Population-attributable fraction of risk factors for severe maternal morbidity

Socio-demographic and infrastructural variables influencing maternal risk concentration among ever-married women of reproductive age in rural West Bengal, India

BACKGROUND

The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about one in six in the poorest parts of the world.

OBJECTIVES

The present study aims to determine prevalence of maternal risk and the influencing variables among ever-married women belonging to the reproductive age group (15-49) of Birbhum district, West Bengal.

METHODS

A cohort-based retrospective cross-sectional study was carried out among the sample of 229 respondents through a purposive stratified random sampling method and a pre-designed semi-structured questionnaire. The ordinal logistic regression (OLR) model was taken as a tool of assessment. Before developing the proportional OLR model, we have checked the multicollinearity effect among the predictors and the first-order effect modifier was evaluated as well. We performed data analysis using SPSS version 26.

RESULTS

The result shows that illiterate women (Odds ratios [OR] = 2.81, 95% CI, 0.277-1.791), from lower standard of living (OR = 1.14, 95% CI, -0.845-1.116), married before the age of 15 years (OR = 21.96, 95% CI, -0.55-6.73) and between the age of 15-18 years (OR = 24.51. 95% CI, -0.45-6.85) are more likely to be affected by the higher concentration of maternal risk. Other important predictor is the time of pregnancy registration. Considering the transport and related en-route causalities, the result portraying a clear picture where the distance and travel time becoming significant factors in determining the concentration of maternal risk.

CONCLUSION

Incidences of child marriages should be restricted. Eradicating factors influencing an individual's decision to seek care would be an essential contribution in excluding the dominant maternal risk factors.

Association between stillbirth and severe maternal morbidity

BACKGROUND

Severe maternal morbidity has been increasing in the past few decades. Few studies have examined the risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries.

OBJECTIVE

This study aimed to examine the prevalence and risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries during delivery hospitalization as a primary outcome and during the postpartum period as a secondary outcome.

STUDY DESIGN

This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from California (2008-2018), Michigan (2008-2020), Missouri (2008-2014), Pennsylvania (2008-2014), and South Carolina (2008-2020). Relative risk regression analysis was used to examine the crude and adjusted relative risks of severe maternal morbidity along with 95% confidence intervals among individuals with stillbirths vs individuals with live-birth deliveries, adjusting for birth year, state of residence, maternal sociodemographic characteristics, and the obstetric comorbidity index.

RESULTS

Of the 8,694,912 deliveries, 35,012 (0.40%) were stillbirths. Compared with individuals with live-birth deliveries, those with stillbirths were more likely to be non-Hispanic Black (10.8% vs 20.5%); have Medicaid (46.5% vs 52.0%); have pregnancy complications, including preexisting diabetes mellitus (1.1% vs 4.3%), preexisting hypertension (2.3% vs 6.2%), and preeclampsia (4.4% vs 8.4%); have multiple pregnancies (1.6% vs 6.2%); and reside in South Carolina (7.4% vs 11.6%). During delivery hospitalization, the prevalence rates of severe maternal morbidity were 791 cases per 10,000 deliveries for stillbirths and 154 cases per 10,000 deliveries for live-birth deliveries, whereas the prevalence rates for nontransfusion severe maternal morbidity were 502 cases per 10,000 deliveries for stillbirths and 68 cases per 10,000 deliveries for live-birth deliveries. The crude relative risk for severe maternal morbidity was 5.1 (95% confidence interval, 4.9-5.3), whereas the adjusted relative risk was 1.6 (95% confidence interval, 1.5-1.8). For nontransfusion severe maternal morbidity among stillbirths vs live-birth deliveries, the crude relative risk was 7.4 (95% confidence interval, 7.0-7.7), whereas the adjusted relative risk was 2.0 (95% confidence interval, 1.8-2.3). This risk was not only elevated among individuals with stillbirth during the delivery hospitalization but also through 1 year after delivery (severe maternal morbidity adjusted relative risk, 1.3; 95% confidence interval, 1.1-1.4; nontransfusion severe maternal morbidity adjusted relative risk, 1.2; 95% confidence interval, 1.1-1.3).

CONCLUSION

Stillbirth was found to be an important contributor to severe maternal morbidity.

Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity

OBJECTIVE

To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.

METHODS

We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.

RESULTS

In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%.

CONCLUSION

Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.

Affordable Care Act Medicaid expansions and maternal morbidity

In this paper, we test whether the Affordable Care Act Medicaid expansions are associated with maternal morbidity. The ACA expansions may have affected maternal morbidity by increasing pre-conception access to health care, and by improving the quality of delivery care, through enhancing hospitals' financial positions. We use difference-in-difference models in conjunction with event studies. Data come from individual-level birth certificates and state-level hospital discharge data. The results show little evidence that the expansions are associated with overall maternal morbidity or indicators of specific adverse events including eclampsia, ruptured uterus, and unplanned hysterectomy. The results are consistent with prior research showing that the ACA Medicaid expansions are not statistically associated with pre-pregnancy health or maternal health during pregnancy. Our results add to this story and find little evidence of improvements in maternal health upon delivery.

Early Gestational Weight Gain and the Risk of Preeclampsia in Dichorionic Twin Pregnancies

OBJECTIVE

The purpose of our study was to evaluate the body mass index (BMI)-specific association between early gestational weight gain (GWG) in dichorionic twin pregnancies and the risk of preeclampsia.

STUDY DESIGN

We conducted a retrospective cohort study of all dichorionic twin pregnancies from 1998 to 2013. Data were obtained from a perinatal database and chart abstraction. Prepregnancy BMI was categorized as normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥30 kg/m2). Early GWG was defined as the last measured weight from 160/7 to 196/7weeks' gestation minus prepregnancy weight. GWG was standardized for gestational duration using BMI-specific z-score charts for dichorionic pregnancies. Preeclampsia was diagnosed using American College of Obstetricians and Gynecologists criteria and identified with International Classification of Diseases-9 coding. Early GWG z-score was modeled as a three-level categorical variable (≤ - 1 standard deviation [SD], 0, 3 +1 SD), where -1 to +1 was the referent group. We estimated risk differences and 95% confidence intervals (CIs) via marginal standardization.

RESULTS

We included 1,693 dichorionic twin pregnancies in the cohort. In adjusted analysis, the incidence of preeclampsia increased with increasing early GWG among women with normal BMI. Women with normal BMI and a GWG z-score < - 1 (equivalent to 2.6 kg by 20 weeks) had 2.5 fewer cases of preeclampsia per 100 births (95% CI: -4.7 to - 0.3) compared with the referent; those with GWG z-score > +1 (equivalent to gaining 9.8 kg by 20 weeks) had 2.8 more cases of preeclampsia per 100 (95 % CI: 0.1-5.5) compared with the referent. In adjusted analyses, early GWG had minimal impact on the risk of preeclampsia in women with overweight or obesity.

CONCLUSION

GWG of 2.6 kg or less by 20 weeks was associated with a decreased risk of preeclampsia among women pregnant with dichorionic twins and normal prepregnancy BMI. Current GWG guidelines focus on optimizing fetal weight and gestational length. Our findings demonstrate the importance of considering other outcomes when making GWG recommendations for twin pregnancy.

KEY POINTS

· Early GWG decreased with increasing BMI category.. · Among women with normal weight, as early GWG increased so did the risk of preeclampsia.. · There was no association between early GWG and preeclampsia among women with overweight or obesity..

Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals

Importance

Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.

Objective

To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.

Design, Setting, and Participants

This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.

Exposures

Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.

Main Outcome and Measures

The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.

Results

Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.

Conclusions and Relevance

In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

Severe Maternal Morbidity in Pregnancies Complicated by Fetal Congenital Heart Disease

Background

Maternal risk factors for fetal congenital heart disease (CHD) may also be associated with delivery complications in the mother.

Objectives

This study aimed to determine the prevalence of and risk factors for severe maternal morbidity (SMM) and maternal hospital transfer in pregnancies complicated by fetal CHD.

Methods

A population-based retrospective cohort study utilizing linked Ohio birth certificates and birth defect data for all live births from 2011 to 2015 was performed. The primary outcome was composite SMM. Secondary outcome was maternal hospital transfer prior to delivery. Pregnancies with isolated fetal CHD were compared to pregnancies with no fetal anomalies and isolated fetal cleft lip/palate (CLP).

Results

A total of 682,929 mothers with live births were included. Of these, 5,844 (0.85%) mothers had fetal CHD, and 963 (0.14%) had fetal CLP. SMM in pregnancies with fetal CHD was higher than that in those with no anomalies (3.6% vs 1.9%, P < 0.001) or CLP (3.6% vs 1.9%, P = 0.006). After adjusting for known risk factors, fetal CHD remained independently associated with SMM when compared to no fetal anomalies (adjusted relative risk [adjRR]: 1.81, 95% CI: 1.58-2.08) and CLP (adjRR: 1.81, 95% CI: 1.12-2.92). Maternal hospital transfer occurred more frequently in fetal CHD cases vs for those without fetal anomalies with an increased adjusted risk (adjRR: 3.65, 95% CI: 3.14-4.25).

Conclusions

Pregnancies with isolated fetal CHD have increased risk of SMM and maternal hospital transfer after adjusting for known risk factors. This may inform delivery planning for mothers with fetal CHD. Understanding the biological mechanisms may provide insight into other adverse perinatal outcomes in this population.

Maternal Morbidity Predicted by an Intersectional Social Determinants of Health Phenotype: A Secondary Analysis of the NuMoM2b Dataset

Maternal race, ethnicity and socio-economic position are known to be associated with increased risk for a range of poor pregnancy outcomes, including maternal morbidity and mortality. Previously, researchers seeking to identify the contributing factors focused on maternal behaviors and pregnancy complications. Less understood is the contribution of the social determinants of health (SDoH) in observed differences by race/ethnicity in these key outcomes. In this secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) dataset, latent mixture modeling was used to construct groups of healthy, nulliparous participants with a non-anomalous fetus in a cephalic presentation having a trial of labor (N = 5763) based on SDoH variables. The primary outcome was a composite score of postpartum maternal morbidity. A postpartum maternal morbidity event was experienced by 350 individuals (6.1%). Latent class analysis using SDoH variables revealed six groups of participants, with postpartum maternal morbidity rates ranging from 8.7% to 4.5% across groups (p < 0.001). Two SDoH groups had the highest odds for maternal morbidity. These higher-risk groups were comprised of participants with the lowest income and highest stress and those who had lived in the USA for the shortest periods of time. SDoH phenotype predicted MM outcomes and identified two important, yet distinct groups of pregnant people who were the most likely have a maternal morbidity event.

Morbidity of late-season influenza during pregnancy

BACKGROUND

In the Northern Hemisphere, influenza season typically starts in December and lasts through March. Pregnant people are at increased risk for influenza-related morbidity and mortality. Potentially, new viral strains or reduced provider suspicion leading to delayed diagnosis of late-season influenza could result in an increased risk of severe infection.

OBJECTIVE

This study aimed to assess the incidence and morbidity associated with late-season influenza in pregnancy, compared with influenza in other seasons.

STUDY DESIGN

This was a retrospective cohort study using the 2007-2018 National Inpatient Sample. Pregnant patients with discharge diagnosis codes consistent with influenza infection were compared on the basis of hospital admission quarter (quarter 1: October to December; quarter 2: January to March; quarter 3: April to June; quarter 4: July to September), with quarter 3 defined as "late-season." The primary outcome was the severe maternal morbidity composite defined by the Centers for Disease Control and Prevention. The secondary outcomes included sepsis, shock, acute renal failure, acute heart failure, temporary tracheostomy, and invasive mechanical ventilation. Associations between outcomes and quarter of infection were adjusted for age, hospitalization type (antepartum, delivery, or postpartum), and comorbid conditions using relative risk regression, weighted to reflect the National Inpatient Sample design.

RESULTS

Of 7355 hospitalizations, corresponding to a weighted national estimate of 36,042, 2266 (30.8%) occurred in quarter 1, 4051 (55.0%) in quarter 2, 633 (8.6%) in quarter 3, and 405 (5.5%) in quarter 4. A nonsignificant trend toward higher rates of severe maternal morbidity was seen in the "late-season" compared with other quarters (13.9% [quarter 3] vs 10.5% [quarter 1] vs 12.1% [quarter 2] vs 13.6% [quarter 4]; P=.07). Moreover, sepsis was more common in patients with late-season influenza (8.0% [quarter 3] vs 4.8% [quarter 1] vs 5.8% [quarter 2] vs 5.9% [quarter 4]; P=.03). In the adjusted analyses, patients with late-season influenza had a 1.34 (95% confidence interval, 1.01-1.78) higher risk of severe maternal morbidity and 1.57 (95% confidence interval, 1.06-2.32) higher risk of sepsis than patients with influenza in quarter 1.

CONCLUSION

Influenza infection between April and June, that is, late-season influenza, is associated with a higher risk of severe maternal morbidity and sepsis in pregnant patients. Obstetrical providers must continue to have awareness and suspicion for influenza infection during these months.

Maternal age-specific drivers of severe maternal morbidity

BACKGROUND

The maternal age influences the risk of adverse pregnancy outcomes, including severe maternal morbidity. However, the leading drivers of severe maternal morbidity may differ between the maternal age groups.

OBJECTIVE

To compare the contribution of different risk factors to the risk of severe maternal morbidity between various maternal age groups and estimate their population-attributable risks.

STUDY DESIGN

This was a retrospective, population-based cohort study of all US live births from 2012 to 2016 using birth certificate records. The demographic, medical, and pregnancy factors were compared between the 4 maternal age strata (<18 years, 18-34 years, 35-39 years, and ≥40 years). The primary outcome was composite severe maternal morbidity, defined as having maternal intensive care unit admission, eclampsia, unplanned hysterectomy, or a ruptured uterus. Multivariate logistic regression estimated the relative influence of the risk factors associated with severe maternal morbidity among the maternal age categories. Population-attributable fraction calculations assessed the contribution of the individual risk factors to overall severe maternal morbidity.

RESULTS

Of 19,473,910 births in the United States from 2012 to 2016, 80,553 (41 cases per 10,000 delivery hospitalizations) experienced severe maternal morbidity. The highest rates of severe maternal morbidity were observed at the extremes of maternal age: 45 per 10,000 at <18 years (risk ratio, 1.31; 95% confidence interval, [1.16-1.48]) and 73 per 10,000 (risk ratio, 2.02; 95% confidence interval, [1.96-2.09]) for ≥40 years. In all the age groups, preterm delivery, cesarean delivery, chronic hypertension, and preeclampsia were significantly associated with an increased adjusted relative risk of severe maternal morbidity. Cesarean delivery and preeclampsia increased the severe maternal morbidity risk among all the age groups and were more influential among the youngest mothers. The risk factors with the greatest population-attributable fractions were non-Hispanic Black race (5.4%), preeclampsia (10.9%), preterm delivery (29.4%), and cesarean delivery (38.1%). On the basis of these estimates, the births occurring in mothers at the extremes of maternal age (<18 and ≥35 years) contributed 4 severe maternal morbidity cases per 10,000 live births. Preterm birth and cesarean delivery contributed 12 and 15 cases of severe maternal morbidity per 10,000 live births, respectively.

CONCLUSION

Both adolescent and advanced-age pregnancies have an increased risk of severe maternal morbidity. However, there are age-specific differences in the drivers of severe maternal morbidity. This information may allow for better identification of those at a higher risk of severe maternal morbidity and may ultimately aid in patient counseling. KEY WORDS: adolescents, advanced-age pregnancy, maternal morbidity, population-attributable fraction.

Correlation between hemorrhage risk prediction score and severe maternal morbidity

BACKGROUND

Obstetrical hemorrhage is a leading cause of severe maternal morbidity, a key indicator of a nation's healthcare delivery system and often associated with a high rate of preventability. Limited data suggest that a patient's hemorrhage risk score may be associated with risk for maternal morbidity such as severe hemorrhage, intensive care unit admission, or transfusion. Little is known regarding the relationship between hemorrhage risk score and nontransfusion-related morbidity.

OBJECTIVE

We sought to evaluate the association between a patient's California Maternal Quality Care Collaborative admission hemorrhage risk score and severe maternal morbidity.

STUDY DESIGN

This was a retrospective cohort of delivery admissions from 2018 to 2019 in a single healthcare network. Admission risk scores were assigned to each patient using the California Maternal Quality Care Collaborative criteria. Rates of transfusion- and nontransfusion-associated severe maternal morbidity were compared across low-, medium-, and high-risk strata. We defined severe maternal morbidity as the presence of any International Classification of Diseases diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, need for intensive care unit admission, or prolonged postpartum hospital length of stay. A multivariable logistic regression was used to assess the association between hemorrhage risk score and severe maternal morbidity.

RESULTS

In the overall cohort, severe maternal morbidity occurred in 2.4% (n=517) of all deliveries. Excluding cases requiring transfusion, 0.6% (n=131) of cases still had a severe maternal morbidity event. The incidence of severe maternal morbidity was 1.6% (n=264) in patients categorized as low risk for hemorrhage compared with 2.5% (n=118) and 13.6% (n=135) in patients who were categorized as medium or high risk for hemorrhage, respectively (P<.001). Patients classified as high risk had a significant association with both severe maternal morbidity (adjusted odds ratio, 8.8; 95% confidence interval, 7.0-11) and nontransfusion-associated severe maternal morbidity (adjusted odds ratio, 3.6; 95% confidence interval, 2.2-5.9).

CONCLUSION

In addition to predicting the risk for obstetrical hemorrhage and transfusion, our findings indicate that the California Maternal Quality Care Collaborative admission hemorrhage risk tool predicts risk for transfusion- and nontransfusion-associated severe maternal morbidity. Our findings imply that despite awareness and the identification of patients at high risk for obstetrical hemorrhage on admission, significant hemorrhage-associated morbidity persisted. Our data indicate that the identification of risk alone may be insufficient to reduce morbidity and imply that further work is needed to investigate and implement new practices in response to a patient's score stratum.

Perinatal outcomes in twin pregnancies complicated by gestational diabetes

BACKGROUND

Gestational diabetes in singleton pregnancies increases the risk for large for gestational age infants, hypertensive disorders of pregnancy, and neonatal morbidity. Compared with singleton gestations, twin gestations are at increased risk for fetal growth abnormalities, hypertensive disorders, and neonatal morbidity. Whether gestational diabetes further increases the risk for these outcomes is unclear.

OBJECTIVE

We sought to determine the relationship between gestational diabetes and the risk for preeclampsia, fetal growth abnormalities, and neonatal intensive care unit admissions in a large cohort of women with twin pregnancies.

STUDY DESIGN

We used a retrospective cohort of all twin gestations that were delivered at our institution from 1998 to 2013. We excluded pregnancies delivered before 24 weeks' gestation, monochorionic-monoamniotic twins, and patients with preexisting diabetes for a final cohort of 2573 twin deliveries. Gestational diabetes was defined as 2 abnormal values on a 100 g, 3-hour glucose challenge test as defined by the Carpenter-Coustan criteria or a 1-hour value of 200 mg/dL after a 50 g glucose test. Multivariable Poisson regression models were used to estimate the associations between gestational diabetes and preeclampsia, small for gestational age infants, large for gestational age infants, and admission to the neonatal intensive care unit after adjusting for prepregnancy body mass index, maternal race, maternal age, parity, use of in vitro fertilization, prepregnancy smoking status, and chronic hypertension as confounders.

RESULTS

The unadjusted incidence of gestational diabetes was 6.5% (n=167). Women with gestational diabetes were more likely to be aged 35 years or older, living with obesity, and have conceived via in vitro fertilization than women without gestational diabetes. Preeclampsia was more common among women with twin pregnancies complicated by gestational diabetes (31%) than among women with twin pregnancies without gestational diabetes (18%) (adjusted risk ratio, 1.5; 95% confidence interval, 1.1-2.1). A diagnosis of small for gestational age infant was less common among women with gestational diabetes (17%) than among women without gestational diabetes (24%), although the results were imprecise (adjusted risk ratio, 0.8; 95% confidence interval, 0.5-1.1). There was no association between gestational diabetes and the incidence of large for gestational age neonates or neonatal intensive care unit admissions. Among women with gestational diabetes who reached 35 weeks' gestation, 62% (n=60) required medical management.

CONCLUSION

Gestational diabetes is a risk factor for preeclampsia among women with twin pregnancies. Close blood pressure monitoring and patient education are critical for this high-risk group. The association between gestational diabetes and neonatal outcomes among women with twin pregnancies is less precise, although it may reduce the incidence of small for gestational age infants. Prospective studies to determine if glycemic control decreases the risk for preeclampsia in twin pregnancies with gestational diabetes are needed.

Coronavirus disease 2019 in pregnancy was associated with maternal morbidity and preterm birth

BACKGROUND

Despite the mainly reassuring outcomes for pregnant women with coronavirus disease 2019 reported by previous case series with small sample sizes, some recent reports of severe maternal morbidity requiring intubation and of maternal deaths show the need for additional data about the impact of coronavirus disease 2019 on pregnancy outcomes.

OBJECTIVE

This study aimed to report the maternal characteristics and clinical outcomes of pregnant women with coronavirus disease 2019.

STUDY DESIGN

This retrospective, single-center study includes all consecutive pregnant women with confirmed (laboratory-confirmed) or suspected (according to the Chinese management guideline [version 7.0]) coronavirus disease 2019, regardless of gestational age at diagnosis, admitted to the Strasbourg University Hospital (France) from March 1, 2020, to April 3, 2020. Maternal characteristics, laboratory and imaging findings, and maternal and neonatal outcomes were extracted from medical records.

RESULTS

The study includes 54 pregnant women with confirmed (n=38) and suspected (n=16) coronavirus disease 2019. Of these, 32 had an ongoing pregnancy, 1 had a miscarriage, and 21 had live births: 12 vaginal and 9 cesarean deliveries. Among the women who gave birth, preterm deliveries were medically indicated for their coronavirus disease 2019-related condition for 5 of 21 women (23.8%): 3 (14.3%) before 32 weeks' gestation and 2 (9.5%) before 28 weeks' gestation. Oxygen support was required for 13 of 54 women (24.1%), including high-flow oxygen (n=2), noninvasive (n=1) and invasive (n=3) mechanical ventilation, and extracorporeal membrane oxygenation (n=1). Of these, 3, aged 35 years or older with positive test result for severe acute respiratory syndrome coronavirus 2 using reverse transcription polymerase chain reaction, had respiratory failure requiring indicated delivery before 29 weeks' gestation. All 3 women were overweight or obese, and 2 had an additional comorbidity.

CONCLUSION

Coronavirus disease 2019 in pregnancy was associated with maternal morbidity and preterm birth. Its association with other well-known risk factors for severe maternal morbidity in pregnant women with no infection, including maternal age above 35 years, overweight, and obesity, suggests further studies are required to determine whether these risk factors are also associated with poorer maternal outcome in these women.