key: cord-0784158-jgujyuj2
authors: Dell’Utri, Chiara; Manzoni, Elisabetta; Cipriani, Sonia; Spizzico, Claudio; Dell’Acqua, Andrea; Barbara, Giussy; Parazzini, Fabio; Kusterman, Alessandra
title: Effects of SARS Cov-2 epidemic on the Obstetrical and Gynecological Emergency Service accesses. What happened and what shall we expect now?()
date: 2020-09-07
journal: Eur J Obstet Gynecol Reprod Biol
DOI: 10.1016/j.ejogrb.2020.09.006
sha: b8b1489bc03f44e912aa9e34d3ec8d1d6b01d556
doc_id: 784158
cord_uid: jgujyuj2

OBJECTIVE: During the lockdown period, the fear about the risk of infection in hospital has reduced the admission to Emergency Services (ES) with possible negative health effects. We have investigated the changes in the emergency flow occurred during SARS-CoV-2 pandemic in an obstetrics and gynecological ES and the short-term adverse outcomes on women’s and reproductive health. STUDY DESIGN: The study was conducted in the OBGYN ES of the Clinica Mangiagalli, the largest maternity clinic of Milan, Lombardy, Northern Italy. We analyzed retrospectively the records of all women consecutively admitted at the ES from February 23(rd) to June 24(th) 2019, and compared them with the admissions during the lockdown executive order from February 23(rd) to June 23(rd), 2020. Patients were assessed in terms of demographic features, presentation times, triage classification (urgent/not urgent), reason for admission and outcome of the visit (discharge/admission to the ward). A total of 9291 data were retrieved from ES files and automation system, 5644 from 2019 and 3647 from 2020. Categorical variables were compared by the chi-square test calculating the p value and computed were percentage changes (with 95% Confidence interval, CI). RESULTS: During the period February 24 (th) - May 31 (th) 2020 the admissions at the ES decreased by 35.4% (95% CI—34.1 to 36.6) compared with the corresponding period in 2019. The reduction was more marked for gynecological complaints (-63.5%, 95%CI -60.5 to -66.5): in particular we observed a reduction of admissions for genital infection/cystitis of 75.7% (95%CI -71.4 to -80.1). The admission for complaints associated with pregnancy decreased by 28.5% (95%CI -27.2 to-29.9). In the index period, five fetal deaths were diagnosed compared with one observed in the reference period in 2019 (chi square computed using as denominator all observed pregnancies = 4.29, p = 0.04). The frequency of admission for elective caesarean section/labor induction increased from 47.5% in 2019 to 53.6% in 2020: this difference was statistically significant. CONCLUSION: The lockdown negatively influenced ES admissions and consequently the women’s/reproductive health. As possible short-term consequences, we observed an increase of intrauterine deaths and a decrease of natural births.

Key words: COVID-19, emergency service, birth, fetal death, pregnancy

The respiratory disease that emerged in December 2019 caused by a novel coronavirus SARS-COV-2 rapidly spread from the Chinese city of Wuhan worldwide, causing a serious public health emergency 1 . The World Health Organization (WHO) issued a warning and declared a world health emergency on January 31 st 2020, and on March 11 th 2020 declared the state of pandemic. Northern Italy became one of the epicenters of SARS CoV-2 pandemic in Europe, Lombardy being the most affected region. On 23 th February 2020, the Italian National Health Authority imposed in Lombardy limitations to movement of the population followed on 9 th March by a national lockdown, including also the temporary closure of non-essential shops and businesses. In the period 18 th May to 2 nd June, factories, bars, restaurants and barbers were reopened, but limitations to social contact were still present. During the whole period any movement for health reasons was always allowed. 

We retrospectively collected the data of women who were admitted respectively from February 23 rd to June 24 th , 2019, and 3647 during the lockdown executive order from February 23 rd to June 23 rd , 2020, in the Obstetrics and Gynecology ES of the Clinica Mangiagalli, the largest maternity clinic in Milan, Lombardy, Italy,

The difference between dates is due to the presence of the leap year in 2020, total days of observation where the same.

All consecutive women admitted to the ES during the considered periods were included, independently of their age or reason for admission.

We retrieved data from ES files and automation system. Patients were assessed in terms of demographic features, presentation times, triage classification (urgent/not urgent), reason for admission and outcome of the visit (discharge/admission to the ward).

The staff of the ES comprises registered obstetricians and gynecologists. Triage was conducted using a-four-level-classifications with corresponding colors (red/immediate priority, yellow/urgent priority; green/ less urgent priority, white/not urgent).

The number of newly diagnosed of SARS-CoV-2 infected cases in Lombardy was obtained by official data of Regional Health Authority 6. Percentage changes (with the corresponding 95% Confidence interval) in the absolute numbers observed in 2020 vs 2019 were also computed.

Given the retrospective observational nature of the study based on anonimous routine data base, approval by the Local Ethics Committee was not necessary.

During the period February 24 th -May 31 th 2020 a total of 3647 admissions were registered at the ES with a 35.4% reduction (95% CI -34.1 to-36.6) compared with the equivalent period in 2019.

The highest reduction rate was observed during the 5 th week analyzed, from March 22 nd to March 28 th 2020, which corresponds to the maximum increase of newly infected cases registered in Lombardy (Fig.1 ). Table 1 shows the distribution of admissions according selected demographic characteristics and reported complaints.

The decrease was about double among Italian than foreign women. In particular no decrease was observed among African women. We have also considered the changing trends in the main reasons of admission among pregnant women. The admissions due bleeding in pregnancy decreased by -46.6% (95%CI -51.9 to -41. 3 

This study analyzes the impact of the COVID-19 epidemic on an OBGYN ES.

In comparison to 2019, the ES admission rate observed during the lockdown period decreased significantly by 35.4%, the frequency of intrauterine fetal deaths diagnosed at admission increased and of natural deliveries decreased. The highest reduction rate was observed during the 5 th week analyzed, from March 22 nd to March 28 th 2020, which corresponds to the maximum increase of newly infected cases registered in our region.

During that weeks, the frightening effect that aroused from the media campaign reporting the struggle of the National Health Service, the constant display of dramatic images of hospitalized patients in intensive care units and the daily report of increasing number of deaths, critically increased the fear of the population and thus influenced the attitudes of women toward the search of care. This phenomenon has been recognized in Italy also for other specialties, such as cardiology 2,3 .

The reduction of the patient visits was higher in Italian than in foreign women. In particular no reduction was observed among African women. This difference may be due to the fact that African women live in a closed community, and most of them have less access to media information due to a language barrier. Moreover, analyzing the reasons for visits to ES of

African women it appears that they seek urgent care either for pregnancy related complications or for delivery and/or for severe menorrhagia, not for nonurgent issues (data not shown). During the whole lockdown period, private practice was allowed. Thus it is possible that Italian women, to avoid hospital access, chose more frequently a safer environment by asking for their General

Practitioner or private gynecologist. The number of women diagnosed with intrauterine fetal deaths at the ES confirmed by the absence of the heartbeat during the ultrasound at admission was relevant, increased from one case in 2019 to five cases in 2020. We hypothesize that the increase could have been due to the inclination of the women to wait longer for the visit, which resulted in underestimating important signs, such as the reduction of fetal movements felt by the mother, for hours or days.

The data shows a change in the mode of delivery, favoring the pre-planned induced births and the hospitalizations for chosen c-sections, compared to the natural births. It could have been due to the doctors advising the pregnant women to preplan their birth, so that they could feel safer knowing they would have a prefixed birth plan, given the uncertainty and the continuous changes related to the emergency situation of COVID-19.

Potential limitations of this analysis should be considered. We have analyzed data obtained by a routine data base, including only the main diagnosis/complaint of the woman attending the ES.

This limitation is, however, similar in both the considered periods. Among strengths we have to considered the large sample size.

In conclusion, our analysis shows that lockdown has had relevant impact on ES admission and consequently on the woman's health such as an increase of intrauterine fetal death, a decrease of natural birth and an increase, although in a not statistically significant way, of admission for menorrhagia requiring blood transfusion.

At the moment it is not possible to estimate the effect that the reduction of patient visits at the ES have on the long term health of the women general population, but some consequences due to under-or delayed diagnosis, for example of infections, can be expected.

We believe it's necessary to raise awareness to the correct use of hospitals and ESs, informing the population on how and when to use hospital services. An important focus should be teaching not to underestimate important signs and symptoms that could bring serious consequences, in the medium and long run, putting the mother and the fetus at risk also in case of a new lockdown.

J o u r n a l P r e -p r o o f Green line= number of registered cases of SARS-CoV2-infection in Lombardy; blue bar=2019, red bar=2020 CI= confidence interval UL= upper limit LL= lower limit . Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week 13

J o u r n a l P r e -p r o o f 

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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

The authors report no conflict of interest Funding No funding