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

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.