Offspring cardiometabolic outcomes and postnatal growth trajectories after exposure to maternal SARS-CoV-2 infection

OBJECTIVE

The objective of this study is to determine whether in utero exposure to SARS-CoV-2 is associated with increased risk for a cardiometabolic diagnosis by 18 months of age.

METHODS

This retrospective electronic health record (EHR)-based cohort study included the live-born offspring of all individuals who delivered during the COVID-19 pandemic (April 1, 2020-December 31, 2021) at eight hospitals in Massachusetts. Offspring exposure was defined as a positive maternal SARS-CoV-2 polymerase chain reaction test during pregnancy. The primary outcome was presence of an ICD-10 code for a cardiometabolic disorder in offspring EHR by 18 months. Weight-, length-, and BMI-for-age z scores were calculated and compared at 6-month intervals from birth to 18 months.

RESULTS

A total of 29,510 offspring (1599 exposed and 27,911 unexposed) were included. By 18 months, 6.7% of exposed and 4.4% of unexposed offspring had received a cardiometabolic diagnosis (crude odds ratio [OR] 1.47 [95% CI: 1.10 to 1.94], p = 0.007; adjusted OR 1.38 [1.06 to 1.77], p = 0.01). Exposed offspring had a significantly greater mean BMI-for-age z score versus unexposed offspring at 6 months (z score difference 0.19 [95% CI: 0.10 to 0.29], p < 0.001; adjusted difference 0.04 [-0.06 to 0.13], p = 0.4).

CONCLUSIONS

Exposure to maternal SARS-CoV-2 infection was associated with an increased risk of receiving a cardiometabolic diagnosis by 18 months preceded by greater BMI-for-age at 6 months.

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores

OBJECTIVE

 Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity.

STUDY DESIGN

 Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots.

RESULTS

 A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated.

CONCLUSION

 A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries.

KEY POINTS

· EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

Regional Variation in Antenatal Late Preterm Steroid Use Following the ALPS Trial

Importance

The publication of the Antenatal Late Preterm Steroids (ALPS) trial in February 2016 demonstrated that antenatal administration of betamethasone in the late preterm period (between 34 to 36 weeks of gestation) for individuals with a high risk of delivery decreased neonatal respiratory morbidity. National estimates have suggested the trial did change obstetric practice, but little is known if the evidence was adopted uniformly or equitably.

Objective

To assess regional variation in the use of late preterm steroids after the publication of the Antenatal Late Preterm Steroids (ALPS) Trial and to understand factors associated with a region's pace of adoption.

Design, Setting, and Participants

This cross-sectional study used US natality data from February 2015 to October 2017 from hospital referral regions (HRRs) within the US. Inclusion criteria included live-born, nonanomalous, singleton, late preterm (34 to 36 completed weeks of gestation) neonates born to individuals without pregestational diabetes. This study was conducted from November 15, 2022, to January 13, 2023.

Main Outcome and Measures

HRRs were categorized as either a slower adopter or faster adopter of antenatal late preterm steroids based on the observed vs expected pace of antenatal steroid adoption in a 1-year period after the trial's dissemination. Patient and regional factors hypothesized a priori to be associated with the uptake of late preterm steroids were compared between faster and slower adopters. Comparisons were made using Student t test or Wilcoxon rank-sum test, as appropriate. A multivariable logistic regression was constructed to identify factors associated with faster adopter status in the postperiod.

Results

There were 666 097 late preterm births in 282 HRRs. The mean (SD) maternal age in HRRs was 27.9 (1.2) years. The median (IQR) percentage of births by race categories in HRRs for patients identifying as American Indian or Alaskan Native was 0.5% (0.2%-1.3%); Asian or Pacific Islander, 3.0% (1.7%-5.3%); Black, 12.9% (5.1%-29.1%); and White, 78.6% (66.6%-87.0%). The median percentage of births in HRRs to patients of Hispanic ethnicity was 11.2% (6.3%-27.4%). In this study, 136 HRRs (48.2%) were classified as faster adopters and 146 (51.8%) were classified as slower adopters. Faster adopters increased their steroid use by 12.1 percentage points (from 5.9% to 18.0%) compared with a 5.5 percentage point increase (from 3.7% to 9.2%) among slower adopters (P < .001). Most examined patient and regional factors were not associated with a region's pace of adoption, with the exception of the regional prevalence of prior preterm birth (adjusted odds ratio [aOR], 2.04 [95% CI, 1.48-2.82]) and the percentage of deliveries at 34 to 35 weeks of gestation (aOR, 0.68 [95% CI, 0.47-0.99]) compared with 36 weeks.

Conclusions and Relevance

In this cross-sectional study, there was widespread geographic variation in the adoption of antenatal steroid administration for late preterm births that largely remained unexplained by population factors. These findings should prompt further investigations to barriers to timely or equitable access to new evidence-based practices and guide future dissemination strategies with the goal of more uniform adoption.

Epidemiology of Emergency Medical Services-Attended out-of-Hospital Deliveries and Complications in the United States

BACKGROUND

Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S.

METHODS

We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics.

RESULTS

Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p < 0.001).

CONCLUSION

In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Experiences and Communication Preferences in Pregnancy Care Among Patients With a Spanish Language Preference: A Qualitative Study

OBJECTIVE

To explore Spanish-speaking patients' experiences and preferences regarding communication during pregnancy care with specific attention to language barriers.

METHODS

Patients with a Spanish language preference who gave birth between July 2022 and February 2023 at an academic medical center were invited to participate in focus groups. Focus groups were held over Zoom, audio-recorded, transcribed in Spanish, translated into English, and reviewed for translation accuracy. Thematic analysis was conducted with deductive and inductive approaches. Three investigators double-coded all transcripts, and discrepancies were resolved through team consensus.

RESULTS

Seven focus groups (27 total participants, range 2-6 per group) were held. Three key themes emerged regarding patient experiences and communication preferences when seeking pregnancy care: 1) language concordance and discordance between patients and clinicians are not binary-they exist on a continuum; 2) language-discordant care is common and presents communication challenges, even with qualified interpreters present; and 3) language discordance can be overcome with positive interpersonal dynamics between clinicians and patients.

CONCLUSION

Our findings highlight the importance of relationship to overcome language discordance among patients with limited English proficiency during pregnancy care. These findings inform potential structural change and patient-clinician dyad interventions to better meet the communication needs of patients with limited English proficiency.

Provider confidence in counseling preconception, pregnant, and postpartum patients regarding COVID-19 vaccination: A cross-sectional survey study

Background and Aims

Healthcare provider counseling surrounding COVID-19 vaccine in pregnancy and lactation is essential to vaccination uptake in this population; however, provider knowledge and confidence are not well characterized. We aimed to assess knowledge and confidence in COVID-19 vaccine counseling among practitioners who provide care to pregnant persons and to describe factors associated with confidence in counseling.

Methods

A web-based anonymous survey was distributed via email to a cross-sectional convenience sample of Obstetrics and Gynecology, Primary Care, and Internal Medicine faculty at three hospitals in a single healthcare network in Massachusetts, United States. Individual demographics and institution-specific variables were included in the survey along with questions assessing both attitudes toward COVID-19 illness and confidence in counseling regarding the use of the vaccine in pregnancy.

Results

Almost all providers (151, 98.1%) reported that they received a COVID-19 vaccine, and most (111, 72.1%) reported that they believe the benefits of the vaccine in pregnancy outweigh the risks. Forty-one (26.6%) reported feeling very confident in counseling patients who primarily speak English about the evidence for messenger ribonucleic acid vaccination in pregnancy, and 36 (23%) reported feeling very confident in counseling patients who are not primarily English-speaking. Forty-three providers (28.1%) expressed strong confidence in their comfort talking to individuals with vaccine hesitancy based on historic and continued racism and systemic injustices. The sources that survey respondents most used to find information regarding COVID-19 vaccination in pregnancy were the Centers for Disease Control (112, 74.2%), hospital-specific resources (94, 62.3%), and the American College of Obstetricians and Gynecologists (82, 54.3%).

Conclusion

Ensuring that providers feel comfortable bridging the gap between their belief that the vaccine is beneficial for pregnant patients and their comfort with holding conversations with patients regarding vaccination is paramount to ensure equitable access to vaccines for pregnant patients.

Sex-Specific Neurodevelopmental Outcomes Among Offspring of Mothers With SARS-CoV-2 Infection During Pregnancy

Importance

Prior studies using large registries have suggested a modest increase in risk for neurodevelopmental diagnoses among children of mothers with immune activation during pregnancy, and such risk may be sex-specific.

Objective

To determine whether in utero exposure to SARS-CoV-2 is associated with sex-specific risk for neurodevelopmental disorders up to 18 months after birth, compared with unexposed offspring born during or prior to the COVID-19 pandemic period.

Design, Setting, and Participants

This retrospective cohort study included the live offspring of all mothers who delivered between January 1 and December 31, 2018 (born and followed up before the COVID-19 pandemic), between March 1 and December 31, 2019 (born before and followed up during the COVID-19 pandemic), and between March 1, 2020, and May 31, 2021 (born and followed up during the COVID-19 pandemic). Offspring were born at any of 8 hospitals across 2 health systems in Massachusetts.

Exposures

Polymerase chain reaction evidence of maternal SARS-CoV-2 infection during pregnancy.

Main Outcomes and Measures

Electronic health record documentation of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes corresponding to neurodevelopmental disorders.

Results

The COVID-19 pandemic cohort included 18 355 live births (9399 boys [51.2%]), including 883 (4.8%) with maternal SARS-CoV-2 positivity during pregnancy. The cohort included 1809 Asian individuals (9.9%), 1635 Black individuals (8.9%), 12 718 White individuals (69.3%), and 1714 individuals (9.3%) who were of other race (American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, more than 1 race); 2617 individuals (14.3%) were of Hispanic ethnicity. Mean maternal age was 33.0 (IQR, 30.0-36.0) years. In adjusted regression models accounting for race, ethnicity, insurance status, hospital type (academic center vs community), maternal age, and preterm status, maternal SARS-CoV-2 positivity was associated with a statistically significant elevation in risk for neurodevelopmental diagnoses at 12 months among male offspring (adjusted OR, 1.94 [95% CI 1.12-3.17]; P = .01) but not female offspring (adjusted OR, 0.89 [95% CI, 0.39-1.76]; P = .77). Similar effects were identified using matched analyses in lieu of regression. At 18 months, more modest effects were observed in male offspring (adjusted OR, 1.42 [95% CI, 0.92-2.11]; P = .10).

Conclusions and Relevance

In this cohort study of offspring with SARS-CoV-2 exposure in utero, such exposure was associated with greater magnitude of risk for neurodevelopmental diagnoses among male offspring at 12 months following birth. As with prior studies of maternal infection, substantially larger cohorts and longer follow-up will be required to reliably estimate or refute risk.

The Application of a Standard Risk Threshold for the Stratification of Maternal Morbidity among Population Subgroups

OBJECTIVE

 The aim of this study was to determine if a universally applied risk score threshold for severe maternal morbidity (SMM) resulted in different performance characteristics among subgroups of the population.

STUDY DESIGN

 This is a retrospective cohort study of deliveries that occurred between July 1, 2016, and June 30, 2020, in a single health system. We examined the performance of a validated comorbidity score to stratify SMM risk in our cohort. We considered the risk score that was associated with the highest decile of predicted risk as a "screen positive" for morbidity. We then used this same threshold to calculate the sensitivity and positive predictive value (PPV) of this "highest risk" designation among subgroups of the overall cohort based on the following characteristics: age, race/ethnicity, parity, gestational age, and planned mode of delivery.

RESULTS

 In the overall cohort of 53,982 women, the C-statistic was 0.755 (95% confidence interval [CI], 0.741-0.769) and calibration plot demonstrated that the risk score was well calibrated. The model performed less well in the following groups: non-White or Hispanic (C-statistic, 0.734; 95% CI, 0.712-0.755), nulliparas (C-statistic, 0.735; 95% CI, 0.716-0.754), term deliveries (C-statistic, 0.712; 95% CI, 0.694-0.729), and planned vaginal delivery (C-statistic, 0.728; 95% CI, 0.709-0.747). There were differences in the PPVs by gestational age (7.8% term and 29.7% preterm) and by planned mode of delivery (8.7% vaginal and 17.7% cesarean delivery). Sensitivities were lower in women who were <35 years (36.6%), non-White or Hispanic (40.7%), nulliparous (38.9%), and those having a planned vaginal delivery (40.9%) than their counterparts.

CONCLUSION

 The performance of a risk score for SMM can vary by population subgroups when using standard thresholds derived from the overall cohort. If applied without such considerations, such thresholds may be less likely to identify certain subgroups of the population that may be at increased risk of SMM.

KEY POINTS

· Predictive risk models are helpful at condensing complex information into an interpretable output.. · Model performance may vary among different population subgroups.. · Prediction models should be examined for their potential to exacerbate underlying disparities..

Comparison of Maternal and Neonatal Subspecialty Care Provision by Hospital

OBJECTIVE

The aim of the study is to determine the relationship between a hospital's provision of subspecialty neonatal and maternal care. Specifically, we sought to understand where women with high-risk maternal conditions received intrapartum care and estimate the potential transfer burden for those with maternal high-risk conditions delivering at hospitals without subspecialty maternal care.

STUDY DESIGN

This is a descriptive study using data from 2015 State Inpatient Databases and the American Hospital Association Annual Survey. Characteristics were compared between hospitals based on the concordance of their maternal and neonatal care. The incidences of high-risk maternal conditions (pre-eclampsia with severe features, placenta previa with prior cesarean delivery, cardiac disease, pulmonary edema, and acute liver failure) were compared. To determine the potential referral burden, the percent of women with high-risk conditions delivering at a hospital without subspecialty maternal care but delivering in a county with a hospital with subspecialty maternal care was calculated.

RESULTS

The analysis included 486,398 women who delivered at 544 hospitals, of which 104 (19%) and 182 (33%) had subspecialty maternal and neonatal care, respectively. Ninety-eight hospitals provided both subspecialty maternal and neonatal care; however, 84 hospitals provided only subspecialty neonatal care but no subspecialty maternal care. Among high-risk maternal conditions examined, approximately 65% of women delivered at a hospital with subspecialty maternal care. Of the remainder who delivered at a hospital without subspecialty maternal care, one-third were in a county where subspecialty care was present. For women with high-risk conditions who delivered in a county without subspecialty maternal care, the median distance to the closest county with subspecialty care was 52.8 miles (IQR: 34.3-87.7 miles).

CONCLUSION

Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care. This discordance may present a challenge when both high-risk maternal and neonatal conditions are present.

KEY POINTS

· High-risk women who deliver at hospitals without subspecialty care are in more rural areas.. · Approximately 50% of hospitals with subspecialty neonatal care do not provide subspecialty maternal care.. · This discordance may present a challenge when both high-risk maternal and neonatal conditions are present..

Antibiotic administration and wound complications after obstetric anal sphincter injuries

BACKGROUND

Obstetric anal sphincter injuries are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after obstetric anal sphincter injuries. However, the rate of antibiotic administration in a contemporary obstetrical population is not known.

OBJECTIVE

This study aimed to describe the rate of antibiotic administration for obstetric anal sphincter injuries, to characterize factors associated with antibiotic administration on the day of delivery among women with obstetric anal sphincter injuries, and to determine if there was an association between antibiotic administration and reduced wound complications.

STUDY DESIGN

This was a retrospective cohort study of women with a singleton vaginal birth complicated by obstetric anal sphincter injuries between 2016 and 2021 in a single healthcare system. Information about any antibiotic administration on the day of delivery was collected. Information on wound complications (determined by International Classification of Disease, 10th Revision, codes) that occurred within the first 6 months postpartum were available for patients who delivered at tertiary-care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications.

RESULTS

During the study period, 1550 women met the inclusion criteria of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary-care hospitals than at community-based hospitals (68.7 vs 26.8%; P<.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio, 2.72; 95% confidence interval, 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.97). At tertiary-care hospitals, 43 women (4.1%) had a wound complication, and more than 80% of those presented within the first 2 weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (adjusted odds ratio, 0.34; 95% confidence interval, 0.13-0.91). All patients received a regimen with gram-positive bacterial coverage; there was no association between type of antibiotic regimen administered and wound complications.

CONCLUSION

Any antibiotic administration on the day of delivery was associated with a decreased rate of wound complications after obstetric anal sphincter injuries. However, only about half of the women with obstetric anal sphincter injuries received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population.

Cost-effectiveness of induction of labor at 39 weeks vs expectant management by cervical examination

BACKGROUND

Previous analyses have demonstrated the cost effectiveness of elective induction of labor at 39 weeks of gestation for healthy nulliparous people. However, elective induction of labor is resource intensive, and optimal resource allocation requires a thorough understanding of which subgroups of patients will benefit most.

OBJECTIVE

This study aimed to determine whether induction of labor at 39 weeks of gestation is more cost-effective in patients with favorable or unfavorable cervical examinations.

STUDY DESIGN

We constructed 2 decision analysis models using TreeAge software: one modeling induction of labor at 39 weeks of gestation vs expectant management for a group of nulliparous patients with unfavorable cervical examinations and the other modeling induction of labor at 39 weeks of gestation vs expectant management for a group with favorable cervical examinations. Estimates of cost, probability, and health state utility were derived from the literature. Based on previous literature, we assumed that people with favorable cervical examinations would have a lower baseline rate of cesarean delivery and higher rates of spontaneous labor.

RESULTS

In our base case analysis, induction of labor at 39 weeks of gestation was cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. The incremental cost per quality-adjusted life year was 50-fold lower for people with unfavorable cervical examinations ($2150 vs $115,100). Induction of labor resulted in 3885 fewer cesarean deliveries and 58 fewer stillbirths per 100,000 patients for those with unfavorable examinations, whereas induction of labor resulted in 2293 fewer cesarean deliveries and 48 fewer stillbirths with labor induction for those with favorable cervical examinations. The results were sensitive to multiple inputs, including the likelihood of cesarean delivery, the cost of induction, the cost of vaginal or cesarean delivery, and the probability of spontaneous labor. In Monte Carlo analysis, the base case findings held true for 64.1% of modeled scenarios for patients with unfavorable cervixes and 55.4% of modeled scenarios for patients with favorable cervixes.

CONCLUSION

With a willingness-to-pay threshold of $100,000 per quality-adjusted life year, induction of labor at 39 weeks of gestation may be cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. This result was driven by the likelihood of labor in patients with favorable cervical examinations, and the resultant avoidance of prolonged pregnancy and its complications, including hypertensive disorders of pregnancy and stillbirths. Health systems may wish to prioritize patients with unfavorable cervical examinations for elective induction of labor at 39 weeks of gestation, which may be opposite to common practice.

Antenatal Steroid Exposure Among Term Newborns

This cross-sectional study evaluates the association between dissemination of the Antenatal Late Preterm Steroid trial and changes in steroid exposure among term newborns.

Sex-specific neurodevelopmental outcomes in offspring of mothers with SARS-CoV-2 in pregnancy: an electronic health records cohort

Importance

Prior studies using large registries suggested a modest increase in risk for neurodevelopmental diagnoses among children of mothers with immune activation during pregnancy, and such risk may be sex-specific.

Objective

To determine whether in utero exposure to the novel coronavirus SARS-CoV-2 is associated with sex-specific risk for neurodevelopmental disorders up to 18 months after birth, compared to unexposed offspring born during or prior to the pandemic period.

Design

Retrospective cohort.

Participants

Live offspring of all mothers who delivered between March 2018 and May 2021 at any of eight hospitals across two health systems in Massachusetts.

Exposure

PCR evidence of maternal SARS-CoV-2 infection during pregnancy.

Main Outcome and Measures

Electronic health record documentation of ICD-10 diagnostic codes corresponding to neurodevelopmental disorders.

Results

The pandemic cohort included 18,323 live births, including 877 (4.8%) to individuals with SARS-CoV-2 positivity during pregnancy. The cohort included 1806 (9.9%) Asian individuals, 1634 (8.9%) Black individuals, 1711 (9.3%) individuals of another race, and 12,694 (69%) White individuals; 2614 (14%) were of Hispanic ethnicity. Mean maternal age was 33.0 years (IQR 30.0-36.0). In adjusted regression models accounting for race, ethnicity, insurance status, hospital type (academic center vs. community), maternal age, and preterm status, SARS-CoV-2 positivity was associated with statistically significant elevation in risk for neurodevelopmental diagnoses among male offspring (adjusted OR 1.99, 95% CI 1.19-3.34; p=0.009) but not female offspring (adjusted OR 0.90, 95% CI 0.43-1.88; p=0.8). Similar effects were identified using matched analyses in lieu of regression.

Conclusion and Relevance

SARS-CoV-2 exposure in utero was associated with greater magnitude of risk for neurodevelopmental diagnoses among male offspring in the 12 months following birth. As with prior studies of maternal infection, substantially larger cohorts and longer follow-up will be required to reliably estimate or refute risk.

Trial Registration

NA.

Key Points

Question: Are rates of neurodevelopmental disorder diagnoses greater among male or female children with COVID-19 exposure in utero compared to those with no such exposure?Findings: In a cohort of 18,323 infants delivered after February 2020, males but not females born to mothers with a positive SARS-CoV-2 PCR test during pregnancy were more likely to receive a neurodevelopmental diagnosis in the first 12 months after delivery, even after accounting for preterm delivery.Meaning: These findings suggest that male offspring exposed to COVID-19 in utero may be at increased risk for neurodevelopmental disorders.

Comparison of Natural Language Processing of Clinical Notes With a Validated Risk-Stratification Tool to Predict Severe Maternal Morbidity

IMPORTANCE

Risk-stratification tools are routinely used in obstetrics to assist care teams in assessing and communicating risk associated with delivery. Electronic health record data and machine learning methods may offer a novel opportunity to improve and automate risk assessment.

OBJECTIVE

To compare the predictive performance of natural language processing (NLP) of clinician documentation with that of a previously validated tool to identify individuals at high risk for maternal morbidity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective diagnostic study was conducted at Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, and included individuals admitted for delivery at the former institution from July 1, 2016, to February 29, 2020. A subset of these encounters (admissions from February to December 2018) was part of a previous prospective validation study of the Obstetric Comorbidity Index (OB-CMI), a comorbidity-weighted score to stratify risk of severe maternal morbidity (SMM).

EXPOSURES

Natural language processing of clinician documentation and OB-CMI scores.

MAIN OUTCOMES AND MEASURES

Natural language processing of clinician-authored admission notes was used to predict SMM in individuals delivering at the same institution but not included in the prospective OB-CMI study. The NLP model was then compared with the OB-CMI in the subset with a known OB-CMI score. Model discrimination between the 2 approaches was compared using the DeLong test. Sensitivity and positive predictive value for the identification of individuals at highest risk were prioritized as the characteristics of interest.

RESULTS

This study included 19 794 individuals; 4034 (20.4%) were included in the original prospective validation study of the OB-CMI (testing set), and the remaining 15 760 (79.6%) composed the training set. Mean (SD) age was 32.3 (5.2) years in the testing cohort and 32.2 (5.2) years in the training cohort. A total of 115 individuals in the testing cohort (2.9%) and 468 in the training cohort (3.0%) experienced SMM. The NLP model was built from a pruned vocabulary of 2783 unique words that occurred within the 15 760 admission notes from individuals in the training set. The area under the receiver operating characteristic curve of the NLP-based model for the prediction of SMM was 0.76 (95% CI, 0.72-0.81) and was comparable with that of the OB-CMI model (0.74; 95% CI, 0.70-0.79) in the testing set (P = .53). Sensitivity (NLP, 28.7%; OB-CMI, 24.4%) and positive predictive value (NLP, 19.4%; OB-CMI, 17.6%) were comparable between the NLP and OB-CMI high-risk designations for the prediction of SMM.

CONCLUSIONS AND RELEVANCE

In this study, the NLP method and a validated risk-stratification tool had a similar ability to identify patients at high risk of SMM. Future prospective research is needed to validate the NLP approach in clinical practice and determine whether it could augment or replace tools requiring manual user input.

Validation of childbirth-related posttraumatic stress disorder using psychophysiological assessment

Women with posttraumatic stress disorder (PTSD) related to traumatic childbirth show similarly elevated psychophysiological responses as individuals with PTSD related to other traumatic events.

Increased traumatic childbirth and postpartum depression and lack of exclusive breastfeeding in Black and Latinx individuals

The findings underscore the disproportionate burden of mental health complications following childbirth on Black and Latinx individuals delivering during the coronavirus pandemic and call for eliminating disparities.

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas

OBJECTIVE

This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI.

STUDY DESIGN

This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations.

RESULTS

Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81).

CONCLUSION

Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI.

KEY POINTS

· Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

Neurodevelopmental Outcomes at 1 Year in Infants of Mothers Who Tested Positive for SARS-CoV-2 During Pregnancy

Importance

Epidemiologic studies suggest maternal immune activation during pregnancy may be associated with neurodevelopmental effects in offspring.

Objective

To evaluate whether in utero exposure to SARS-CoV-2 is associated with risk for neurodevelopmental disorders in the first 12 months after birth.

Design, Setting, and Participants

This retrospective cohort study examined live offspring of all mothers who delivered between March and September 2020 at any of 6 Massachusetts hospitals across 2 health systems. Statistical analysis was performed from October to December 2021.

Exposures

Maternal SARS-CoV-2 infection confirmed by a polymerase chain reaction test during pregnancy.

Main Outcomes and Measures

Neurodevelopmental disorders determined from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnostic codes over the first 12 months of life; sociodemographic and clinical features of mothers and offspring; all drawn from the electronic health record.

Results

The cohort included 7772 live births (7466 pregnancies, 96% singleton, 222 births to SARS-CoV-2 positive mothers), with mean (SD) maternal age of 32.9 (5.0) years; offspring were 9.9% Asian (772), 8.4% Black (656), and 69.0% White (5363); 15.1% (1134) were of Hispanic ethnicity. Preterm delivery was more likely among exposed mothers: 14.4% (32) vs 8.7% (654) (P = .003). Maternal SARS-CoV-2 positivity during pregnancy was associated with greater rate of neurodevelopmental diagnoses in unadjusted models (odds ratio [OR], 2.17 [95% CI, 1.24-3.79]; P = .006) as well as those adjusted for race, ethnicity, insurance status, offspring sex, maternal age, and preterm status (adjusted OR, 1.86 [95% CI, 1.03-3.36]; P = .04). Third-trimester infection was associated with effects of larger magnitude (adjusted OR, 2.34 [95% CI, 1.23-4.44]; P = .01).

Conclusions and Relevance

This cohort study of SARS-CoV-2 exposure in utero found preliminary evidence that maternal SARS-CoV-2 may be associated with neurodevelopmental sequelae in some offspring. Prospective studies with longer follow-up duration will be required to exclude confounding and confirm these associations.

Change in emergency medical services-attended out-of-hospital deliveries during COVID-19 in the United States

Background: The COVID-19 pandemic disrupted access to routine in-person prenatal care, potentially leading to higher risk of out-of-hospital deliveries. Unplanned out-of-hospital deliveries pose a substantial risk of morbidity and mortality for pregnant patients and newborns. Our objective was to determine the change in rate of emergency medical services (EMS)-attended out-of-hospital deliveries during the COVID-19 pandemic. We hypothesized that COVID-19-related stay-at-home orders were associated with a higher rate of out-of-hospital deliveries during the initial wave of COVID-19.Methods: We conducted an interrupted time series analysis using the 2019 and 2020 National EMS Information System datasets. We included 9-1-1 scene activations for patients 12-50 years old with out-of-hospital deliveries who were treated and transported by EMS. We calculated the weekly rate of deliveries per 100,000 EMS emergency activations each year overall, and for each census division. The interruption modeled was the enactment of stay-at-home orders, with March 25-31 selected as when most orders had been enacted. We fit ordinary least squares regression models with Newey-West standard errors to adjust for autocorrelation, testing for a change in level and slope overall and by census division.Results: A total of 10,778 out-of-hospital deliveries were included, 58% (n = 6,254) in 2020. The mean weekly rate of out-of-hospital deliveries in 2019 was 29.4 per 100,000 activations (95% CI: 28.4 to 30.4) versus 33.0 (95% CI: 31.8 to 34.1) in 2020. There was an immediate increase of 6.3 deliveries per 100,000 activations (95% CI: 3.3 to 9.3) after the week of March 25-31, with a subsequent decrease of 0.3 deliveries per 100,000 per week after (95% CI: -0.4 to -0.2). There were also statistically significant immediate increases in out-of-hospital deliveries after March 25-31 in the New England, East North Central, West South Central, and Mountain divisions.Conclusion: EMS-attended out-of-hospital deliveries remained rare during the COVID-19 pandemic, but there was an immediate increase during the initial wave of the pandemic with evidence of geographic variation. Large-scale disruptions in the health care system may result in increases in uncommon patient presentations to EMS.

US Incidence of Late-Preterm Steroid Use and Associated Neonatal Respiratory Morbidity After Publication of the Antenatal Late Preterm Steroids Trial, 2015-2017

IMPORTANCE

The Antenatal Late Preterm Steroids (ALPS) trial demonstrated a 20% reduction in the risk of respiratory complications in neonates at risk for a late-preterm birth who were exposed to antenatal corticosteroids compared with those who were not.

OBJECTIVE

To assess whether new evidence of steroid administration for neonatal respiratory benefit in the late-preterm period is associated with changes in obstetric practice and the use of assisted ventilation for the neonate after delivery.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of US births from February 1, 2015, to October 31, 2017, as ascertained from US natality data, included live-born, singleton neonates born between 34 and 36 completed weeks of gestation to people without pregestational diabetes. An interrupted time series analysis using Poisson regression models was conducted. Data were analyzed from July 11, 2022, to November 9, 2022.

EXPOSURES

Public dissemination of the ALPS trial results, which occurred during a 9-month period from February 1, 2016 (first published online), to October 31, 2016 (time of the last major professional society's guideline update in the months after the trial's publication).

MAIN OUTCOMES AND MEASURES

Steroid use, any assisted ventilation use, and assisted ventilation use for more than 6 hours immediately after the dissemination period.

RESULTS

A total of 707 862 births were included, divided among the 12-month predissemination period (n = 250 643), dissemination period (n = 195 736), and 12-month postdissemination period (n = 261 493). Most births were at 36 weeks of gestation (53.9% in the predissemination and postdissemination period; P = .10). Small but significant differences were found between the predissemination and postdissemination period cohorts: there were more individuals 35 years or older (19.5% vs 17.9%), fewer White individuals (67.8% vs 69.8%), and more publicly insured individuals (50.5% vs 50.1%) in the postdissemination period compared with the predissemination period, respectively (P < .001 for all). Compared with what rates were expected based on the predissemination trends, the adjusted rate of steroid use increased from 5.0% to 11.7% (adjusted incidence rate ratio [IRR], 2.34; 95% CI, 2.13-2.57), and assisted ventilation use decreased from 8.9% to 8.2% (adjusted IRR, 0.91; 95% CI, 0.85-0.98) after the dissemination period. No change was observed in assisted ventilation use for more than 6 hours (adjusted IRR, 0.98; 95% CI, 0.87-1.10).

CONCLUSIONS AND RELEVANCE

These findings suggest that there was an immediate change in practice of administering antenatal steroids and a reduction in neonatal morbidity among late-preterm births associated with the dissemination of the ALPS trial, suggesting that this evidence may be translating into a reduction in immediate respiratory morbidity outside the context of a clinical trial.

The Loop Electrosurgical Excision Procedure and Cone Conundrum: The Role of Cumulative Excised Depth in Predicting Preterm Birth

Objective  The objective was to determine factors associated with spontaneous preterm birth at less than 37 weeks in a cohort of patients who underwent a loop electrosurgical excision procedure (LEEP) or cone prior to pregnancy. Study Design  This was a nested case-control study within a cohort of patients who underwent at least one LEEP or cone and had care for the next singleton pregnancy at either of two institutions between 1994 and 2014. Cases had spontaneous preterm birth at less than 37 weeks. Exposures included potential risk factors for preterm birth such as cumulative depth of excised cervix and time since excision. Reverse stepwise selection was used to identify the covariates for multivariable logistic regression. Results  A total of 134 patients were included. Eighteen (13%) had a spontaneous preterm birth at less than 37 weeks. Median second-trimester cervical lengths were similar between those who delivered preterm and term (3.9-cm preterm and 3.6-cm term, p  = 0.69). Patients who delivered preterm had a significantly greater median total excised depth of cervix (1.2 vs. 0.8 cm, p  = 0.04). After adjustment for confounders, total excised depth remained significantly associated with preterm birth (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI]: 1.3-3.8). Conclusion  Total excised depth should be considered in addition to cervical length screening when managing subsequent pregnancies. Key Points A history of a LEEP or cone excision has been associated with spontaneous preterm birth.A two-fold increase in spontaneous preterm birth was seen per cumulative centimeter excised.There was no difference in second-trimester cervical length between the term and preterm groups.

Placental Expression of ACE2 and TMPRSS2 in Maternal Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Are Placental Defenses Mediated by Fetal Sex?

BACKGROUND

Expression of angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), host molecules required for viral entry, may underlie sex differences in vulnerability to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated whether placental ACE2 and TMPRSS2 expression vary by fetal sex in the presence of maternal SARS-CoV-2 infection.

METHODS

Placental ACE2 and TMPRSS2 expression was quantified by quantitative reverse transcription polymerase chain reaction (RT-PCR) and by Western blot in 68 pregnant women (38 SARS-CoV-2 positive, 30 SARS-CoV-2 negative) delivering at Mass General Brigham from April to June 2020. The impact of fetal sex and maternal SARS-CoV-2 exposure on ACE2 and TMPRSS2 was analyzed by 2-way analysis of variance (ANOVA).

RESULTS

Maternal SARS-CoV-2 infection impacted placental TMPRSS2 expression in a sexually dimorphic fashion (2-way ANOVA interaction, P = .002). We observed no impact of fetal sex or maternal SARS-CoV-2 status on ACE2. TMPRSS2 expression was significantly correlated with ACE2 expression in males (Spearman ρ = 0.54, P = .02) but not females (ρ = 0.23, P = .34) exposed to maternal SARS-CoV-2.

CONCLUSIONS

Sex differences in placental TMPRSS2 but not ACE2 were observed in the setting of maternal SARS-CoV-2 infection, which may have implications for offspring vulnerability to placental infection.

Postpartum depression screening: Treatment engagement, barriers to care, and change in depressive symptoms

BACKGROUND

Postpartum depression (PPD) is a common condition associated with childbirth, yet many women do not receive the treatment they need. Despite the growing practice of PPD screening, treatment and clinical outcomes among patients identified as likely having PPD remain unclear.

METHOD

Women who were systematically screened and scored ≥12 on the Edinburgh Postnatal Depression Scale (EPDS)-indicative of possible PPD-at their routine 6-week postpartum visit were eligible to participate and were contacted after 3 months for a follow-up interview and assessment.

RESULTS

A total of 33 women participated in the study, out of 100 who scored ≥12 on the EPDS. Among the participants, 70% reported they received a referral to a health care provider for PPD, and nearly one-half said that they received psychotherapy and/or were prescribed a psychotropic. The 2 most commonly described barriers to treatment were perceptions of not needing or wanting help and concerns about breastfeeding while taking psychotropics. Nearly 40% of women scored ≥12 on the EPDS at the follow-up interview.

CONCLUSIONS

Further systematic research on outcomes after PPD screening is needed to ensure that screening translates into meaningfully improved clinical outcomes.

Derivation and external validation of risk stratification models for severe maternal morbidity using prenatal encounter diagnosis codes

OBJECTIVE

We sought to develop a prediction model using prenatal diagnosis codes that could help clinicians objectively stratify a women's risk for delivery-related morbidity.

STUDY DESIGN

We performed a prospective cohort study of women delivering at a single academic medical center between 2016 and 2019. Diagnosis codes from outpatient encounters were extracted from the electronic health record. Standard and common machine-learning methods for variable selection were compared. The performance characteristics from the selected model in the training data set-a LASSO model with a lambda that minimized the Bayes information criteria-were compared in a testing and external validation set.

RESULTS

The model identified a group of women, those in the highest decile of predicted risk, who were at a two to threefold increased risk of maternal morbidity.

CONCLUSION

As EHR data becomes more ubiquitous, other data types generated from the prenatal period may improve the model's performance.

Frequency and severity of prehospital obstetric events encountered by emergency medical services in the United States

Background

Prehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US.

Methods

We conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider’s impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen’s kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations.

Results

A total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen’s kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS).

Conclusion

Prehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04129-1.

Association between morbidity among term newborns and low-risk caesarean delivery rates

OBJECTIVE

To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns.

DESIGN

Cross-sectional study.

SETTING

Population-based study of US county-level birth data from 2015 to 2017.

POPULATION

Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity.

METHODS

The primary exposure was county-level CD rates.

MAIN OUTCOME MEASURES

The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors.

RESULTS

The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses.

CONCLUSIONS

Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA.

TWEETABLE ABSTRACT

Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.

Association between hospital-level cesarean delivery rates and severe maternal morbidity and unexpected newborn complications

BACKGROUND

Although there are many indications for a cesarean delivery, the "optimal" cesarean delivery rate is unknown. Neonatal and maternal morbidity have largely not been considered in the generation of hospital-level cesarean delivery rate targets.

OBJECTIVE

We sought to examine if the widely adopted and reported markers of maternal and neonatal morbidity were associated with hospital cesarean delivery rates to provide context for potential comparison and consideration for defining cesarean delivery rate targets. We hypothesized that hospitals with higher cesarean delivery rates would have increased rates of severe maternal morbidity, though we were less certain of the associations of the cesarean delivery rates with unexpected newborn complications.

STUDY DESIGN

This is a cross-sectional, ecological study using data from the 2016 Nationwide Readmission Database of hospitals with at least 100 deliveries per year. The exposure of interest was hospital cesarean delivery rate. The outcomes were (1) severe maternal morbidity with and without transfusion-in accordance with the Centers for Disease Control and Prevention's definition, and (2) neonatal morbidity-defined using The Joint Commission's Perinatal Quality metric of moderate and severe unexpected newborn complications among term, singleton, and nonanomalous neonates. Before assuming a single linear relationship to model the associations between morbidity and cesarean delivery rates, the Joinpoint Regression Analysis program was used to examine for potential splines in the relationships with both severe maternal morbidity (with and without transfusion) and severe and moderate unexpected newborn complications. Poisson regression model was then used to determine the association between morbidity and cesarean delivery rates.

RESULTS

The analysis included 831,111 deliveries from 621 hospitals. The mean cesarean delivery rate was 30.5%. The median severe maternal morbidity rate was 1.40 per 100 deliveries (interquartile range, 0.71-2.21 per 1000 deliveries). Excluding transfusion, the median severe maternal morbidity rate was 0.47 per 100 deliveries (interquartile range, 0.22-0.73 per 100 deliveries). The median rate of severe and moderate unexpected newborn complications was 1.01 per 100 low-risk newborns (interquartile range, 0.64-1.69 per 100 low-risk newborns) and 1.79 per 1000 low-risk newborns (interquartile range, 0.94-2.93 per 100 low-risk newborns), respectively. In the unadjusted analysis, every percentage point increase in a hospital's cesarean delivery rate was associated with a 3.4% (95% confidence interval, 2.3%-4.4%) and a 2.3% (95% confidence interval, 1.0%-3.5%) increase in severe maternal morbidity including and excluding transfusion, respectively. After adjustment for the case mix and hospital factors, only the relationship with severe maternal morbidity including transfusion remained significant: 3.3% (95% confidence interval, 1.7%-4.9%) increase in severe maternal morbidity per 1 percentage point increase in the cesarean delivery rate. There was no observed association between cesarean delivery rates and unexpected newborn complications CONCLUSION: Severe maternal morbidity and unexpected newborn complications occur in fewer than 5 in 100 births. Findings from this analysis of hospitals with cesarean delivery rates ranging from 6.8%-56.3% suggest that those with lower cesarean delivery rates have lower severe maternal morbidity (which includes transfusion) and similar unexpected newborn complications compared with hospitals with higher cesarean delivery rates. This work may provide a helpful context to providers, hospitals, and policymakers who are measuring and reporting outcomes. Regarding neonatal morbidity in particular, the Joint Commission manual notes that the unexpected newborn complication metric was specifically designed to be compared against maternal-focused metrics such as cesarean delivery rates. More work is needed to define and identify appropriate measures of maternal and neonatal morbidity for these types of comparisons.

Pregnancy after breast cancer: A population-based study of survival and obstetric outcomes

e18783

Background: Studies have suggested that pregnancy after breast cancer is safe, but the women who are able to conceive after cancer may also have a better prognosis. We sought to evaluate survival and obstetric outcomes among breast cancer patients in a population-based cohort. Methods: We studied women aged 18-45 years with a history of stage I-III breast cancer reported to the California Cancer Registry (CCR, 2000-2012). CCR data were linked to the 2000-2012 California Office of Statewide Health Planning and Development (OSHPD) birth cohort to ascertain both oncologic characteristics and obstetric outcomes. We compared overall survival (OS) for breast cancer patients who did or did not conceive at least 1 year after diagnosis. Breast cancer patients who conceived were matched in a 1:5 ratio to breast cancer patients who did not conceive via optimal bipartite matching accounting for follow-up time such that controls were diagnosed within a 3-month window of the cases and were alive at the time the case delivered; the distributions of cases and controls were directly balanced on socioeconomic and clinical covariates including stage, hormone receptors, and receipt of chemotherapy and radiation. For the obstetric outcomes, propensity score matching in a 1:5 ratio was used to match the same breast cancer patients who conceived to population based controls without cancer who delivered during the study years. Wald statistics, conditional Cox proportional hazards model, and conditional logistic regressions were used to evaluate outcomes. Results: We matched 417 patients aged 18-45 years at time of breast cancer diagnosis who conceived at least one year following diagnosis with 2,085 breast cancer patients who did not conceive. All covariates were balanced within 0.1 mean standardized difference. The majority of the cohort was non-Hispanic White (51%), with stage II disease (53%). The 5-year overall survival for cases relative to controls was 97.6% and 95.7% respectively. There was no difference in overall survival between patients who conceived and those who did not conceive following treatment for breast cancer (HR 0.58, 95% CI 0.3-1.1). Breast cancer patients did not have higher risks of preterm birth before 37 weeks (odds ratio [OR] 0.91, 95% CI 0.39-2.14), small-for-gestational age birthweight ( < 10th percentile: OR 0.93, 95% CI 0.67-1.29; < 5th percentile: OR 0.67, 95% CI 0.39-1.14), cesarean delivery (OR 1.12, 95% CI 0.92-1.35), severe maternal morbidity (OR 1.14, 95% CI 0.61-2.12), or neonatal morbidity (OR 1.08, 95% CI 0.77-1.53) relative to controls. Conclusions: In a population-based cohort, breast cancer patients who conceived at least 1 year after diagnosis did not have worse OS than matched breast cancer patients who did not conceive. Breast cancer patients who conceived during the study period did not have an increased risk of adverse obstetric outcomes compared to population-based controls without cancer.

COVID-19 is associated with traumatic childbirth and subsequent mother-infant bonding problems

BACKGROUND

Knowledge of women's experience of childbirth in the outbreak of the coronavirus (COVID-19) pandemic and associated maternal health outcomes is scarce.

METHODS

A sample of primarily American women who gave birth around the height of COVID-19 (n = 1,611) and matched controls, i.e., women who gave birth before COVID-19 (n = 640), completed an anonymous Internet survey about recent childbirth, birth-related traumatic stress (peritraumatic distress inventory; PTSD-checklist), maternal bonding (maternal attachment inventory; mother-to-infant bonding scale) and breastfeeding status. Groups (n = 637 in each) were matched on demographics, prior mental health/trauma and childbirth factors to determine the unique contribution of COVID-19 to the psychological experience of childbirth.

RESULTS

Mothers in COVID-19-exposed communities endorsed more clinically acute stress response to childbirth than matched controls (Z = 2.65, p = .008, OR= 1.38). A path mediation model revealed that acute stress mediated the relationship between study group and postpartum outcomes. Specifically, higher acute stress response in birth was associated with more childbirth-related posttraumatic stress disorder symptoms (β = .42, p < .001) and less bonding with the infant (β = .26, p < .001), including breastfeeding problems (β = .10, p < .01).

LIMITATIONS

Use of a convenient internet sample introduces bias towards more educated women and reliance on retrospective self-report assessments may entail recall bias.

CONCLUSIONS

COVID-19 is a major stressor for delivering women. It can heighten traumatic childbirth experiences and interfere with successful postpartum adjustment. Clinical attention to traumatic stress in childbirth and problems with caring for the young during this pandemic is important.

Compromised SARS-CoV-2-specific placental antibody transfer

SARS-CoV-2 infection causes more severe disease in pregnant women compared to age-matched non-pregnant women. Whether maternal infection causes changes in the transfer of immunity to infants remains unclear. Maternal infections have previously been associated with compromised placental antibody transfer, but the mechanism underlying this compromised transfer is not established. Here, we used systems serology to characterize the Fc profile of influenza-, pertussis-, and SARS-CoV-2-specific antibodies transferred across the placenta. Influenza- and pertussis-specific antibodies were actively transferred. However, SARS-CoV-2-specific antibody transfer was significantly reduced compared to influenza- and pertussis-specific antibodies, and cord titers and functional activity were lower than in maternal plasma. This effect was only observed in third-trimester infection. SARS-CoV-2-specific transfer was linked to altered SARS-CoV-2-antibody glycosylation profiles and was partially rescued by infection-induced increases in IgG and increased FCGR3A placental expression. These results point to unexpected compensatory mechanisms to boost immunity in neonates, providing insights for maternal vaccine design.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes

OBJECTIVE

This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction.

STUDY DESIGN

This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery.

RESULTS

Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin.

CONCLUSION

In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Association of sexual assault history with traumatic childbirth and subsequent PTSD

Although childbirth-related posttraumatic stress (CB-PTSD) has received recognition, how sexual assault (SA) history influences obstetrical and traumatic stress outcomes remains unclear. Six hundred eighty-three women provided information about their childbirth and mental health. Obstetric complications and unplanned cesareans were more prevalent among women with SA history. They also had higher rates of probable CB-PTSD and were two times more likely to have premature deliveries than women without SA history. Screening women for history of sexual trauma is warranted to optimize birth outcomes.

Assessment of Maternal and Neonatal SARS-CoV-2 Viral Load, Transplacental Antibody Transfer, and Placental Pathology in Pregnancies During the COVID-19 Pandemic

Importance

Biological data are lacking with respect to risk of vertical transmission and mechanisms of fetoplacental protection in maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Objective

To quantify SARS-CoV-2 viral load in maternal and neonatal biofluids, transplacental passage of anti-SARS-CoV-2 antibody, and incidence of fetoplacental infection.

Design, Setting, and Participants

This cohort study was conducted among pregnant women presenting for care at 3 tertiary care centers in Boston, Massachusetts. Women with reverse transcription-polymerase chain reaction (RT-PCR) results positive for SARS-CoV-2 were recruited from April 2 to June 13, 2020, and follow-up occurred through July 10, 2020. Contemporaneous participants without SARS-CoV-2 infection were enrolled as a convenience sample from pregnant women with RT-PCR results negative for SARS-CoV-2.

Exposures

SARS-CoV-2 infection in pregnancy, defined by nasopharyngeal swab RT-PCR.

Main Outcomes and Measures

The main outcomes were SARS-CoV-2 viral load in maternal plasma or respiratory fluids and umbilical cord plasma, quantification of anti-SARS-CoV-2 antibodies in maternal and cord plasma, and presence of SARS-CoV-2 RNA in the placenta.

Results

Among 127 pregnant women enrolled, 64 with RT-PCR results positive for SARS-CoV-2 (mean [SD] age, 31.6 [5.6] years) and 63 with RT-PCR results negative for SARS-CoV-2 (mean [SD] age, 33.9 [5.4] years) provided samples for analysis. Of women with SARS-CoV-2 infection, 23 (36%) were asymptomatic, 22 (34%) had mild disease, 7 (11%) had moderate disease, 10 (16%) had severe disease, and 2 (3%) had critical disease. In viral load analyses among 107 women, there was no detectable viremia in maternal or cord blood and no evidence of vertical transmission. Among 77 neonates tested in whom SARS-CoV-2 antibodies were quantified in cord blood, 1 had detectable immunoglobuilin M to nucleocapsid. Among 88 placentas tested, SARS-CoV-2 RNA was not detected in any. In antibody analyses among 37 women with SARS-CoV-2 infection, anti-receptor binding domain immunoglobin G was detected in 24 women (65%) and anti-nucleocapsid was detected in 26 women (70%). Mother-to-neonate transfer of anti-SARS-CoV-2 antibodies was significantly lower than transfer of anti-influenza hemagglutinin A antibodies (mean [SD] cord-to-maternal ratio: anti-receptor binding domain immunoglobin G, 0.72 [0.57]; anti-nucleocapsid, 0.74 [0.44]; anti-influenza, 1.44 [0.80]; P < .001). Nonoverlapping placental expression of SARS-CoV-2 receptors angiotensin-converting enzyme 2 and transmembrane serine protease 2 was noted.

Conclusions and Relevance

In this cohort study, there was no evidence of placental infection or definitive vertical transmission of SARS-CoV-2. Transplacental transfer of anti-SARS-CoV-2 antibodies was inefficient. Lack of viremia and reduced coexpression and colocalization of placental angiotensin-converting enzyme 2 and transmembrane serine protease 2 may serve as protective mechanisms against vertical transmission.