Higher severe acute respiratory syndrome coronavirus 2 infection rate in pregnant patients.

BACKGROUND: During the early months of the coronavirus disease 2019 pandemic, risks associated with severe acute respiratory syndrome coronavirus 2 in pregnancy were uncertain. Pregnant patients can serve as a model for the success of clinical and public health responses during public health emergencies as they are typically in frequent contact with the medical system. Population-based estimates of severe acute respiratory syndrome coronavirus 2 infections in pregnancy are unknown because of incomplete ascertainment of pregnancy status or inclusion of only single centers or hospitalized cases. Whether pregnant women were protected by the public health response or through their interactions with obstetrical providers in the early months of pandemic is not clearly understood. OBJECTIVE: This study aimed to estimate the severe acute respiratory syndrome coronavirus 2 infection rate in pregnancy and to examine the disparities by race and ethnicity and English language proficiency in Washington State. STUDY DESIGN: Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection diagnosed between March 1, 2020, and June 30, 2020 were identified within 35 hospitals and clinics, capturing 61% of annual deliveries in Washington State. Infection rates in pregnancy were estimated overall and by Washington State Accountable Community of Health region and cross-sectionally compared with severe acute respiratory syndrome coronavirus 2 infection rates in similarly aged adults in Washington State. Race and ethnicity and language used for medical care of pregnant patients were compared with recent data from Washington State. RESULTS: A total of 240 pregnant patients with severe acute respiratory syndrome coronavirus 2 infections were identified during the study period with 70.7% from minority racial and ethnic groups. The principal findings in our study were as follows: (1) the severe acute respiratory syndrome coronavirus 2 infection rate was 13.9 per 1000 deliveries in pregnant patients (95% confidence interval, 8.3-23.2) compared with 7.3 per 1000 (95% confidence interval, 7.2-7.4) in adults aged 20 to 39 years in Washington State (rate ratio, 1.7; 95% confidence interval, 1.3-2.3); (2) the severe acute respiratory syndrome coronavirus 2 infection rate reduced to 11.3 per 1000 deliveries (95% confidence interval, 6.3-20.3) when excluding 45 cases of severe acute respiratory syndrome coronavirus disease 2 detected through asymptomatic screening (rate ratio, 1.3; 95% confidence interval, 0.96-1.9); (3) the proportion of pregnant patients in non-White racial and ethnic groups with severe acute respiratory syndrome coronavirus disease 2 infection was 2- to 4-fold higher than the race and ethnicity distribution of women in Washington State who delivered live births in 2018; and (4) the proportion of pregnant patients with severe acute respiratory syndrome coronavirus 2 infection receiving medical care in a non-English language was higher than estimates of pregnant patients receiving care with limited English proficiency in Washington State (30.4% vs 7.6%). CONCLUSION: The severe acute respiratory syndrome coronavirus 2 infection rate in pregnant people was 70% higher than similarly aged adults in Washington State, which could not be completely explained by universal screening at delivery. Pregnant patients from nearly all racial and ethnic minority groups and patients receiving medical care in a non-English language were overrepresented. Pregnant women were not protected from severe acute respiratory syndrome coronavirus 2 infection in the early months of the pandemic. Moreover, the greatest burden of infections occurred in nearly all racial and ethnic minority groups. These data coupled with a broader recognition that pregnancy is a risk factor for severe illness and maternal mortality strongly suggested that pregnant people should be broadly prioritized for coronavirus disease 2019 vaccine allocation in the United States similar to some states.

Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State.

BACKGROUND: Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown. OBJECTIVE: This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality. STUDY DESIGN: Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery. RESULTS: The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001). CONCLUSION: Coronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.

Clinical characteristics of 46 pregnant women with a severe acute respiratory syndrome coronavirus 2 infection in Washington State.

BACKGROUND: The impact of coronavirus disease 2019 on pregnant women is incompletely understood, but early data from case series suggest a variable course of illness from asymptomatic or mild disease to maternal death. It is unclear whether pregnant women manifest enhanced disease similar to influenza viral infection or whether specific risk factors might predispose to severe disease. OBJECTIVE: To describe maternal disease and obstetrical outcomes associated with coronavirus disease 2019 in pregnancy to rapidly inform clinical care. STUDY DESIGN: This is a retrospective study of pregnant patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 6 hospital systems in Washington State between Jan. 21, 2020, and April 17, 2020. Demographics, medical and obstetrical history, and coronavirus disease 2019 encounter data were abstracted from medical records. RESULTS: A total of 46 pregnant patients with a severe acute respiratory syndrome coronavirus 2 infection were identified from hospital systems capturing 40% of births in Washington State. Nearly all pregnant individuals with a severe acute respiratory syndrome coronavirus 2 infection were symptomatic (93.5%, n=43) and the majority were in their second or third trimester (43.5% [n=20] and 50.0% [n=23], respectively). Symptoms resolved in a median of 24 days (interquartile range, 13-37). Notably, 7 women were hospitalized (16%) including 1 admitted to the intensive care unit. A total of 6 cases (15%) were categorized as severe coronavirus disease 2019 with nearly all patients being either overweight or obese before pregnancy or with asthma or other comorbidities. Of the 8 deliveries that occurred during the study period, there was 1 preterm birth at 33 weeks' gestation to improve pulmonary status in a woman with class III obesity, and 1 stillbirth of unknown etiology. CONCLUSION: Severe coronavirus disease 2019 developed in approximately 15% of pregnant patients and occurred primarily in overweight or obese women with underlying conditions. Obesity and coronavirus disease 2019 may synergistically increase risk for a medically indicated preterm birth to improve maternal pulmonary status in late pregnancy. These findings support categorizing pregnant patients as a higher-risk group, particularly those with chronic comorbidities.

Cellular-Enabled Glucometers and Maternal Glucose Control: A Quality Improvement Initiative.

BACKGROUND: Management of diabetes in pregnancy is burdensome due to self-glucose monitoring, recording, and reporting demands. Cellular-enabled glucometers provide real-time transmission of glucose values independent of internet access and cell phone data plans. We describe a quality improvement (QI) intervention that introduced cellular-enabled glucometers for use during pregnancies complicated by diabetes. METHODS: Our aim was to improve maternal glucose control in a cohort of insulin-requiring pregnant women enrolled in a telemedicine diabetes program. During initial establishment of a QI program, women were offered cellular-enabled glucometers but could elect to keep their standard meter. The primary outcome evaluated was glycosylated hemoglobin A1c (HbA1c) at delivery. RESULTS: Baseline characteristics including initial HbA1c were similar between women using a standard glucometer (n = 45) and those using a cellular-enabled glucometer (n = 72). Women who used a cellular-enabled glucometer had a lower HbA1c at delivery compared to those using a standard glucometer (5.8% vs 6.3%, P = .03). This improvement was particularly notable for women with poor glucose control (defined as HbA1c >6.5%) at initial obstetric visit. Women with poor glucose control who used a cellular-enabled glucose monitor had significantly lower HbA1c at delivery (6.0% vs 6.8%, P = .03) and greater change from initial visit compared to those using a standard glucometer (-2.6% vs -1.4%, P = .02). No statistically significant differences were detected in tracked neonatal outcomes. CONCLUSION: For pregnancies complicated by insulin-requiring diabetes, use of cellular-enabled glucometers as part of a perinatal diabetes program improves glucose control at delivery with timely transmission of accurate values throughout gestation.

Adherence to self-glucose monitoring recommendations and perinatal outcomes in pregnancies complicated by diabetes mellitus.

BACKGROUND: Self-glucose monitoring is critical for the management of diabetes mellitus in pregnancy; yet, validated reports of adherence to testing recommendations and associated perinatal outcomes are limited. OBJECTIVE: Using cloud-based, self-glucose monitoring technology, we sought to answer the following questions: (1) Are there differences in the rates of testing adherence based on type of diabetes mellitus in pregnancy? (2) Is adherence to glucose monitoring recommendations associated with perinatal outcomes in pregnancies that are complicated by diabetes mellitus? We hypothesized that adherence to glucose testing recommendations varies by type of diabetes mellitus and that increased adherence to testing recommendations would be associated with improved perinatal outcomes. STUDY DESIGN: This single-center, prospective cohort study included women with type 2 diabetes mellitus and gestational diabetes mellitus who were enrolled in a perinatal diabetes program at <29 weeks gestation between December 2015 and June 2018. All women received a cellular-enabled glucometer that uploaded glucose values to a cloud-based, Health Insurance Portability and Accountability Act-compliant platform in real time that ensured transmission of accurate glucose values. The primary outcome was adherence to self-glucose monitoring recommendations. Four glucose checks were advised daily, and percentage of adherence was calculated. Secondary outcomes were preeclampsia, cesarean delivery, large-for-gestational-age neonates, and neonatal hypoglycemia. The study was powered to detect a 10% difference in the primary outcome of adherence to advised self-glucose monitoring by diabetes mellitus type. Adjusted risk ratios and 95% confidence intervals were generated with the use of logistic regression. RESULTS: This study included 103 eligible women. Baseline characteristics differed between groups, with women with type 2 diabetes mellitus having higher initial HgbA1c and body mass index when compared with women with gestational diabetes mellitus. No differences were noted in age or parity. Adherence was calculated over 20±6 weeks for women with type 2 diabetes mellitus compared with 9±4 weeks for women with gestational diabetes mellitus. Overall adherence to glucose monitoring was significantly less for women with type 2 diabetes mellitus compared with those with gestational diabetes mellitus. Mean testing adherence rates were 51%, 66%, and 70% for type 2 diabetes mellitus, and gestational diabetes mellitus, class A1 and A2, respectively (P=.016). We found that, for every 10% increase in adherence to testing recommendations, the odds of cesarean delivery, neonatal hypoglycemia, and large-for-gestational-age fetuses decreases by 15-20%. There was no association between adherence and rates of preeclampsia. CONCLUSION: This study shows that overall adherence to testing recommendations differs by diabetes mellitus type and is associated with neonatal outcomes. Improved outcomes with higher adherence may reflect more timely medication adjustments in response to real-time glucose values. Programs aimed at improving adherence could prove beneficial.

Utility of volumetric assessment of cervical funneling to predict cerclage failure.

OBJECTIVE: To assess the utility of cervical funnel volume as a predictor of cerclage failure. METHODS: We performed a retrospective cohort study of pregnant women with a McDonald cerclage and sonographic evidence of cervical funneling between 1/2008 and 2/2014. Funnel volume (FV) was calculated and used as a correction factor for cervical length (CL) or cerclage height (CH). Receiver operating characteristic (ROC) curves were used to compare the predictive value of CL, CL:FV, CH and CH:FV for cerclage failure at <28 or <34 weeks. CL:FV was further stratified to the <5th, <10th and >10th percentiles and analyzed for prediction of preterm delivery. RESULTS: Subjects with cerclage failure (n = 30) delivered at a mean gestational age of 29.8 +/- 5.3 weeks compared to 38.1+/- 1.39 weeks in those without failure (n = 27; p < 0.001). ROC curves demonstrated CL:FV was the best predictor of delivery <28 weeks (AUC 0.80), while CL was the best predictor of delivery <34 weeks (AUC 0.76). Stratification of CL:FV into <5th versus >10th percentile groups was predictive of early preterm delivery (25.1 weeks versus 34 weeks, p = 0.01). CONCLUSIONS: Volumetric assessment of cervical funneling may improve prediction of cerclage failure in the mid-trimester.

Principles of Anti-infective Dosing in Pregnancy.

PURPOSE: Anti-infectives are among the most commonly prescribed medications in pregnancy. However, detailed information on the pharmacokinetics and pharmacodynamics of these medications in pregnancy is limited, leading to uncertainty among clinicians regarding the tolerability and efficacy of treatments. The purposes of this review were to highlight key physiologic changes during pregnancy that influence drug behavior, and to discuss areas of active research related to anti-infective drugs in pregnancy. METHODS: A review of literature in PubMed was performed for topics related to physiologic changes of pregnancy, postcesarean surgical site infections, vaccines in pregnancy, and intrauterine infections. The literature was reviewed and pertinent sources were utilized for this article. FINDINGS: Physiologic changes during pregnancy may impact drug disposition and efficacy. Cefazolin regimens are the current prophylactic treatment of choice for postcesarean surgical site infections. Vaccines are provided in pregnancy for both maternal and neonatal benefit. Broad-spectrum antibiotics continue to be used as first-line therapy for intrauterine infections. IMPLICATIONS: Continued efforts to broaden the knowledge base on anti-infective drug behavior in pregnancy will result in increased therapeutic options for this population.