Timing and severity of COVID-19 during pregnancy and risk of preterm birth in the International Registry of Coronavirus Exposure in Pregnancy

Impact of SARS-COV-2 Infection on Maternal, Obstetric and Neonatal Outcomes in a Cohort of Vaccinated Women: A Pilot Study

We aimed to investigate the impact of COVID-19 infection on maternal characteristics and obstetric and neonatal outcomes in a cohort of women in labor previously vaccinated who tested positive for SARS-CoV-2 infection, compared to aged-matched healthy controls. A retrospective case-control study was conducted among 66 women in labor. Clinical data were obtained from medical records. The attendance rates at childbirth and parenting classes, as well as the implementation of a birth plan, were significantly lower in the COVID-19 infection group (6.1% vs. 48.5%, <0.001; 6.1% vs. 33.3%, p = .005, respectively). Women with COVID-19 had a higher prevalence of prolonged postpartum hospital stay (33.3% vs. 9.1%, p = .016), and significantly higher prevalence of spontaneous preterm birth (27.3% vs. 1.09%, p = .006). Breastfeeding within the first 24 hr was also lower in women with COVID-19 (72.7% vs. 97.0%, p = .006). Maternal characteristics and neonatal outcomes are influenced by COVID-19 infection in vaccinated women. Complications include spontaneous preterm birth, prolonged postpartum hospital stay, and lack of breastfeeding within the first 24 hr. Childbirth education, parenting classes and implementing a birth plan may be associated with a decreased risk of COVID-19 infection.

SARS-CoV-2 infection, inflammation and birth outcomes in a prospective NYC pregnancy cohort

Associations between antenatal SARS-CoV-2 infection and pregnancy outcomes have been conflicting and the role of the immune system is currently unclear. This prospective cohort study investigated the interaction of antenatal SARS-CoV-2 infection, changes in cytokine and HS-CRP levels, birthweight and gestational age at birth. 2352 pregnant participants from New York City (2020-2022) were included. Plasma levels of interleukin (IL)-1β, IL-6, IL-17A and high-sensitivity C-reactive protein (HS-CRP) were quantified in blood specimens obtained across pregnancy. Quantile and linear regression models were conducted to 1) assess the impact of antenatal SARS-CoV-2 infection, overall and by timing of detection of SARS-CoV-2 positivity (< 20 weeks versus ≥ 20 weeks), on birthweight and gestational age at delivery; 2) examine the relationship between SARS-CoV-2 infection and maternal immune changes during pregnancy. All models were adjusted for maternal demographic and obstetric factors and pandemic timing. Birthweight models were additionally adjusted for gestational age at delivery and fetal sex. Immune marker models were also adjusted for gestational age at specimen collection and multiplex assay batch. 371 (15.8%) participants were infected with SARS-CoV-2 during pregnancy, of which 98 (26.4%) were infected at < 20 weeks gestation. Neither SARS-CoV-2 infection in general nor in early or late pregnancy was associated with lower birthweight nor earlier gestational age at delivery. Further, we did not observe cytokine or HS-CRP changes in response to SARS-CoV-2 infection and thus found no evidence to support a potential association between immune dysregulation and the diversity in pregnancy outcomes following infection.

Neurodevelopmental delay in children exposed to maternal SARS-CoV-2 in-utero

It is unclear if SARS CoV-2 infection during pregnancy is associated with adverse neurodevelopmental repercussions to infants. We assessed pediatric neurodevelopmental outcomes in children born to mothers with laboratory-confirmed SARS CoV-2 infection during pregnancy. Neurodevelopmental outcomes of in-utero exposed children were compared to that of pre-pandemic control children in Los Angeles (LA), CA, USA and Rio de Janeiro, Brazil. Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III), the gold standard tool for evaluating neurodevelopment until 36 months of age and Ages and Stages Questionnaires (ASQ-3), a frequently used screening instrument for evaluating neurodevelopment in this same age group were the assessment tools used. Developmental delay (DD) was defined as having a score < - 2 SD below the norm (< 70) in at least one of three Bayley-III domains, (cognitive, motor or language) or a score below the cut-off (dark zone) in at least one of five ASQ-3 domains (communication, gross motor, fine motor, problem solving, personal-social). Exposed children were born between April 2020 and December 2022 while control children were born between January 2016 to December 2019. Neurodevelopmental testing was performed in 300 children total: 172 COVID-19 exposed children between 5-30 months of age and 128 control children between 6-38 months of age. Bayley-III results demonstrated that 12 of 128 exposed children (9.4%) had DD versus 2 of 128 controls (1.6%), p = 0.0007. Eight of 44 additional exposed children had DD on ASQ-3 testing. Fully, 20 of 172 exposed children (11.6%) and 2 of 128 control children (1.6%), p = 0.0006 had DD. In Rio, 12% of exposed children versus 2.6% of controls, p = 0.02 had DD. In LA, 5.7% of exposed children versus 0 controls, p = 0.12 had DD. Severe/critical maternal COVID-19 predicted below average neurodevelopment in the exposed cohort (OR 2.6, 95% CI 1.1-6.4). Children exposed to antenatal COVID-19 have a tenfold higher frequency of DD as compared to controls and should be offered neurodevelopmental follow-up.

Characteristics and Outcomes of Coronavirus Disease- 2019 Among Pregnant Women in Saudi Arabia; a Retrospective Study

Background

Pregnancy-related coronavirus disease 2019 infection ranges from asymptomatic to very serious illness. This study aimed to determine the impact of the COVID-19 infection on pregnant women in the Jazan region of Saudi Arabia.

Methods

Retrospective observational study of women who had COVID-19 positive test in pregnancy admitted in King Fahd Hospital, Abu Arish General Hospital, and Sabya General Hospital, Jazan, Saudi Arabia during the period between March 2020 and March 2022. Data were extracted from the patient's records. Frequency and percentage distributions were calculated for categorical variables. Descriptive studies and regression analysis were conducted to evaluate the association between selected variables and pregnancy outcomes.

Results

Of the 33 pregnant women with confirmed infection, the majority were in their second and third trimester, with approximately 42.4% requiring intensive care unit (ICU) admission and oxygen therapy. The most prevalent symptoms were high respiratory rate and low blood pressure, often accompanied by fever, cough, and shortness of breath. Live births resulted in 54.5% of the cases, while two maternal deaths were reported. Significant associations were found between the need for non-invasive ventilation and timing of infection (p = 0.026), the mode of delivery and timing of infection (p = 0.036), and the mode of delivery and body mass index (BMI) (p = 0.007).

Conclusion

COVID-19 poses significant risks to pregnant women, particularly in the third trimester, and emphasized the importance of early identification of high-risk pregnancies, strategic planning, and enhanced monitoring during antenatal care.

The effect of SARS-CoV-2 infection and vaccination on Th17 and regulatory T cells in a pregnancy cohort in NYC

Disturbances in T-cells, specifically the Th17/Treg balance, have been implicated in adverse pregnancy outcomes. We investigated these two T-cell populations following pre-pregnancy and pregnancy SARS-CoV-2 infection and COVID-19 vaccination in 351 participants from a pregnancy cohort in New York City (Generation C; 2020-2022). SARS-CoV-2 infection status was determined via laboratory or medical diagnosis and COVID-19 vaccination status via survey and electronic medical records data. Peripheral blood mononuclear cells (PBMCs) were collected at routine prenatal visits throughout gestation (median 108 days; IQR 67-191 days) with repeated measures for 104 participants (29.6%). T-cell populations CD4+/CD3+, Th17/CD4+, Treg/CD4+ and the Th17/Treg ratio were quantified using flow cytometry. Results showed that inter-individual differences are a main influencing factor in Th17 and Treg variance, however total variance explained remained small (R2 = 15-39%). Overall, Th17 and Treg populations were not significantly affected by SARS-CoV-2 infection during pregnancy in adjusted linear mixed models (p>0.05), however comparison of repeated measures among SARS-CoV-2 infected participants and non-infected controls suggests a relative increase of the Th17/Treg ratio following infection. In addition, the Th17/Treg ratio was significantly higher after SARS-CoV-2 infection prior to pregnancy (10-138 weeks) compared to controls (β=0.48, p=0.003). COVID-19 vaccination was not associated with Th17 and Treg cells. Our findings suggest an impact of SARS-CoV-2 infection on the Th17/Treg ratio, likely depending on severity of infection, yet the observed trends and their potential consequences for pregnancy outcomes require further investigation. Our study contributes to growing evidence that COVID-19 vaccination during pregnancy does not lead to an exacerbated immune response.

Pregnancy and infant outcomes following SARS-CoV-2 infection in pregnancy during delta variant predominance - Surveillance for Emerging Threats to Pregnant People and Infants

BACKGROUND

SARS-CoV-2 infection in pregnancy is associated with an increased risk of adverse birth outcomes such as preterm birth, stillbirth, and maternal and infant complications. Previous research suggests an increased risk of severe COVID-19 illness and stillbirth in pregnant people during delta variant predominance in 2021; however, those studies did not assess timing of infection during pregnancy, and few of them described COVID-19 vaccination status.

OBJECTIVE

Using a large population-based cohort, this study compared pregnancy and infant outcomes and described demographic and clinical characteristics of pregnant people with SARS-CoV-2 infection prior to and during the delta variant period.

STUDY DESIGN

This retrospective cohort analysis included persons with confirmed SARS-CoV-2 infection in pregnancy from 6 US jurisdictions reporting to the Surveillance for Emerging Threats to Pregnant People and Infants Network. Data were collected through case reports of polymerase chain reaction-positive pregnant persons and linkages to birth certificates, fetal death records, and immunization records. We described clinical characteristics and compared frequency of spontaneous abortion (<20 weeks of gestation), stillbirth (≥20 weeks), preterm birth (<37 weeks), small for gestational age, and term infant neonatal intensive care unit admission between the time periods of pre-delta and delta variant predominance. Study time periods were determined by when variants constituted more than 50% of sequences isolated according to regional SARS-CoV-2 genomic surveillance data, with time periods defined for pre-delta (March 3, 2020-June 25, 2021) and Delta (June 26, 2021-December 25, 2021). Adjusted prevalence ratios were estimated for each outcome measure using Poisson regression and were adjusted for continuous maternal age, race and ethnicity, and insurance status at delivery.

RESULTS

Among 57,563 pregnancy outcomes, 57,188 (99.3%) were liveborn infants, 65 (0.1%) were spontaneous abortions, and 310 (0.5%) were stillbirths. Most pregnant persons were unvaccinated at the time of SARS-CoV-2 infection, with a higher proportion in pre-delta (99.4%) than in the delta period (78.4%). Of those with infections during delta and who were previously vaccinated, the timing from last vaccination to infection was a median of 183 days. Compared to pre-delta, infections during delta were associated with a higher frequency of stillbirths (0.7% vs 0.4%; adjusted prevalence ratio, 1.55; 95% confidence interval, 1.14-2.09) and preterm births (12.8% vs 11.9%; adjusted prevalence ratio, 1.14; 95% confidence interval, 1.07-1.20). The delta period was associated with a lower frequency of neonatal intensive care unit admission (adjusted prevalence ratio, 0.74; 95% confidence interval, 0.67-0.82) than in the pre-delta period. During the delta period, infection during the third trimester was associated with a higher frequency of preterm birth (adjusted prevalence ratio, 1.41; 95% confidence interval, 1.28-1.56) and neonatal intensive care unit admission (adjusted prevalence ratio, 1.21; 95% confidence interval, 1.01-1.45) compared to the first and second trimester combined.

CONCLUSION

In this US-based cohort of persons with SARS-CoV-2 infection in pregnancy, the majority were unvaccinated, and frequencies of stillbirth and preterm birth were higher during the delta variant predominance period than in the pre-delta period. During the delta period, frequency of preterm birth and neonatal intensive care unit admission was higher among infections occurring in the third trimester vs those earlier in pregnancy. These findings demonstrate population-level increases of adverse fetal and infant outcomes, specifically in the presence of a COVID-19 variant with more severe presentation.

Critical care, maternal and neonatal outcomes of pregnant women with COVID-19 admitted to eight intensive care units during the wildtype, alpha and delta waves of the pandemic across the North West of England-a retrospective review

INTRODUCTION

Few studies have described obstetric and critical care outcomes in pregnant women with COVID-19 needing intensive care unit (ICU) admission.

MATERIAL AND METHODS

Obstetric and critical care outcomes of COVID-19 women admitted to eight ICUs from April 1, 2020 to September 15, 2021, in the North West of England were retrospectively analyzed. Women admitted to ICU were assigned to three groups: antepartum women discharged from ICU prior to delivery (antepartum ICU-discharged group), antepartum women who had expedited delivery (antepartum ICU-delivered group) and a postpartum group. Our aims were to describe maternal characteristics and assess how delivery influenced the obstetric and critical care outcomes in these women.

RESULTS

During the study period, 615 women tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), of whom 62 (10.1%) needed ICU admission due to symptomatic COVID-19. Pregnancy loss (3.2%) was recorded in two women. Detailed obstetric and critical outcomes from 60 women are reported. Nine antepartum women (15%) admitted to ICU were discharged and continued their pregnancy, 13 antepartum women (21.7%) had expedited delivery by cesarean birth after ICU admission and 38 (63.3%) women were admitted to ICU during the postpartum period. Antepartum ICU-discharged women contracted the SARS-CoV-2 at an earlier median gestational age (23 weeks; p = 0.0003) and needed ICU admission at an earlier median gestational age (28 weeks, p = 0.03) compared with antepartum ICU-delivered (28 and 32 weeks) and postpartum women (35.5 and 36 weeks). Antepartum ICU-discharged women had the lowest rate of mechanical ventilation receipt (11.1%) compared with antepartum ICU-delivered women (52.3%) and postpartum women (44.3%) but the difference was not statistically significant (p = 0.13). No significant differences were observed in the frequency and severity of critical care complications in the antepartum ICU-discharged, antepartum-ICU delivered and postpartum women.

CONCLUSIONS

Of the women admitted to ICU antepartum, 40% were discharged while remaining pregnant and 60% had expedited delivery. Antepartum women who were discharged from ICU without giving birth may receive lower rates of mechanical ventilation than those who delivered in ICU or admitted postpartum; however, further studies are needed to confirm or refute this association.

Cesarean Delivery Outcomes for Patients with Coronavirus Disease-2019 in the USA

INTRODUCTION

Coronavirus disease-2019 (COVID-19) may have increased morbidity and mortality in patients having Cesarean delivery (CD) in the USA.

METHODS

We performed a retrospective cohort study of patients who had CD in 2020 using the national inpatient sample. After stratification by COVID-19 status, demographics, comorbidities, complications, mortality, and costs were compared.

RESULTS

There were 31,444,222 hospitalizations in the USA in 2020 with a mortality rate of 2.8%. Among these, 1,453,945 patients had COVID-19 and mortality was 13.2%. There were 1,108,755 patients who had CD and 15,550 had COVID-19. Patients with COVID-19 more frequently had Medicaid and were Hispanic. Patients with COVID-19 had more comorbidities including chronic hypertension, diabetes mellitus, pre-eclampsia, and eclampsia. Mortality in CD patients with COVID-19 was 30 in 10,000 patients, while for non-COVID-19 patients, it was 1 in 10,000 patients, P < 0.001. The crude odds ratio for mortality in COVID-19 patients was 32.1 (95% confidence interval = 22.9 to 44.7), P < 0.001 and the adjusted odds ratio was 29.3 (95% confidence interval = 20.7 to 41.4), P < 0.001.

CONCLUSIONS

CD patients with COVID-19 had 30-fold higher mortality before widespread vaccination was available with Hispanic and Medicaid patients disproportionately impacted. Potential explanations for this disparity include reduced access to personal protective equipment (e.g., masks) and testing, as well as socio-economic factors. Further research is needed to understand the factors that contributed to disparities in infection and clinical outcomes among obstetric patients during the COVID-19 pandemic. In future pandemics, enhanced efforts will be needed to protect economically disadvantaged women who are pregnant.

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States

BACKGROUND

Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19.

RESULTS

Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women.

CONCLUSIONS

Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes.

Delivery outcomes in a cohort of pregnant patients with COVID-19 with and without viral pneumonia

BACKGROUND

Among pregnant people, COVID-19 can lead to adverse outcomes, but the specific pregnancy outcomes that are affected by the disease are unclear. In addition, the effect of the severity of COVID-19 on pregnancy outcomes has not been clearly identified.

OBJECTIVE

This study aimed to evaluate the associations between COVID-19 with and without viral pneumonia and cesarean delivery, preterm delivery, preeclampsia, and stillbirth.

STUDY DESIGN

We conducted a retrospective cohort study (April 2020-May 2021) of deliveries between 20 and 42 weeks of gestation from US hospitals in the Premier Healthcare Database. The primary outcomes were cesarean delivery, preterm delivery, preeclampsia, and stillbirth. We used a viral pneumonia diagnosis (International Classification of Diseases -Tenth-Clinical Modification codes J12.8 and J12.9) to categorize patients by severity of COVID-19. Pregnancies were categorized into 3 groups: NOCOVID (no COVID-19), COVID (COVID-19 without viral pneumonia), and PNA (COVID-19 with viral pneumonia). Groups were balanced for risk factors by propensity-score matching.

RESULTS

A total of 814,649 deliveries from 853 US hospitals were included (NOCOVID: n=799,132; COVID: n=14,744; PNA: n=773). After propensity-score matching, the risks of cesarean delivery and preeclampsia were similar in the COVID group compared with the NOCOVID group (matched risk ratio, 0.97; 95% confidence interval, 0.94-1.00; and matched risk ratio, 1.02; 95% confidence interval, 0.96-1.07; respectively). The risks of preterm delivery and stillbirth were greater in the COVID group than in the NOCOVID group (matched risk ratio, 1.11; 95% confidence interval, 1.05-1.19; and matched risk ratio, 1.30; 95% confidence interval, 1.01-1.66; respectively). The risks of cesarean delivery, preeclampsia, and preterm delivery were higher in the PNA group than in the COVID group (matched risk ratio, 1.76; 95% confidence interval, 1.53-2.03; matched risk ratio, 1.37; 95% confidence interval, 1.08-1.74; and matched risk ratio, 3.33; 95% confidence interval, 2.56-4.33; respectively). The risk of stillbirth was similar in the PNA and COVID group (matched risk ratio, 1.17; 95% confidence interval, 0.40-3.44).

CONCLUSION

Within a large national cohort of hospitalized pregnant people, we found that the risk of some adverse delivery outcomes was elevated in people with COVID-19 with and without viral pneumonia, with much higher risks in the group with viral pneumonia.

Reduction in preterm birth among COVID-19-vaccinated pregnant individuals in the United States

BACKGROUND

Most studies investigating preterm birth and COVID-19 vaccination have suggested no difference in preterm birth rates between vaccinated and unvaccinated pregnant individuals; however, 1 recent study suggested a protective effect of COVID-19 vaccination on preterm birth rates in Australia.

OBJECTIVE

This study aimed to determine whether a similar association and protective effect of COVID-19 vaccination on preterm birth would be found in our multistate, US cohort.

STUDY DESIGN

A cohort study was conducted using the Vizient Clinical Database, which included data from 192 hospitals in 38 states. Pregnant individuals who delivered between January 2021 and April 2022 were included. Propensity score matching was used to match a "treated" group of pregnant individuals with any COVID-19 vaccination (incomplete or complete vaccination) to a group that had not received any COVID-19 vaccination (the "untreated" group). A complete vaccination series of ≥2 doses of the Moderna or Pfizer vaccines or at least 1 dose of the Johnson & Johnson vaccine was considered. An incomplete series was receipt of 1 dose of the Pfizer or Moderna vaccine. We examined the association between COVID-19 vaccination status and preterm birth at <28, <34, and <37 weeks of gestation. Multivariable logistic regression models were used to adjust for potential confounders, with adjusted odds ratios as the measure of treatment effect.

RESULTS

Matching with replacement was performed for 5749 treated participants. After propensity score matching, there was no difference in maternal demographics of age, race, insurance status, parity, or comorbid conditions. Vaccinated individuals were 26% less likely to deliver at <37 weeks of gestation (adjusted odds ratio, 0.74; 95% confidence interval, 0.73-0.75; P<.001), 37% less likely to deliver at <34 weeks of gestation (adjusted odds ratio, 0.63; 95% confidence interval, 0.61-0.64; P<.001), and 43% less likely to deliver at <28 weeks of gestation (adjusted odds ratio, 0.57; 95% confidence interval, 0.55-0.60; P<0.001) than unvaccinated individuals.

CONCLUSION

Vaccination against COVID-19 may be protective against preterm birth.

Impact of timing and severity of COVID-19 infection in pregnancy on intrauterine fetal growth- a registry-based study from Qatar

BACKGROUND

The novel coronavirus disease (COVID-19) pandemic has impacted pregnant women, increasing maternal and neonatal morbidity. The placenta is a potential target for the pathophysiological processes due to the increased thrombotic inflammatory activation and inadequate uteroplacental perfusion and oxygenation, potentially causing intrauterine growth restriction. This study investigates the impact of gestational age at diagnosis of COVID-19 and the presence of symptoms on intrauterine fetal growth in pregnant women.

METHODS

A retrospective review of COVID-19 positive pregnant women in Qatar from March 2020 to March 2021 was conducted. They were divided based on trimester of pregnancy in which they were infected. The outcomes included birthweight, customised fetal birthweight centiles, small for gestational age (SGA) baby and daily growth increments, compared between the trimesters and between symptomatic and asymptomatic women.

RESULTS

In our cohort, 218 women (20.5%) were infected in the first trimester, 399 (37.5%) in the second and 446 (42%) in the third. Women in the second trimester were significantly younger and symptomatic. Women infected in the first trimester were least likely to have diabetes. The mean birthweight, risk of SGA (11.5% vs 10% vs 14.6%, p = 0.302), and median customized growth centiles (47.6% vs 45.9% vs 46.1%)were similar between the groups. Symptomatic women had significantly lower mean birthweight (3147 gms vs 3222 gms) and median birthweight centiles (43.9% vs 54.0%)compared to the asymptomatic (p<0.05 for both). In women infected within 20 weeks of gestation, a delay in daily fetal growth increments was noted with symptomatic disease, although not statistically significant.

CONCLUSION

This study shows that women with symptomatic disease had lower birth centiles and birth weights. This was regardless of the gestational age at which they were infected. Early symptomatic disease seems to have an impact on fetal growth velocity; however, larger studies are needed to corroborate these findings.

A critical review of COVID-19 course and vaccination in dermatology patients on immunomodulatory/biologic therapy: recommendations should not differ between non-pregnant and pregnant individuals

COVID-19 can have detrimental effects on immunosuppressed patients. Here, we evaluate the evidence regarding continuing immunomodulatory/biologic (IMBI) therapy in pregnant dermatology patients during the COVID-19 pandemic. Also, we discuss the risks of COVID-19 vaccination in pregnant dermatology patients on IMBI therapy. As indicated in this review, regarding continuing IMBI therapy in pregnant dermatology patients during the pandemic, there is no compelling reason for treating them differently than non-pregnant. The body of evidence indicates that mRNA COVID-19 vaccines are safe during pregnancy. Studies on rheumatology patients, a group that overlaps significantly with the dermatology group, provided essential findings. IMBI in a non-pregnant rheumatology patient was not associated with COVID-19 mortality (except for rituximab), and vaccination of the rheumatology patient during pregnancy improved the obstetric outcomes compared to the unvaccinated patient. Based on this data, it can be stated that after weighing the benefit-risk profile of the available COVID-19 vaccines, the recommendation for the pregnant dermatology patient speaks in favor of the COVID-19 vaccination. COVID-19 vaccine recommendations in pregnant dermatology patients on IMBI should not differ from those for their non-pregnant counterparts.

Emulating Target Trials to Avoid Immortal Time Bias - An Application to Antibiotic Initiation and Preterm Delivery

BACKGROUND

Randomized trials in pregnancy are extremely challenging, and observational studies are often the only option to evaluate medication safety during pregnancy. However, such studies are often susceptible to immortal time bias if treatment initiation occurs after time zero of follow-up. We describe how emulating a sequence of target trials avoids immortal time bias and apply the approach to estimate the safety of antibiotic initiation between 24 and 37 weeks gestation on preterm delivery.

METHODS

The Tsepamo Study captured birth outcomes at hospitals throughout Botswana from 2014 to 2021. We emulated 13 sequential target trials of antibiotic initiation versus no initiation among individuals presenting to care <24 weeks, one for each week from 24 to 37 weeks. For each trial, eligible individuals had not previously initiated antibiotics. We also conducted an analysis susceptible to immortal time bias by defining time zero as 24 weeks and exposure as antibiotic initiation between 24 and 37 weeks. We calculated adjusted risk ratios (RR) and 95% confidence intervals (CI) for preterm delivery.

RESULTS

Of 111,403 eligible individuals, 17,009 (15.3%) initiated antibiotics between 24 and 37 weeks. In the sequence of target trials, RRs (95% CIs) ranged from 1.04 (0.90, 1.19) to 1.24 (1.11, 1.39) (pooled RR: 1.11 [1.06, 1.15]). In the analysis susceptible to immortal time bias, the RR was 0.90 (0.86, 0.94).

CONCLUSIONS

Defining exposure as antibiotic initiation at any time during follow-up after time zero resulted in substantial immortal time bias, making antibiotics appear protective against preterm delivery. Conducting a sequence of target trials can avoid immortal time bias in pregnancy studies.

Global knowledge, attitude, and practice towards COVID-19 among pregnant women: a systematic review and meta-analysis

BACKGROUND

Pregnant women form a specially vulnerable group due to unique changes in pregnancy, leading to a higher risk of getting a severe infection. As severe COVID-19 increases the risk of preeclampsia, preterm delivery, gestational diabetes, and low birth weight in pregnancy, there is a need to enhance pregnant women's knowledge, attitudes, and practices to prevent these complications. This systematic review and meta-analysis aimed to determine their levels of knowledge, attitudes, and practice (KAP) regarding COVID-19 at the global level.

METHODS

The systematic literature search was conducted in the English language, including Google Scholar, Scopus, PubMed/MEDLINE, Science Direct, Web of Science, EMBASE, Springer, and ProQuest, from the occurrence of the pandemic until September 2022. We used The Newcastle Ottawa scale for cross-sectional studies checklist to evaluate the risk of bias in the studies. Data were extracted by a Microsoft Excel spreadsheet and analyzed by STATA software version 14. We also employed Cochran Q statistics to assess the heterogeneity of studies and utilized Inverse variance random-effects models to estimate the pooled level of pregnant women's KAP towards COVID-19 infection prevention.

RESULTS

Based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and inclusion criteria, 53 qualified studies were acquired from several countries. In total, 51 articles (17,319 participants) for knowledge, 15 articles (6,509 participants) for attitudes, and 24 articles (11,032 participants) for practice were included in this meta-analysis. The pooled good knowledge, positive attitude, and appropriate practice in pregnant women were estimated at 59%(95%CI: 52-66%), 57%(95%CI: 42-72%), and 53%(95%CI: 41-65%), respectively. According to subgroup analysis, the level of knowledge, attitude, and practice were 61%(95%CI: 49-72), 52%(95%CI: 30-74), and 50%(95%CI: 39-60), respectively, in Africa, and 58.8%(95%CI: 49.2-68.4), 60%(95%CI: 41-80) and 60% (95%CI: 41-78), respectively, in Asia.

CONCLUSION

The Knowledge, attitude, and practice towards COVID-19 infection prevention in pregnant women were low. It is suggested that health education programs and empowerment of communities, especially pregnant women, about COVID-19 continue with better planning. For future studies, we propose to investigate the KAP of COVID-19 in pregnant women in countries of other continents and geographical regions.

Effects of intrauterine exposure to SARS-CoV-2 on infants' development: a rapid review and meta-analysis

Potential medium- and long-term neurodevelopmental sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy have not been ruled out. We aimed to systematically review and summarize the evidence regarding the effects of intrauterine exposure to SARS-CoV-2 on infant development and behavior. Scopus, PubMed, Web of Science, CINAHL, and PsycNet databases were searched for studies published up to February 6, 2023, investigating the effects of gestational SARS-CoV-2 on infant development and behavior. We performed narrative synthesis according to updated protocols. Studies using comparison groups and with the Ages and Stages Questionnaires-Third Edition (ASQ-3) scores available were included in a meta-analysis performed according to Cochrane protocols. We used the Newcastle-Ottawa Quality Assessment Scale to analyze the risk of bias. Heterogeneity was calculated using the I² statistic. The search identified 2,782 studies. After removing duplicates and applying the eligibility criteria, we performed a narrative synthesis of 10 included studies and a meta-analysis of three. There was no evidence of higher developmental delay rates in infants exposed to SARS-CoV-2 during pregnancy compared to non-exposed infants. However, the exposed infants scored lower than either the non-exposed children or pre-pandemic cohorts in some domains. Pooled results from the random-effects model indicated that SARS-CoV-2-exposed infants had lower scores on fine motor (mean difference [MD] = -4.70, 95% confidence interval [CI]: -8.76; -0.63), and problem-solving (MD = -3.05, 95% CI: -5.88; -0.22) domains than non-exposed infants (heterogeneity: I² = 69% and 88%, respectively). There was no difference between the exposed and non-exposed infants in the communication, gross motor, and personal-social ASQ-3 domains.  Conclusion: We did not find evidence confirming the association between SARS-CoV-2 gestational exposure and neurodevelopmental delays. However, the meta-analysis indicated that gestational exposure negatively affected fine motor and problem-solving skills. Robust evidence on this topic is still incipient, and the available studies present methodological inconsistencies that limit the drawing of clear-cut conclusions.   PROSPERO registration: #CRD42022308002; March 14, 2022. What is Known: • COVID-19 is associated with adverse pregnancy outcomes potentially linked to neurodevelopmental delays. • SARS-CoV-2 vertical transmission is rare; however, infections during pregnancy can be deleterious to the fetus, possibly mediated by maternal immune activation and other inflammatory mechanisms. What is New: • No evidence of increased developmental delay rates among SARS-CoV-2 gestational-exposed infants was found. However, a meta-analysis of three studies showed lower scores in fine motor and personal social ASQ-3 domains among exposed infants. • SARS-CoV-2 gestational exposure and the pandemic can affect child development via many mechanisms. Potential neurodevelopmental sequelae of SARS-CoV-2 exposure during gestation have not been ruled out.

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.

SARS-CoV-2 Transplacental Transmission: A Rare Occurrence? An Overview of the Protective Role of the Placenta

The outbreak of the coronavirus disease 2019 (COVID-19) pandemic, caused by novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a global public health crisis, causing substantial concern especially to the pregnant population. Pregnant women infected with SARS-CoV-2 are at greater risk of devastating pregnancy complications such as premature delivery and stillbirth. Irrespective of the emerging reported cases of neonatal COVID-19, reassuringly, confirmatory evidence of vertical transmission is still lacking. The protective role of the placenta in limiting in utero spread of virus to the developing fetus is intriguing. The short- and long-term impact of maternal COVID-19 infection in the newborn remains an unresolved question. In this review, we explore the recent evidence of SARS-CoV-2 vertical transmission, cell-entry pathways, placental responses towards SARS-CoV-2 infection, and its potential effects on the offspring. We further discuss how the placenta serves as a defensive front against SARS-CoV-2 by exerting various cellular and molecular defense pathways. A better understanding of the placental barrier, immune defense, and modulation strategies involved in restricting transplacental transmission may provide valuable insights for future development of antiviral and immunomodulatory therapies to improve pregnancy outcomes.

The Significance of Low Magnesium Levels in COVID-19 Patients

Magnesium is the fourth most common mineral in the human body and the second richest intracellular cation. This element is necessary for many physiological reactions, especially in the cardiovascular and respiratory systems. COVID-19 is an infectious disease caused by SARS-CoV-2. The majority of people who become ill as a result of COVID-19 have mild-to-moderate symptoms and recover without specific treatment. Moreover, there are people who develop severe forms of COVID-19, which require highly specialized medical assistance. Magnesium deficiency may play a role in the pathophysiology of infection with SARS-CoV-2. The primary manifestation of COVID-19 remains respiratory, but the virus can spread to other organs and tissues, complicating the clinical picture and culminating in multiorgan failure. The key mechanisms involved in the disease include direct viral cytotoxicity, endothelial dysfunction, and exaggerated release of inflammatory cytokines. The aim of this review was to summarize the available data regarding the role of magnesium in COVID-19 patients and its particularities in different clinical settings.