Recurrent Severe Maternal Morbidity in an Obstetric Population With a High Comorbidity Burden

OBJECTIVE

To evaluate the risk of severe maternal morbidity (SMM) in subsequent pregnancies in patients who experienced SMM in a previous pregnancy compared with those who did not.

METHODS

We conducted a retrospective cohort study of patients with two or more deliveries at 23 or more weeks of gestation at a single Southeastern U.S. tertiary care center between 2015 and 2018. The primary exposure was SMM including transfusion (transfusion SMM) in a previous pregnancy, as defined by the Centers for Disease Control and Prevention, using International Classification of Diseases, Ninth or Tenth Revision codes. The primary outcome was transfusion SMM in any subsequent pregnancy in the study time frame. Generalized estimating equation models were used to estimate the relative risk (RR) and associated 95% CIs of transfusion SMM in patients with transfusion SMM in a prior pregnancy compared with patients without transfusion SMM in a previous pregnancy. Severe maternal morbidity without transfusion (nontransfusion SMM) and cross-analysis to determine risk of a different type of SMM after a history of SMM were analyzed similarly.

RESULTS

Of 852 included patients, transfusion SMM and nontransfusion SMM occurred in 90 (10.6%) and 18 (2.1%), respectively, in the first captured pregnancy and in 79 (9.3%) and 9 (1.1%), respectively, in subsequent pregnancies. Anemia (34.6-40.0%), obesity (33.4-40.4%), substance use disorder (14.2-14.6%), and preeclampsia (12.0-11.4%) were the most prevalent morbidities at first captured and subsequent pregnancies, respectively. There was a 16-fold higher risk of transfusion SMM in a subsequent pregnancy after experiencing transfusion SMM in the first captured pregnancy (57.8% vs 3.5%, RR 16.3 95% CI, 10.8-24.6). Nontransfusion SMM was similarly higher in patients with nontransfusion SMM in their first captured pregnancy compared with those without (16.7% vs 0.7%, RR 23.2 95% CI, 6.3-85.4). Additionally, patients who experienced transfusion SMM in their first captured pregnancies were at sixfold higher risk of developing nontransfusion SMM in a subsequent pregnancy (RR 6.2, 95% CI, 1.7-22.6). However, in cross-analysis of patients who experienced nontransfusion SMM, the risk of transfusion SMM in a subsequent pregnancy was not statistically significant.

CONCLUSION

The risks of SMM in subsequent pregnancies after previous SMM are extremely high and are higher than previous estimates. Future studies should estimate the contributions of comorbidities and other structural determinants including social vulnerability to help design interventions to reduce subsequent pregnancy risks.

Neutralizing Antibody Responses to Messenger RNA Coronavirus Disease 2019 Vaccines Versus Severe Acute Respiratory Syndrome Coronavirus 2 Infection Among Pregnant Women and Vaccine-Induced Antibody Transfer to Infants

Background

Early coronavirus disease 2019 (COVID-19) vaccine trials excluded pregnant women, resulting in limited data about immunogenicity and maternal-fetal antibody transfer, particularly by gestational timing of vaccination.

Methods

In this multicenter observational immunogenicity study, pregnant and nonpregnant women receiving COVID-19 vaccines were prospectively enrolled. Participants had sera collected before vaccination, at 14-28 days after each vaccine dose, at delivery (umbilical cord and peripheral), and from their infants at 3 and 6 months. Geometric mean titers (GMTs) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ID50 neutralizing antibody (nAb) against D614G-like viruses were compared by participant characteristics.

Results

Overall, 23 nonpregnant and 85 pregnant participants (trimester of first vaccine dose: 10 first, 47 second, 28 third) were enrolled. Ninety-three percent (76/82 with blood samples) of pregnant participants had detectable SARS-CoV-2 nAb after 2 vaccine doses, but GMTs (95% confidence intervals) were lower in pregnant participants than nonpregnant participants (1722 [1136-2612] vs 4419 [2012-9703]; P = .04). By 3 and 6 months, 28% and 74% of infants, respectively, of vaccinated participants had no detectable nAb to D614G-like viruses. Among the 71 pregnant participants without detectable nAb before vaccination, cord blood GMTs at delivery were 5-fold higher among participants vaccinated during the third versus first trimester, and cord blood nAb titers appeared inversely correlated with weeks since first vaccine dose (R2 = 0.06, P = .06).

Conclusions

Though most pregnant women develop nAb after 2 doses of mRNA COVID-19 vaccines, this analysis suggests that infant protection from maternal vaccination varies by gestational timing of vaccination and wanes. Additional prevention strategies such as caregiver vaccination may warrant consideration to optimize infant protection.

Value of HbA1c in Obese Women with Gestational Diabetes

OBJECTIVE

We sought to assess the association of hemoglobin A1c (HbA1c) with adverse perinatal outcomes in obese women with gestational diabetes mellitus (GDM).

STUDY DESIGN

This was a secondary analysis of a multicenter randomized controlled trial assessing early (14-20 weeks) versus routine (24-28 weeks) screening for GDM in obese women. Women were included if they were diagnosed with GDM at either time during pregnancy and had a HbA1c result available. The primary exposure was HbA1c at 24 to 28 weeks. The primary outcome was a composite of macrosomia, primary cesarean, pregnancy-induced hypertension, shoulder dystocia, neonatal hypoglycemia, or hyperbilirubinemia. Receiver operating characteristics (ROC) curves were used to assess the association of HbA1c with the composite outcome. The Liu method was used to select an optimal HbA1c cutoff, and the incidence of the outcome compared.

RESULTS

Of 125 women with GDM, 93 (74%) had a HbA1c at 24 to 28 weeks and 103 (82.4%) had a HbA1c at 14 to 20 weeks. Baseline characteristics were balanced between groups above and below the cutoff. The area under the ROC curve for HbA1c and its association with the adverse perinatal composite outcome was 0.6 (95% confidence interval [CI]: 0.5-0.7). The frequency of the primary outcome was similar among women with low and high HbA1c at 24 to 28 weeks (adjusted relative risk, 1.12, 95% CI: 0.97-1.29). Compared with women with a decreasing HbA1c during pregnancy, women with a stable or increasing HbA1c did not have a significant increase in the primary adverse perinatal composite outcome. However, the frequency of preterm delivery was higher among women with stable or increasing HbA1c compared with those with a decreasing HbA1c (26.1 vs. 6.7%, p = 0.03).

CONCLUSION

A single HbA1c in women with GDM is not associated with a composite perinatal adverse outcome, but a HbA1c that increases or remains stable between 14 to 20 and 24 to 28 weeks is associated with an increase in preterm delivery.

KEY POINTS

· A single HbA1c in GDM is not associated with a composite perinatal adverse outcome.. · HbA1c that increases or remains stable may be associated with an increase in preterm delivery.. · HbA1c at 24 to 28 weeks was not significantly associated with the adverse perinatal composite outcome..

Incidence, Clinical Characteristics, and Risk Factors of SARS-CoV-2 Infection among Pregnant Individuals in the United States

BACKGROUND

Data about the risk of SARS-CoV-2 infection among pregnant individuals are needed to inform infection prevention guidance and counseling for this population.

METHODS

We prospectively followed a cohort of pregnant individuals during August 2020-March 2021 at three U.S. sites. The three primary outcomes were incidence rates of any SARS-CoV-2 infection, symptomatic infection, and asymptomatic infection, during pregnancy during periods of SARS-CoV-2 circulation. Participants self-collected weekly mid-turbinate nasal swabs for SARS-CoV-2 RT-PCR testing, completed weekly illness symptom questionnaires, and submitted additional swabs with COVID-19-like symptoms. An overall SARS-CoV-2 infection incidence rate weighted by population counts of women of reproductive age in each state was calculated.

RESULTS

Among 1098 pregnant individuals followed for a mean of 10 weeks, nine percent (99/1098) had SARS-CoV-2 infections during the study. Population weighted incidence rates of SARS-CoV-2 infection were 10.0 per 1,000 (95% confidence interval [CI] 5.7-14.3) person-weeks for any infection, 5.7 per 1,000 (95% CI 1.7-9.7) for symptomatic infections, and 3.5 per 1,000 (95% CI 0-7.1) for asymptomatic infections. Among 96 participants with SARS-CoV-2 infection and symptom data, the most common symptoms were nasal congestion (72%), cough (64%), headache (59%), and change in taste or smell (54%); 28% had measured or subjective fever. The median symptom duration was 10 days (IQR6-16 days).

CONCLUSION

Pregnant individuals had a 1% risk of SARS-CoV-2 infection per week. Study findings provide information about SARS-CoV-2 infection risk during pregnancy to inform counseling for pregnant individuals about infection prevention practices, including COVID-19 vaccination.

Interdelivery Interval and Diabetes Mellitus in a Subsequent Pregnancy

OBJECTIVE

We determined whether time between deliveries is associated with developing diabetes at the time of a subsequent delivery.

STUDY DESIGN

This is a case-control study of women who had two consecutive singleton births at the same institution with no pregestational diabetes in the baseline pregnancy. Cases were defined as women who were diagnosed with any type of diabetes at the time of the subsequent delivery. Controls were defined as women who had no diagnosis of diabetes at the time of the subsequent delivery. Interdelivery interval (IDI) was categorized as < 18, 18 to 60, or > 60 months.

RESULTS

Of 12,263 women, 4.1% (N = 501) were diagnosed with diabetes at the subsequent delivery. Women with diabetes were more likely to have an IDI of >60 months than women without diabetes (9.0 vs. 4.2%, p < 0.001). After controlling for confounding factors, an IDI > 60 months remained associated with development of pregestational or gestational diabetes by the conclusion of the subsequent pregnancy (adjusted odds ratio = 2.13 compared with an IDI of 18-60 months, 95% confidence interval 1.44-3.15).

CONCLUSION

A longer IDI is an independent risk factor for the development of diabetes at the time of a subsequent delivery.

Applicability of the modified ACOG/SGO referral criteria for adnexal mass within a limited-resource setting

OBJECTIVE

To evaluate the performance of the modified American Congress of Obstetricians and Gynecologists (ACOG)/Society of Gynecologic Oncology (SGO) referral guidelines in a high-risk limited-resource setting.

METHODS

In a retrospective study, data were assessed for all women who underwent surgery for an adnexal mass at John H. Stroger Jr Hospital, Chicago, IL, USA, between July 2006 and July 2011. Sensitivity, specificity, and positive and negative predictive values were calculated both for actual practice referral patterns and for the modified ACOG/SGO guidelines.

RESULTS

Among 542 study women, 176 (32.5%) were diagnosed with ovarian malignancy. The ACOG/SGO guidelines showed 81.3% sensitivity and 71.9% specificity for the prediction of malignancy at time of surgery, with positive and negative predictive values of 58.1% and 88.9%, respectively. Actual practice patterns demonstrated lower sensitivity (68.2%; P<0.001) but higher specificity (84.2%; P<0.001).

CONCLUSION

As compared with practice patterns, the modified ACOG/SGO guidelines lacked sufficient specificity for referral and might not be applicable in high-risk, low-resource settings. For this population, screening should be based on stratifying patients into low-, intermediate-, and high-risk categories to allow limited resources to be focused on women at highest risk.