Identifying pregnancies in insurance claims data: Methods and application to retinoid teratogenic surveillance

Epidemiology and Economic Burden of Diagnosed Congenital Cytomegalovirus Infection in the First 2 Years of Life among Commercially Insured and Medicaid-Insured Individuals in the United States

PURPOSE

Congenital cytomegalovirus (cCMV) is the leading infectious cause of congenital birth defects. Although approximately 20% to 25% of infants born with cCMV develop long-term health complications such as sensorineural hearing loss, developmental issues, and microcephaly, studies on the disease burden of cCMV are limited. In this study, we assessed the epidemiology, economic burden, and disease burden of clinically diagnosed cCMV in the United States using insurance claims data.

METHODS

This retrospective study utilized Merative MarketScan Commercial Claims and Encounters and Multi-State Medicaid data from 2010 to 2019. Annual prevalence of clinically diagnosed cCMV at birth was estimated separately for each payer population. To assess economic burden, infants whose first cCMV diagnosis (index date) was within 1 month of birth were included in the cCMV cohort and matched to infants without cCMV infection for whom an index date was selected at random from all medical claims within 1 month of birth. Cohorts were matched 1:1 on demographics, insurance type, birth, and index years. All infants were required to have ≥2 years of continuous enrollment with prescription drug coverage after the index date (study period). Health care resource use and costs in 2021 USD ($) were summarized separately for the first and second years of the study period. Costs for birth admissions were also described.

FINDINGS

The prevalence of clinically diagnosed cCMV at birth peaked in 2018 at 18.43 and 34.37 per 100,000 in the commercial and Medicaid populations, respectively. One hundred eighteen commercially insured (mean age at index date, 0.3 months; 46.6% female) and 351 Medicaid-insured matched pairs (mean age at index date, 0.2 months; 43.6% female) were included in the economic burden analyses. Mean (median) birth admission costs for commercially and Medicaid-insured infants with clinically diagnosed cCMV were $195,630 ($22,896; vs $24,195 [$3105]) and $57,182 ($9807; vs $5732 [$1566]), respectively. Additionally, excess costs due to cCMV in years 1 and 2 were $9427 ($5089) and $15,901 ($1573) for commercially insured, and $11,104 ($1446) and $12,205 ($721) for Medicaid-insured, respectively. Among potential cCMV sequelae, infants in the cCMV cohort experienced higher rates of hearing loss and developmental/motor delays during the first 2 years.

IMPLICATIONS

Diagnosed prevalence of cCMV at birth increased over time from 2010 to 2018. Infants with clinically diagnosed cCMV have costlier birth admissions and substantial disease burden in the first 2 years of life. These results emphasize the need for primary prevention methods, such as vaccination, to decrease the burden of cCMV.

Modern Evidence Generation on Medication Effectiveness and Safety During Pregnancy: Study Design Considerations

Non-randomized studies will remain the mainstay for evidence on medications' effects in pregnancy since the number of pregnant participants in randomized clinical trials is insufficient to evaluate uncommon but serious pregnancy outcomes. There has been a growing interest in conceptualizing causal inference based on observational data as an attempt to emulate a hypothetical randomized trial: the target trial. This approach can help identify design flaws and ensuing biases and can point toward potential solutions. Adoption of the target trial emulation framework in perinatal studies raises unique challenges due to the distinct role of gestational time. Challenges include, among others, identifying the timing of conception, pregnancy losses as competing events for later outcomes, different etiologically relevant time windows depending on the outcome, and time-varying outcome risks. We discuss various considerations in developing a protocol for a target trial evaluating drug effects in pregnancy and its observational emulation in databases and registries. While not a panacea, the framework offers a valuable tool to guide us through the specification of the causal questions, the study population and the treatment strategies to be compared and helps to identify avoidable biases as well as unavoidable deviations from the optimal protocol. Making these deviations explicit elucidates the assumptions we make when drawing causal conclusions, and the types of analyses that can be undertaken to quantify the potential magnitude of such biases. Such discipline in the design, conduct, and reporting of pregnancy studies will ultimately lead to the best information possible to inform treatment decisions during pregnancy.

Exposure to potentially teratogenic medications before and during the first trimester of pregnancy compared to women of childbearing age: A retrospective analysis of Swiss claims data (2015-2021)

INTRODUCTION

Exposure to potentially teratogenic medications during pregnancy is underinvestigated in Switzerland. We aimed to assess exposure to potential teratogens preconceptionally, during the first trimester, and in women of childbearing age, and specifically explore the effectiveness of the valproate pregnancy prevention program (2018).

MATERIAL AND METHODS

Retrospective study using the Swiss Helsana claims database. In a pregnancy cohort (2015-2021) and a cohort of women of childbearing age (2021 and 2018), we defined three 90-day time periods: (1) first trimester, (2) preconceptional period (days 180-90 before pregnancy), and (3) January 01, 2021, and March 31, 2021 (women of childbearing age). During all periods, we quantified the exposure prevalence to at least one dispensed weak, proven, and unequivocally potent teratogen overall and by age strata. We quantified the exposure prevalence to each individual teratogen, and to valproate during pregnancy by calendar year to compare its use before and after the introduction of a pregnancy prevention program (2018). We investigated the use of systemic retinoids particularly isotretinoin in women of childbearing age.

RESULTS

Of 34 584 pregnant women, 1.4% were exposed to potential teratogens during the first trimester (weak: 1.3%, proven: 0.06%, unequivocally potent: 0.04%). During the preconceptional period, 2.9% were exposed to any teratogen compared to 4.7% of women of childbearing age (Ntotal = 95 059). Systemic glucocorticoids were the most prevalent weak teratogens during all time periods (75% of all claimed teratogens during the first trimester). In the first trimester, the antibiotic cotrimoxazole and the thyreostatic thiamazole (weak teratogens), ranked second and third, followed by the antiseizure medications carbamazepine and topiramate (proven teratogens). Among women of childbearing age, exposure to weak and proven teratogens increased with age, whereas exposure to unequivocally potent teratogens decreased with age. This was due to 2.3% of women <26 years who claimed systemic isotretinoin. Valproate use during pregnancy decreased after the introduction of a pregnancy prevention program (2.39/10 000 pregnancies [2015-2018] vs. 0.93/10 000 pregnancies [2019-2021]).

CONCLUSIONS

Most medications with potential teratogenic effects dispensed to women of childbearing age and pregnant women were in the group of weak teratogenicity level, and many women discontinued treatment before pregnancy. Preliminary evidence suggests the valproate pregnancy prevention program in Switzerland may be beneficial.

Development of a Pregnancy Cohort in Commercial Insurance Claims Data: Evaluation of Deliveries Identified From Inpatient Versus Outpatient Claims

PURPOSE

Studies using insurance claims data to identify pregnancies are rarely able to directly assess the validity of the pregnancy/delivery. Inpatient versus outpatient delivery claims may provide different levels of evidence, but more stringent requirements could result in exclusion of true pregnancies. We identified delivery codes from the inpatient and outpatient settings and examined possible confirmatory evidence suggesting that a delivery truly occurred.

METHODS

Using a US commercial insurance database (2006-2021), we identified potential pregnancies by presence of delivery claims from a provider and/or facility. We classified deliveries as inpatient (claim date during inpatient admission) or outpatient (claim date not during inpatient admission). We identified possible confirmatory evidence for each delivery including: (1) Presence of both provider and facility delivery codes; (2) presence of both diagnosis and procedure delivery codes; (3) labor and delivery revenue codes; (4) gestational age diagnosis codes; (5) pregnancy-related care codes; (6) linkage to an infant claim; and (7) infant insurance enrollment and linkage to a birthing parent. We quantified the proportion of deliveries with confirmatory evidence by delivery setting. Among deliveries with ≥ 1 piece of confirmatory evidence, we compared patient characteristics by apparent delivery setting.

RESULTS

Among 4 084 474 delivery episodes, 96.4% were classified as inpatient and 3.6% outpatient. 99.9% of inpatient and 94.0% of outpatient deliveries had ≥ 1 piece of confirmatory evidence. Pregnancy-related care codes were the most common type of confirmatory evidence (99.0% inpatient, 85.7% outpatient). Deliveries classified as inpatient occurred among patients who were older and more clinically complex (i.e., more pregnancy complications, chronic diseases, and prescription medications).

CONCLUSIONS

The vast majority of deliveries had confirmatory evidence regardless of apparent setting. Patient characteristics differed by delivery setting. Inclusion of apparent outpatient deliveries may increase the sample size of the study population and improve the generalizability of study results.

PregMedNet: Multifaceted Maternal Medication Impacts on Neonatal Complications

While medication intake is common among pregnant women, medication safety remains underexplored, leading to unclear guidance for patients and healthcare professionals. PregMedNet addresses this gap by providing a multifaceted maternal medication safety framework based on systematic analysis of 1.19 million mother-baby dyads from U.S. claims databases. A novel confounding adjustment pipeline was applied to systematically control confounders for multiple medication-disease pairs, robustly identifying both known and novel maternal medication effects. Notably, one of the newly discovered associations was experimentally validated, demonstrating the reliability of claims data and machine learning for perinatal medication safety studies. Additionally, potential biological mechanisms of newly identified associations were generated using a graph learning method. These findings highlight PregMedNet's value in promoting safer medication use during pregnancy and maternal-neonatal outcomes.

Utilisation patterns of immunomodulators and pregnancy outcomes in systemic lupus erythematosus: Insights from Korean national data

OBJECTIVES

To investigate the trends in immunomodulator use and pregnancy outcomes among pregnant women with systemic lupus erythematosus (SLE), a condition requiring medication to maintain disease activity.

METHODS

This descriptive study used data from the National Health Information Database in Korea from 2002 to 2018. We included 5,044 pregnancies initiated between 2005 and 2017 in 3,120 SLE patients. Annual trends in SLE therapy, drug utilisation patterns during the preconception and pregnancy periods, and pregnancy outcomes were analysed.

RESULTS

Pregnancy compatible immunosuppressant (PC-IS) and hydroxychloroquine use during the first trimester were 10.7% and 41.4%, respectively. Most SLE medications exhibited a decline in usage from the preconception period to the first trimester. A prescription rate of 0.9% for pregnancy incompatible immunosuppressants (PIC-IS) was observed during the first trimester, and the incidence of live births, stillbirths, and abortions remained consistent from 2005 to 2017.

CONCLUSIONS

Insufficient usage of hydroxychloroquine and PC-IS, along with a reduction in PIC-IS usage primarily during early pregnancy rather than before conception, highlights the unmet need for preconceptional family planning with appropriate medication management strategies in SLE pregnancies.

Contemporary Burden of Cardiovascular Disease in Pregnancy: Insights from a Real-World Pregnancy Electronic Health Record Cohort

Importance

Cardiovascular disease (CVD) is the leading cause of maternal morbidity and mortality, however the contemporary burden and secular trends in pregnancy-related CV complications are not well characterized.

Objective

We sought to examine contemporary trends in prevalence of maternal cardiometabolic comorbidities and established CVD, as well as future pregnancy-related CV complications across a large multi-institutional health system.

Design

Retrospective analysis of longitudinal electronic health record (EHR)-based cohort of pregnancies.

Setting

Multi-institutional healthcare network in New England.

Participants

Pregnancy encounters between 2001 to 2019 identified using diagnosis and procedure codes followed by manual adjudication within a previously validated primary care EHR cohort. Estimated gestational ages recovered from unstructured notes using regular expressions (RegEx) were used to define individual pregnancy episodes.

Main Outcomes and Measures

We quantified the prevalence of maternal cardiometabolic comorbidities and established CVD at time of pregnancy, as well as the incidence of pregnancy-related CV complications assessed within 1 year postpartum. We examined trends in cardiometabolic risk factors and CVD burden over nearly two decades.

Results

Our EHR pregnancy cohort comprised 57,683 pregnancies among 38,997 individuals (mean age range at start of pregnancy 27 to 37 years). RegEx recovered gestational age for 74% of pregnancies, with good correlation between gestational age ascertained via RegEx vs manual review (Pearson r 0.9). Overall prevalence of maternal CVD was 4% (age-adjusted 7%) and increased over 19 years of follow-up (age-adjusted prevalence of maternal CVD: 1% in 2001 to 7% in 2019, p <0.001). The incidence of pregnancy-related CV complications was 15% (age-adjusted 17%) and also increased over the follow-up period (age-adjusted incidence 11% in 2001 to 14% in 2019, p <0.001). Finally, CV complications were more likely to occur in individuals with greater burden of maternal CV comorbidities and CVD (diabetes: 6% vs 3%, hypertension: 23% vs 5%, pre-existing CVD: 10% vs 3%, P<0.001 for all).

Conclusions and Relevance

Analysis of a large-scale EHR-based pregnancy cohort spanning two decades demonstrates rising prevalence of both maternal cardiometabolic comorbidities and CVD at the time of pregnancy, as well as increasing incidence of subsequent pregnancy-related CV complications. Pregnancy represents a critical opportunity for cardiometabolic health optimization.

KEY POINTS

Question: What are the contemporary real-world trends in the prevalence of maternal cardiovascular comorbidities and cardiovascular disease and incidence of cardiovascular complications in pregnancy?Findings: In an analysis of 57,683 pregnancies among 38,997 individuals from a large scale EHR-based pregnancy cohort, prevalence of maternal cardiometabolic comorbidities and cardiovascular disease and incidence of pregnancy-related cardiovascular complications increased over the course of nearly two decades.Meaning: The contemporary burden of pregnancy-related cardiovascular complications is rising at an alarming rate and highlights pregnancy as a critical opportunity for cardiovascular health optimization.

Association of Opioid Use Disorder-Related Service Trajectories during Pregnancy and Postpartum Health Service Use: A Group-Based Multitrajectory Modeling Study

OBJECTIVE

The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations.

METHODS

We used the Merative MarketScan Commercial Claims and Encounters Database (2013-2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization.

RESULTS

Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits (HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered ≥80%) alone, both throughout or in the latter half of pregnancy (HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services (HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy (HRHOS = 2.33), or in the latter half, with or without services (HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services (HRHOS = 1.73).

CONCLUSIONS

Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

Using national in vitro fertilization registries to validate clinical outcomes after in vitro fertilization covered by health insurance

OBJECTIVE

To evaluate in vitro fertilization (IVF) cycles covered by health insurance using a national commercial claims database and validate key clinical events against national IVF registries.

DESIGN

Retrospective cohort study.

PATIENTS

US women aged 20-44 years who underwent IVF from 2005-2020 in Optum's deidentified Clinformatics Data Mart Database (CDM).

INTERVENTION

Undergoing IVF.

MAIN OUTCOME MEASURES

In vitro fertilization cycles and rates of pregnancies (inclusive of losses and terminations), live births, and live birth types (e.g., singleton, twin, and triplet or higher-order).

RESULTS

We identified more than 3,000 IVF cycles in each year from 2005-2020 within CDM. When comparing our rates of clinical outcomes with external benchmark data, the results were similar across all the years of our study. For example, in 2020, the percentages of pregnancies after first embryo transfer were 62.03% (95% confidence interval [CI], 59.48-64.47) in CDM and 64.96% in data from the Society for Assisted Reproductive Technology (SART). The rates of live birth after first embryo transfer were 44.58% (95% CI, 41.90-47.21) in CDM in 2020 and 46.95% in SART in 2020. The rate of singleton births was 94.17% (95% CI, 92.24-96.10) in CDM in 2020, and this rate was 94.37% in SART in 2020. For twin births, the rates were 5.48% (95% CI, 3.60-7.35) in CDM in 2020 and 5.46% in SART in 2020. The rates of triplet or higher-order births were 0.35% (95% CI, 0.00-0.84) in CDM in 2020 and 0.17% in SART in 2020.

CONCLUSIONS

We found that CDM can be used to accurately identify IVF cycles covered by insurance and key clinical outcomes such as rates of pregnancies, live births, and live birth types, and our reported rates were similar to national IVF clinical registry data. Our findings support that CDM is a robust data source to conduct research about IVF insurance coverage and can accurately evaluate clinical outcomes resulting from IVF. Policymakers who are considering insurance coverage for IVF can use CDM to model and measure the impact of new or existing policies for IVF insurance coverage.

Lithium Use During Pregnancy in 14 Countries

Importance

In pregnancy, the benefits of lithium treatment for relapse prevention in psychiatric conditions must be weighed against potential teratogenic effects. Currently, there is a paucity of information on how and when lithium is used by pregnant women.

Objective

To examine lithium use in the perinatal period.

Design, Setting, and Participants

This cohort study used individual-level data of pregnancies from January 1, 2000, to December 31, 2021, in Australia, Denmark, Finland, Germany, Hong Kong, Iceland, Israel, New Zealand, Norway, South Korea, Sweden, Taiwan, the UK, and 2 cohorts in the US. Analyses were performed from September 1 to November 30, 2023.

Exposures

The prevalence of lithium use as the proportion of pregnancies with at least 1 prescription fill or prescription within 3 months before pregnancy until childbirth was estimated using a common protocol. Lithium use during pregnancy by trimester and in the 3 months before and after pregnancy was examined.

Main Outcomes and Measures

Comparison of prevalence between the first and last 3-year periods of available data.

Results

Among 21 659 454 pregnancies from all collaborating sites, the prevalence of lithium use ranged from 0.07 per 1000 pregnancies in Hong Kong to 1.56 per 1000 in the US publicly insured population. Lithium use increased per 1000 pregnancies in 10 populations (Australia [0.60 to 0.74], Denmark [0.09 to 0.51], Finland [0.10 to 0.29], Iceland [0.24 to 0.99], Israel [0.25 to 0.37], Norway [0.24 to 0.47], South Korea [0.30 to 0.44], Sweden [0.42 to 1.07], the UK [0.07 to 0.10], and Taiwan [0.15 to 0.19]), remained stable in 4 populations (Germany [0.17 to 0.16], Hong Kong [0.06 to 0.06], and the publicly [1.50 to 1.34] and commercially [0.38 to 0.36] insured US populations), and decreased in 1 population (New Zealand [0.54 to 0.39]). Use of lithium decreased with each trimester of pregnancy, while prevalence of postpartum use was similar to prepregnancy levels. The proportion of lithium use in the second trimester compared with the prepregnancy period ranged from 2% in South Korea to 80% in Denmark.

Conclusions and Relevance

Prevalence of lithium use in pregnant women over the past 2 decades varied markedly between populations. Patterns of use before, during, and after pregnancy suggest that many women discontinued lithium use during pregnancy and reinitiated treatment after childbirth, with large variations between countries. These findings underscore the need for internationally harmonized guidelines, specifically for psychiatric conditions among pregnant women that may benefit from lithium treatment.

Changes in Postpartum Opioid Prescribing After Implementation of State Opioid Prescribing Limits

Importance

In response to the growing opioid crisis, states implemented opioid prescribing limits to reduce exposure to opioid analgesics. Research in other clinical contexts has found that these limits are relatively ineffective at changing opioid analgesic prescribing.

Objective

To examine the association of state-level opioid prescribing limits with opioid prescribing within the 30-day postpartum period, as disaggregated by type of delivery (vaginal vs cesarean) and opioid naivete.

Design, Setting, and Participants

This retrospective, observational cohort study used commercial claims data from January 1, 2014, to December 31, 2021, from 49 US states and a difference-in-differences staggered adoption estimator to examine changes in postpartum opioid prescribing among all deliveries to enrollees between the ages of 18 and 44 years in the US.

Exposures

The implementation of a state opioid prescribing limit between 2017 and 2019.

Main Outcomes and Measurements

The primary outcomes for this analysis were the number of prescriptions for opioid analgesics, proportion of prescriptions with a supply greater than 7 days, and milligrams of morphine equivalent (MMEs) per delivery between 3 days before and 30 days after delivery.

Results

A total of 1 572 338 deliveries (enrollee mean [SD] age, 30.20 [1.59] years) were identified between 2014 and 2021, with 32.3% coded as cesarean deliveries. A total of 98.4% of these were to opioid-naive patients. The mean MMEs per delivery was 310.79, with higher rates in earlier years, states that had an opioid prescribing limit, and cesarean deliveries. In a covariate-adjusted difference-in-differences regression analysis, opioid prescribing limits were associated with a decrease of 148.70 MMEs per delivery (95% CI, -657.97 to 360.57) compared with states without such limits. However, these changes were not statistically significant. The pattern of results was similar among other opioid-prescribing outcomes and types of deliveries.

Conclusions and Relevance

The results of this cohort study suggest that opioid prescribing limits are not associated with changes in postpartum opioid prescribing regardless of delivery type or opioid naivete, which is consistent with research findings on these limits in other conditions or settings. Future research could explore what kinds of prevention mechanisms reduce the risk of opioid prescribing during pregnancy and postpartum.

Incidence of induced abortion among commercially insured pregnant patients with cancer

OBJECTIVES

This study aimed to characterize pregnancy outcomes and the incidence of induced abortion among pregnant people with a diagnosis of malignancy.

STUDY DESIGN

We conducted a retrospective cohort study among privately insured people aged 12 to 55 years from the fourth quarter of 2015-2020 using US claims data from Merative MarketScan Research Databases. We included pregnancies from seven states with favorable policies for private insurance coverage of abortion.

RESULTS

There were 1471 of 183,685 (0.8%) pregnancies with a cancer diagnosis. Among those receiving anticancer therapy, 21.6% (95% CI: 14.4-30.4%) underwent induced abortion compared with 10.9% (95% CI: 10.8-11.1%) of pregnant patients without a cancer diagnosis.

CONCLUSIONS

Abortion restrictions may affect many pregnant women requiring cancer treatment in early pregnancy.

The Awareness of and Adherence to the Pregnancy Prevention Program for Oral Retinoids: A Questionnaire Survey in Denmark

PURPOSE

We aimed to investigate the awareness of oral retinoid teratogenicity and the adherence to the pregnancy prevention program (PPP) related to oral retinoid use by physicians, pharmacists, and patients in Denmark.

METHODS

As part of the multi-country survey, web-based questionnaires were distributed among Danish dermatologists, general practitioners, community pharmacists, and women of childbearing age, who were using or had used oral retinoids within the past 5 years.

RESULTS

A total of 62 physicians, 96 pharmacists, and 50 oral retinoid using women responded; 95%, 100%, and 98%, respectively, were aware of the teratogenic risks of oral retinoids. For physicians, the most applied PPP measures were the usage of the patient (44%) and the healthcare professional (19%) guides, while the least applied measure was signing medication risk awareness form (3%). Among the pharmacists, the warning sign on the outer medication package was the most used measure (45%). Among the women, a majority (90%) had read the patient information leaflet included in the medication package and 72% discussed the use of contraception with their healthcare provider, while risk awareness forms and patient cards were seen by only few.

CONCLUSIONS

In Denmark, physicians, pharmacists, and medicine users were aware about the teratogenic effects of oral retinoids. Adherence to pregnancy prevention measures varied, suggesting unwillingness to use the measures that require patients' signatures among physicians and a lack of awareness of pharmacy targeting measures. Accessibility of the latter measures need to be optimized to improve the safety of oral retinoid use.

TNF-α inhibitor use during pregnancy and the risk of preeclampsia: population-based cohort study

BACKGROUND

Although the clinical importance of preeclampsia is widely recognized, few treatment options are available for prevention. TNF-α inhibitors have been hypothesized to potentially prevent the disease. We aimed to examine whether exposure to TNF-α inhibitors during pregnancy reduces the risk of preeclampsia.

METHODS

We conducted a population-based pregnancy cohort study using nationwide samples of publicly (Medicaid data, 2000-2018) and commercially (MarketScan Research Database, 2003-2020) insured pregnant women linked to their liveborn infants. Exposure was ascertained based on a filled prescription or administration code for TNF-α inhibitors during the first and second trimester of pregnancy. The outcomes included early-onset preeclampsia, late-onset preeclampsia, and small-for-gestational age. For baseline confounding adjustment, we leveraged propensity score overlap weights to estimate risk ratios (RR).

RESULTS

Among 4 315 658 pregnancies in the Medicaid and the MarketScan cohort, 2736 (0.063%) were exposed to TNF-α inhibitors during the first trimester and 1712 (0.040%) during the second trimester. After adjustment, the risk of early-onset preeclampsia was not decreased among mothers exposed during the first trimester compared with unexposed women with treatment indications [RR pooled : 1.25, 95% confidence interval (CI) 0.93-1.67]. Similarly, the risk of late-onset preeclampsia was not decreased among mothers exposed during the second trimester compared with unexposed women (RR pooled : 0.99, 95% CI 0.81-1.22).

CONCLUSION

Contrary to the hypothesis, exposure to TNF-α inhibitors during pregnancy did not appear to be associated with a reduced risk of early-onset or late-onset preeclampsia. These findings do not support consideration of the use of TNF-α inhibitors for the prevention of preeclampsia.

Perinatal Outcomes Associated With Metformin Use During Pregnancy in Women With Pregestational Type 2 Diabetes Mellitus

OBJECTIVE

We emulated a modified randomized trial (Metformin in Women With Type 2 Diabetes in Pregnancy [MiTy]) to compare the perinatal outcomes in women continuing versus discontinuing metformin during pregnancy among those with type 2 diabetes treated with metformin plus insulin before pregnancy.

RESEARCH DESIGN AND METHODS

This study used two health care claims databases (U.S., 2000-2020). Pregnant women age 18-45 years with type 2 diabetes who were treated with metformin plus insulin at conception were eligible. The primary outcome was a composite of preterm birth, birth injury, neonatal respiratory distress, neonatal hypoglycemia, and neonatal intensive care unit admission. Secondary outcomes included the components of the primary composite outcome, gestational hypertension, preeclampsia, maternal hypoglycemia, cesarean delivery, infants large for gestational age, infants small for gestational age (SGA), sepsis, and hyperbilirubinemia. We adjusted for potential baseline confounders, including demographic characteristics, comorbidities, and proxies for diabetes progression.

RESULTS

Of 2,983 eligible patients, 72% discontinued use of metformin during pregnancy. The average age at conception was 32 years, and the prevalence of several comorbidities was higher among continuers. The risk of the composite outcome was 46% for continuers and 48% for discontinuers. The adjusted risk ratio was 0.92 (95% CI 0.81, 1.03). Risks were similar between treatments and consistent between databases for most secondary outcomes, except for SGA, which was elevated in continuers only in the commercially insured population.

CONCLUSIONS

Our findings were consistent with those reported in the MiTy randomized trial. Continuing metformin during pregnancy was not associated with increased risk of a neonatal composite adverse outcome. However, a possible metformin-associated risk of SGA warrants further consideration.

Dispensed drugs during pregnancy in outpatient care between 2015 and 2021 in Switzerland: a retrospective analysis of Swiss healthcare claims data

AIM OF THE STUDY

We aimed to evaluate the utilisation of all prescribed drugs during pregnancy dispensed in outpatient care in Switzerland between 2015 and 2021.

METHODS

We conducted a descriptive study using the Swiss Helsana claims database (2015-2021). We established a cohort of pregnancies by identifying deliveries and estimating the date of the last menstrual period. We analysed the drug burden during a 270-day pre-pregnancy period, during pregnancy (overall and by trimester), and during a 270-day postpartum period. Subsequently, we quantified 1) the median number of drug dispensations (total vs. unique drug claims); and 2) the prevalence of exposure to at least one dispensed drug and the number of dispensed drugs (0, 1, 2, 3, 4, and ≥5); and 3) the 15 most frequently dispensed drugs were identified during each period, overall and stratified by maternal age.

RESULTS

Among 34,584 pregnant women (5.6% of all successful pregnancies in Switzerland), 87.5% claimed at least one drug (not including vitamins, supplements, and vaccines), and 33.3% claimed at least five drugs during pregnancy. During trimester 1 alone, 8.2% of women claimed at least five distinct drugs. The proportion of women who claimed prescribed drugs was lower pre-pregnancy (69.1%) and similar postpartum (85.6%) when compared to during pregnancy (87.5%). The most frequently claimed drugs during pregnancy were meaningfully different during pregnancy than before and after.

CONCLUSIONS

This study suggests that 8 of 10 women in Switzerland are exposed to prescribed drugs during pregnancy. Most drugs dispensed during pregnancy are comparatively well investigated and are considered safe. However, the high drug burden in this vulnerable patient population underlines the importance of evidence on the benefit-risk profile of individual drugs taken during pregnancy.

Hierarchical Clustering Analysis to Inform Classification of Congenital Malformations for Surveillance of Medication Safety in Pregnancy

There is growing interest in the secondary use of healthcare data to evaluate medication safety in pregnancy. Tree-based scan statistics (TBSS) offer an innovative approach to help identify potential safety signals. TBSS utilize hierarchically organized outcomes, generally based on existing clinical coding systems that group outcomes by organ system. When assessing teratogenicity, such groupings often lack a sound embryologic basis given the etiologic heterogeneity of congenital malformations. The study objective was to enhance the grouping of congenital malformations to be used in scanning approaches through implementation of hierarchical clustering analysis (HCA) and to pilot test an HCA-enhanced TBSS approach for medication safety surveillance in pregnancy in two test cases using >4.2 million mother-child dyads from two US-nationwide databases. HCA identified (1) malformation combinations belonging to the same organ system already grouped in existing classifications, (2) known combinations across different organ systems not previously grouped, (3) unknown combinations not previously grouped, and (4) malformations seemingly standing on their own. Testing the approach with valproate and topiramate identified expected signals, and a signal for an HCA-cluster missed by traditional classification. Augmenting existing classifications with clusters identified through large data exploration may be promising when defining phenotypes for surveillance and causal inference studies.

Internal validation of gestational age estimation algorithms in health-care databases using pregnancies conceived through fertility procedures

Fertility procedures recorded in health-care databases can be used to estimate the start of pregnancy, which can serve as a reference standard to validate gestational age estimates based on International Classification of Diseases codes. In a cohort of 17 398 US MarketScan pregnancies (2011-2020) in which conception was achieved via fertility procedures, we estimated gestational age at the end of pregnancy using algorithms based on (1) time (days) since the fertility procedure (the reference standard); (2) International Classification of Diseases, Ninth Revision (ICD-9)/International Classification of Diseases, Tenth Revision (ICD-10) (before/after October 2015) codes indicating gestational length recorded at the end of pregnancy (method A); and (3) ICD-10 end-of-pregnancy codes enhanced with Z3A codes denoting specific gestation weeks recorded at prenatal visits (method B). We calculated the proportion of pregnancies with an estimated gestational age falling within 14 days ($\pm$14 days) of the reference standard. Method A accuracy was similar for ICD-9 and ICD-10 codes. After 2015, method B was more accurate than method A: For term births, within-14-day agreement was 90.8% for method A and 98.7% for method B. Corresponding estimates were 70.1% and 95.6% for preterm births; 35.3% and 92.6% for stillbirths; 54.3% and 64.2% for spontaneous abortions; and 16.7% and 84.6% for elective terminations. ICD-10-based algorithms that incorporate Z3A codes improve the accuracy of gestational age estimation in health-care databases, especially for preterm births and non-live births.

Chronic Hypertension During Pregnancy: Prevalence and Treatment in the United States, 2008-2021

BACKGROUND

Treatment of chronic hypertension during pregnancy has been shown to reduce the risk of adverse perinatal outcomes. In this study, we examined the prevalence and treatment of chronic hypertension during pregnancy and assessed changes in these outcomes following the release of the updated 2017 hypertension guidelines of the American College of Cardiology and American Heart Association.

METHODS

We analyzed the MerativeTM Marketscan® Research Database of United States commercial insurance claims from 2007 to 2021. We assessed the prevalence of chronic hypertension during pregnancy and oral antihypertensive medication use over time. We then performed interrupted time series analyses to evaluate changes in these outcomes.

RESULTS

The prevalence of chronic hypertension steadily increased from 1.8% to 3.7% among 1 900 196 pregnancies between 2008 and 2021. Antihypertensive medication use among pregnant individuals with chronic hypertension was relatively stable (57%-60%) over the study period. The proportion of pregnant individuals with chronic hypertension treated with methyldopa or hydrochlorothiazide decreased (from 29% to 2% and from 11% to 5%, respectively), while the proportion treated with labetalol or nifedipine increased (from 19% to 42% and from 9% to 17%, respectively). The prevalence or treatment of chronic hypertension during pregnancy did not change following the 2017 American College of Cardiology and American Heart Association hypertension guidelines.

CONCLUSIONS

The prevalence of chronic hypertension during pregnancy doubled between 2008 and 2021 in a nationwide cohort of individuals with commercial insurance. Labetalol replaced methyldopa as the most commonly used antihypertensive during pregnancy. However, only about 60% of individuals with chronic hypertension in pregnancy were treated with antihypertensive medications.

Patterns of paternal medication dispensation around the time of conception

BACKGROUND

Past research on the safety of prenatal exposure to medications has focused on maternal use during gestation, with limited research into the potential effects of paternal use during the spermatogenic period preceding conception. Knowing the most common medications used by fathers around the time of conception can inform research priorities in this field.

OBJECTIVES

To identify the most common medications dispensed to fathers in the preconception period.

METHODS

Within the MarketScan research database of commercially insured individuals in the United States from 2011 to 2020, we identified pregnancies, estimated the date of conception, linked each pregnancy to the father using family enrolment information and required minimum enrolment period and prescription benefits. Then, we described the use of prescription medications by the father during the 90 days before conception based on pharmacy dispensation claims.

RESULTS

Of 4,437,550 pregnancies, 51.6% were linked with a father. Among the 1,413,762 pregnancies connected with a father that also met the inclusion criteria, the most common classes of medications dispensed were psychotropics (8.66%), antibiotics (7.21%), and analgesics (6.82%). The most frequently dispensed medications were amoxicillin (3.75%), azithromycin (3.15%), fluticasone (2.70%) and acetaminophen/hydrocodone (2.70%). Some fathers filled prescriptions for medications associated with foetal embryopathy when used by the mother, including mycophenolate (0.04%), methotrexate (0.03%) and isotretinoin (0.02%).

CONCLUSIONS

More than a third of fathers filled at least one prescription medication in the preconception period, and several of them are known to be embryotoxic, emphasizing the necessity for further investigation into the potential teratogenicity of paternal exposure.

Prescription medication use during pregnancy in the United States from 2011 to 2020: trends and safety evidence

BACKGROUND

Medication use during pregnancy has increased in the United States despite the lack of safety data for many medications.

OBJECTIVE

This study aimed to inform research priorities by examining trends in medication use during pregnancy and identifying gaps in safety information on the most commonly prescribed medications.

STUDY DESIGN

We identified population-based cohorts of commercially (MarketScan 2011-2020) and publicly (Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files 2011-2018) insured pregnancies ending in live birth from 2 health care utilization databases. Medication use was based on filled prescriptions between the date of last menstrual period through delivery, as well as the period before the last menstrual period and during specific trimesters. We also included a cross-sectional representative sample of pregnancies ascertained by the National Health and Nutrition Examination Survey (2011-2020), with information on prescription medication use during the preceding month obtained through maternal interviews. Teratogen Information System was used to classify the available evidence on teratogenic risk.

RESULTS

Among over 3 million pregnancies, the medications most commonly dispensed at any time during pregnancy were analgesics, antibiotics, and antiemetics. The top medications were ondansetron (16.8%), amoxicillin (13.5%), and azithromycin (12.4%) in MarketScan, nitrofurantoin (22.2%), acetaminophen (21.3%; mostly as part of acetaminophen-hydrocodone products), and ondansetron (19.5%) in Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files, and levothyroxine (5.0%), sertraline (2.9%), and insulin (2.9%) in the National Health and Nutrition Examination Survey group. The most commonly dispensed suspected teratogens during the first trimester were antithyroid medications. The use of antidiabetic and psychotropic medications has continued to increase in the United States during the last decade, opioid dispensation has decreased by half, and antibiotics and antiemetics continue to be common. For one-quarter of medications, there is insufficient evidence available to characterize their safety profile in pregnancy.

CONCLUSION

There is a need for more drug research in pregnant patients. Future research should focus on anti-infectives with high utilization and limited level of evidence on safety for use during pregnancy. Although lack of evidence is not evidence of safety concerns, it does not indicate risk either. In many instances, the benefits outweigh the risks when these medications are used clinically, and some of the medications with no proven safety may be necessary to treat patients.

Metformin Use in the First Trimester of Pregnancy and Risk for Nonlive Birth and Congenital Malformations: Emulating a Target Trial Using Real-World Data

BACKGROUND

Metformin is a first-line pharmacotherapy for type 2 diabetes, but there is limited evidence about its safety in early pregnancy.

OBJECTIVE

To evaluate the teratogenicity of metformin use in the first trimester of pregnancy.

DESIGN

In an observational cohort of pregnant women with pregestational type 2 diabetes receiving metformin monotherapy before the last menstrual period (LMP), a target trial with 2 treatment strategies was emulated: insulin monotherapy (discontinue metformin treatment and initiate insulin within 90 days of LMP) or insulin plus metformin (continue metformin and initiate insulin within 90 days of LMP).

SETTING

U.S. Medicaid health care administration database (2000 to 2018).

PARTICIPANTS

12 489 pregnant women who met the eligibility criteria.

MEASUREMENTS

The risk and risk ratio of nonlive births, live births with congenital malformations, and congenital malformations among live births were estimated using standardization to adjust for covariates.

RESULTS

A total of 850 women were in the insulin monotherapy group and 1557 in the insulin plus metformin group. The estimated risk for nonlive birth was 32.7% under insulin monotherapy (reference) and 34.3% under insulin plus metformin (risk ratio, 1.02 [95% CI, 1.01 to 1.04]). The estimated risk for live birth with congenital malformations was 8.0% (CI, 5.7% to 10.2%) under insulin monotherapy and 5.7% (CI, 4.5% to 7.3%) under insulin plus metformin (risk ratio, 0.72 [CI, 0.51 to 1.09]).

LIMITATION

Possible residual confounding by glycemic control and body mass index.

CONCLUSION

Compared with switching to insulin monotherapy, continuing metformin and adding insulin in early pregnancy resulted in little to no increased risk for nonlive birth among women receiving metformin before pregnancy. Under conventional statistical criteria, anything between a 49% decrease and a 9% increase in risk for congenital malformations was highly compatible with our data.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Use of Real-World Data and Machine Learning to Screen for Maternal and Paternal Characteristics Associated with Cardiac Malformations

Effective prevention of cardiac malformations, a leading cause of infant morbidity, is constrained by limited understanding of etiology. The study objective was to screen for associations between maternal and paternal characteristics and cardiac malformations. We selected 720,381 pregnancies linked to live-born infants (n=9,076 cardiac malformations) in 2011-2021 MarketScan US insurance claims data. Odds ratios were estimated with clinical diagnostic and medication codes using logistic regression. Screening of 2,000 associations selected 81 associated codes at the 5% false discovery rate. Grouping of selected codes, using latent semantic analysis and the Apriori-SD algorithm, identified elevated risk with known risk factors, including maternal diabetes and chronic hypertension. Less recognized potential signals included maternal fingolimod or azathioprine use. Signals identified might be explained by confounding, measurement error, and selection bias and warrant further investigation. The screening methods employed identified known risk factors, suggesting potential utility for identifying novel risk factors for other pregnancy outcomes.

Hydroxychloroquine in Lupus Pregnancy and Risk of Preeclampsia

OBJECTIVE

Systemic lupus erythematosus (SLE) disproportionately affects women during childbearing years, and hydroxychloroquine (HCQ) is the standard first-line treatment. Preeclampsia complicates up to one-third of pregnancies in lupus patients, although reports vary by parity and multifetal gestation. We investigated whether taking HCQ early in pregnancy may reduce the risk of preeclampsia.

METHODS

We studied 1,068 live birth singleton pregnancies among 1,020 privately insured patients with SLE (2007-2016). HCQ treatment was defined as three months preconception through the first trimester, and prescription fills were a proxy for taking HCQ. Modified Poisson regression estimated risk ratios (RRs) and 95% confidence intervals (CIs), stratified by parity. Propensity scores accounted for confounders, and stratified analyses examined effect modification.

RESULTS

Approximately 15% of pregnant patients were diagnosed with preeclampsia. In 52% of pregnancies, patients had one or more HCQ fills. Pregnant patients exposed to HCQ had more comorbidities, SLE activity, and azathioprine treatment. We found no evidence of a statistical association between HCQ and preeclampsia among nulliparous (RR 1.26 [95% CI 0.82-1.93]) and multiparous pregnancies (RR 1.20 [95% CI 0.80-1.70]). Additional controls for confounding decreased the RRs toward the null (nulliparous pregnancy, propensity score-adjusted [PS-adj] RR 1.09 [95% CI 0.68-1.76]; multiparous pregnancy, PS-adj RR 1.01 [95% CI 0.66-1.53]).

CONCLUSION

Using a large insurance-based database, we did not observe a decreased risk of preeclampsia associated with HCQ treatment in pregnancy, although we cannot rule out residual and unmeasured confounding and misclassification. Further studies leveraging large population-based data and prospective collection could characterize how HCQ influences preeclampsia risk in pregnant patients with SLE and among persons at greater risk of hypertensive disorders of pregnancy.

Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Signs or symptoms of suspected preeclampsia - A retrospective national database study of prevalence, costs, and outcomes

BACKGROUND

Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia.

METHODS

This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control).

RESULTS

Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control).

CONCLUSION

There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management.

Antihypertensive Medication Use before and during Pregnancy and the Risk of Severe Maternal Morbidity in Individuals with Prepregnancy Hypertension

OBJECTIVE

Our objective is to examine severe maternal morbidity (SMM) and patterns of antihypertensive medication use before and during pregnancy among individuals with chronic hypertension.

STUDY DESIGN

We examined 11,759 pregnancies resulting in a live birth or stillbirth to individuals with chronic hypertension and one or more antihypertensive prescription 6 months before pregnancy (Optum, 2007-17). We examined whether study outcomes were associated with the use of medication as compared to no use during pregnancy. In addition, patterns of medication use based on the Food and Drug Administration guidance and literature were evaluated. Medication use was divided into prepregnancy and during pregnancy use and classified as pregnancy recommended (PR) or not pregnancy recommended (nPR) or no medication use. SMM was defined per the Centers for Disease Control and Prevention definition of 21 indicators. Risk ratios (RR) reflecting the association of SMM with the use of antihypertensive medications were computed using modified Poisson regression with robust standard errors and adjusted for maternal age, education, and birth year.

RESULTS

Overall, 83% of individuals filled an antihypertensive prescription during pregnancy and 6.3% experienced SMM. The majority of individuals with a prescription prior to pregnancy had a prescription for the same medication in pregnancy. Individuals with any versus no medication use in pregnancy had increased adjusted RR (aRR) of SMM (1.18, 95% confidence interval [CI]: 0.96-1.44). Compared to the use of PR medications before and during pregnancy, aRRs were 1.42 (95% CI: 1.18-1.69, 12.4% of sample) for nPR use before and during pregnancy, 1.52 (1.23-1.86; 12.4%) for nPR (before) and PR (during) use, and 2.67 (1.73-4.15) for PR and nPR use. Patterns with no medication use during pregnancy were not statistically significant.

CONCLUSION

Pattern of antihypertensive medication use before and during pregnancy may be associated with an elevated risk of SMM. Further research is required to elucidate whether this association is related to the severity of hypertension, medication effectiveness, or suboptimal quality of care.

KEY POINTS

· Individuals with any medication use compared to no medication use in pregnancy had an increased risk of SMM.. · Specific medication use patterns were associated with an elevated risk of SMM.. · Pattern of antihypertensive medication use before and during pregnancy may be associated with an increased risk of SMM..

Risk of Autism after Prenatal Topiramate, Valproate, or Lamotrigine Exposure

BACKGROUND

Maternal use of valproate during pregnancy has been associated with an increased risk of neurodevelopmental disorders in children. Although most studies of other antiseizure medications have not shown increased risks of these disorders, there are limited and conflicting data regarding the risk of autism spectrum disorder associated with maternal topiramate use.

METHODS

We identified a population-based cohort of pregnant women and their children within two health care utilization databases in the United States, with data from 2000 through 2020. Exposure to specific antiseizure medications was defined on the basis of prescription fills from gestational week 19 until delivery. Children who had been exposed to topiramate during the second half of pregnancy were compared with those unexposed to any antiseizure medication during pregnancy with respect to the risk of autism spectrum disorder. Valproate was used as a positive control, and lamotrigine was used as a negative control.

RESULTS

The estimated cumulative incidence of autism spectrum disorder at 8 years of age was 1.9% for the full population of children who had not been exposed to antiseizure medication (4,199,796 children). With restriction to children born to mothers with epilepsy, the incidence was 4.2% with no exposure to antiseizure medication (8815 children), 6.2% with exposure to topiramate (1030 children), 10.5% with exposure to valproate (800 children), and 4.1% with exposure to lamotrigine (4205 children). Propensity score-adjusted hazard ratios in a comparison with no exposure to antiseizure medication were 0.96 (95% confidence interval [CI], 0.56 to 1.65) for exposure to topiramate, 2.67 (95% CI, 1.69 to 4.20) for exposure to valproate, and 1.00 (95% CI, 0.69 to 1.46) for exposure to lamotrigine.

CONCLUSIONS

The incidence of autism spectrum disorder was higher among children prenatally exposed to the studied antiseizure medications than in the general population. However, after adjustment for indication and other confounders, the association was substantially attenuated for topiramate and lamotrigine, whereas an increased risk remained for valproate. (Funded by the National Institute of Mental Health.).

Placental Abruption and Cardiovascular Event Risk (PACER): Design, data linkage, and preliminary findings

BACKGROUND

Obstetrical complications impact the health of mothers and offspring along the life course, resulting in an increased burden of chronic diseases. One specific complication is abruption, a life-threatening condition with consequences for cardiovascular health that remains poorly studied.

OBJECTIVES

To describe the design and data linkage algorithms for the Placental Abruption and Cardiovascular Event Risk (PACER) cohort.

POPULATION

All subjects who delivered in New Jersey, USA, between 1993 and 2020.

DESIGN

Retrospective, population-based, birth cohort study.

METHODS

We linked the vital records data of foetal deaths and live births to delivery and all subsequent hospitalisations along the life course for birthing persons and newborns. The linkage was based on a probabilistic record-matching algorithm.

PRELIMINARY RESULTS

Over the 28 years of follow-up, we identified 1,877,824 birthing persons with 3,093,241 deliveries (1.1%, n = 33,058 abruption prevalence). The linkage rates for live births-hospitalisations and foetal deaths-hospitalisations were 92.4% (n = 2,842,012) and 70.7% (n = 13,796), respectively, for the maternal cohort. The corresponding linkage rate for the live births-hospitalisations for the offspring cohort was 70.3% (n = 2,160,736). The median (interquartile range) follow-up for the maternal and offspring cohorts was 15.4 (8.1, 22.4) and 14.4 (7.4, 21.0) years, respectively. We will undertake multiple imputations for missing data and develop inverse probability weights to account for selection bias owing to unlinked records.

CONCLUSIONS

Pregnancy offers a unique window to study chronic diseases along the life course and efforts to identify the aetiology of abruption may provide important insights into the causes of future CVD. This project presents an unprecedented opportunity to understand how abruption may predispose women and their offspring to develop CVD complications and chronic conditions later in life.

Serious Infections in Offspring Exposed in Utero to Vedolizumab

Controlling IBD during pregnancy is important for maternal and fetal outcomes. We created a cohort of children born to mothers with IBD, comparing the risk of infections in those exposed to vedolizumab vs unexposed. We detected no increased risk.

Accounting for Twins and Other Multiple Births in Perinatal Studies Conducted Using Healthcare Administration Data

The analysis of perinatal studies is complicated by twins and other multiple births even when they are not the exposure, outcome, or a confounder of interest. Common approaches to handling multiples in studies of infant outcomes include restriction to singletons, counting outcomes at the pregnancy-level (i.e., by counting if at least one twin experienced a binary outcome), or infant-level analysis including all infants and, typically, accounting for clustering of outcomes by using generalised estimating equations or mixed effects models. Several healthcare administration databases only support restriction to singletons or pregnancy-level approaches. For example, in MarketScan insurance claims data, diagnoses in twins are often assigned to a single infant identifier, thereby preventing ascertainment of infant-level outcomes among multiples. Different approaches correspond to different causal questions, produce different estimands, and often rely on different assumptions. We demonstrate the differences that can arise from these different approaches using Monte Carlo simulations, algebraic formulas, and an applied example. Furthermore, we provide guidance on the handling of multiples in perinatal studies when using healthcare administration data.

Comparative Risk of Major Congenital Malformations With Antiseizure Medication Combinations vs Valproate Monotherapy in Pregnancy

BACKGROUND AND OBJECTIVES

Valproate should be avoided in pregnancy, but it is the most effective drug for generalized epilepsies. Alternative treatment may require combinations of other drugs. Our objectives were to describe first trimester use of antiseizure medication (ASM) combinations that are relevant alternatives to valproate and determine whether specific combinations were associated with a lower risk of major congenital malformations (MCM) compared with valproate monotherapy.

METHODS

We conducted a population-based cohort study using linked national registers from Denmark, Finland, Iceland, Norway, and Sweden and administrative health care data from the United States and New South Wales, Australia. We described first trimester use of ASM combinations among pregnant people with epilepsy from 2000 to 2020. We compared the risk of MCM after first trimester exposure to ASM combinations vs valproate monotherapy and low-dose valproate plus lamotrigine or levetiracetam vs high-dose valproate (≥1,000 mg/d). We used log-binomial regression with propensity score weights to calculate adjusted risk ratios (aRRs) and 95% CIs for each dataset. Results were pooled using fixed-effects meta-analysis.

RESULTS

Among 50,905 pregnancies in people with epilepsy identified from 7.8 million total pregnancies, 788 used lamotrigine and levetiracetam, 291 used lamotrigine and topiramate, 208 used levetiracetam and topiramate, 80 used lamotrigine and zonisamide, and 91 used levetiracetam and zonisamide. After excluding pregnancies with use of other ASMs, known teratogens, or a child diagnosed with MCM of infectious or genetic cause, we compared 587 exposed to lamotrigine-levetiracetam duotherapy and 186 exposed to lamotrigine-topiramate duotherapy with 1959 exposed to valproate monotherapy. Pooled aRRs were 0.41 (95% CI 0.24-0.69) and 1.26 (0.71-2.23), respectively. Duotherapy combinations containing low-dose valproate were infrequent, and comparisons with high-dose valproate monotherapy were inconclusive but suggested a lower risk for combination therapy. Other combinations were too rare for comparative safety analyses.

DISCUSSION

Lamotrigine-levetiracetam duotherapy in first trimester was associated with a 60% lower risk of MCM than valproate monotherapy, while lamotrigine-topiramate was not associated with a reduced risk. Duotherapy with lamotrigine and levetiracetam may be favored to treat epilepsy in people with childbearing potential compared with valproate regarding MCM, but whether this combination is as effective as valproate remains to be determined.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in people with epilepsy treated in the first trimester of pregnancy, the risk of major congenital malformations is lower with lamotrigine-levetiracetam duotherapy than with valproate alone, but similar with lamotrigine-topiramate.

Use of isotretinoin among girls and women of childbearing age and occurrence of isotretinoin-exposed pregnancies in Germany: A population-based study

BACKGROUND

Exposure to isotretinoin during pregnancy must be avoided due to its teratogenicity, but real-world data on its use are scarce. We aimed to describe (i) isotretinoin use in women of childbearing age in Germany; (ii) the occurrence of isotretinoin-exposed pregnancies; and (iii) malformations among children exposed in utero.

METHODS AND FINDINGS

Using observational data from the German Pharmacoepidemiological Research Database (GePaRD, claims data from approximately 20% of the German population), we conducted annual cross-sectional analyses to determine age-standardized prevalence of isotretinoin use between 2004 and 2019 among girls and women aged 13 to 49 years. In cohort analyses, we estimated the number of exposed pregnancies by assessing whether there was prescription supply overlapping the beginning of pregnancy (estimated supply was varied in sensitivity analyses) or a dispensation within the first 8 weeks of pregnancy. Data of live-born children classified as exposed in a critical period according to these criteria were reviewed to assess the presence of congenital malformations. The age-standardized prevalence of isotretinoin use per 1,000 girls and women increased from 1.20 (95% confidence interval [CI]: 1.16, 1.24) in 2004 to 1.96 (95% CI: 1.92, 2.01) in 2019. In the base case analysis, we identified 178 pregnancies exposed to isotretinoin, with the number per year doubling during the study period, and at least 45% of exposed pregnancies ended in an induced abortion. In sensitivity analyses, the number of exposed pregnancies ranged between 172 and 375. Among live-born children, 6 had major congenital malformations. The main limitation of this study was the lack of information on the prescribed dose, i.e., the supply had to be estimated based on the dispensed amount of isotretinoin.

CONCLUSIONS

Isotretinoin use among girls and women of childbearing age increased in Germany between 2004 and 2019, and there was a considerable number of pregnancies likely exposed to isotretinoin in a critical period. This highlights the importance of monitoring compliance with the existing risk minimization measures for isotretinoin in Germany.

Common teratogenic medication exposures-a population-based study of pregnancies in the United States

BACKGROUND

Risk mitigation for most teratogenic medications relies on risk communication via drug label, and prenatal exposures remain common. Information on the types of and risk factors for prenatal exposures to medications with teratogenic risk can guide strategies to reduce exposure.

OBJECTIVE

This study aimed to identify medications with known or potential teratogenic risk commonly used during pregnancy among privately insured persons.

STUDY DESIGN

We used the Merative™ MarketScan® Commercial Database to identify pregnancies with live or nonlive (ectopic pregnancies, spontaneous and elective abortions, stillbirths) outcomes among persons aged 12 to 55 years from 2011 to 2018. Start/end dates of medication exposure and pregnancy outcomes were identified via an adapted algorithm based on validation studies. We required continuous health plan enrollment from 90 days before conception until 30 days after the pregnancy end date. Medications with known or potential teratogenic risk were selected from TERIS (Teratogen Information System) and drug monographs based on the level of risk and quality of evidence (138 with known and 60 with potential risk). We defined prenatal exposure on the basis of ≥1 outpatient pharmacy claim or medical encounter for medication administration during target pregnancy periods considering medication risk profiles (eg, risk only in the first trimester or at a certain dose threshold). Sex hormones and hormone analogs, and abortion and postpartum/abortion hemorrhage treatments were not considered as teratogenic medications because of challenges in separating pregnancy-related indications, nor were opioids (because of complex risk-benefit considerations) or antiobesity medications if their only teratogenic mechanism was weight loss.

RESULTS

Among all pregnancies, the 10 medications with known teratogenic risk and the highest prenatal exposures were sulfamethoxazole/trimethoprim (1988 per 100,000 pregnancy-years), high-dose fluconazole (1248), topiramate (351), lisinopril (144), warfarin (57), losartan (56), carbamazepine (50), valproate (49), vedolizumab (28 since 2015), and valsartan (25). Prevalence of exposure to sulfamethoxazole/trimethoprim decreased from 2346 to 1453 per 100,000 pregnancy-years from 2011 to 2018, but prevalence of exposure to vedolizumab increased 6-fold since its approval in 2015. Prenatal exposures in the first trimester were higher among nonlive pregnancies than among live-birth pregnancies, with the largest difference observed for warfarin (nonlive 370 vs live birth 78), followed by valproate (258 vs 86) and topiramate (1728 vs 674). Prenatal exposures to medications with potential teratogenic risk were most prevalent for low-dose fluconazole (6495), metoprolol (1325), and atenolol (448). The largest first-trimester exposure differences between nonlive and live-birth pregnancies were observed for lithium (242 vs 89), gabapentin (1639 vs 653), and duloxetine (1914 vs 860). Steady increases in hydralazine and gabapentin exposures were observed during the study years, whereas atenolol exposure decreased (561 to 280).

CONCLUSION

Several medications with teratogenic risk for which there are potentially safer alternatives continue to be used during pregnancy. The fluctuating rates of prenatal exposure observed for select teratogenic medications suggest that regular reevaluation of risk mitigation strategies is needed. Future research focusing on understanding the clinical context of medication use is necessary to develop effective strategies for reducing exposures to medications with teratogenic risk during pregnancy.

Characteristics and outcomes of pregnancies in the Maternal Outcomes Masterset real-world database

PURPOSE

Describe patient characteristics and pregnancy outcomes among all pregnant patients, and additionally describe infant outcomes among the subset with linked infants in the Maternal Outcomes Masterset (MOM).

METHODS

We used closed claims within the MOM data to identify publicly and privately insured patients at the first record of pregnancy January 1, 2018-December 1, 2021, with ≥180 days baseline enrollment. We described characteristics during baseline and follow-up (until an observed pregnancy endpoint, disenrollment, or 42-week maximum). We described maternal and infant characteristics overall and by infant linkage and contextualized them within national statistics.

RESULTS

Among the 1 438 861 pregnant patients meeting the study criteria, the most common pregnancy endpoint recorded was live birth (42%) followed by spontaneous abortion (14%). Among 602 721 patients with a live birth, 99% had a week-specific gestational age recorded and 35% had at least one linked infant. Patients with infant linkage and sufficient follow-up (N = 155 621) had similar baseline comorbidities, pregnancy complications, and gestational age at delivery as those without any linkage. However, more patients with linkage had commercial coverage (70% vs. 31%), and were therefore older (50% vs. 31% aged ≥30 years) and more likely to have an unknown race (57% vs. 34%).

CONCLUSIONS

In this large sample of pregnant patients, maternal and infant characteristics generally align with national statistics, providing confidence in the use of this data source for pregnancy research. Further, confirmation that the subset of patients with infant linkage is similar to the overall pregnancy cohort provides assurance that this subset can be considered representative.

Identifying pregnancy episodes and estimating the last menstrual period using an administrative database in Korea: an application to patients with systemic lupus erythematosus

OBJECTIVES

This study developed an algorithm for identifying pregnancy episodes and estimating the last menstrual period (LMP) in an administrative claims database and applied it to investigate the use of pregnancy-incompatible immunosuppressants among pregnant women with systemic lupus erythematosus (SLE).

METHODS

An algorithm was developed and applied to a nationwide claims database in Korea. Pregnancy episodes were identified using a hierarchy of pregnancy outcomes and clinically plausible periods for subsequent episodes. The LMP was estimated using preterm delivery, sonography, and abortion procedure codes. Otherwise, outcome-specific estimates were applied, assigning a fixed gestational age to the corresponding pregnancy outcome. The algorithm was used to examine the prevalence of pregnancies and utilization of pregnancy-incompatible immunosuppressants (cyclophosphamide [CYC]/mycophenolate mofetil [MMF]/methotrexate [MTX]) and non-steroidal anti-inflammatory drugs (NSAIDs) during pregnancy in SLE patients.

RESULTS

The pregnancy outcomes identified in SLE patients included live births (67%), stillbirths (2%), and abortions (31%). The LMP was mostly estimated with outcome-specific estimates for full-term births (92.3%) and using sonography procedure codes (54.7%) and preterm delivery diagnosis codes (37.9%) for preterm births. The use of CYC/MMF/MTX decreased from 7.6% during preconception to 0.2% at the end of pregnancy. CYC/MMF/MTX use was observed in 3.6% of women within 3 months preconception and 2.5% during 0-7 weeks of pregnancy.

CONCLUSIONS

This study presents the first pregnancy algorithm using a Korean administrative claims database. Although further validation is necessary, this study provides a foundation for evaluating the safety of medications during pregnancy using secondary databases in Korea, especially for rare diseases.

Postpartum Depression in Reproductive-Age Women With and Without Rheumatic Disease: A Population-Based Matched Cohort Study

OBJECTIVE

To examine postpartum depression (PPD) among women with axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), or rheumatoid arthritis (RA) in comparison with a matched population without rheumatic disease (RD).

METHODS

A retrospective analysis using the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database was conducted. Pregnant women with axSpA, PsA, or RA were identified, and the delivery date was used as the index date. We restricted the sample to women ≤ 55 years with continuous enrollment ≥ 6 months before date of last menstrual period and throughout pregnancy. Each patient was matched with 4 individuals without RD on: (1) maternal age at delivery, (2) prior history of depression, and (3) duration of depression before delivery. Cox frailty proportional hazards models estimated the crude and adjusted hazard ratios (aHR) and 95% CI of incident postpartum depression within 1 year among women with axSpA, PsA, or RA (axSpA/PsA/RA cohort) compared to the matched non-RD comparison group.

RESULTS

Overall, 2667 women with axSpA, PsA, or RA and 10,668 patients without any RD were included. The median follow-up time in days was 256 (IQR 93-366) and 265 (IQR 99-366) for the axSpA/PsA/RA cohort and matched non-RD comparison group, respectively. Development of PPD was more common in the axSpA/PsA/RA cohort relative to the matched non-RD comparison group (axSpA/PsA/RA cohort: 17.2%; matched non-RD comparison group: 12.8%; aHR 1.22, 95% CI 1.09-1.36).

CONCLUSION

Postpartum depression is significantly higher in women of reproductive age with axSpA/PsA/RA when compared to those without RD.

Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study

OBJECTIVES

To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms.

STUDY DESIGN

This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control).

MAIN OUTCOME MEASURES

Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms).

RESULTS

Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%).

CONCLUSIONS

Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.

Associations between pregnancy glucose measurements and risk of preterm birth: a retrospective cohort study of commercially insured women in the United States from 2003 to 2021

PURPOSE

To investigate associations between glucose measurements during pregnancy and risk of preterm birth (PTB).

METHODS

Retrospective cohort study of commercially insured women with singleton live births in the United States from 2003 to 2021 using longitudinal medical claims, socioeconomic data, and eight glucose results from different fasting and post-load tests performed between 24 and 28 weeks of gestation for gestational diabetes screening. Risk ratios of PTB (<37 weeks) were estimated via Poisson regression for z-standardized glucose measures. Non-linear relationships for continuous glucose measures were examined via generalized additive models.

RESULTS

Elevations in all eight glucose measures were associated with increased risk (adjusted risk ratio point estimates: 1.05-1.19) of PTB for 196,377 women with non-fasting 50-g glucose challenge test (one glucose result), 31,522 women with complete 100-g, 3-hour fasting oral glucose tolerance test (OGTT) results (four glucose results), and 10,978 women with complete 75-g, 2-hour fasting OGTT results (three glucose results). Associations were consistent after adjusting for and stratifying by sociodemographic and clinical factors. Substantial non-linear relationships (U-, J-, and S-shaped) were observed between several glucose measurements and PTB.

CONCLUSIONS

Elevations in various glucose measures were linearly and non-linearly associated with increased PTB risk, even before diagnostic thresholds for gestational diabetes.

Identification of pregnancies and their outcomes in healthcare claims data, 2008-2019: An algorithm

Pregnancy is a condition of broad interest across many medical and health services research domains, but one not easily identified in healthcare claims data. Our objective was to establish an algorithm to identify pregnant women and their pregnancies in claims data. We identified pregnancy-related diagnosis, procedure, and diagnosis-related group codes, accounting for the transition to International Statistical Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis and procedure codes, in health encounter reporting on 10/1/2015. We selected women in Merative MarketScan commercial databases aged 15-49 years with pregnancy-related claims, and their infants, during 2008-2019. Pregnancies, pregnancy outcomes, and gestational ages were assigned using the constellation of service dates, code types, pregnancy outcomes, and linkage to infant records. We describe pregnancy outcomes and gestational ages, as well as maternal age, census region, and health plan type. In a sensitivity analysis, we compared our algorithm-assigned date of last menstrual period (LMP) to fertility procedure-based LMP (date of procedure + 14 days) among women with embryo transfer or insemination procedures. Among 5,812,699 identified pregnancies, most (77.9%) were livebirths, followed by spontaneous abortions (16.2%); 3,274,353 (72.2%) livebirths could be linked to infants. Most pregnancies were among women 25-34 years (59.1%), living in the South (39.1%) and Midwest (22.4%), with large employer-sponsored insurance (52.0%). Outcome distributions were similar across ICD-9 and ICD-10 eras, with some variation in gestational age distribution observed. Sensitivity analyses supported our algorithm's framework; algorithm- and fertility procedure-derived LMP estimates were within a week of each other (mean difference: -4 days [IQR: -13 to 6 days]; n = 107,870). We have developed an algorithm to identify pregnancies, their gestational age, and outcomes, across ICD-9 and ICD-10 eras using administrative data. This algorithm may be useful to reproductive health researchers investigating a broad range of pregnancy and infant outcomes.

Novel methods for pregnancy drug safety surveillance in the FDA Sentinel System

PURPOSE

It is a priority of the US Food and Drug Administration (FDA) to monitor the safety of medications used during pregnancy. Pregnancy exposure registries and cohort studies utilizing electronic health record data are primary sources of information but are limited by small sample sizes and limited outcome assessment. TreeScan™, a statistical data mining tool, can be applied within the FDA Sentinel System to simultaneously identify multiple potential adverse neonatal and infant outcomes after maternal medication exposure.

METHODS

We implemented TreeScan using the Sentinel analytic tools in a cohort of linked live birth deliveries and infants nested in the IBM MarketScan® Research Database. As a case study, we compared first trimester fluoroquinolone use and cephalosporin use. We used the Bernoulli and Poisson TreeScan statistics with compatible propensity score-based study designs for confounding control (matching and stratification) and used multiple propensity score models with various strategies for confounding control to inform best practices. We developed a hierarchical outcome tree including major congenital malformations and outcomes of gestational length and birth weight.

RESULTS

A total of 1791 fluoroquinolone-exposed and 8739 cephalosporin-exposed mother-infant pairs were eligible for analysis. Both TreeScan analysis methods resulted in single alerts that were deemed to be due to uncontrolled confounding or otherwise not warranting follow-up.

CONCLUSIONS

In this implementation of TreeScan using Sentinel analytic tools, we did not observe any new safety signals for fluoroquinolone use in the first trimester. TreeScan, with tailored or high-dimensional propensity scores for confounding control, is a valuable tool in addition to current safety surveillance methods for medications used during pregnancy.

Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth

BACKGROUND

The International Classification of Diseases , 10th Revision, Clinical Modification (ICD-10-CM) introduced diagnosis codes for week of gestation. Our objective was to assess the validity of these codes among live births, which could have major utility in perinatal research and quality improvement.

METHODS

We used linked birth certificate and patient discharge data from births in California during 2016-2019 (N = 1,843,992). We identified gestational age using Z3A.xx ICD-10-CM diagnosis codes in birthing patient discharge data and compared it with the gold standard of obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (≥37 weeks, <37 weeks, <32 weeks, <28 weeks), given these categories are frequently of interest, and evaluated differences in validity of preterm birth (<37 weeks' gestation) by patient characteristics.

RESULTS

One-million seven-hundred seventy-thousand one-hundred three patients had a gestational age recorded in patient discharge and birth certificate data. When comparing gestational age in patient discharge data with birth certificate data, the concordance correlation coefficient was 0.96 (95% confidence interval [CI] = 0.96, 0.96) and the mean difference between the two measurements was 0.047 weeks (95% CI = 0.046, 0.047 weeks). Ninety-five percent of the differences between the two measurements were between -1.00 week and +1.09 weeks. Sensitivity and specificity were 0.94 to 1.00 for all gestational age categories and were 0.94 to 1.00 for preterm birth across sociodemographic groups.

CONCLUSIONS

We found week-specific gestational age at delivery ICD-10-CM diagnosis codes in patient discharge data to have high validity when compared with the best obstetric estimate on the birth certificate.

Comanagement with rheumatology and prescription biologics filled during pregnancy in women with rheumatic diseases: a retrospective analysis of US administrative claims data

OBJECTIVES

To evaluate comanagement with rheumatology and biological prescriptions filled during pregnancy among women with axial spondyloarthritis (axSpA), rheumatoid arthritis (RA) or psoriatic arthritis (PsA) and to examine factors associated with receiving comanagement with rheumatology during pregnancy.

DESIGN

A retrospective analysis of US claims data.

SETTING

Commercially insured enrollees using data from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database.

PARTICIPANTS

We identified 4131 pregnant women aged ≤55 years from the 2013-2018 IBM MarketScan Commercial Claims and Encounters Database with an International Classification of Disease, 9th Revision/10th Revision codes for RA, axSpA or PsA, with continuous enrolment at ≥3 months before the date of the last menstrual period (LMP) (index date) and throughout pregnancy.

PRIMARY OUTCOMES

Filled biologics (prescriptions and infusions) claims were categorised by 90 days before the LMP and trimester, as were primary care, obstetrician and rheumatological claims.

RESULTS

The prevalence of axSpA, RA and PsA was 0.7%, 0.2% and 0.04% among reproductive age women. The average maternal age was 32.7 years (SD 5.7). During pregnancy, 9.1% of those with axSpA (n=2,410) and 56.4% of those with RA/PsA (n=1,721) had a rheumatological claim. Biologics claims were less common among those with axSpA (90 days before LMP: 1.6%, during pregnancy: 1.1%) than those with RA/PsA (90 days before LMP: 11.9%, during pregnancy: 6.9%). Medications during pregnancy included corticosteroids (axSpA: 0.3%, RA/PsA: 2.2%), non-biological disease-modifying antirheumatic drugs (axSpA: 0.2%, RA/PsA: 1.7%), non-steroidal anti-inflammatory drugs (axSpA: 0.2%, RA/PsA: 1.3%) and opioids (axSpA: 0.2%, RA/PsA: 0.6%). Established rheumatological care and biologics claims during the 90 days before LMP showed good prediction accuracy for receiving comanagement with rheumatology during pregnancy (axSpA: area under the receiver operator curve (AUC) 0.73, RA/PsA: AUC 0.70).

CONCLUSION

Comanagement with rheumatology during pregnancy occurs infrequently, especially for women with axSpA. Biologics claims during pregnancy may not align with published guidelines. Future research is warranted to improve comanagement with rheumatology during pregnancy.

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

BACKGROUND

The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions.

OBJECTIVE

We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development.

DESIGN

Retrospective cohort study using linked claims and electronic health record data.

PARTICIPANTS

We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use.

MAIN MEASURES

We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression.

RESULTS

Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m². In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals.

CONCLUSIONS

Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Need for Improved Collection and Harmonization of Rural Maternal Healthcare Data

Representation in data sets is critical to improving healthcare for the largest possible number of people. Unfortunately, pregnancy is a very understudied period of time. Further, the gap in available data is wide between pregnancies in urban areas versus rural areas. There are many limitations in the current data that is available. Herein, we review these limitations and strengths of available data sources. In addition, we propose a new mechanism to enhance the granularity, depth, and speed with which data is made available regarding rural pregnancy.

Temporal Events Detector for Pregnancy Care (TED-PC): A rule-based algorithm to infer gestational age and delivery date from electronic health records of pregnant women with and without COVID-19

OBJECTIVE

Identifying the time of SARS-CoV-2 viral infection relative to specific gestational weeks is critical for delineating the role of viral infection timing in adverse pregnancy outcomes. However, this task is difficult when it comes to Electronic Health Records (EHR). In combating the COVID-19 pandemic for maternal health, we sought to develop and validate a clinical information extraction algorithm to detect the time of clinical events relative to gestational weeks.

MATERIALS AND METHODS

We used EHR from the National COVID Cohort Collaborative (N3C), in which the EHR are normalized by the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). We performed EHR phenotyping, resulting in 270,897 pregnant women (June 1st, 2018 to May 31st, 2021). We developed a rule-based algorithm and performed a multi-level evaluation to test content validity and clinical validity, and extreme length of gestation (<150 or >300).

RESULTS

The algorithm identified 296,194 pregnancies (16,659 COVID-19, 174,744 without COVID-19) in 270,897 pregnant women. For inferring gestational age, 95% cases (n = 40) have moderate-high accuracy (Cohen's Kappa = 0.62); 100% cases (n = 40) have moderate-high granularity of temporal information (Cohen's Kappa = 1). For inferring delivery dates, the accuracy is 100% (Cohen's Kappa = 1). The accuracy of gestational age detection for the extreme length of gestation is 93.3% (Cohen's Kappa = 1). Mothers with COVID-19 showed higher prevalence in obesity or overweight (35.1% vs. 29.5%), diabetes (17.8% vs. 17.0%), chronic obstructive pulmonary disease (0.2% vs. 0.1%), respiratory distress syndrome or acute respiratory failure (1.8% vs. 0.2%).

DISCUSSION

We explored the characteristics of pregnant women by different gestational weeks of SARS-CoV-2 infection with our algorithm. TED-PC is the first to infer the exact gestational week linked with every clinical event from EHR and detect the timing of SARS-CoV-2 infection in pregnant women.

CONCLUSION

The algorithm shows excellent clinical validity in inferring gestational age and delivery dates, which supports multiple EHR cohorts on N3C studying the impact of COVID-19 on pregnancy.

Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine

OBJECTIVE

To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol.

METHODS

This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity.

RESULTS

Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99).

CONCLUSION

Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.

Effectiveness and safety of intrauterine insemination vs. assisted reproductive technology: emulating a target trial using an observational database of administrative claims

OBJECTIVE

To compare the effectiveness and safety of 1 cycle of assisted reproductive technology (ART) vs. 3 cycles of intrauterine insemination (IUI).

DESIGN

Target trial emulation using observational data.

SETTING

A healthcare claims database (2011-2015).

PATIENT(S)

The patients were 29,021 women aged 18-45 years with an infertility diagnosis and no history of IUI or ART within the past 12 months.

INTERVENTION(S)

One ART cycle immediately, with no more cycles of ART or IUI within the next 4 months; or 1 IUI cycle immediately, with 2 additional consecutive cycles of IUI within the next 4 months unless pregnancy occurred.

MAIN OUTCOME MEASURE(S)

Live births, multiple births, congenital malformations, preterm births, small-for-gestational-age newborns, large-for-gestational-age newborns, admission to neonatal intensive care unit (NICU), gestational diabetes, preeclampsia, and gestational hypertension.

RESULT(S)

The probability of live birth was 27.3% for ART and 26.3% for IUI. The observational analogue of per-protocol risk difference (95% confidence interval) for ART compared with IUI was 1.0% (-0.1%, 2.2%) for live births, 4.3% (3.7%, 4.9%) for multiple births, 3.4% (2.8%, 4.0%) for preterm births, 1.5% (0.9%, 2.1%) for NICU admissions, and 0.6% (0.2%, 1.0%) for gestational diabetes. The risk differences for the other outcomes were <0.5%. The results of the 2 strategies were similar in women ≤40 years, but in women >40 years the probability of live birth was greater for ART (14.4%) than for IUI (7.4%).

CONCLUSION(S)

Compared with 3 cycles of IUI, 1 cycle of ART was estimated to have a similar probability of live birth but slightly higher risks of multiple gestations, preterm births, and NICU admissions.

Validity of Administrative Data for Identifying Birth-Related Outcomes with the End Date of Pregnancy in a Japanese University Hospital

This study aimed to develop and validate claims-based algorithms for identifying live birth, fetal death, and cesarean section by utilizing administrative data from a university hospital in Japan. We included women who visited the Department of Obstetrics at a university hospital in 2018. The diagnosis, medical procedures, and medication data were used to identify potential cases of live birth, fetal death, and cesarean section. By reviewing electronic medical records, we evaluated the positive predictive values (PPVs) and the accuracy of the end date of pregnancy for each claims datum. “Selected algorithm 1” based on PPVs and “selected algorithm 2” based on both the PPVs and the accuracy of the end date of pregnancy were developed. A total of 1757 women were included, and the mean age was 32.8 years. The PPVs of “selected algorithm 1” and “selected algorithm 2” were both 98.1% for live birth, 99.0% and 98.9% for fetal death, and 99.7% and 100.0% for cesarean section, respectively. These findings suggest that the developed algorithms are useful for future studies for evaluating live birth, fetal death, and cesarean section with an accurate end date of pregnancy.