Gestational diabetes mellitus: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data

Defining and reporting adverse events of special interest in comparative maternal vaccine studies: a systematic review

Introduction

The GAIA (Global Alignment on Immunisation Safety Assessment in Pregnancy) consortium was established in 2014 with the aim of creating a standardised, globally coordinated approach to monitoring the safety of vaccines administered in pregnancy. The consortium developed twenty-six standardised definitions for classifying obstetric and infant adverse events. This systematic review sought to evaluate the current state of adverse event reporting in maternal vaccine trials following the publication of the case definitions by GAIA, and the extent to which these case definitions have been adopted in maternal vaccine safety research.

Methods

A comprehensive search of published literature was undertaken to identify maternal vaccine research studies. PubMed, EMBASE, Web of Science, and Cochrane were searched using a combination of MeSH terms and keyword searches to identify observational or interventional studies that examined vaccine safety in pregnant women with a comparator group. A two-reviewer screening process was undertaken, and a narrative synthesis of the results presented.

Results

14,737 titles were identified from database searches, 435 titles were selected as potentially relevant, 256 were excluded, the remaining 116 papers were included. Influenza vaccine was the most studied (25.0%), followed by TDaP (20.7%) and SARS-CoV-2 (12.9%).Ninety-one studies (78.4%) were conducted in high-income settings. Forty-eight (41.4%) utilised electronic health-records. The majority focused on reporting adverse events of special interest (AESI) in pregnancy (65.0%) alone or in addition to reactogenicity (27.6%). The most frequently reported AESI were preterm birth, small for gestational age and hypertensive disorders. Fewer than 10 studies reported use of GAIA definitions. Gestational age assessment was poorly described; of 39 studies reporting stillbirths 30.8% provided no description of the gestational age threshold.

Conclusions

Low-income settings remain under-represented in comparative maternal vaccine safety research. There has been poor uptake of GAIA case definitions. A lack of harmonisation and standardisation persists limiting comparability of the generated safety data.

Obstetric and neonatal outcomes in South Africa

BACKGROUND

Background epidemiologic population data from low- and middle-income countries (LMIC), on maternal, foetal and neonatal adverse outcomes are limited. We aimed to estimate the incidence of maternal, foetal and neonatal adverse outcomes at South African maternal vaccine trial sites as reported directly in the clinical notes as well as using the 'Global Alignment of Immunization Safety Assessment in Pregnancy' case definitions (GAIA-CDs). GAIA-CDs were utilized as a tool to standardise data collection and outcome assessment, and the applicability and utility of the GAIA-CDs was evaluated in a LMIC observational study.

METHODS

We conducted a retrospective record review of maternity and neonatal case records for births that occurred in Soweto, Inner City- Johannesburg and Metro-East Cape Town, South Africa, between 1st July 2017 and 30th June 2018. Study staff abstracted data from randomly selected medical charts onto standardized study-specific forms. Incidence (per 100,000 population) was calculated for adverse maternal, foetal and neonatal outcomes, which were identified as priority outcomes in vaccine safety studies by the Brighton Collaboration and World Health Organization. Outcomes reported directly in the clinical notes and outcomes which fulfilled GAIA-CDs were compared. Incidence of outcomes was calculated by combining cases which were either reported in clinical notes by attending physicians and/ or fulfilled GAIA-CDs.

FINDINGS

Of 9371 pregnant women enrolled, 27·6% were HIV-infected, 19·9% attended antenatal clinic in the 1st trimester of pregnancy and 55·3% had ≥1 ultrasound examination. Fourteen percent of women had hypertensive disease of pregnancy, 1·3% had gestational diabetes mellitus and 16% experienced preterm labour. There were 150 stillbirths (1·6%), 26·8% of infants were preterm and five percent had microcephaly. Data available in clinical notes for some adverse outcomes, including maternal- & neonatal death, severe pre-eclampsia/ eclampsia, were able to fulfil GAIA-CDs criteria for all of the clinically-reported cases, however, missing data required to fulfil other GAIA-CD criteria (including stillbirth, gestational diabetes mellitus and gestational hypertension) led to poor correlation between clinically-reported adverse outcomes and outcomes fulfilling GAIA-CDs. Challenges were also encountered in accurately ascertaining gestational age.

INTERPRETATION

This study contributes to the expanding body of data on background rates of adverse maternal and foetal/ neonatal outcomes in LMICs. Utilization of GAIA-CDs assists with alignment of data, however, some GAIA-CDs require amendment to improve the applicability in LMICs.

FUNDING

This study was funded by Pfizer (Inc).

Standardizing case definitions for monitoring the safety of maternal vaccines globally: GAIA definitions, a review of progress to date

In 2014, the Global Alignment on Immunization safety Assessment in pregnancy consortium (GAIA) was formed, with the goal of developing a harmonized, globally-concerted approach to actively monitor the safety of vaccines in pregnancy. A total of 26 standardized definitions for the classification of adverse events have been developed. The aim of this review was to identify and describe studies undertaken to assess the performance of these definitions. A literature search was undertaken to identify published studies assessing the performance of the definitions, and reference lists were snowballed. Data were abstracted by two investigators and a narrative review of the results is presented. Four studies that have evaluated 13 GAIA case definitions (50%) were identified. Five case definitions have been assessed in high-income settings only. Recommendations have been made by the investigators to improve the performance of the definitions. These include ensuring consistency across definitions, removal of the potential for ambiguity or variations in interpretation and ensuring that higher-level criteria are acceptable at lower levels of confidence. Future research should prioritize the key case definitions that have not been assessed in low- and middle-income settings, as well as the 13 that have not undergone any validation.

Protocol for a pregnancy registry of maternal and infant outcomes in Uganda –The PREPARE Study

Background: Pregnancy is associated with complications which must be differentiated from adverse events associated with the administration of vaccines during pregnancy both in clinical trials and post licensure surveillance. The frequency of pregnancy related complications varies significantly by geographical location and the prevalence of pregnancy and neonatal outcomes are poorly documented in most low-resource settings. In preparation for Group B Streptococcus maternal vaccination trials, we describe a protocol for a pregnancy register at Kawempe National Referral Hospital, Kampala, Uganda to describe pregnancy maternal and infant outcomes. Methods: The study has two components. Firstly, an active, prospective surveillance cohort consisting of pregnant women in their first or second trimester recruited and followed up through their hospital scheduled antenatal visits, delivery and their infants through their extended programme of immunisation visits until 14 weeks of age. Data on obstetric and neonatal outcomes defined by the Brighton Collaboration Global Alliance of Immunisation Safety Assessment in Pregnancy criteria will be collected. Secondly, a passive surveillance cohort collecting data through routine electronic health records on all women and infants attending care at KNRH.  Data will be collected on vaccinations and medications including antiretroviral therapy received in antenatal clinic and prior to hospital discharge. Discussion:  Conducting vaccine research in resource-limited settings is essential for equity and to answer priority safety questions specific to these settings. It requires improved vaccine safety monitoring, which is especially pertinent in maternal vaccine research. During a trial, understanding the epidemiology and background rates of adverse events in the study population is essential to establish thresholds which indicate a safety signal. These data need to be systematically and reliably collected. This study will describe rates of adverse pregnancy outcomes in a cohort of 4,000 women and infants and any associated medications or vaccines received at a new vaccine trial site in Uganda.

Determinants of Pregnancy-Induced Hypertension among Mothers Attending Public Hospitals in Wolaita Zone, South Ethiopia: Findings from Unmatched Case-Control Study

BACKGROUND

It has been estimated that approximately 14% of maternal death has resulted due to pregnancy-induced hypertension. Evidence also suggests that pregnancy-induced hypertension may result in adverse maternal and child outcomes. The aim of this study was to assess the determinants of pregnancy-induced hypertension among mothers attending antenatal and delivery services at public health hospitals in Wolaita zone, southern Ethiopia.

METHODS

An institutionally based unmatched case-control study was conducted at three public hospitals. A total of 283 study participants were recruited for this study. Cases were selected consecutively as they were being diagnosed for pregnancy-induced hypertension, and two controls were selected for each case. Data were collected via the face-to-face interview technique using a pretested questionnaire. Unconditional logistic regression analysis was used to identify the independent predictor variables and produced odds ratio (OR) as a measure of association.

RESULTS

The mean ± (SD) ages of cases and controls were 26.1 ± 5.4 and 26.1 ± 4.5 years, respectively. Being rural residents (AOR: 2.25, 95% CI: 1.09-4.65), illiterate (AOR: 3.12, 95% CI: 1.20-8.08), having the history of pregnancy-induced hypertension (AOR: 6.62, 95% CI: 2.48-17.71), history of kidney disease (AOR: 3.14, 95% CI: 1.05-9.38), and family history of hypertension (AOR: 5.59, 95% CI: 2.73-11.45) were determinants that increased the odds of suffering from hypertensive disorders of pregnancy. More importantly, eating vegetables and fruit reduces the odds of suffering from pregnancy-induced hypertension by 77% (AOR: 0.23, 95% CI: 0.06-0.79).

CONCLUSION

Being rural residents, illiterate, having a history of pregnancy-induced hypertension, and history of kidney disease, as well as the family history of hypertension were identified determinates of hypertensive disorders of pregnancy in the study area. Furthermore, fruit and vegetable intakes were identified as protective factors for pregnancy-induced hypertension. Therefore, early diagnosis and intervention of this disorder are warranted to reduce adverse outcomes.

Pregnancy-induced Cardiovascular Pathologies: Importance of Structural Components and Lipids

Pregnancy leads to adaptations for maternal and fetal energy needs. The cardiovascular system bears the brunt of the adaptations as the heart and vessels enable nutrient supply to maternal organs facilitated by the placenta to the fetus. The components of the cardiovascular system are critical in the balance between maternal homeostatic and fetus driven homeorhetic regulation. Since lipids intersect maternal cardiovascular function and fetal needs with growth and in stress, factors affecting lipid deposition and mobilization impact risk outcomes. Here, the cardiovascular components and functional derangements associated with cardiovascular pathology in pregnancy, vis-à-vis lipid deposition, mobilization and maternal and/or cardiac and fetal energy needs are detailed. Most reports on the components and associated pathology in pregnancy, are on derangements affecting the extracellular matrix and epicardial fat, followed by the endothelium, vascular smooth muscle, pericytes and myocytes. Targeted studies on all cardiovascular components and pathological outcomes in pregnancy will enhance targeted interventions.