other studies including interpregnancy interval and maternal deprivation index, strengthening the existing evidence. The association is plausible because the cervix and lower uterine segment are anatomically merged in the second stage of labour and inadvertent cervical incision might damage the integrity of the cervix. The association was at least as strong as that described for previous excisional surgery for cervical dysplasia. Current National Institute of Clinical Excellence Guidelines recommend considering prophylactic cervical cerclage for an ultrasound-measured cervical length < 25mm if there is a history of cervical trauma. Given the plausibility and emerging epidemiological evidence, it would seem prudent to offer the same screening and treatment when there is a history of second stage caesarean birth.The observed association is relevant in other ways. Counselling about instrumental versus caesarean birth may be influenced by knowledge of future risks. Additionally, surgeons may need to be aware of the potential importance of avoiding inadvertent cervical incision, while still avoiding upper segment incision and its attendant risk of future intrapartum uterine rupture.The study by Williams et al is well designed, yet there remains potential for confounding not adjusted for in the analysis. Further, missing data for body mass index (1.6%) and cigarette smoking (13%) were classified as unknown and not imputed which can also cause bias. As there are only a handful of observational studies, it would be sensible to confirm the association, and explore potential causative mechanisms (e.g., by monitoring cervical length in subsequent pregnancies).Clinical prediction models for spontaneous preterm labour in asymptomatic women have been developed but need improvement before incorporation into clinical practice. Addition of new risk factors such as second stage caesarean birth and better understanding of the causes of preterm birth could improve these models and ultimately improve outcomes through offering prophylaxis with cervical cerclage, vaginal progesterone, or pessary for women at high risk.Given the massive personal, clinical, and economic burden imposed by preterm birth, the plausibility of the association, and the growing evidence from observational studies, I believe cervical surveillance warranted, with a view to offering prophylactic measures when there is a history of second stage caesarean birth.No disclosures: A completed disclosure of interest form is available to view online as supporting information.

Objective: To study the occurrence of major congenital abnormalities in offspring of women with type 1 and type 2 diabetes and investigate the association between glycated haemoglobin (HbA1c) and major congenital malformations. Design: Register-based study Population: All singletons born alive from January 1, 2000–December 31, 2015 in the North Denmark and Central Denmark regions of Denmark and their mothers. Methods: We used data from Danish health registers and the LABKA database. Logistic regression models were used to compute crude and adjusted prevalence odds ratios (cORs and aORs) with 95% confidence intervals (CIs) for major congenital malformations overall and for subtypes, by type of maternal pre-existing diabetes and HbA1c levels. Main Outcome Measures: Major congenital malformations (overall and specific subtypes). Results: Among 314,245 infants included, 2,020 (0.64%) had mothers with type 1 diabetes and 498 (0.16%) had mothers with type 2 diabetes. We found an aOR of 2.9 (95% CI: 2.5, 3.5) and 1.9 (95% CI: 1.3; 2.8) for major malformations for type 1 and type 2 diabetes, respectively. The highest occurrence was for major congenital heart diseases. For both type 1 and type 2 diabetes, the prevalence of major congenital malformations increased with higher levels of maternal HbA1c. Mothers with type 1 diabetes had higher risks than those without diabetes irrespective of HbA1c, and women with HbA1c levels ≥9.5% had 8 times the odds of major congenital malformations [aOR 8.7 (95% CI: 5.4; 14.5)]. Conclusions: The prevalence of major congenital malformations progressively increased with poorer glycemic control during pregnancy.

Objective To investigate the impact of intrapartum fever on maternity and fetus. Design Retrospective cohort study. Setting Women’s Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China Population We studied intrapartum fever, as well as non-fever parturients, between January 1, 2018 and December 31, 2018. Methods We collected pregnancy outcomes of intrapartum fever and non-fever mother and neonatal data. Main outcomes and measures The obstetrics outcomes, complete blood cell count (CBC) and thereby converted neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and monocyte to lymphocyte ratio (MLR), as well as vaginal secretion were observed in women with and without intrapartum fever. Results Prepartum white blood cell (WBC), red blood cell (RBC), and hemoglobin (Hb) were all higher in febrile group, and WBC still higher but RBC and Hb lower after birth. Postpartum NLR and MLR were all higher in fever group but not preferred overtly difference before delivery. Additionally, the comparison of WBC, RBC, Hb, platelets (PLT), neutrophils, and monocytes in prepartum and postpartum all showed significant difference. Conclusions The differences of the prepartum WBC, RBC, Hb, and monocytes existed in the intrapartum fever and afebrile groups. Besides, the parturition could bring about the change of the value of CBC and intrapartum fever might aggravate or alleviate this change. Additionally, the intrapartum fever might not be caused mainly by infection and the difference between bacteria and fungus could reflect in the CBC. Keywords: Intrapartum fever, perinatal period, vaginal discharge examination

Objective We evaluated patient and professional’s experience with virtual antenatal clinic appointments during the COVID-19 pandemic, to determine satisfaction and enquire into the safety and quality of care received. Design, Setting, Population and Methods A total of 148 women who attended a virtual antenatal clinic appointment at our UK tertiary obstetric care centre over a two-week period provided feedback (62% response rate). A further 37 health care professionals (HCP) delivering care in the virtual antenatal clinics participated in another questionnaire study (82% response rate). Main Outcome Measures and Results We showed that women were highly satisfied with the virtual clinics, with 86% rating their experience as good/very good, and this was not associated with any statistically significant differences in age, ethnicity, number of previous births or pregnancy loss(es) (p>0.05). Even though, 56% preferred face-to-face appointments, 44% either expressed no preference or preferred virtual, and these preferences were not associated with significant differences in patient demographics (p>0.05). For HCP, 67% rated their experience of virtual clinics as good/very good; 78% described their experience as the same or better than face-to-face clinics; 15% preferred virtual clinics and 44% had no preference. Importantly, 67% found it easy/very easy to adapt to virtual clinics. Over 90% of HCP agreed virtual clinics should be implemented long-term. Conclusions Our study demonstrates high satisfaction with telephone, antenatal clinics during the pandemic, which supports the transition towards widespread digitalisation of antenatal care, suited to twenty first century patients and professionals. Funding None Keywords COVID-19, Virtual clinic, antenatal, satisfaction

Abstract Objective: We aimed to preliminarily assess whether low-dose aspirin（LDA）is beneficial in preventing preeclampsia in twin pregnancies. Design: An observational cohort study. Setting: Two hospital centers in Chongqing, China. Population: 932 twin-pregnant women. Methods: Among 932 participants, 277 in the First Affiliated Hospital of Chongqing Medical University were routinely treated with aspirin (100mg daily) from 12-16 weeks to 35 weeks of gestational age, while 655 in Chongqing Health Center for Women and Children were not taking aspirin during the whole pregnancy. We followed each subject and the individual details were recorded. Main Outcome Measures: The main outcome was to compare the incidence of preeclampsia in women with or without aspirin intaking. Results: LDA significantly reduced the risk of PE (OR: 0.48, 95% CI: 0.24-0.95, p=0.048) and ＜34 weeks preterm birth (OR: 0.50, 95% CI: 0.29-0.86, p=0.013), but showed possible benefits to lower the rate of SGA babies (OR: 0.74, 95% CI: 0.55-1.00, p=0.063). Moreover, the risk of postpartum hemorrhage was not increased by LDA (OR: 0.89, 95% CI: 0.35-2.26, p=1.000). Conclusions: Treatment with low-dose aspirin in women pregnant with twins could offer some protection against adverse pregnancy outcomes in the absence of any significantly increased risk of postpartum hemorrhage. Funding: The National Key Research and Development Program of China (2018YFC1002900), and National Natural Science Foundation of China (81520108013, 81771613, 81671488, 81871189). Keywords: Twin pregnancy, low-dose aspirin, preeclampsia, preterm birth, small for gestational age

Objective: to evaluate the efficacy of spontaneous pushing with pursed lips breathing compared to directed pushing during the second period of labor in the occurrence of episiotomy. Methods: this is a quasi-randomized clinical trial, with 62 low-risk pregnant women in the second stage of labor. They were randomly allocated in control (CG) (n = 31) and intervention (IG) (n = 31) groups. The IG performed spontaneous pushing with pursed lips breathing while the CG was oriented to perform directed pushing associated with Valsalva Maneuver (MV). Results: There was no difference between the groups regarding the occurrence of episiotomy (RR 1,1; 95%IC 1,0 to 1,2). However, there was a decrease in the duration of the maternal pushing by 3.2 minutes (MD 3,2; 95%CI 1,4 to 5,1) and a difference in maternal anxiety (Md (IQR) IG 46 (35-52), CG 51 (44-56) p:0,049), both favoring the IG. There was no difference in others maternal and neonatal outcomes Conclusions: spontaneous pushing with pursed lips breathing was effective in reducing the duration of the pushing and showed a difference in maternal anxiety, but did not decrease the occurrence of episiotomy, nor did it alter the other studied maternal and neonatal outcomes.

Title: Implementation of early management of iron deficiency in pregnancy during the SARS-CoV-2 pandemicStewart T1, Lambourne J2, Thorpe-Jones D1, Thomas DW1.1University Hospitals Plymouth NHS Trust, Plymouth, Devon, PL6 8DH. 2East Kent Hospitals NHS Foundation Trust, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent, TN24 0LZ

We conducted a study that aimed to shed light on the effects of COVID-19 on the emotional state of pregnant and postpartum women, which are specifically vulnerable groups. A cross-sectional study based on a web questionnaire for the assessment of general emotional stressor during the quarantine period of COVID-19, from April 20th till May 7th. Overall, 356 women of whom 251 pregnant and 101 post-partum filled the questionnaire. Among 251 pregnant women, 199 (79.3 %) reported moderate-high stress, 145 (57.8 %) high anxiety. A hundred and three (41.0%) reported a high level of depression (PH2>3). Among pregnant women, the following were the most prevalent stressors: fear that someone in their family will acquire the virus (80.1%), concern for the health of the baby (77.7%), fear that someone close will die from COVID-19 (72.9%) and worry of being infected within the hospital (71.7%). Univariate analysis of stress revealed that age (χ2=10.93, p<.004) and income level (χ2=13.35, p<.001) were associated with the level of stress. Stepwise logistic regression revealed that both age and income levels below the mean were predictors of stress. Among the 165 multiparous pregnant women, age (25-34 vs. 35-44) as a predictor of stress (p<.04). Our study clearly showed an enormous negative effect of the COVID-19 pandemic on the emotional condition of both pregnant and postpartum women. This provides an insight into the relation between economy and emotional state during the uncertainty period. This adds challenges to the healthcare system in providing means and solutions during disasters

Objective: To assess the clinical significance of a low 180-minute glucose value in a 100gr oral glucose tolerance test (OGTT) and a single high abnormal value. Design: A retrospective cohort study. Setting: A single outpatient health clinic. Population: Women with one abnormal high OGTT glucose value. The study group included women with 180-minute plasma glucose levels of ≤60 mg/dl and one abnormal value in the OGTT. The control group was comprised of women with one abnormal value in the OGTT and normal 180-minute glucose value. Methods: Pregnancy related outcomes and level of glycemic control of both groups were compared. Main outcome measures: The primary outcome was glycemic control, defined as fasting blood glucose measurements>90 mg/dl or post-prandial glucose values >140 mg/dl or 120 md/dl (1-hour and 2-hour post-prandial, respectively) in>30% of the measurements. Secondary outcomes were the rate of insulin treatment and the perinatal outcome consisting of birthweight, large-for-gestational-age and polyhydramnios. Results: 301 women were included, of them, 143 in the study group and 158 in the control group. Pre-pregnancy body mass index, first trimester fasting glucose levels, previous gestational diabetes mellitus, and familial diabetes were similar for both groups. Suboptimal glycemic control was more prevalent among the women in the study group (14% vs. 5.1%, respectively, P=0.01). The need for insulin treatment was similar in both groups (9.8% vs. 4.4%, P=.1). Conclusion: Women with one abnormal value and a 180-minute hypoglycemia in the OGTT are at increased risk for suboptimal glycemic control.

A document by Rupakala B M, written on Authorea.

Letter to the Editor, BJOG Exchange

The best suggestion for COVID-19 in a non-infected pregnant population is still prevention: a commentaryRui-Hong Xue1, He-Feng Huang2,3,4,5

Objective: Description of characteristics, risk factors, management strategies and maternal, obstetric and neonatal outcomes of SARS-CoV-2 infected pregnant women in the Netherlands. Design: Multi-centre prospective nationwide population-based cohort study. Setting: Nationwide. Population: All pregnant women in the Netherlands with confirmed SARS-CoV-2 infection in home-isolation or admitted to hospital between March 1st, 2020 and August 31st, 2020. Methods: Pregnant women with positive PCR or antibody tests were registered using the Netherlands Obstetrics Surveillance System. Testing occurred according to national guidelines (selective testing). Data from the national birth registry (Perined) and Dutch National Institute for Public Health and the Environment (RIVM) were used as reference. Main Outcome Measures: Incidence of pregnant women with SARS-CoV-2 infection. Maternal, obstetric and neonatal outcomes including hospital and critical care admission, clinical management and mode of birth. Results: Of 312 registered women, 65 (20%) were admitted to hospital, of whom 5 (2%) to intensive care and 9 (14%) to obstetric high care units. Risk factors for admission were non-Caucasian background (n=28; OR 6.67, 95%CI 4.08-10.90) and being overweight or obese (n=38; OR 2.64, 95%CI1.51 to 4.61). Hospital and intensive care admission were higher compared to age-matched infected women (respectively, OR 14.57, 95%CI 10.99-19.03 and OR 5.02, 95%CI 2.04-12.34). One maternal death occurred. Caesarean section after labour onset was increased (OR 2.50; 95%CI 1.57-3.97). Conclusions: Pregnant women with SARS-CoV-2 infection are at increased risk of hospital admission, ICU admission and caesarean section. Funding: No funding was received. Keywords: Pregnancy, COVID-19, SARS-CoV-2, Pregnancy complications, Pregnancy outcome, Obstetric surveillance system.