Obstetric Medicine

To update obstetric care providers about asthma management.

Asthma is the most frequent comorbid chronic illness in pregnancy. Convincing evidence shows that uncontrolled asthma magnifies the risk of maternal, fetal and neonate complications. Unfortunately, one in four women take no inhaler during pregnancy, and it is likely that decreased adherence, rather than changes in pathology, explains uncontrolled maternal asthma. Patient surveys reveal a need for information and reassurance. Although some molecules are preferred in pregnancy, there is currently no basis to withhold any asthma medication – old or new. Biomarkers such as blood eosinophils and fractional exhaled nitric oxide are an effective way to assess the risk of asthma attacks and the likelihood of responding to inhaled steroids. Furthermore, practice-changing trials in mild asthma show that switching reliever-only regimens to as-needed ‘controller-and-reliever’ therapy is effective. We suggest that applying these changes can alleviate women’s concerns and improve outcomes.

Systemic lupus erythematosus has a predilection for women of childbearing age. Globally a shortage of rheumatologists exists resulting in general physicians and obstetricians treating systemic lupus erythematosus in pregnancy.

We conducted a survey amongst medical and obstetric registrars in South Africa to assess their subjective and objective competence in managing pregnant women with systemic lupus erythematosus.

The pass rate for the objective section was 70.8% with no statistically significant difference in the pass rate between medical and obstetric registrars. Participants felt unprepared to manage pregnant women with systemic lupus erythematosus, with a mean overall score of 3.4 out of 7 for the subjective section, based on four Likert scale type questions.

Trainees are not able to accurately assess their own levels of competence in order to identify their learning needs. Due to the shortage of rheumatologists and lack of obstetric physicians in South Africa, general physicians and obstetricians must be equipped to provide adequate care to pregnant women with systemic lupus erythematosus.

Autoimmune conditions are associated with adverse pregnancy and offspring outcomes; however, the prevalence in pregnant women is not well understood. Estimates based on administrative data alone may underestimate prevalence.

A cross-sectional survey of women attending a tertiary referral hospital for antenatal care in December 2018–February 2019 and review of the hospital’s maternity database of women giving birth from October 2017–June 2018 to estimate autoimmune disease prevalence.

A total of 400 women completed surveys (78% response rate) and 41 (10.3%) reported an autoimmune disease, most commonly Hashimoto’s thyroiditis (2.8%) and psoriasis (2.5%). From the maternity database, 112 of 2756 women giving birth (4.1%) had a recorded autoimmune disease, most commonly Hashimoto’s thyroiditis (1.3%) followed by coeliac disease, Graves’ disease, and immune thrombocytopenic purpura (all 0.4%).

Autoimmune disease prevalence in pregnant women is higher when self-reported and may be more common than previously reported using administrative data.

It is unclear whether pregnant women from ethnic minority groups and with metabolic disorders are disproportionately affected by SARS-CoV-2 infection within deprived areas. No previous studies have compared pregnancy outcomes with an appropriate comparator group.

Cross-sectional study of 32 women with SARS-CoV-2 compared to background departmental figures from the three months prior to the outbreak. Clinical characteristics were compared to the UK Obstetric Surveillance System report.

Estimated incidence was 10 times the national average (50.3 vs 4.9 per 1000 maternities). Women from Black (OR, 95% CI: 3.01, 1.08–7.38) and Asian (OR, 95% CI: 2.68, 1.23–6.05) ethnic groups were over-represented; however, there was no association with metabolic disorders. Babies born to women diagnosed with coronavirus were more likely to be born premature, or by caesarean delivery, however there was no difference in birthweight centile for gestational age.

Women from Black and Asian backgrounds are disproportionately affected, even within an area of high ethnic diversity. Mothers do not appear more severely affected than women nationally; however, babies are more likely to be born preterm, or by caesarean delivery, compared to usual departmental figures. It is unclear whether this is due to increased intervention or a direct result of coronavirus infection.

Optimal obstetric management for women with coronavirus disease (COVID-19) is not known. We describe the management of six pregnant women requiring in-hospital care for severe COVID-19.

A retrospective chart review was conducted to identify pregnant women who tested positive for Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) between 15 March and 30 June 2020. A subset of women meeting criteria for severe COVID-19 was included.

Four women required non-invasive supplemental oxygen therapy and two required mechanical ventilation. Four women were discharged from hospital undelivered and two required preterm delivery. One woman had a pulmonary embolism, and two required re-admission for worsening symptoms.

Management of pregnant women with severe COVID-19 is complex and should involve multidisciplinary expertise. Avoiding early delivery may be a safe option. We recommend an individualized approach to care, including careful consideration of the expected risks and benefits of expectant obstetric management versus delivery.