Pregnancy as an opportunity to prevent type 2 diabetes mellitus: FIGO Best Practice Advice

Gestational diabetes (GDM) impacts approximately 17 million pregnancies worldwide. Women with a history of GDM have an 8–10-fold higher risk of developing type 2 diabetes and a 2-fold higher risk of developing cardiovascular disease (CVD) compared with women without prior GDM. Although it is possible to prevent and/or delay progression of GDM to type 2 diabetes, this is not widely undertaken. Considering the increasing global rates of type 2 diabetes and CVD in women, it is essential to utilize pregnancy as an opportunity to identify women at risk and initiate preventive intervention. This article reviews existing clinical guidelines for postpartum identification and management of women with previous GDM and identifies key recommendations for the prevention and/or delayed progression to type 2 diabetes for global clinical practice.

Admission Criteria of Obstetric Patients in Selected Intensive Care Units, Khartoum State, Sudan (2022)

The Obstetric admissions to the intensive care unit (ICU) require special care and attention by a multidisciplinary team. Pregnancy is associated with many maternal physiological and organ changes. These changes are primarily due to production of progesterone by the corpus luteum in early pregnancy and the placenta from ten weeks. They are admitted to the ICU for close observation to detect the problems earlier, perform invasive monitoring, increase nursing care or ventilatory support or any intervention that is not available at the wards. The aim of this study was to identify the admission criteria of obstetric patients. A retrospective study was conducted in maternal hospitals, from January to December 2021.70 patients with inclusion criteria were included. The results revealed that most of the patients diagnosed with Preeclampsia25.7%, eclampsia 22.9%, not applicable for the scoring system. Data was collected using a questionnaire filled by researchers from patients’files. The study found that most common cases were admitted to ICU with pre-eclampsia, eclampsia and postpartum hemorrhage, the antenatal care was low, that wasn’t applicable to scoring systems at admission and most patients did not need invasive procedures or mechanical ventilation.

Effect of a model based on education and teleassistance for the management of obstetric emergencies in 10 rural populations from Colombia

Introduction: Pregnant women and health providers in rural areas of low-income and middle-income countries face multiple problems concerning high-quality obstetric care. This study was performed to identify changes in maternal and perinatal indicators after implementing a model based on education and telecare between a high-complexity hospital in 10 low-complexity hospitals in a southwestern region of Colombia.
Methods: A quasiexperimental study with a historic control group and without a pretest was conducted between 2017 and 2019 to make comparisons before and after obstetric emergency care through the use of teleassistance from 10 primary care centers to the referral center (Fundación Valle del Lili, FVL).
Results: A total of 470 patients were treated before teleassistance implementation and 154 patients were treated after teleassistance implementation. After program implementation, the maternal clinical indicators showed a 65% reduction in the number of obstetric patients who were referred with obstetric emergencies. The severity of maternal disease that was measured at the time of admission to level IV through the Modified Early Obstetric Warning System score was observed to decrease.
Conclusion: The implementation of a model based on education and teleassistance between low-complexity hospitals and tertiary care centers generated changes in indicators that reflect greater access to rural areas, lower morbidity at the time of admission, and a decrease in the total number of emergency events.

Exploring the lived experiences of pregnant women and community health care providers during the pandemic of COVID-19 in Bangladesh through a phenomenological analysis

Like many countries, the government of Bangladesh also imposed stay-at-home orders to restrict the spread of severe acute respiratory syndrome coronavirus-2 (COVID-19) in March, 2020. Epidemiological studies were undertaken to estimate the early possible unforeseen effects on maternal mortality due to the disruption of services during the lockdown. Little is known about the constraints faced by the pregnant women and community health workers in accessing and providing basic obstetric services during the pandemic in the country. This study was conducted to explore the lived experience of pregnant women and community health care providers from two southern districts of Bangladesh during the pandemic of COVID-19.

The study participants were recruited through purposive sampling and non-structured in-depth interviews were conducted. Data was collected over the telephone from April to June, 2020. The data collected was analyzed through a phenomenological approach.

Our analysis shows that community health care providers are working under tremendous strains of work load, fear of getting infected and physical and mental fatigue in a widely disrupted health system. Despite the fear of getting infected, the health workers are reluctant to wear personal protective suits because of gender norms. Similarly, the lived experience of pregnant women shows that they are feeling helpless; the joyful event of pregnancy has suddenly turned into a constant fear and stress. They are living in a limbo of hope and despair with a belief that only God could save their lives.

The results of the study present the vulnerability of pregnant women and health workers during the pandemic. It recognizes the challenges and constraints, emphasizing the crucial need for government and non-government organizations to improve maternal and newborn health services to protect the pregnant women and health workers as they face predicted waves of the pandemic in the futur

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country.

Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020.

Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively.

Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy.

Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.
Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.
Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Counselling and pregnancy outcomes in women with congenital heart disease- current status and gap analysis from Madras Medical College Pregnancy And Cardiac disease (M-PAC) registry

Congenital heart disease (CHD) is becoming an increasingly important cause of heart disease in pregnancy in low- and middle – income countries (LMICs). Preconception and contraception counselling based on risk stratification has the potential to reduce maternal complications. Data is lacking from LMICs on the availability and effectiveness of preconception counselling (PCC) in women with CHD (WWCHD).

Madras Medical College Pregnancy and Cardiac disease (M-PAC) Registry is a single center prospective observational registry conducted at a tertiary referral institution in South India from July 2016 to December 2019. Baseline features and feto-maternal outcomes were compared in WWCHD with and without PCC. Predictors of post-delivery contraception were identified.

Of the 107 eligible pregnancies with data on counselling, only 49.5% had received PCC. Pregnancies involving women with corrected CHDs (62.3% vs 33.3%; P ​= ​0.006) and cyanotic CHD (20.8% vs 11.1%; P ​= ​0.042) were more likely to get PCC. High risk mWHO categories were non-significantly less likely to get PCC (32% vs 39%). Primary outcome of death or heart failure was non-significantly low in the PCC group (3.8% vs 7.4% P ​= ​0.4). Patients with high risk m WHO categories were less likely to get Tier I contraceptives post-delivery (46% vs 79.7% P ​= ​0.004).

Preconception and post conception counselling, which have the potential to improve outcome in WWCHD, are being underused in LMICs. Health care systems should ensure multidisciplinary pregnancy and heart team approach to offer timely lesion specific pre-conceptional counselling, shared decision making and appropriate peri-pregnancy care for WWCHD.

Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017–2018)

Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.

We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017–2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights.

Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women’s age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42–1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18–1.33]), primary education (aPR = 1.33; [95% CI: 1.24–1.43), secondary education (aPR = 1.34; [95% CI: 1.26–1.43), higher education (aPR = 2.13; [95% CI: 1.97–2.30), women’s say in choosing husband (aPR = 1.68; [95% CI: 1.57–1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43–2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23–1.36]) were significantly associated with iron consumption for ≥90 days.

These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.

Evaluation of Morbidity and Mortality in Eclampsia: A Study in a Tertiary Care Hospital, Rajshahi, Bangladesh

Introduction: Eclampsia is a hypothetically life-threatening rare tricky situation of the hypertensive disorders of pregnancy, which is responsible for huge records in morbidity and deaths among women of reproductive age and their offspring. It is an occurrence of convulsion linked with pregnancy complicated by preeclampsia. The estimate of incidence and the burden of eclampsia is still a challenging pursuit worldwide; currently only seven countries have national data on the topic. Aim of the study: To assess the morbidity and mortality in eclampsia. Methods: This was a cross sectional observational study carried out in the Department of Obstetrics and Gynaecology in 250 Bedded General Hospital, Pabna, Bangladesh during the period from June 2016 and July 2016. Proper written consent form all the participants were obtained and the ethical committee of the hospital had approved the study before starting the
intervention. In total 178 pregnant women with eclampsia were finalized as the study population. Result: In our study we found in total 148 live births from total 178 mothers which were 83.15% against total study population. Among all the babies 139 were survived which was 93.91% among total live births. Death after birth was 9 in number which was 6.08% among total live births. Early neonatal death was 13 in number which was 7.3% against total mothers. Stillbirths were 16 in number which was 9% against total mothers. In perinatal complication analysis we found 42 babies with jaundice which was 28.38% among live births. Babies with septicemia were 28 (18.92%), with respiratory distress 25 (16.89%), with neonatal convulsion were 7(4.73%) and with no complication were 46 (31.08%). Conclusion: It was observed in our study that; lower income families have a worse performance in all obstetric health
care indicators among women with eclampsia. So, Proper health care and mental health facilities in order to get better obstetric and perinatal outcomes might be the faster route to reduce severe maternal outcome due to eclampsia.

Linking household and health facility surveys to assess obstetric service availability, readiness and coverage: evidence from 17 low- and middle-income countries.

Improving access and quality of obstetric service has the potential to avert preventable maternal, neonatal and stillborn deaths, yet little is known about the quality of care received. This study sought to assess obstetric service availability, readiness and coverage within and between 17 low- and middle-income countries.We linked health facility data from the Service Provision Assessments and Service Availability and Readiness Assessments, with corresponding household survey data obtained from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Based on performance of obstetric signal functions, we defined four levels of facility emergency obstetric care (EmOC) functionality: comprehensive (CEmOC), basic (BEmOC), BEmOC-2, and low/substandard. Facility readiness was evaluated based on the direct observation of 23 essential items; facilities “ready to provide obstetric services” had ?20 of 23 items available. Across countries, we used medians to characterize service availability and readiness, overall and by urban-rural location; analyses also adjusted for care-seeking patterns to estimate population-level coverage of obstetric services.Of the 111?500 health facilities surveyed, 7545 offered obstetric services and were included in the analysis. The median percentages of facilities offering EmOC and “ready to provide obstetric services” were 19% and 10%, respectively. There were considerable urban-rural differences, with absolute differences of 19% and 29% in the availability of facilities offering EmOC and “ready to provide obstetric services”, respectively. Adjusting for care-seeking patterns, results from the linking approach indicated that among women delivering in a facility, a median of 40% delivered in facilities offering EmOC, and 28% delivered in facilities “ready to provide obstetric services”. Relatively higher coverage of facility deliveries (?65%) and coverage of deliveries in facilities “ready to provide obstetric services” (?30% of facility deliveries) were only found in three countries.The low levels of availability, readiness and coverage of obstetric services documented represent substantial missed opportunities within health systems. Global and national efforts need to prioritize upgrading EmOC functionality and improving readiness to deliver obstetric service, particularly in rural areas. The approach of linking health facility and household surveys described here could facilitate the tracking of progress towards quality obstetric care.

Early neonatal mortality in twin pregnancy: Findings from 60 low- and middle-income countries.

Around the world, the incidence of multiple pregnancies reaches its peak in the Central African countries and often represents an increased risk of death for women and children because of higher rates of obstetrical complications and poor management skills in those countries. We sought to assess the association between twins and early neonatal mortality compared with singleton pregnancies. We also assessed the role of skilled birth attendant and mode of delivery on early neonatal mortality in twin pregnancies.We conducted a secondary analysis of individual level data from 60 nationally-representative Demographic and Health Surveys including 521?867 singleton and 14?312 twin births. We investigated the occurrence of deaths within the first week of life in twins compared to singletons and the effect of place and attendance at birth; also, the role of caesarean sections against vaginal births was examined, globally and after countries stratification per caesarean sections rates. A multi-level logistic regression was used accounting for homogeneity within country, and homogeneity within twin pairs.Early neonatal mortality among twins was significantly higher when compared to singleton neonates (adjusted odds ratio (aOR) 7.6; 95% confidence interval (CI)?=?7.0-8.3) in these 60 countries. Early neonatal mortality was also higher among twins than singletons when adjusting for birth weight in a subgroup analysis of those countries with data on birth weight (n?=?20; less than 20% of missing values) (aOR?=?2.8; 95% CI?=?2.2-3.5). For countries with high rates (>15%) of caesarean sections (CS), twins delivered vaginally in health facility had a statistically significant (aOR?=?4.8; 95% CI?=?2.4-9.4) increased risk of early neonatal mortality compared to twins delivered through caesarean sections. Home twin births without SBA was associated with increased mortality compared with delivering at home with SBA (aOR?=?1.3; 95% CI?=?1.0-1.8) and with vaginal birth in health facility (aOR?=?1.7; 95% CI?=?1.4-2.0).Institutional deliveries and increased access of caesarian sections may be considered for twin pregnancies in low- and middle- income countries to decrease early adverse neonatal outcomes.