Forensic assessment of maternal deaths from the COVID-19 during the 2021 pandemic

Abstract

BACKGROUND: According to the literature, the mortality rate from SARS-CoV-2 infection among pregnant women is up to 25%. The high-risk group for the development of severe forms of COVID-19 includes pregnant women with extragenital pathology. Obstetric tactics are determined by the severity of the condition of the mother and fetus, as well as the duration of pregnancy. The decision on early delivery is made as a result of an interdisciplinary medical consultation. Delivery in the midst of the disease is associated with an increase in maternal mortality. According to the literature, including our own research, it has been established that the basis for favorable perinatal outcomes in patients with severe and moderate forms of COVID-19 is: an adequate assessment of the condition of the pregnant woman and fetus (especially at the outpatient stage, where the pregnant woman goes first), early hospitalization, early initiation of intensive care and timely delivery before the onset of irreversible organ changes in pregnant women.

AIM: The aim of this study was to analyze the tactics of pregnancy management, delivery and perinatal outcomes, assessing the quality of medical care at the outpatient and hospital stages provided to pregnant women who died in a specialized obstetric hospital from the extremely severe new coronavirus infection COVID-19 (based on the data of commission forensic examinations).

MATERIALS AND METHODS: This retrospective study of pregnancy outcomes was performed in 11 patients who died from complications of extremely severe COVID-19 in a regional specialized obstetric hospital in Russia based on the data of commission forensic examinations performed in the Bureau of Forensic Medical Examination (Saint Petersburg, Russia) in 2021, at gestation periods of 28–34 weeks (n = 7) and 37–39 weeks (n = 4) in the context of assessing the quality of medical care in the field of obstetrics and gynecology. We confirmed the diagnosis of the new coronavirus infection COVID-19 in 10 (90.9%) patients by SARS-CoV-2 RNA identification using polymerase chain reaction in a nasopharyngeal smear on an average of 4.9 ± 3.6 days from the onset of the disease. In one patient, the clinical diagnosis was confirmed postmortem by the detection of SARS-Cov-2 RNA during autopsy (in the trachea, lungs, and spleen). All patients in the hospital underwent a comprehensive anamnestic, clinical and laboratory examination in the amount regulated by the administrative regulations of the Ministry of Health of the Russian Federation that were relevant at the time of providing medical care. Nine (81.8%) patients sought medical help from a local therapist on 3.1 ± 1.6 days from the onset of the disease and received outpatient treatment for 3.4 ± 1.8 days, two patients not seeing a doctor and receiving outpatient care. The average time before admission to the specialized obstetric hospital was 6.0 ± 2.2 days from the onset of the disease.

RESULTS: During the forensic assessment of the medical records of deceased patients, significant defects in the quality of medical care were identified in the framework of this study at the stages of information collection, diagnosis, treatment, and succession. An indirect causal relationship was established between the most significant defects in the quality of medical care and adverse pregnancy outcomes, since the cause of death or critical conditions were individually determined severe complications, rather than defects in medical care, which, nevertheless, does not exclude their significance in the totality of causes of severe maternal outcomes.

CONCLUSIONS: The data obtained indicate the need for earlier delivery in pregnant women with the new coronavirus infection COVID-19 before the appearance of irreversible changes in patients with progressive respiratory failure, multiple organ failure syndrome, systemic inflammatory response syndrome, and cytokine storm.

Keywords

SARS-CoV-2 / new coronavirus infection / COVID-19 / extremely severe new coronavirus infection in pregnant women / maternal mortality / predictors of adverse pregnancy outcome / delivery / examination of the quality of medical care

References

[1] On approval of criteria for assessing the quality of medical care. Order of the Ministry of Health of the Russian Federation dated May 10, 2017. N 203n. (In Russ.) [cited 2024 Feb 14]. Available from: https://rgk1rzn.ru/wp-content/uploads/2022/12/n203.pdf

[2] Об утверждении критериев оценки качества оказания медицинской помощи. Приказ Министерства здравоохранения РФ от 10.05.17. № 203н. Дата обращения: 14.02.2024. Режим доступа: https://rgk1rzn.ru/wp-content/uploads/2022/12/n203.pdf

[3] On approval of medical criteria for determining the severity of harm caused to human health. Order of the Ministry of Health and Social Development of the Russian Federation dated April 24, 2008 N 194n with amendments and additions dated January 18, 2012. (In Russ.) [cited 2024 Feb 14]. Available from: https://new.med.ru/sites/default/files/ docs/PMc_194n_24042008.pdf

[4] Об утверждении медицинских критериев определения степени тяжести вреда, причиненного здоровью человека. Приказ Министерства здравоохранения и социального развития РФ от 24 апреля 2008 г. № 194н с изменениями и дополнениями от 18.01.2012 г. Дата обращения: 14.02.2024. Режим доступа: https://new.med.ru/sites/default/files/docs/PMc_194n_24042008.pdf

[5] Bezhenar VF, Ailamazyan EK, Zazerskaya IE, et al. Brief clinical recommendations. Tactics for managing pregnant women, women in labor and postpartum with a new coronavirus infection (COVID-19). ICD-10: U07.2, U07.1 (version 2.0 dated 01.11.2021). Saint Petersburg: Eco-Vector; 2021. 58 p. (In Russ.)

[6] Беженарь В.Ф., Айламазян Э.К., Зазерская И.Е. и др. Краткие клинические рекомендации. Тактика ведения беременных, рожениц и родильниц с новой коронавирусной инфекцией (COVID-19). МКБ-10: U07.2, U07.1 (версия 2.0 от 11.01.2021). Санкт-Петербург: Эко-Вектор, 2021. 58 с.

[7] Organization of medical care for pregnant women, women in labor, postpartum women and newborns with a new coronavirus infection (COVID-19). Guidelines. Version 5 (14.02.2024). Moscow: Ministry of Health of the Russian Federation; 2021. 135 p. [cited 2024 Feb 14]. Available from: https://oms66.ru/upload/iblock/fd5/va2z9bp3ova08tfz3n70mgyk6l1ybyrg/BMP_preg_5.pdf

[8] Организация оказания медицинской помощи беременным, роженицам, родильницам и новорожденным при новой коронавирусной инфекции (COVID-19). Методические рекомендации. Версия 5 (28.12.2021). Москва: Министерство здравоохранения Российской Федерации, 2021. 135 с. Дата обращения: 14.02.2024. Режим доступа: https://oms66.ru/upload/iblock/fd5/va2z9bp3ova08tfz3n70mgyk6l1ybyrg/BMP_preg_5.pdf

[9] Prevention, diagnosis and treatment of new coronavirus infection (COVID-19). Temporary guidelines. Version 14 (27.12.2021). Moscow: Ministry of Health of the Russian Federation; 2021. 233 p. [cited 2024 Feb 14]. Available from: https://static-0.minzdrav.gov.ru/system/attachments/attaches/000/059/392/original/VMR_COVID-19_V15.pdf

[10] Профилактика, диагностика и лечение новой коронавирусной инфекции (COVID-19). Временные методические рекомендации. Версия 14 (27.12.2021). Москва: Министерство здравоохранения Российской Федерации, 2021. 233 с. Дата обращения: 14.02.2024. Режим доступа: https://static-0.minzdrav.gov.ru/system/attachments/attaches/000/059/392/original/ВМР_COVID-19_V15.pdf

[11] On approval of the Procedure for providing medical care in the field of obstetrics and gynecology. Order of the Ministry of Health of Russia dated October 20, 2020 N 1130n. Moscow: Ministry of Health of the Russian Federation, 2020. 802 p. [cited 2024 Feb 14]. Available from: https://embryo-ivf.ru/upload/normativ/prikaz_minzdrava_rossii_ot_20_10_2020_n_1130n.pdf

[12] Об утверждении Порядка оказания медицинской помощи по профилю «акушерство и гинекология». Приказ Минздрава России от 20.10.2020 № 1130н. Москва: Министерство здравоохранения Российской Федерации, 2020. 802 с. Дата обращения: 14.02.2024. Режим доступа: https://embryo-ivf.ru/upload/normativ/prikaz_minzdrava_rossii_ot_20_10_2020_n_1130n.pdf

[13] Bezhenar VF, Nesterov IM, Dobrovolskaya IA. Perinatal outcomes of pregnancy and childbirth in moderate to severe COVID-19 patients. Journal of Obstetrics and Women’s Diseases. 2022;71(4):5–12. EDN: QVOLAB doi: 10.17816/JOWD105736

[14] Беженарь В.Ф., Нестеров И.М., Добровольская И.А. Перинатальные исходы беременности и родов у пациенток со среднетяжелыми и тяжелыми формами новой коронавирусной инфекции // Журнал акушерства и женских болезней. 2022. Т. 71, № 4. С. 5–12. EDN: QVOLAB doi: 10.17816/JOWD105736

[15] Bezhenar VF, Romanova ML, Nesterov. IM, et al. Analyzing pregnancy course and outcomes in women with varying degrees of severity of the new coronavirus infection COVID-19 in Saint Petersburg: the lessons from pandemic. Obstetrics, Gynecology and Reproduction. 2022;16(4):365–380. EDN: TJCSGA doi: 10.17749/2313-7347/ob.gyn.rep.2022.314

[16] Беженарь В.Ф., Романова М.Л., Нестеров И.М., и др. Анализ течения и исходов беременности у женщин с различной степенью тяжести новой коронавирусной инфекции COVID-19 в Санкт-Петербурге: уроки пандемии // Акушерство, гинекология и репродукция. 2022. Т. 16, № 4. С. 365–380. EDN: TJCSGA doi: 10.17749/2313-7347/ob.gyn.rep.2022.314

[17] Bezhenar VF, Dobrovolskaya IA, Nesterov IM, et al. Opportunities for predicting adverse pregnancy outcomes in severe COVID-19. Obstetrics, Gynecology and Reproduction. 2023;17(1):75–91. EDN: VUKJOL doi: 10.17749/2313-7347/ob.gyn.rep.2023.338

[18] Беженарь В.Ф., Добровольская И.А., Нестеров И.М., и др. Возможности прогнозирования неблагоприятных исходов беременности при тяжелом течении COVID-19 // Акушерство, гинекология и репродукция. 2023. Т. 17, № 1. С. 75–91. EDN: VUKJOL doi: 10.17749/2313-7347/ob.gyn.rep.2023.338

[19] Bezhenar VF, Dobrovolskaya IA, Nesterov IM, et al. Pregnancy outcomes in moderate and severe forms of COVID-19. Effective Pharmacotherapy. 2022;18(7):12–18. (In Russ.) EDN: CITTFQ doi: 10.33978/2307-3586-2022-18-7-12-18

[20] Беженарь В.Ф., Добровольская И.А., Нестеров И.М., и др. Исходы беременности при среднетяжелых и тяжелых формах COVID-19 // Эффективная фармакотерапия. Акушество и гинекология. 2022. Т. 18, № 7. С. 12–18. EDN: CITTFQ doi: 10.33978/2307-3586-2022-18-7-12-18

[21] Zazerskaya IE, Bezhenar VF, Godzoyeva AO, et al. Pneumonia in pregnant women with COVID-19: is it a new thrombotic microangiopathy in obstetric practice? Journal of Obstetrics and Women’s Diseases. 2020;69(4):29–40. EDN: GHMZPE doi: 10.17816/JOWD69429-40

[22] Зазерская И.Е., Беженарь В.Ф., Годзоева А.О., и др. Пневмония у беременных при COVID-19 — новая тромботическая микроангиопатия в практике акушера-гинеколога? // Журнал акушерства и женских болезней. 2020. Т. 69, № 4. С. 29–40. EDN: GHMZPE doi: 10.17816/JOWD69429-40

[23] Dubrovina SO, Bezhenar VF, Alexandrina A.D., et al.; Dubrovina SO, Bezhenar VF, editors. Miscarriage: management tactics. Moscow: GEOTAR-Media; 2022. 576 p. (In Russ.) EDN: ZEXUCX doi: 10.33029/9704-6660-5-MMT-2022-1-576

[24] Дубровина С.О., Беженарь В.Ф., Александрина А.Д., и др. Невынашивание беременности: тактика ведения / под ред. С.О. Дубровиной, В.Ф. Беженаря. Москва: ГЭОТАР-Медиа, 2022. 576 с. EDN: ZEXUCX doi: 10.33029/9704-6660-5-MMT-2022-1-576

[25] Eremeeva DR, Bezhenar VF, Zainulina MS, et al. Pathogenesis of COVID-19. Role of heparins in the therapy of severe conditions in patients with COVID-19. Obstetrics and Gynecology. 2020;(12):25–33. EDN: USMCRA doi: 10.18565/aig.2020.12.25-33

[26] Еремеева Д.Р., Беженарь В.Ф., Зайнулина М.С., и др. Патогенез COVID-19. Роль гепаринов в терапии тяжелых состояний у пациентов с COVID-19 // Акушерство и гинекология. 2020. № 12. С. 25–33. EDN: USMCRA doi: 10.18565/aig.2020.12.25-33

[27] Mannanova IV, Semenov VT, Ponezheva ZhB, et al. Clinical and laboratory characteristics of COVID-19. RMJ. 2021;29(4):22–25. EDN: UDCBNU

[28] Маннанова И.В., Семенов В.Т., Понежева Ж.Б., и др. Клинико-лабораторная характеристика COVID-19 // РМЖ. 2021. Т. 29, № 4. С. 22–25. EDN: UDCBNU

[29] Bezhenar’ VF, Zazerskaya IE. editors. Community-acquired pneumonia in pregnant women: differential diagnosis, treatment features, obstetric tactics in the context of the new coronavirus infection COVID-19 pandemic. ICD-10 (J13–J16 and J18; U07.1, U07.2): manual. Saint Petersburg: EkoVektor; 2020. 98 p. (In Russ.) [cited 2024 Feb 14]. Available from: https://journals.eco-vector.com/files/journals/7/sup_files/Vneb_Pnevm.pdf

[30] Внебольничные пневмонии у беременных: дифференциальная диагностика, особенности лечения, акушерская тактика в условиях пандемии новой коронавирусной инфекции COVID-19. МКБ-10 (J13–J16 и J18; U07.1, U07.2): учебное пособие / под ред. В.Ф. Беженарь, И.Е. Зазерской. Санкт Петербург: ЭкоВектор, 2020. 98 с.

[31] Dashraath P, Wong JLJ, Lim MXK, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol. 2020;222(6):521–531. doi: 10.1016/j.ajog.2020.03.021

[32] Dashraath P., Wong J.L.J., Lim M.X.K., et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy // Am J Obstet Gynecol. 2020. Vol. 222, N 6. P. 521–531. doi: 10.1016/j.ajog.2020.03.021

[33] Wong SF, Chow KM, Leung TN, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol. 2004;191(1):292–297. doi: 10.1016/j.ajog.2003.11.019

[34] Wong S.F., Chow K.M., Leung T.N., et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome // Am J Obstet Gynecol. 2004. Vol. 191, N 1. P. 292–297. doi: 10.1016/j.ajog.2003.11.019

[35] Jafari M, Pormohammad A, Neshin SAS, et al. Clinical characteristics and outcomes of pregnant women with COVID-19 and comparison with control patients: a systematic review and meta-analysis. Rev Med Virol. 2021;31(5):1–16. doi: 10.1002/rmv.2208.

[36] Jafari M., Pormohammad A., Neshin S.A.S. et al. Clinical characteristics and outcomes of pregnant women with COVID-19 and comparison with control patients: a systematic review and meta-analysis // Rev Med Virol. 2021. Vol. 31, N 5. P. 1–16. doi: 10.1002/rmv.2208

[37] Bezhenar VF, Zazerskaya IE, Bettikher OA, et al. Controversial issues in obstetric management of women with novel coronavirus disease COVID-19 during pregnancy and childbirth. Obstetrics and Gynecology. 2020;(5):13–21. EDN: PPMNAW doi: 10.18565/aig.2020.5.13-21

[38] Беженарь В.Ф., Зазерская И.Е., Беттихер О.А., и др. Спорные вопросы акушерской тактики при ведении беременности и родоразрешении пациенток с новой коронавирусной инфекцией COVID-19 // Акушерство и гинекология. 2020. № 5. С. 13–21. EDN: PPMNAW doi: 10.18565/aig.2020.5.13-21

[39] Figueiro-Filho EA, Yudin M, Farine D, COVID-19 during pregnancy: an overview of maternal characteristics, clinical symptoms, maternal and neonatal outcomes of 10,996 cases described in 15 countries. J Perinat Med. 2020;48(9):900–911. doi: 10.1515/jpm-2020-0364

[40] Figueiro-Filho E.A., Yudin M., Farine D. COVID-19 during pregnancy: an overview of maternal characteristics, clinical symptoms, maternal and neonatal outcomes of 10,996 cases described in 15 countries // J Perinat Med. 2020. Vol. 48, N 9. P. 900–911. doi: 10.1515/jpm-2020-0364

[41] Dubey P, Reddy SY, Manuel S, et al. Maternal and neonatal characteristics and outcomes among COVID-19 infected women: An updated systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;252:490–501. doi: 10.1016/j.ejogrb.2020.07.034

[42] Dubey P., Reddy S.Y., Manuel S., et al. Maternal and neonatal characteristics and outcomes among COVID-19 infected women: an updated systematic review and meta-analysis // Eur J Obstet Gynecol Reprod Biol. 2020. Vol. 252. P. 490–501. doi: 10.1016/j.ejogrb.2020.07.034

[43] Belokrinitskaya TE, Artymuk NV, Filippov OS, et al. Maternal and perinatal outcomes during COVID-19 pandemia in far east and siberian federal region of Russia. Russian journal of Human Reproduction. 2021;7(2):130–136. EDN: RZCCZR doi: 10.17116/repro202127021130

[44] Белокриницкая Т.Е., Артымук Н.В., Филиппов О.С., и др. Материнские и перинатальные исходы в условиях пандемии новой коронавирусной инфекции COVID-19 в Дальневосточном и Сибирском федеральных округах // Проблемы репродукции. 2021. Т. 7, № 2. С. 130–136. EDN: RZCCZR doi: 10.17116/repro202127021130

[45] Vergara-Merino L, Meza N, Couve-Pérez C, et al. Maternal and perinatal outcomes related to COVID-19 and pregnancy: an overview of systematic reviews. Acta Obstet Gynecol Scand. 2021;100(7):1200–1218. doi: 10.1111/aogs.14118

[46] Vergara-Merino L., Meza N., Couve-Pérez C., et al. Maternal and perinatal outcomes related to COVID-19 and pregnancy: an overview of systematic reviews // Acta Obstet Gynecol Scand. 2021. Vol. 100, N 7. P. 1200–1218. doi: 10.1111/aogs.14118

RIGHTS & PERMISSIONS

Eсо-Vector