Coronavirus Disease 2019 (COVID-19) Pandemic and Pregnancy Outcomes in a U.S. Population

Characteristics and Medication Use Patterns of Pregnancies With COVID-19 Ending in Live-Birth in the Sentinel System

BACKGROUND

Pregnant women are at high risk for developing severe illness related to COVID-19. We adapted the "COVID-19 infectiOn aNd medicineS In pregnancy" (CONSIGN) study protocol as part of an international collaboration to examine medication use patterns among pregnancies in the US.

METHODS

We identified eligible women aged 12-55 years with documented live-birth deliveries in the Sentinel Distributed Database who had at least one qualifying diagnosis for COVID-19 or a positive-confirmed test for SARS-CoV-2, by trimester of COVID-19 infection. We conducted two sets of analyses comparing medication groups and COVID-19 treatment utilization in the 30 days prior to or after COVID-19 among pregnancies with COVID-19 to: (1) pregnancies without COVID-19 during 6 months prior to or during pregnancy; and (2) non-pregnancy episodes with COVID-19.

RESULTS

From 2020 to 2022, we identified 52 355 pregnancies with COVID-19 matched to 52 355 pregnancies without COVID-19 (assigned same matched COVID-19 date), and 40 518 matched non-pregnancy episodes with COVID-19. Outpatient medication use in the 30 days prior to or after the COVID-19 date (or matched date) was quite low (< 15%) among pregnancies with and without COVID-19. Non-pregnancy episodes with COVID-19 had higher use of all medication groups in 30 days prior to COVID-19. However, in the 30 days post-COVID-19, anti-bacterials, anti-inflammatories such as NSAIDs, and analgesics were more common, and COVID-19-specific medications were less frequently used (< 1%) among pregnancies with COVID-19. Assessing COVID-19 severity, more pregnancies had a non-severe COVID-19 diagnosis than non-pregnancy episodes with COVID-19 (87.2% vs. 79.9%).

CONCLUSIONS

In this retrospective evaluation, selected medication utilization was higher post-COVID-19 among pregnancies with COVID-19, compared to those without COVID-19 and to non-pregnancy episodes with COVID-19. However, the low use of COVID-19-specific medications underscores the need for a safety evaluation of therapies used for COVID-19 management in the pregnant population.

Preserved prenatal lung growth assessed by fetal MRI in the omicron-dominated phase of the SARS-CoV-2 pandemic

OBJECTIVES

With SARS-CoV-2 evolving, disease severity and presentation have changed due to changes in mechanisms of entry and effector site as well as due to effects of vaccination- and/or infection-acquired immunity. We re-assessed fetal lung pathology in pregnancies with uncomplicated SARS-CoV-2 infections during the late, omicron-dominated pandemic phase to inform disease understanding and pregnancy consultation.

METHODS

In this case-control study, fetal lung volumes were assessed by fetal MRI in 24 pregnancies affected by mild maternal SARS-CoV-2 infection during the omicron-dominated pandemic phase with prevailing immunity through vaccination and/or prior SARS-CoV-2 infection.

RESULTS

Fetal lung volumes (normalized to estimated fetal weight) in 24 pregnancies (GA 33.3 ± 3.8, 12 female fetuses) following mild, uncomplicated SARS-CoV-2 infection did not differ significantly from both, published reference values (96.3% ± 22.5% of 50th percentile reference values, p = 0.43), or fetal lung volumes of a site-specific, non-COVID control group (n = 15, 94.2% ± 18.5%, p = 0.76). Placental assessment revealed no group differences in thrombotic changes or placental heterogeneity (p > 0.05, respectively), and fetal lung volume did not correlate with placental heterogeneity when adjusting for gestational age at scan (p > 0.05).

CONCLUSION

Assessment of fetal lung volume by MRI revealed unaffected lung growth in pregnancies affected by uncomplicated SARS-CoV-2 infection in the omicron-dominated pandemic phase in the presence of prevailing hybrid immunity. This finding contrasts sharply with the observed reduction in fetal lung volume following maternal alpha-variant infection in the pre-vaccination era and might reflect tropism- as well as immunity-related effects.

KEY POINTS

Question: Is fetal lung development affected by mild maternal SARS-CoV-2 infection during the omicron-dominated phase of the pandemic?

FINDINGS

Fetal lung volume in 24 affected pregnancies did not differ significantly from published reference values or fetal lung volumes in 15 site-specific, non-COVID-affected control pregnancies.

CLINICAL RELEVANCE

Preserved fetal lung volume following mild maternal SARS-CoV-2 infection during the omicron-dominated phase contrasts with previous findings of reduced volume in unvaccinated pregnancies during the alpha-dominated pandemic phase. These observations might reflect tropism- as well as immunity-related effects.

Impact of maternal COVID-19 infection on offspring immunity and maternal-fetal outcomes at different pregnancy stages: a cohort study

OBJECTIVE

To investigate the impact of COVID-19 infection on maternal and neonatal outcomes and immunity in pregnant women in China.

METHODS

283 pregnant women with COVID-19 were included in the prospective observational cohort study and divided into five groups based on infection stage. Antibody levels were measured in plasma, umbilical cord blood, and breast milk, and combined with clinical data and 6-month follow-up results. We measured SARS-CoV-2 antibody levels using a chemiluminescence immunoassay and analyzed the data with the Kruskal-Wallis test, χ2 test, or Fisher's exact test.

RESULTS

No significant differences were found in age, BMI, weight change during pregnancy, or the incidence of gestational hypertension, gestational diabetes, gestational hypothyroidism, intrahepatic cholestasis, transaminitis, preterm birth, small for gestational age, neonatal NICU transfers, developmental delays, and hearing damage among the five groups. The incidence of COVID-19 in infants from mothers infected at different stages of pregnancy was significantly lower than in the uninfected group (P < 0.05). Maternal and umbilical cord blood showed significantly higher IgG levels in the infected group compared to the uninfected group at different stages of pregnancy (P < 0.05). The median transplacental antibody transfer ratio across all infection groups was 1.15 (0.98-1.30), with no significant differences between them. The reinfection group had significantly higher IgA levels during pregnancy compared to other groups (P < 0.05).

CONCLUSION

No adverse outcomes were observed in mothers or infants at any stage of maternal SARS-CoV-2 infection. Antibodies in umbilical cord blood and breast milk may offer passive immunity to newborns for 1-3 months. Reinfection during pregnancy may extend this immunity without raising the risk of adverse outcomes.

Prevalence, Management, and Comorbidities of Adults With Atrial Fibrillation in the United States, 2019 to 2023

Background

Due to evolving risk factor profiles and an aging population, atrial fibrillation poses a significant public health challenge in the United States. Therefore, a contemporary and nationally representative epidemiological study is necessary to reassess atrial fibrillation's impact on the health care system.

Objectives

The purpose of the study was to provide the most current and detailed assessment of atrial fibrillation's prevalence and management in the United States.

Methods

This retrospective cohort study was performed using data from Epic's Cosmos platform between January 1, 2019, and December 31, 2023. This is a multicenter, population-based study encompassing data from over 259 million patient records. The study cohort, 4,834,977 patients with atrial fibrillation, were identified from an initial cohort of 124,247,691 residents of the United States aged 18 years and older.

Results

This study identified 4,834,977 patients with nontransient atrial fibrillation, with a mean age of 76 years; 55.43% of the patients were male, and 83.05% were non-Hispanic White. The overall prevalence of atrial fibrillation was 3.89%, where 0.26% of adults under 50 and 24.58% of those 90 and older had the condition. Geographically, rural areas reported a higher prevalence (5.29%) than urban areas (3.66%), with the Midwest, South, and Northeast experiencing higher rates compared to the Mountain and Pacific states. Roughly 30% of individuals with atrial fibrillation did not receive anticoagulant medication.

Conclusions

The findings of this geographically diverse and nationally representative investigation align with recent prevalence studies, highlighting the increased burden of atrial fibrillation on the United States health care system.

Maternal and neonatal outcomes in women with COVID-19: A retrospective cohort study

Background

Considering the conflicting evidence that exists regarding the effect of the coronavirus disease 2019 (COVID-19) on pregnancy and newborn outcomes, it is necessary to conduct this research during the first year in the north of Iran, a highly visited and trafficked place, which increases the possibility of contracting the virus and severity of the infection.

Objective

This study aimed to compare maternal and neonatal outcomes in pregnant women with and without COVID-19.

Materials and Methods

In this retrospective cohort study, data from 160 pregnant women referred to 3 hospitals in Mazandaran, Iran from April 2020 to March 2021 were extracted from their medical records using checklists. Participants were divided into 2 groups: group A) 80 pregnant women with COVID-19 and group B) 80 noninfected pregnant women. All information related to maternal and neonatal outcomes were extracted and compared from the files of the 2 groups. The results obtained from comparing 2 groups of pregnant women from the result of the reverse-transcription polymerase chain reaction test were analyzed.

Results

The most common symptoms in the COVID-19 group were fever and cough. Pregnancy complications such as abortion, pre-eclampsia, and premature birth were not significant between groups (p = 0.4, 0.45, 0.45, respectively). No statistically significant difference was observed between groups regarding maternal and neonatal outcomes.

Conclusion

Despite the peak and severity of the COVID-19 disease in the first year of the pandemic, it seems that it had no effect on maternal and neonatal outcomes in each trimester of pregnancy in affected women.

Adverse delivery hospitalisation outcomes in 2020 during the COVID-19 pandemic

OBJECTIVE

To evaluate risk for adverse obstetric outcomes associated with the coronavirus disease 2019 (COVID-19) pandemic period and with COVID-19 diagnoses.

DESIGN

Serial cross-sectional study.

SETTING

A national sample of US delivery hospitalisations before (1/2016 to 2/2020) and during the first 10 months of (3/2020 to 12/2020) the COVID-19 pandemic.

POPULATION

All 2016-2020 US delivery hospitalisations in the National Inpatient Sample.

METHODS

Delivery hospitalisations were identified and stratified into pre-pandemic and pandemic periods and the likelihood of adverse obstetric outcomes was compared using logistic regression models with adjusted odds ratios (aOR) with 95% confidence intervals (CI) as measures of association. Risk for adverse outcomes was also analysed specifically for 2020 deliveries with a COVID-19 diagnosis.

MAIN OUTCOME MEASURE

Adverse maternal outcomes including respiratory complications and cardiac morbidity.

RESULTS

Of an estimated 18.2 million deliveries, 2.9 million occurred during the pandemic. The proportion of delivery hospitalisations with a COVID-19 diagnosis increased from 0.1% in March 2020 to 3.1% in December. Comparing the pandemic period to the pre-pandemic period, there were higher adjusted odds of transfusion (aOR 1.12, 95% CI 1.05-1.19), a respiratory complication composite (aOR 1.37, 95% CI 1.29-1.46), cardiac severe maternal morbidity (aOR 1.30, 95% 1.20-1.39), postpartum haemorrhage (aOR 1.19, 95% CI 1.15-1.24), placental abruption/antepartum haemorrhage (OR 1.04, 95% CI 1.00-1.08), and hypertensive disorders of pregnancy (OR 1.23, 95% CI 1.21-1.26). These associations were similar to unadjusted analysis. Risk for these outcomes during the pandemic period was significantly higher in the presence of a COVID-19 diagnosis.

CONCLUSIONS

In a national estimate of delivery hospitalisations, the odds of cardiac and respiratory outcomes were higher in 2020 compared with 2016-2019. COVID-19 diagnoses were specifically associated with a range of serious complications.

Racial differences in hypertensive disorders in pregnancy during the COVID-19 pandemic

OBJECTIVE

To compare rates of pregnancy induced hypertensive disorders during the period of the COVID-19 pandemic to prior, baseline years.

METHODS

We conducted a retrospective study of 17,742 patients on rates for pregnancy induced hypertensive disorders delivering at 2 local hospitals before (Cohort 1; January 2018 to December 2019; n = 8245) and after (Cohort 2; February 2020 to February 2022; n = 9497) the onset of the COVID-19 pandemic. The primary outcomes were rates of gestational hypertension, pre-eclampsia, and chronic hypertension in patients.Wecompared by year (2018-2022), by patient COVID infection status, and by racial demographics.

RESULTS

During the pandemic (Cohort 2), there were lower rates of chronic hypertension (7.4 % vs 6.5 %, p =.02), higher rates of gestational hypertension (26.3 % vs 27.8 %, p =.03), and higher rates of preeclampsia (11.3 % vs 13.1 %, p <.001) compared to years prior to the pandemic (Cohort 1). When evaluating by year, rates of chronic hypertension did not statistically change while rates for preeclampsia increased in the first year of the pandemic and remained high, and rates for gestational hypertension did not increase until the second year of the pandemic. When evaluating by COVID infection status, rates for gestational hypertension were significantly higher for individuals with a positive COVID infection status (COVID negative = 27.4 % vs. COVID positive = 32.8 %; p <.004). Rates of preeclampsia did not differ according to COVID infection status (p = 0.15).

CONCLUSION

In this study, rates of pregnancy induced hypertensive disorders increased during the COVID pandemic regardless of COVID infection status.

Autoimmune, Autoinflammatory Disease and Cutaneous Malignancy Associations with Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating cutaneous disease characterized by severe painful inflammatory nodules/abscesses. At present, data regarding the epidemiology and pathophysiology of this disease are limited.

OBJECTIVE

To define the prevalence and comorbidity associations of HS.

METHODS

This was a cross-sectional study of EPICTM Cosmos© examining over 180 million US patients. Prevalences were calculated by demographic and odds ratios (OR) and identified comorbidity correlations.

RESULTS

All examined metabolism-related, psychological, and autoimmune/autoinflammatory (AI) diseases correlated with HS. The strongest associations were with pyoderma gangrenosum [OR 26.56; confidence interval (CI): 24.98-28.23], Down syndrome (OR 11.31; CI 10.93-11.70), and polycystic ovarian syndrome (OR 11.24; CI 11.09-11.38). Novel AI associations were found between HS and lupus (OR 6.60; CI 6.26-6.94) and multiple sclerosis (MS; OR 2.38; CI 2.29-2.48). Cutaneous malignancies were largely not associated in the unsegmented cohort; however, among Black patients, novel associations with melanoma (OR 2.39; CI 1.86-3.08) and basal cell carcinoma (OR 2.69; CI 2.15-3.36) were identified.

LIMITATIONS

International Classification of Diseases (ICD)-based disease identification relies on coding fidelity and diagnostic accuracy.

CONCLUSION

This is the first study to identify correlations between HS with melanoma and basal cell carcinoma (BCC) among Black patients as well as MS and lupus in all patients with HS.

SARS-CoV-2 infection by trimester of pregnancy and adverse perinatal outcomes: a Mexican retrospective cohort study

OBJECTIVE

Conflicting evidence for the association between COVID-19 and adverse perinatal outcomes exists. This study examined the associations between maternal COVID-19 during pregnancy and adverse perinatal outcomes including preterm birth (PTB), low birth weight (LBW), small-for-gestational age (SGA), large-for-gestational age (LGA) and fetal death; as well as whether the associations differ by trimester of infection.

DESIGN AND SETTING

The study used a retrospective Mexican birth cohort from the Instituto Mexicano del Seguro Social (IMSS), Mexico, between January 2020 and November 2021.

PARTICIPANTS

We used the social security administrative dataset from IMSS that had COVID-19 information and linked it with the IMSS routine hospitalisation dataset, to identify deliveries in the study period with a test for SARS-CoV-2 during pregnancy.

OUTCOME MEASURES

PTB, LBW, SGA, LGA and fetal death. We used targeted maximum likelihood estimators, to quantify associations (risk ratio, RR) and CIs. We fit models for the overall COVID-19 sample, and separately for those with mild or severe disease, and by trimester of infection. Additionally, we investigated potential bias induced by missing non-tested pregnancies.

RESULTS

The overall sample comprised 17 340 singleton pregnancies, of which 30% tested positive. We found that those with mild COVID-19 had an RR of 0.89 (95% CI 0.80 to 0.99) for PTB and those with severe COVID-19 had an RR of 1.53 (95% CI 1.07 to 2.19) for LGA. COVID-19 in the first trimester was associated with fetal death, RR=2.36 (95% CI 1.04, 5.36). Results also demonstrate that missing non-tested pregnancies might induce bias in the associations.

CONCLUSIONS

In the overall sample, there was no evidence of an association between COVID-19 and adverse perinatal outcomes. However, the findings suggest that severe COVID-19 may increase the risk of some perinatal outcomes, with the first trimester potentially being a high-risk period.

The (temporary) Covid-19 baby bust in Mexico

In this paper, we investigate whether fertility and newborn health changed during the Covid-19 pandemic in Mexico. We use national administrative data and an event-study design to examine the impact of the Covid-19 pandemic on fertility and newborn health characteristics. Our findings suggest that Mexico's fertility declined temporarily as measured by conceptions that likely occurred during the stay-at-home order. Initially, the general fertility rate fell by 11-12 per cent but quickly rebounded and returned close to its original levels by the end of 2021. Newborn health also deteriorated during the pandemic. Instances of low birthweight and prematurity substantially increased, with both remaining elevated over the entire pandemic period.

Neonatal outcomes of maternal prenatal coronavirus infection

The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes in life and healthcare all over the world. Pregnant women and their newborns require extra attention due to the increased risk of adverse outcomes. Adverse pregnancy outcomes include intensive care unit (ICU) admission, pulmonary, cardiac, and renal impairment leading to mortality. Immaturity and variations of the neonatal immune system may be advantageous in responding to the virus. Neonates are at risk of vertical transmission and in-utero infection. Impaired intrauterine growth, prematurity, vertical transmission, and neonatal ICU admission are the most concerning issues. Data on maternal and neonatal outcomes should be interpreted cautiously due to study designs, patient characteristics, clinical variables, the effects of variants, and vaccination beyond the pandemic. Cesarean section, immediate separation of mother-infant dyads, isolation of neonates, and avoidance of breast milk were performed to reduce transmission risk at the beginning of the pandemic in the era of insufficient knowledge. Vertical transmission was found to be low with favorable short-term outcomes. Serious fetal and neonatal outcomes are not expected, according to growing evidence. Long-term effects may be associated with fetal programming. Knowledge and lessons from COVID-19 will be helpful for the next pandemic if it occurs. IMPACT: Prenatal infection with SARS-CoV-2 is associated with adverse maternal and neonatal outcomes. Our review includes the effects of COVID-19 on the fetus and neonates, transmission routes, placental effects, fetal and neonatal outcomes, and long-term effects on neonates. There is a growing body of data and evidence about the COVID-19 pandemic. Knowledge and lessons from the pandemic will be helpful for the next pandemic if it happens.

Obstetric Intervention and Perinatal Outcomes During the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE

To quantify pandemic-related changes in obstetric intervention and perinatal outcomes in the United States.

METHODS

We carried out a retrospective study of all live births and fetal deaths in the United States, 2015-2021, with data obtained from the natality, fetal death, and linked live birth-infant death files of the National Center for Health Statistics. Analyses were carried out among all singletons; singletons of patients with prepregnancy diabetes, prepregnancy hypertension, and hypertensive disorders of pregnancy; and twins. Outcomes of interest included preterm birth, preterm labor induction or preterm cesarean delivery, macrosomia, postterm birth, and perinatal death. Interrupted time series analyses were used to estimate changes in the prepandemic period (January 2015-February 2020), at pandemic onset (March 2020), and in the pandemic period (March 2020-December 2021).

RESULTS

The study population included 26,604,392 live births and 155,214 stillbirths. The prepandemic period was characterized by temporal increases in preterm birth and preterm labor induction or cesarean delivery rates and temporal reductions in macrosomia, postterm birth, and perinatal mortality. Pandemic onset was associated with absolute decreases in preterm birth (decrease of 0.322/100 live births, 95% CI 0.506-0.139) and preterm labor induction or cesarean delivery (decrease of 0.190/100 live births, 95% CI 0.334-0.047) and absolute increases in macrosomia (increase of 0.046/100 live births), postterm birth (increase of 0.015/100 live births), and perinatal death (increase of 0.501/1,000 total births, 95% CI 0.220-0.783). These changes were larger in subpopulations at high risk (eg, among singletons of patients with prepregnancy diabetes). Among singletons of patients with prepregnancy diabetes, pandemic onset was associated with a decrease in preterm birth (decrease of 1.634/100 live births) and preterm labor induction or cesarean delivery (decrease of 1.521/100 live births) and increases in macrosomia (increase of 0.328/100 live births) and perinatal death (increase of 9.840/1,000 total births, 95% CI 3.933-15.75). Most changes were reversed in the months after pandemic onset.

CONCLUSION

The onset of the coronavirus disease 2019 (COVID-19) pandemic was associated with a transient decrease in obstetric intervention (especially preterm labor induction or cesarean delivery) and a transient increase in perinatal mortality.

Effects of the COVID-19 early pandemic on delivery outcomes among women with and without COVID-19 at birth

BACKGROUND

The COVID-19 pandemic may influence delivery outcomes through direct effects of infection or indirect effects of disruptions in prenatal care. We examined early pandemic-related changes in birth outcomes for pregnant women with and without a COVID-19 diagnosis at delivery.

METHODS

We compared four delivery outcomes-preterm delivery (PTD), severe maternal morbidity (SMM), stillbirth, and cesarean birth-between 2017 and 2019 (prepandemic) and between April and December 2020 (early-pandemic) using interrupted time series models on 11.8 million deliveries, stratified by COVID-19 infection status at birth with entropy weighting for historical controls, from the Healthcare Cost and Utilization Project across 43 states and the District of Columbia.

RESULTS

Relative to 2017-2019, women without COVID-19 at delivery in 2020 had lower odds of PTD (OR = 0.93; 95% CI = 0.92-0.94) and SMM (OR = 0.88; 95% CI = 0.85-0.91) but increased odds of stillbirth (OR = 1.04; 95% CI = 1.01-1.08). Absolute effects were small across race/ethnicity groups. Deliveries with COVID-19 had an excess of each outcome, by factors of 1.07-1.46 for outcomes except SMM at 4.21. The effect for SMM was more pronounced for Asian/Pacific Islander non-Hispanic (API; OR = 10.51; 95% CI = 5.49-20.14) and Hispanic (OR = 5.09; 95% CI = 4.29-6.03) pregnant women than for White non-Hispanic (OR = 3.28; 95% CI = 2.65-4.06) women.

DISCUSSION

Decreasing rates of PTD and SMM and increasing rates of stillbirth among deliveries without COVID-19 were small but suggest indirect effects of the pandemic on maternal outcomes. Among pregnant women with COVID-19 at delivery, adverse effects, particularly SMM for API and Hispanic women, underscore the importance of addressing health disparities.

Can prenatal ultrasound predict adverse neonatal outcomes in SARS-CoV-2-affected pregnancies?

BACKGROUND

On the basis of available data, at least 1 ultrasound assessment of pregnancies recovering from SARS-CoV-2 infection is recommended. However, reports on prenatal imaging findings and potential associations with neonatal outcomes following SARS-CoV-2 infection in pregnancy have been inconclusive.

OBJECTIVE

This study aimed to describe the sonographic characteristics of pregnancies after confirmed SARS-CoV-2 infection and assess the association of prenatal ultrasound findings with adverse neonatal outcomes.

STUDY DESIGN

This was an observational prospective cohort study of pregnancies diagnosed with SARS-CoV-2 by reverse transcription polymerase chain reaction between March 2020 and May 2021. Prenatal ultrasound evaluation was performed at least once after diagnosis of infection, with the following parameters measured: standard fetal biometric measurements, umbilical and middle cerebral artery Dopplers, placental thickness, amniotic fluid volume, and anatomic survey for infection-associated findings. The primary outcome was the composite adverse neonatal outcome, defined as ≥1 of the following: preterm birth, neonatal intensive care unit admission, small for gestational age, respiratory distress, intrauterine fetal demise, neonatal demise, or other neonatal complications. Secondary outcomes were sonographic findings stratified by trimester of infection and severity of SARS-CoV-2 infection. Prenatal ultrasound findings were compared with neonatal outcomes, severity of infection, and trimester of infection.

RESULTS

A total of 103 SARS-CoV-2-affected mother-infant pairs with prenatal ultrasound evaluation were identified; 3 cases were excluded because of known major fetal anomalies. Of the 100 included cases, neonatal outcomes were available in 92 pregnancies (97 infants); of these, 28 (29%) had the composite adverse neonatal outcome, and 23 (23%) had at least 1 abnormal prenatal ultrasound finding. The most common abnormalities seen on ultrasound were placentomegaly (11/23; 47.8%) and fetal growth restriction (8/23; 34.8%). The latter was associated with a higher rate of the composite adverse neonatal outcome (25% vs 1.5%; adjusted odds ratio, 22.67; 95% confidence interval, 2.63-194.91; P<.001), even when small for gestational age was removed from this composite outcome. The Cochran Mantel-Haenszel test controlling for possible fetal growth restriction confounders continued to show this association (relative risk, 3.7; 95% confidence interval, 2.6-5.9; P<.001). Median estimated fetal weight and birthweight were lower in patients with the composite adverse neonatal outcome (P<.001). Infection in the third trimester was associated with lower median percentile of estimated fetal weight (P=.019). An association between placentomegaly and third-trimester SARS-CoV-2 infection was noted (P=.045).

CONCLUSION

In our study of SARS-CoV-2-affected maternal-infant pairs, rates of fetal growth restriction were comparable to those found in the general population. However, composite adverse neonatal outcome rates were high. Pregnancies with fetal growth restriction after SARS-CoV-2 infection were associated with an increased risk for the adverse neonatal outcome and may require close surveillance.

Impact of telehealth implementation on diagnosis of hypertensive disorders of pregnancy

BACKGROUND

COVID-19 caused a rapid integration of telehealth into prenatal care. This raises questions about the ability to screen for hypertensive disorders of pregnancy when caring for patients remotely.

OBJECTIVE

This study aimed to assess the effect of telehealth adaptation on the timing and severity of diagnosis of hypertensive disorders of pregnancy.

STUDY DESIGN

This was a retrospective study of patients with hypertensive disorders of pregnancy who delivered from April 2019 to October 2019 (before the pandemic) and April 2020 to October 2020 (during the pandemic) at 1 urban tertiary care center. The primary outcome was mean gestational age at diagnosis of a hypertensive disorder of pregnancy. The secondary outcomes included severity of diagnosis, both initially and at the time of delivery. The results were adjusted for baseline characteristic difference at P<.10, using multivariable logistic regression and analysis of covariance, as appropriate. The sample size was calculated based on a previous cohort study of patients who developed preeclampsia, with a mean gestational age at delivery of 36.3 weeks and a standard deviation of 2.8 weeks. A sample size of 124 patients would be needed per group to detect a gestational age difference of 1 week with 80% power and a 95% confidence interval.

RESULTS

Overall, 498 patients were included, with 231 from 2019 and 267 from 2020. Of note, 17.1% of patients had preeclampsia with severe features initially, and 29.3% of patients met the criteria at delivery. In 2020, 80.5% of patients used telehealth (vs 0.9% of patients in 2019), doing so for a mean of 29.0% of prenatal appointments. Unadjusted and adjusted analyses showed no significant difference in gestational age at diagnosis or diagnosis severity between cohorts. In the adjusted analysis, cohort year was not significantly associated with severity of initial diagnosis (adjusted odds ratio, 0.86; 95% confidence interval, 0.53-1.39; P=.53) or severity of diagnosis at delivery (adjusted odds ratio, 0.97; 95% confidence interval, 0.64-1.46; P=.87). However, Black race was significantly associated with increased risk of having severe preeclampsia at initial diagnosis (adjusted odds ratio, 1.70; 95% confidence interval, 1.01-2.85; P=.046). In addition, Black race (adjusted odds ratio, 2.62; 95% confidence interval, 1.60-4.28; P<.001), Hispanic ethnicity (adjusted odds ratio for non-Hispanic, 0.40; 95% confidence interval, 0.19-0.82; P=.01), and initial body mass index (adjusted odds ratio, 1.04; 95% confidence interval, 1.01-1.06; P=.005) were significantly associated with a diagnosis of severe preeclampsia at delivery.

CONCLUSION

The adaptation of telehealth was not associated with delays in the diagnosis of hypertensive disorders of pregnancy or with increased severity of diagnoses.

Assessing racial residential segregation as a risk factor for severe maternal morbidity

PURPOSE

To measure associations of area-level racial and economic residential segregation with severe maternal morbidity (SMM).

METHODS

We conducted a retrospective cohort study of births at two Philadelphia hospitals between 2018 and 2020 to analyze associations of segregation, quantified using the Index of Concentration at the Extremes (ICE), with SMM. We used stratified multivariable, multilevel, logistic regression models to determine whether associations of ICE with SMM varied by self-identified race or hospital catchment.

RESULTS

Of the 25,979 patients (44.1% Black, 35.8% White), 1381 (5.3%) had SMM (Black [6.1%], White [4.4%]). SMM was higher among patients residing outside (6.3%), than inside (5.0%) Philadelphia (P < .001). Overall, ICE was not associated with SMM. However, ICErace (higher proportion of White vs. Black households) was associated with lower odds of SMM among patients residing inside Philadelphia (aOR 0.87, 95% CI: 0.80-0.94) and higher odds outside Philadelphia (aOR 1.12, 95% CI: 0.95-1.31). Moran's I indicated spatial autocorrelation of SMM overall (P < .001); when stratified, autocorrelation was only evident outside Philadelphia.

CONCLUSIONS

Overall, ICE was not associated with SMM. However, higher ICErace was associated with lower odds of SMM among Philadelphia residents. Findings highlight the importance of hospital catchment area and referral patterns in spatial analyses of hospital datasets.

A spectrum of pathological changes induced by SARS-COV-2: An observational study in a cohort of pregnant women from Mizoram, India

Background

Maternal infection by SARS-CoV-2 may lead to adverse pregnancy outcomes and causes pathological changes in the placenta. However, consensus regarding characteristic pathological features is lacking. Researchof the placental histopathology in a cohort of women from Mizoram, India, was conducted to relate the SARS-CoV-2 infection's effectswith pregnancy and its outcome.

Materials and methods

The characteristics of 72 pregnant women diagnosed positive for SARS-CoV-2 who eventually delivered at Zoram Medical College Hospital, Mizoram, neonates' well-being, and histopathological features of placentas were studied.

Results

Of 72 women in this study, 59 (81.9%) gave birth at full term. Among these births, 5 were normal vaginal deliveries, while the remaining 67 (93.1%) were delivered via cesarean section. The reasons for cesarean delivery were either related to SARS-CoV-2 infection (n ​= ​49), existing obstetric problems (n ​= ​15) or fetal-distress (n ​= ​5). All deliveries resulted in live births of COVID-negative babies, with 80.6% (n ​= ​58) of the newborns having a birth weight of over 2.5 ​kg. APGAR scores ranged from 4 to 6 in 61 (84.7%) of the babies, and 10 neonates required resuscitation, of which 8 were managed in the neonatal intensive care unit (NICU). The placental histopathology showed increased fibrin thrombi in 8 cases (11.1%), while 20 cases (28%) showed focal infarction, microcalcification levels were elevated in 16 cases (22.2%), and a small percentage of cases (1.4%) exhibited small fibrotic villi and inter-villus agglutination. Placental chorioangiosis was detected in 28 (38.9%) of the cases, while avascular villi were seen in 6 cases. Meconium-stained liquor was observed in a single case. Intervillous hemorrhage was found in 42 cases, whileintervillous inflammation and increased syncytial knots were present in 14 and 5 cases, respectively. The placenta pathology of 10 neonates who required resuscitation/NICU admission was not significantly different from that of the 62 neonates who did not require it. However, a higher proportion of placenta from the asymptomatic group showed no abnormality compared to the symptomatic group (p ​= ​0.046).

Conclusion

SARS-CoV-2 infection causes a range of morphological changes and lesions in the placenta, including chorangiosis, villositis, chorioamnionitis, fetal vascular malperfusion/thrombosis, fibrin-deposition, increased syncytial-knotting, increased microcalcification, increased villous agglutination, focal infarct, intervilloushemorrhage as well as inflammation. Placental histopathological findings from this study can provide additional information to the existing literature on the subject.

The effects of COVID-19 on placental morphology

The impact of the COVID-19 infection, caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), during the pandemic has been considerably more severe in pregnant women than non-pregnant women. Therefore, a review detailing the morphological alterations and physiological changes associated with COVID-19 during pregnancy and the effect that these changes have on the feto-placental unit is of high priority. This knowledge is crucial for these mothers, their babies and clinicians to ensure a healthy life post-pandemic. Hence, we review the placental morphological changes due to COVID-19 to enhance the general understanding of how pregnant mothers, their placentas and unborn children may have been affected by this pandemic. Based on current literature, we deduced that COVID-19 pregnancies were oxygen deficient, which could further result in other pregnancy-related complications like preeclampsia and IUGR. Therefore, we present an up-to-date review of the COVID-19 pathophysiological implications on the placenta, covering the function of the placenta in COVID-19, the effects of this virus on the placenta, its functions and its link to other gestational complications. Furthermore, we highlight the possible effects of COVID-19 therapeutic interventions on pregnant mothers and their unborn children. Based on the literature, we strongly suggest that consistent surveillance for the mothers and infants from COVID-19 pregnancies be prioritised in the future. Though the pandemic is now in the past, its effects are long-term, necessitating the monitoring of clinical manifestations in the near future.

Exploring Prenatal Care Quality and Access During the COVID-19 Pandemic Among Pregnant Immigrants in Philadelphia Through the Lens of Community-Based Organizations

Background

The peak of the COVID-19 pandemic led to decreased maternal and child health care engagement, especially among marginalized populations. Existing disparities in prenatal care access and quality faced by pregnant immigrant people are likely to be amplified by the pandemic.

Materials and Methods

We conducted a study with direct service providers (DSPs) at community-based organizations (CBOs) serving pregnant immigrant families in the Philadelphia region. Semistructured interviews addressed barriers and facilitators to prenatal health care access and engagement among immigrant families both before and then after the onset of the pandemic in March 2020. Additional questions elicited context about the demographics of service populations, organizational connectedness to health care providers, and pandemic-related operational changes.

Results

Between June and November 2021, 10 interviews were conducted in English and Spanish with DSPs at 5 CBOs. Primary themes included diminished access and quality of care received due to decreased language accessibility, increased restrictions around support persons, shifts to telemedicine, and changes to appointment scheduling. Additional themes included heightened hesitancy engaging with services due to documentation status, confusion around legal rights, financial strain, and health insurance status. Interviewees provided suggestions for improving service access during and postpandemic for immigrant pregnant people, including implementation of culturally responsive group prenatal care, institutional policies to improve understanding of legal rights, and increased financial supports.

Conclusions

Understanding emergent and exacerbated barriers to prenatal care access and quality during the COVID-19 pandemic provides context for how to improve health equity for immigrant pregnant people through public health and health care policies as the pandemic continues, and once it has subsided.

COVID-19 pandemic and neonatal birth weight: a systematic review and meta-analysis

OBJECTIVES

Lockdown was implemented in many countries during the pandemic, which led to myriad changes in pregnant women's lives. However, the potential impacts of the COVID-19 pandemic on neonatal outcomes remain unclear. We aimed to evaluate the association between the pandemic and neonatal birth weight.

STUDY DESIGN

This was a systematic review and meta-analysis of the previous literature.

METHODS

We searched the MEDLINE and Embase databases up to May 2022 and extracted 36 eligible studies that compared neonatal birth weight between the pandemic and the prepandemic period. The following outcomes were included: mean birth weight, low birth weight (LBW), very low birth weight (VLBW), macrosomia, small for gestational age (SGA), very small for gestational age (VSGA), and large for gestational age (LGA). Statistical heterogeneity among studies was assessed to determine whether a random effects model or fixed effects model was conducted.

RESULTS

Of the 4514 studies identified, 36 articles were eligible for inclusion. A total of 1,883,936 neonates during the pandemic and 4,667,133 neonates during the prepandemic were reported. We identified a significant increase in mean birth weight (pooled mean difference [95% confidence interval (CI)] = 15.06 [10.36, 19.76], I² = 0.0%, 12 studies) and a reduction in VLBW (pooled OR [95% CI] = 0.86 [0.77, 0.97], I² = 55.4%, 12 studies). No overall effect was identified for other outcomes: LBW, macrosomia, SGA, VSGA, and LGA. There was publication bias for mean birth weight with a borderline significance (Egger's P = 0.050).

CONCLUSION

Pooled results showed the pandemic was significantly associated with an increase in mean birth weight and a reduction in VLBW, but not for other outcomes. This review provided clues about the indirect effects of the pandemic on neonatal birth weight and more healthcare measures needed to improve neonatal long-term health.

Maternal and neonatal outcomes following SARS-CoV-2 infection

Infection with SARS-CoV-2 causing COVID-19 in pregnancy is known to confer risks to both the pregnant patient and fetus. A review of the current literature demonstrates that pregnant individuals with SARS-CoV-2 infection are at risk for higher composite morbidity, intensive care unit admission, ventilatory support, pre-eclampsia, preterm birth, and neonatal intensive care unit admissions compared to pregnant individuals without SARS-CoV-2. Worse obstetric morbidity and mortality generally correlate with the severity of COVID-19. Comorbidities such as diabetes increase the risk of severe COVID-19. An increased risk of stillbirth appears to be predominantly confined to pregnancies affected in the Delta variant time period. Further, vaccination against SARS-CoV-2 has been demonstrated to be safe and effective in pregnancy and while breastfeeding. Therefore, continued counseling encouraging vaccination remains imperative. The long-term maternal and neonatal consequences of pregnancies affected by SARS-CoV-2 remain unknown, and therefore continued research in this regard is warranted.

Pregnancy during a Pandemic: A Cohort Study Comparing Adverse Outcomes during and before the COVID-19 Pandemic

OBJECTIVE

This study was aimed to evaluate how the novel coronavirus disease 2019 (COVID-19) pandemic may have negatively impacted birth outcomes in patients who tested negative for the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus.

STUDY DESIGN

We conducted a retrospective cohort study using electronic health records of pregnant women admitted to a tertiary medical center in New York City, an epicenter of the pandemic. Women with a singleton gestation admitted for delivery from March 27 to May 31, 2019, and March 27 to May 31, 2020, were included. Women less than 18 years of age, those with a positive SARS-CoV-2 polymerize chain reaction (PCR) test on admission, fetal anomaly, or multiple gestation were excluded. Adverse pregnancy outcomes were compared between groups. Univariable and multivariable logistic regression analyses were used to assess outcomes. The primary outcome was preterm birth.

RESULTS

Women who delivered during the 2020 study interval had a significantly higher rate of hypertensive disorders of pregnancy (gestational hypertension [GHTN] or preeclampsia; odds ratio [OR] = 1.40, 95% confidence interval [CI]: 1.05-1.85; p = 0.02), postpartum hemorrhage (PPH; OR = 1.77, 95% CI: 1.14-2.73; p = 0.01), and preterm birth (OR = 1.49, 95% CI: 1.10-2.02; p = 0.01). Gestational age at delivery was significantly lower in the 2020 cohort compared with the 2019 cohort (39.3 versus 39.4 weeks, p = 0.03). After adjusting for confounding variables, multivariate analysis confirmed a persistent increase in hypertensive disorders of pregnancy (OR = 1.56, 95% CI: 1.10-2.20, p = 0.01), PPH (OR = 1.74, 95% CI: 1.06-2.86, p = 0.03), and preterm birth (OR = 1.72, 95% CI: 1.20-2.47, p = 0.003) in patients who delivered in 2020 compared with the same period in 2019. Specifically, medically indicated preterm births increased during the pandemic (OR = 3.17, 95% CI: 1.77-5.67, p < 0.0001).

CONCLUSION

Those who delivered during the COVID-19 pandemic study interval were more likely to experience hypertensive disorders of pregnancy, medically indicated preterm birth, and PPH even in the absence of SARS-CoV2 infection.

KEY POINTS

· Stressful life events can lead to adverse pregnancy outcomes.. · Even patients negative for COVID-19 experienced GHTN, preeclampsia, PPH and preterm birth during the pandemic.. · Pandemic-related stress may adversely affect perinatal outcomes..

Fewer Preterm Births in the First COVID-19 Pandemic Year? An Evaluation of the Berlin Perinatal Data for the Years 2017 to 2020

Introduction The study analyzes and interprets possible effects of the COVID-19 pandemic on the preterm birth rate. Research questions included: were there fewer preterm births in Berlin in 2020, the first year of the pandemic, compared to the three years before the pandemic? Were there differences in preterm birth rates grouped according to weeks of gestation? Method The perinatal data of all singleton pregnancies were evaluated with regard to birth rates in Berlin, and the numbers of preterm neonates born in the three pre-pandemic years from 2017 to 2019 were compared to the rate for 2020, the first year of the pandemic. Results The overall number of singleton pregnancies born in maternity hospitals and labor wards in Berlin decreased in the first year of the pandemic. The percentage of preterm neonates born before 37 + 0 weeks of gestation (GW) was significantly lower in 2020 compared to the three previous years, with significantly more preterm neonates born before 28 + 0 GW and significantly fewer preterm neonates born between 28 + 0 to 35 + 0 GW. In 2020, significantly fewer neonates born before 37 + 0 weeks of gestation were delivered by primary caesarean section. The incidence of induced births was approximately the same. Conclusions In the first year of the pandemic, a range of social, iatrogenic, and biological factors may have had an impact on preterm birth rates. A Germany-wide evaluation of perinatal data across different German federal states for the period 2020 to 2022 would offer the opportunity to identify the causes of this lower rate of preterm births and determine whether conclusions can be drawn from this which would affect future strategies to reduce preterm birth rates.

Patterns of Prenatal Care Delivery and Obstetric Outcomes before and during the COVID-19 Pandemic

OBJECTIVE

 Health care providers and health systems confronted new challenges to deliver timely, high-quality prenatal care during the coronavirus disease 2019 (COVID-19) pandemic as the pandemic raised concerns that care would be delayed or substantively changed. This study describes trends in prenatal care delivery in 2020 compared with 2018 to 2019 in a large, commercially insured population and investigates changes in obstetric care processes and outcomes.

STUDY DESIGN

 This retrospective cohort study uses de-identified administrative claims for commercially insured patients. Patients whose entire pregnancy took place from March 1 to December 31 in years 2018, 2019, and 2020 were included. Trends in prenatal care, including in-person, virtual, and emergency department visits, were evaluated, as were prenatal ultrasounds. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included preterm birth and stillbirth. To determine whether COVID-19 pandemic-related changes in prenatal care had an impact on maternal outcomes, we compared the outcome rates during the pandemic period in 2020 to equivalent periods in 2018 and 2019.

RESULTS

 In total, 35,112 patients were included in the study. There was a significant increase in the prevalence of telehealth visits, from 1.1 to 1.2% prior to the pandemic to 17.2% in 2020, as well as a significant decrease in patients who had at least one emergency department visit during 2020. Overall prenatal care and ultrasound utilization were unchanged. The rate of SMM across this period was stable (2.3-2.8%) with a statistically significant decrease in the preterm birth rate in 2020 (7.4%) compared with previous years (8.2-8.6%; p < 0.05) and an unchanged stillbirth rate was observed.

CONCLUSION

 At a time when many fields of health care were reshaped during the pandemic, these observations reveal considerable resiliency in both the processes and outcomes of obstetric care.

KEY POINTS

· Overall prenatal care and ultrasound were unchanged from 2018 to 2019 to 2020.. · There was a large increase in the prevalence of telehealth visits in 2020.. · There was no change in the rate of severe maternal morbidity or stillbirth in 2020 compared with 2018 to 2019..

SARS-CoV-2 Seroconversion and Pregnancy Outcomes in a Population of Pregnant Women Recruited in Milan, Italy, between April 2020 and October 2020

The possible link between SARS-CoV-2 infection and adverse pregnancy outcomes has so far demonstrated heterogeneous results in terms of maternal, fetal, and neonatal complications. We aim to investigate the correlation between SARS-CoV-2 seroconversion and/or neutralization titer and pregnancy outcomes. We analyzed a population of 528 pregnant women followed up from the first trimester of gestation until delivery. For each woman, we collected a first blood sample between 11 and 13 weeks of gestation and a second sample in the perinatal period (between peripartum and puerperium) to assess the presence of SARS-CoV-2 antibodies and/or microneutralization titer (MN titer). Data on pregnancy outcomes (gestational age at delivery, preterm birth before 34 weeks, hypertensive disorders, gestational diabetes, and abnormal fetal growth) were collected. We observed that serologic status per se is not associated with major pregnancy complications. On the contrary, the MN titer was associated with increased odds of gestational diabetes. Although we mainly reported asymptomatic SARS-CoV-2 infections and the absence of severe maternal and neonatal adverse outcomes, SARS-CoV-2 infection might challenge the maternal immune system and explain the moderate increase in adverse outcome odds.

Impacts of COVID-19 pandemic on preterm birth: a systematic review and meta-analysis

OBJECTIVES

The COVID-19 pandemic has significantly affected healthcare systems and daily well-being. However, the reports of the indirect impacts of the pandemic on preterm birth remain conflicting. We performed a meta-analysis to examine whether the pandemic altered the risk of preterm birth.

STUDY DESIGN

This was a systematic review and meta-analysis of the previous literature.

METHODS

We searched MEDLINE and Embase databases until March 2022 using appropriate keywords and extracted 63 eligible studies that compared preterm between the COVID-19 pandemic period and the prepandemic period. A random effects model was used to obtain the pooled odds of each outcome. The study protocol was registered with PROSPERO (No. CRD42022326717).

RESULTS

The search identified 3827 studies, of which 63 reports were included. A total of 3,220,370 pregnancies during the COVID-19 pandemic period and 6,122,615 pregnancies during the prepandemic period were studied. Compared with the prepandemic period, we identified a significant decreased odds of preterm birth (PTB; <37 weeks' gestation; pooled odds ratio [OR; 95% confidence interval (CI)] = 0.96 [0.94, 0.98]; I2 = 78.7%; 62 studies) and extremely PTB (<28 weeks' gestation; pooled OR [95% CI] = 0.92 [0.87, 0.97]; I2 = 26.4%; 25 studies) during the pandemic, whereas there was only a borderline significant reduction in the odds of very PTB (<32 weeks' gestation; pooled OR [95% CI] = 0.93 [0.86, 1.01]; I2 = 90.1%; 33 studies) between the two periods. There was significant publication bias for PTB.

CONCLUSION

Pooled results suggested the COVID-19 pandemic was associated with preterm birth, although there was only a borderline significant reduction for very PTB during the pandemic compared with the prepandemic period. Large studies showed conflicting results, and further research on whether the change is related to pandemic mitigation measures was warranted.

Postpartum Blood Loss in COVID-19 Patients-Propensity Score Matched Analysis

The aim of this study was to compare the estimated blood loss and the frequency of obstetric hemorrhage among pregnant women with and without COVID-19 infection. The study was carried out in the Department of Obstetrics and Gynecology, at the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Poland. From 15 May 2020 to 26 April 2021, a total of 224 parturients with COVID-19 infection were admitted for labor. The control group consisted of 300 randomly recruited pre-pandemic deliveries that took place between 15 May 2019 and 26 April 2020 at the Department. The primary outcome was the presence of postpartum hemorrhage, defined as an estimated blood loss of ≥500 mL within 24 h after birth or the need to transfuse 2 or more units of packed red blood cells (pRBCs). Secondary outcomes were the difference between hemoglobin and hematocrit levels at 24 h postpartum, the number of pRBCs units transfused, and the need for transperitoneal drainage. After applying the propensity-score-matching procedure for postpartum bleeding risk factors, 325 eligible patients were included in the final analysis, divided into 203 COVID-19 positive and 122 COVID-19 negative prepandemic deliveries. SARS-CoV-2 infected patients were characterized by a longer activated partial thromboplastin time (APTT), a reduced prothrombin time (PT), and lower platelet count at initial presentation. COVID-19 deliveries were found to be associated with a higher frequency of postpartum hemorrhage, an increased estimated blood loss, the more frequent use of peritoneal drainage, and more pRBCs units transfused. During the pandemic, an increased risk of postpartum hemorrhage posed another threat to SARS-CoV-2 infected pregnant women. It is essential to be aware of this when approaching COVID-19 delivery and to implement efficient preventative methods.

Changes in preterm birth during the COVID-19 pandemic by duration of exposure and race and ethnicity

OBJECTIVE

We aimed to determine whether coronavirus-disease-2019 (COVID-19) pandemic exposure duration was associated with PTB and if the pandemic modified racial disparities.

STUDY DESIGN

We analyzed Philadelphia births and replicated in New Haven. Compared to matched months in two prior years, we analyzed overall PTB, specific PTB phenotypes, and stillbirth.

RESULTS

Overall, PTB was similar between periods with the following exceptions. Compared to pre-pandemic, early pregnancy (&lt;14 weeks') pandemic exposure was associated with lower risk of PTB &lt; 28 weeks' (aRR 0.60 [0.30-1.10]) and later exposure with higher risk (aRR 1.77 [0.78-3.97]) (interaction p = 0.04). PTB &lt; 32 weeks' among White patients decreased during the pandemic, resulting in non-significant widening of the Black-White disparity from aRR 2.51 (95%CI: 1.53-4.16) to aRR 4.07 (95%CI: 1.56-12.01) (interaction P = 0.41). No findings replicated in New Haven.

CONCLUSION

We detected no overall pandemic effects on PTB, but potential indirect benefits for some patients which could widen disparities remains possible.

Clinical Manifestation and Obstetric Outcomes in Pregnant Women with SARS-CoV-2 Infection at Delivery: A Retrospective Cohort Analysis

This retrospective cohort study aimed to analyze the clinical manifestations, complications, and maternal-fetal outcomes in patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during delivery. The cohort included 61 pregnant women positive for SARS-CoV-2 infection at the time of delivery. Patients were divided into two groups: symptomatic and asymptomatic. We found a significantly higher rate of leukocytosis (p < 0.00078) and lymphopenia (p < 0.0024) in symptomatic women compared with asymptomatic ones. Other laboratory parameters, such as CRP (p = 0.002), AST (p = 0.007), LDH (p = 0.0142), ferritin (p = 0.0036), and D-dimer (p = 0.00124), were also significantly more often increased in the group of symptomatic pregnant women. Overall, symptomatic pregnant women with SARS-CoV-2 infection at the delivery show more often altered laboratory parameters compared with asymptomatic ones; nevertheless, they have a slightly higher but non-significant rate of preterm delivery, cesarean section, as well as lower neonatal birth weight and Apgar score, compared with asymptomatic women.

Review of Impact of COVID-19 on Maternal, Neonatal Outcomes, and Placental Changes

Coronavirus disease (COVID-19), caused by SARS-CoV-2, is a disease that has caused a global impact. COVID-19 is transmitted through airborne droplets, respiratory secretions, and direct contact. The pandemic has affected individuals of different ages, and studying the impact of COVID-19 on maternal and newborn outcomes is critical. In this review, we highlight the impact of COVID-19 infection in pregnancy and its repercussion in the maternal-fetal binomial. Physiological changes that occur during pregnancy have significant effects on the immune system, cardiopulmonary system, and coagulation, and these changes can result in an altered response to COVID-19 infection. The symptoms, risk factors, and maternal health consequences of COVID-19 were discussed. In addition, the impact of newborns born to mothers with COVID-19 was reviewed. Finally, placental changes and vertical transmission of COVID-19 during pregnancy were also discussed in this review.

Comparison of Pregnancy and Birth Outcomes Before vs During the COVID-19 Pandemic

Importance

Little is known about changes in obstetric outcomes during the COVID-19 pandemic.

Objective

To assess whether obstetric outcomes and pregnancy-related complications changed during the COVID-19 pandemic.

Design, Setting, and Participants

This retrospective cohort study included pregnant patients receiving care at 463 US hospitals whose information appeared in the PINC AI Healthcare Database. The relative differences in birth outcomes, pregnancy-related complications, and length of stay (LOS) during the pandemic period (March 1, 2020, to April 31, 2021) were compared with the prepandemic period (January 1, 2019, to February 28, 2020) using logistic and Poisson models, adjusting for patients' characteristics, and comorbidities and with month and hospital fixed effects.

Exposures

COVID-19 pandemic period.

Main Outcomes and Measures

The 3 primary outcomes were the relative change in preterm vs term births, mortality outcomes, and mode of delivery. Secondary outcomes included the relative change in pregnancy-related complications and LOS.

Results

There were 849 544 and 805 324 pregnant patients in the prepandemic and COVID-19 pandemic periods, respectively, and there were no significant differences in patient characteristics between periods, including age (≥35 years: 153 606 [18.1%] vs 148 274 [18.4%]), race and ethnicity (eg, Hispanic patients: 145 475 [47.1%] vs 143 905 [17.9%]; White patients: 456 014 [53.7%] vs 433 668 [53.9%]), insurance type (Medicaid: 366 233 [43.1%] vs 346 331 [43.0%]), and comorbidities (all standardized mean differences <0.10). There was a 5.2% decrease in live births during the pandemic. Maternal death during delivery hospitalization increased from 5.17 to 8.69 deaths per 100 000 pregnant patients (odds ratio [OR], 1.75; 95% CI, 1.19-2.58). There were minimal changes in mode of delivery (vaginal: OR, 1.01; 95% CI, 0.996-1.02; primary cesarean: OR, 1.02; 95% CI, 1.01-1.04; vaginal birth after cesarean: OR, 0.98; 95% CI, 0.95-1.00; repeated cesarean: OR, 0.96; 95% CI, 0.95-0.97). LOS during delivery hospitalization decreased by 7% (rate ratio, 0.931; 95% CI, 0.928-0.933). Lastly, the adjusted odds of gestational hypertension (OR, 1.08; 95% CI, 1.06-1.11), obstetric hemorrhage (OR, 1.07; 95% CI, 1.04-1.10), preeclampsia (OR, 1.04; 95% CI, 1.02-1.06), and preexisting chronic hypertension (OR, 1.06; 95% CI, 1.03-1.09) increased. No significant changes in preexisting racial and ethnic disparities were observed.

Conclusions and Relevance

During the COVID-19 pandemic, there were increased odds of maternal death during delivery hospitalization, cardiovascular disorders, and obstetric hemorrhage. Further efforts are needed to ensure risks potentially associated with the COVID-19 pandemic do not persist beyond the current state of the pandemic.

Neighborhood Characteristics and Racial Disparities in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Seropositivity in Pregnancy

OBJECTIVE

To quantify the extent to which neighborhood characteristics contribute to racial and ethnic disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity in pregnancy.

METHODS

This cohort study included pregnant patients who presented for childbirth at two hospitals in Philadelphia, Pennsylvania from April 13 to December 31, 2020. Seropositivity for SARS-CoV-2 was determined by measuring immunoglobulin G and immunoglobulin M antibodies by enzyme-linked immunosorbent assay in discarded maternal serum samples obtained for clinical purposes. Race and ethnicity were self-reported and abstracted from medical records. Patients' residential addresses were geocoded to obtain three Census tract variables: community deprivation, racial segregation (Index of Concentration at the Extremes), and crowding. Multivariable mixed effects logistic regression models and causal mediation analyses were used to quantify the extent to which neighborhood variables may explain racial and ethnic disparities in seropositivity.

RESULTS

Among 5,991 pregnant patients, 562 (9.4%) were seropositive for SARS-CoV-2. Higher seropositivity rates were observed among Hispanic (19.3%, 104/538) and Black (14.0%, 373/2,658) patients, compared with Asian (3.2%, 13/406) patients, White (2.7%, 57/2,133) patients, and patients of another race or ethnicity (5.9%, 15/256) (P<.001). In adjusted models, per SD increase, deprivation (adjusted odds ratio [aOR] 1.16, 95% CI 1.02-1.32) and crowding (aOR 1.15, 95% CI 1.05-1.26) were associated with seropositivity, but segregation was not (aOR 0.90, 95% CI 0.78-1.04). Mediation analyses revealed that crowded housing may explain 6.7% (95% CI 2.0-14.7%) of the Hispanic-White disparity and that neighborhood deprivation may explain 10.2% (95% CI 0.5-21.1%) of the Black-White disparity.

CONCLUSION

Neighborhood deprivation and crowding were associated with SARS-CoV-2 seropositivity in pregnancy in the prevaccination era and may partially explain high rates of SARS-CoV-2 seropositivity among Black and Hispanic patients. Investing in structural neighborhood improvements may reduce inequities in viral transmission.

Perspective: Chicken Models for Studying the Ontogenetic Origin of Neuropsychiatric Disorders

Nutrients and xenobiotics cross the blood–placenta barrier, potentially depositing in the fetal brain. The prenatal exposure affects the neuroendocrine and microbial development. The mechanism underlying maternal risk factors reprograming the microbiota–gut–brain axis with long-term effects on psychosocial behaviors in offspring is not clear. In humans, it is not possible to assess the nutrient or xenobiotic deposition in the fetal brain and gastrointestinal system for ethical reasons. Moreover, the maternal–fetal microbe transfer during gestation, natural labor, and breast-feeding constitutes the initial gut microbiome in the progeny, which is inevitable in the most widely utilized rodent models. The social predisposition in precocial birds, including chickens, provides the possibility to test behavioral responses shortly after being hatched. Hence, chickens are advantageous in investigating the ontogenetic origin of behaviors. Chicken embryos are suitable for deposition assessment and mechanistic study due to the accessibility, self-contained development, uniform genetic background, robust microbiota, and easy in vivo experimental manipulation compared to humans and rodents. Therefore, chicken embryos can be used as an alternative to the rodent models in assessing the fetal exposure effect on neurogenesis and investigating the mechanism underlying the ontogenetic origin of neuropsychiatric disorders.

Maternal and Neonatal Outcomes After Assisted Reproductive Technology: A Retrospective Cohort Study in China

Background

With the progress of assisted reproductive technology (ART) and the increasing number of ART pregnancy, its safety has become the focus of attention. The present study aimed to explore the associations of ART pregnancy with maternal and neonatal outcomes, as compared with naturally pregnancy.

Methods

This retrospective cohort study included all pregnant women who delivered at Women’s Hospital of Nanjing Medical University in 2011–2020. We compared maternal characteristics and pregnancy outcomes between group of ART pregnancy and group of naturally pregnancy using Logistic regression adjusted for confounders.

Results

A total of 13,604 ART pregnancies and 198,002 naturally pregnancies were included. The proportion of ART pregnancies has increased every year for the past 10 years, peaking in 2020 (9.0%). Multivariable logistic regression analysis showed that the risks of gestational diabetes, preeclampsia, moderate or severe anemia, liver-related diseases, thyroid-related diseases, preterm birth, placenta previa, postpartum hemorrhage, and cesarean section were significantly increased in ART pregnancy. For neonatal outcomes, women conceived by ART were more likely to have twins or multiples, and the risk of stillbirth or abnormal development was also significantly increased. When restriction to singletons, these risks were reduced. And the effects of ART on the risk of premature rupture of membrane, cord entanglement, intrapartum fever, cesarean section, and stillbirth or abnormal development were more pronounced in singletons pregnancies compared with that in pregnancies of twins or multiples.

Conclusion

Women conceived by ART were at increased risks of several adverse pregnancy outcomes compared with women conceived naturally. Multiple pregnancies could partly explain this phenomenon. For ART pregnancy, prenatal and intrapartum monitoring should be strengthened, and neonatal outcomes should be closely observed.

COVID-19 pandemic and population-level pregnancy and neonatal outcomes in general population: A living systematic review and meta-analysis (Update#2: November 20, 2021)

INTRODUCTION

Conflicting reports of increases and decreases in rates of preterm birth (PTB) and stillbirth in the general population during the coronavirus disease 2019 (COVID-19) pandemic have surfaced. The objective of our study was to conduct a living systematic review and meta-analyses of studies reporting pregnancy and neonatal outcomes by comparing the pandemic and pre-pandemic periods.

MATERIAL AND METHODS

We searched the PubMed and Embase databases and reference lists of articles published up until November 20, 2021, and included English language studies that compared outcomes between the COVID-19 pandemic time period with pre-pandemic time periods. Risk of bias was assessed using the Newcastle-Ottawa scale. We conducted random-effects meta-analysis using the inverse variance method.

RESULTS

Fifty-two studies with low-to-moderate risk of bias, reporting on 2 372 521 pregnancies during the pandemic period and 28 518 300 pregnancies during the pre-pandemic period, were included. There was significant reduction in unadjusted estimates of PTB (43 studies, unadjusted odds ratio [uaOR] 0.95, 95% CI 0.93-0.98), but not in adjusted estimates (five studies, adjusted OR [aOR] 0.94, 95% CI 0.74-1.19). This reduction was noted in studies from single centers/health areas (29 studies, uaOR 0.90, 95% CI 0.85-0.94) but not in regional/national studies (14 studies, uaOR 0.99, 95% CI 0.99-1.01). There was reduction in spontaneous PTB (nine studies, uaOR 0.91, 95% CI 0.88-0.94) but not in induced PTB (eight studies, uaOR 0.90, 95% CI 0.79-1.01). There was no difference in the odds of stillbirth between the pandemic and pre-pandemic time periods (32 studies, uaOR 1.07, 95% CI 0.97-1.18 and three studies, aOR 1.18, 95% CI 0.86-1.63). There was an increase in mean birthweight during the pandemic period compared with the pre-pandemic period (nine studies, mean difference 21 g, 95% CI 13-30 g). The odds of maternal mortality were increased (five studies, uaOR 1.15, 95% CI 1.05-1.26); however, only unadjusted estimates were available, and the result was mostly influenced by one study from Mexico. There was significant publication bias for the outcome of PTB.

CONCLUSIONS

The COVID-19 pandemic may be associated with a reduction in PTB; however, referral bias cannot be excluded. There was no statistically significant difference in stillbirths between pandemic and pre-pandemic periods.

Impact of Coronavirus Disease-19 "Stay-At-Home" Orders on Preterm Birth in Colorado

In this retrospective cohort analysis of Colorado birth certificate records from April to December 2015-2020, we demonstrate that Colorado birthing individuals experienced lower adjusted odds of preterm birth after issuance of coronavirus-19 "stay-at-home" orders. However, this positive birth outcome was experienced only by non-Hispanic white and Hispanic mothers.

Association of SARS-CoV-2 Infection With Serious Maternal Morbidity and Mortality From Obstetric Complications

Importance

It remains unknown whether SARS-CoV-2 infection specifically increases the risk of serious obstetric morbidity.

Objective

To evaluate the association of SARS-CoV-2 infection with serious maternal morbidity or mortality from common obstetric complications.

Design, Setting, and Participants

Retrospective cohort study of 14 104 pregnant and postpartum patients delivered between March 1, 2020, and December 31, 2020 (with final follow-up to February 11, 2021), at 17 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Gestational Research Assessments of COVID-19 (GRAVID) Study. All patients with SARS-CoV-2 were included and compared with those without a positive SARS-CoV-2 test result who delivered on randomly selected dates over the same period.

Exposures

SARS-CoV-2 infection was based on a positive nucleic acid or antigen test result. Secondary analyses further stratified those with SARS-CoV-2 infection by disease severity.

Main Outcomes and Measures

The primary outcome was a composite of maternal death or serious morbidity related to hypertensive disorders of pregnancy, postpartum hemorrhage, or infection other than SARS-CoV-2. The main secondary outcome was cesarean birth.

Results

Of the 14 104 included patients (mean age, 29.7 years), 2352 patients had SARS-CoV-2 infection and 11 752 did not have a positive SARS-CoV-2 test result. Compared with those without a positive SARS-CoV-2 test result, SARS-CoV-2 infection was significantly associated with the primary outcome (13.4% vs 9.2%; difference, 4.2% [95% CI, 2.8%-5.6%]; adjusted relative risk [aRR], 1.41 [95% CI, 1.23-1.61]). All 5 maternal deaths were in the SARS-CoV-2 group. SARS-CoV-2 infection was not significantly associated with cesarean birth (34.7% vs 32.4%; aRR, 1.05 [95% CI, 0.99-1.11]). Compared with those without a positive SARS-CoV-2 test result, moderate or higher COVID-19 severity (n = 586) was significantly associated with the primary outcome (26.1% vs 9.2%; difference, 16.9% [95% CI, 13.3%-20.4%]; aRR, 2.06 [95% CI, 1.73-2.46]) and the major secondary outcome of cesarean birth (45.4% vs 32.4%; difference, 12.8% [95% CI, 8.7%-16.8%]; aRR, 1.17 [95% CI, 1.07-1.28]), but mild or asymptomatic infection (n = 1766) was not significantly associated with the primary outcome (9.2% vs 9.2%; difference, 0% [95% CI, -1.4% to 1.4%]; aRR, 1.11 [95% CI, 0.94-1.32]) or cesarean birth (31.2% vs 32.4%; difference, -1.4% [95% CI, -3.6% to 0.8%]; aRR, 1.00 [95% CI, 0.93-1.07]).

Conclusions and Relevance

Among pregnant and postpartum individuals at 17 US hospitals, SARS-CoV-2 infection was associated with an increased risk for a composite outcome of maternal mortality or serious morbidity from obstetric complications.

Cardiac Arrest and Hypoxic-Ischemic Encephalopathy Following an Emergency Caesarean Section in a COVID-19 Patient

While young, healthy individuals without underlying medical conditions have generally not suffered catastrophic health consequences from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), gravid patients appear to be at much higher risk of complications from this virus. A 29-year-old G3P2 patient at 30 weeks and three days presented with worsening dyspnea and chest pain after testing positive for coronavirus disease 2019 (COVID-19) infection two days prior. Notably, she had not received COVID-19 vaccination. A non-reassuring fetal tracing and fetal bradycardia were discovered on routine prenatal monitoring during admission, and an urgent caesarean section was performed. She subsequently required supplemental oxygen due to respiratory distress and remained hospitalized. She clinically deteriorated from a respiratory standpoint. Several days later, she experienced cardiac arrest with a return of spontaneous circulation (ROSC) in nine minutes. While the baby was discharged home and is doing well, the patient, unfortunately, expired from hypoxic encephalopathy secondary to COVID-19 pneumonia and complications of cardiorespiratory arrest. This case highlights the severe sequelae of COVID-19 infection in a postpartum patient, including ventilator-dependent respiratory failure, sudden cardiac death, hypoxic encephalopathy, and coma.

Changes in rates of adverse pregnancy outcomes during the COVID-19 pandemic: a cross-sectional study in the United States, 2019-2020

OBJECTIVE

Our objective was to assess differences in pregnancy outcomes during the COVID-19 pandemic compared to the previous year.

STUDY DESIGN

In a cross-sectional study of delivery hospitalizations in the Premier Healthcare Database Special COVID-19 Release, we assessed differences in selected maternal and pregnancy outcomes occurring April-December in 2019 and 2020 in the United States.

RESULT

Among 663,620 deliveries occurring in 2019 and 614,093 deliveries occurring in 2020, we observed an increase in in-hospital maternal death from 2019 to 2020, which was no longer statistically significant after excluding deliveries with a COVID-19 diagnosis. Intensive care unit admission and preterm birth decreased from 2019 to 2020. There was no difference in the prevalence of most other outcomes examined.

CONCLUSION

The full impact of the COVID-19 pandemic on maternal and pregnancy outcomes remains to be understood. Most outcomes investigated experienced minimal change from 2019 to 2020.

A Case of Recovery From COVID-19 Pneumonia in Pregnancy After Vaginal Delivery in ICU

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has important implications for gravid patients as they are more likely to experience severe complications of pregnancy such as multisystem inflammatory syndrome if infected with coronavirus disease 2019 (COVID-19). Due to normal physiological adaptations of pregnancy, COVID-19 may strain an already stressed respiratory system, making delivery a viable treatment option. We present a case of a gravid patient infected with COVID-19 pneumonia who delivered vaginally in the intensive care unit (ICU) at our hospital. Further research into clinical progress and management of pregnancy complicated by COVID-19 is necessary.

Changes in Tobacco Use Patterns among Veterans in San Diego during the Recent Peak of the COVID-19 Pandemic

The prevalence of tobacco use increases in times of stress; however, during the initial stage of the COVID-19 pandemic, tobacco use rates stayed the same in most populations. Previous work focused on the initial months of the pandemic, while this study examined the changes in tobacco use during a later peak period of the pandemic. We used data from 61,852 visits to the VA San Diego Healthcare System from November 2019 to February 2021, divided into pre-, early, and peak pandemic periods. Multinomial logistic regression was used to test whether the odds of being a daily or non-daily tobacco user varied over time, by demographic group, or with the presence of specific psychiatric diagnoses. Younger Veterans had a greater reduction in the prevalence of non-daily tobacco use between the early and peak periods, while older Veterans had a rise in daily use from pre- to the early pandemic, which returned to baseline during the peak. Individuals with substance use disorder and serious mental illness diagnoses were more likely to report tobacco use, but psychiatric diagnoses did not predict change over time. These findings demonstrate factors that potentially contribute to changes in tobacco use during a public health crisis and may help guide future targeted cessation efforts.