Effects of prenatal exposure to maternal COVID-19 and perinatal care on neonatal outcome: results from the INTERCOVID Multinational Cohort Study.

BACKGROUND: The effect of COVID-19 in pregnancy on maternal outcomes and its association with preeclampsia and gestational diabetes mellitus have been reported; however, a detailed understanding of the effects of maternal positivity, delivery mode, and perinatal practices on fetal and neonatal outcomes is urgently needed. OBJECTIVE: To evaluate the impact of COVID-19 on fetal and neonatal outcomes and the role of mode of delivery, breastfeeding, and early neonatal care practices on the risk of mother-to-child transmission. STUDY DESIGN: In this cohort study that took place from March 2020 to March 2021, involving 43 institutions in 18 countries, 2 unmatched, consecutive, unexposed women were concomitantly enrolled immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed up until hospital discharge. COVID-19 in pregnancy was determined by laboratory confirmation and/or radiological pulmonary findings or ≥2 predefined COVID-19 symptoms. The outcome measures were indices of neonatal and perinatal morbidity and mortality, neonatal positivity and its correlation with mode of delivery, breastfeeding, and hospital neonatal care practices. RESULTS: A total of 586 neonates born to women with COVID-19 diagnosis and 1535 neonates born to women without COVID-19 diagnosis were enrolled. Women with COVID-19 diagnosis had a higher rate of cesarean delivery (52.8% vs 38.5% for those without COVID-19 diagnosis, P<.01) and pregnancy-related complications, such as hypertensive disorders of pregnancy and fetal distress (all with P<.001), than women without COVID-19 diagnosis. Maternal diagnosis of COVID-19 carried an increased rate of preterm birth (P≤.001) and lower neonatal weight (P≤.001), length, and head circumference at birth. In mothers with COVID-19 diagnosis, the length of in utero exposure was significantly correlated to the risk of the neonate testing positive (odds ratio, 4.5; 95% confidence interval, 2.2-9.4 for length of in utero exposure >14 days). Among neonates born to mothers with COVID-19 diagnosis, birth via cesarean delivery was a risk factor for testing positive for COVID-19 (odds ratio, 2.4; 95% confidence interval, 1.2-4.7), even when severity of maternal conditions was considered and after multivariable logistic analysis. In the subgroup of neonates born to women with COVID-19 diagnosis, the outcomes worsened when the neonate also tested positive, with higher rates of neonatal intensive care unit admission, fever, gastrointestinal and respiratory symptoms, and death, even after adjusting for prematurity. Breastfeeding by mothers with COVID-19 diagnosis and hospital neonatal care practices, including immediate skin-to-skin contact and rooming-in, were not associated with an increased risk of newborn positivity. CONCLUSION: In this multinational cohort study, COVID-19 in pregnancy was associated with increased maternal and neonatal complications. Cesarean delivery was significantly associated with newborn COVID-19 diagnosis. Vaginal delivery should be considered the safest mode of delivery if obstetrical and health conditions allow it. Mother-to-child skin-to-skin contact, rooming-in, and direct breastfeeding were not risk factors for newborn COVID-19 diagnosis, thus well-established best practices can be continued among women with COVID-19 diagnosis.

Diabetes mellitus, maternal adiposity, and insulin-dependent gestational diabetes are associated with COVID-19 in pregnancy: the INTERCOVID study.

BACKGROUND: Among nonpregnant individuals, diabetes mellitus and high body mass index increase the risk of COVID-19 and its severity. OBJECTIVE: This study aimed to determine whether diabetes mellitus and high body mass index are risk factors for COVID-19 in pregnancy and whether gestational diabetes mellitus is associated with COVID-19 diagnosis. STUDY DESIGN: INTERCOVID was a multinational study conducted between March 2020 and February 2021 in 43 institutions from 18 countries, enrolling 2184 pregnant women aged ≥18 years; a total of 2071 women were included in the analyses. For each woman diagnosed with COVID-19, 2 nondiagnosed women delivering or initiating antenatal care at the same institution were also enrolled. The main exposures were preexisting diabetes mellitus, high body mass index (overweight or obesity was defined as a body mass index ≥25 kg/m2), and gestational diabetes mellitus in pregnancy. The main outcome was a confirmed diagnosis of COVID-19 based on a real-time polymerase chain reaction test, antigen test, antibody test, radiological pulmonary findings, or ≥2 predefined COVID-19 symptoms at any time during pregnancy or delivery. Relationships of exposures and COVID-19 diagnosis were assessed using generalized linear models with a Poisson distribution and log link function, with robust standard errors to account for model misspecification. Furthermore, we conducted sensitivity analyses: (1) restricted to those with a real-time polymerase chain reaction test or an antigen test in the last week of pregnancy, (2) restricted to those with a real-time polymerase chain reaction test or an antigen test during the entire pregnancy, (3) generating values for missing data using multiple imputation, and (4) analyses controlling for month of enrollment. In addition, among women who were diagnosed with COVID-19, we examined whether having gestational diabetes mellitus, diabetes mellitus, or high body mass index increased the risk of having symptomatic vs asymptomatic COVID-19. RESULTS: COVID-19 was associated with preexisting diabetes mellitus (risk ratio, 1.94; 95% confidence interval, 1.55-2.42), overweight or obesity (risk ratio, 1.20; 95% confidence interval, 1.06-1.37), and gestational diabetes mellitus (risk ratio, 1.21; 95% confidence interval, 0.99-1.46). The gestational diabetes mellitus association was specifically among women requiring insulin, whether they were of normal weight (risk ratio, 1.79; 95% confidence interval, 1.06-3.01) or overweight or obese (risk ratio, 1.77; 95% confidence interval, 1.28-2.45). A somewhat stronger association with COVID-19 diagnosis was observed among women with preexisting diabetes mellitus, whether they were of normal weight (risk ratio, 1.93; 95% confidence interval, 1.18-3.17) or overweight or obese (risk ratio, 2.32; 95% confidence interval, 1.82-2.97). When the sample was restricted to those with a real-time polymerase chain reaction test or an antigen test in the week before delivery or during the entire pregnancy, including missing variables using imputation or controlling for month of enrollment, the observed associations were comparable. CONCLUSION: Diabetes mellitus and overweight or obesity were risk factors for COVID-19 diagnosis in pregnancy, and insulin-dependent gestational diabetes mellitus was associated with the disease. Therefore, it is essential that women with these comorbidities are vaccinated.

Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study.

BACKGROUND: It is unclear whether the suggested link between COVID-19 during pregnancy and preeclampsia is an independent association or if these are caused by common risk factors. OBJECTIVE: This study aimed to quantify any independent association between COVID-19 during pregnancy and preeclampsia and to determine the effect of these variables on maternal and neonatal morbidity and mortality. STUDY DESIGN: This was a large, longitudinal, prospective, unmatched diagnosed and not-diagnosed observational study assessing the effect of COVID-19 during pregnancy on mothers and neonates. Two consecutive not-diagnosed women were concomitantly enrolled immediately after each diagnosed woman was identified, at any stage during pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed until hospital discharge using the standardized INTERGROWTH-21st protocols and electronic data management system. A total of 43 institutions in 18 countries contributed to the study sample. The independent association between the 2 entities was quantified with the risk factors known to be associated with preeclampsia analyzed in each group. The outcomes were compared among women with COVID-19 alone, preeclampsia alone, both conditions, and those without either of the 2 conditions. RESULTS: We enrolled 2184 pregnant women; of these, 725 (33.2%) were enrolled in the COVID-19 diagnosed and 1459 (66.8%) in the COVID-19 not-diagnosed groups. Of these women, 123 had preeclampsia of which 59 of 725 (8.1%) were in the COVID-19 diagnosed group and 64 of 1459 (4.4%) were in the not-diagnosed group (risk ratio, 1.86; 95% confidence interval, 1.32-2.61). After adjustment for sociodemographic factors and conditions associated with both COVID-19 and preeclampsia, the risk ratio for preeclampsia remained significant among all women (risk ratio, 1.77; 95% confidence interval, 1.25-2.52) and nulliparous women specifically (risk ratio, 1.89; 95% confidence interval, 1.17-3.05). There was a trend but no statistical significance among parous women (risk ratio, 1.64; 95% confidence interval, 0.99-2.73). The risk ratio for preterm birth for all women diagnosed with COVID-19 and preeclampsia was 4.05 (95% confidence interval, 2.99-5.49) and 6.26 (95% confidence interval, 4.35-9.00) for nulliparous women. Compared with women with neither condition diagnosed, the composite adverse perinatal outcome showed a stepwise increase in the risk ratio for COVID-19 without preeclampsia, preeclampsia without COVID-19, and COVID-19 with preeclampsia (risk ratio, 2.16; 95% confidence interval, 1.63-2.86; risk ratio, 2.53; 95% confidence interval, 1.44-4.45; and risk ratio, 2.84; 95% confidence interval, 1.67-4.82, respectively). Similar findings were found for the composite adverse maternal outcome with risk ratios of 1.76 (95% confidence interval, 1.32-2.35), 2.07 (95% confidence interval, 1.20-3.57), and 2.77 (95% confidence interval, 1.66-4.63). The association between COVID-19 and gestational hypertension and the direction of the effects on preterm birth and adverse perinatal and maternal outcomes, were similar to preeclampsia, but confined to nulliparous women with lower risk ratios. CONCLUSION: COVID-19 during pregnancy is strongly associated with preeclampsia, especially among nulliparous women. This association is independent of any risk factors and preexisting conditions. COVID-19 severity does not seem to be a factor in this association. Both conditions are associated independently of and in an additive fashion with preterm birth, severe perinatal morbidity and mortality, and adverse maternal outcomes. Women with preeclampsia should be considered a particularly vulnerable group with regard to the risks posed by COVID-19.

Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study.

Importance: Detailed information about the association of COVID-19 with outcomes in pregnant individuals compared with not-infected pregnant individuals is much needed. Objective: To evaluate the risks associated with COVID-19 in pregnancy on maternal and neonatal outcomes compared with not-infected, concomitant pregnant individuals. Design, Setting, and Participants: In this cohort study that took place from March to October 2020, involving 43 institutions in 18 countries, 2 unmatched, consecutive, not-infected women were concomitantly enrolled immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed up until hospital discharge. Exposures: COVID-19 in pregnancy determined by laboratory confirmation of COVID-19 and/or radiological pulmonary findings or 2 or more predefined COVID-19 symptoms. Main Outcomes and Measures: The primary outcome measures were indices of (maternal and severe neonatal/perinatal) morbidity and mortality; the individual components of these indices were secondary outcomes. Models for these outcomes were adjusted for country, month entering study, maternal age, and history of morbidity. Results: A total of 706 pregnant women with COVID-19 diagnosis and 1424 pregnant women without COVID-19 diagnosis were enrolled, all with broadly similar demographic characteristics (mean [SD] age, 30.2 [6.1] years). Overweight early in pregnancy occurred in 323 women (48.6%) with COVID-19 diagnosis and 554 women (40.2%) without. Women with COVID-19 diagnosis were at higher risk for preeclampsia/eclampsia (relative risk [RR], 1.76; 95% CI, 1.27-2.43), severe infections (RR, 3.38; 95% CI, 1.63-7.01), intensive care unit admission (RR, 5.04; 95% CI, 3.13-8.10), maternal mortality (RR, 22.3; 95% CI, 2.88-172), preterm birth (RR, 1.59; 95% CI, 1.30-1.94), medically indicated preterm birth (RR, 1.97; 95% CI, 1.56-2.51), severe neonatal morbidity index (RR, 2.66; 95% CI, 1.69-4.18), and severe perinatal morbidity and mortality index (RR, 2.14; 95% CI, 1.66-2.75). Fever and shortness of breath for any duration was associated with increased risk of severe maternal complications (RR, 2.56; 95% CI, 1.92-3.40) and neonatal complications (RR, 4.97; 95% CI, 2.11-11.69). Asymptomatic women with COVID-19 diagnosis remained at higher risk only for maternal morbidity (RR, 1.24; 95% CI, 1.00-1.54) and preeclampsia (RR, 1.63; 95% CI, 1.01-2.63). Among women who tested positive (98.1% by real-time polymerase chain reaction), 54 (13%) of their neonates tested positive. Cesarean delivery (RR, 2.15; 95% CI, 1.18-3.91) but not breastfeeding (RR, 1.10; 95% CI, 0.66-1.85) was associated with increased risk for neonatal test positivity. Conclusions and Relevance: In this multinational cohort study, COVID-19 in pregnancy was associated with consistent and substantial increases in severe maternal morbidity and mortality and neonatal complications when pregnant women with and without COVID-19 diagnosis were compared. The findings should alert pregnant individuals and clinicians to implement strictly all the recommended COVID-19 preventive measures.

Datos en tiempos de pandemia: la urgencia de un nuevo pacto. Reflexiones desde América Latina y el Caribe / Data in times of pandemic: The urgency of a new covenant. Reflections from Latin America and the Caribbean / Dades en temps de pandemia: la urgencia d'un nou pacte. Reflexions des d'Amèrica Llatina I Carib

Los avances de las Tecnologías de la Información y la Comunicación (TIC) permiten acceder en tiempo real a una cantidad ingente de datos, a través de los cuales es posible conocer el comportamiento de hechos sociales. En este escenario, la actual pandemia por SARS-CoV-2 ha permitido, bajo cuestionables criterios de inmediatez y urgencia, circular información que genera realidad e impacta en la toma de decisiones; y, además, ha favorecido la apropiación del dato, exponiendo a las personas a violaciones de sus derechos fundamentales. Ambos asuntos son sensibles para América Latina y el Caribe, región que hoy se presenta no sólo como el epicentro de la pandemia sino también de las desigualdades. La contribución que desde la reflexión y deliberación bioética puede realizarse en esta materia, adquiere especial relevancia con vistas a generar un nuevo pacto para el tratamiento de los datos

Advances in Information and Communication Technologies (ICT) provide real-time access to a vast amount of data, through which it is possible to know the behavior of social facts. In this scenario, the current SARS-CoV-2 pandemic has allowed, under questionable criteria of immediacy and urgency, to circulate information that generates reality and impacts on decision-making; and has also favored the appropriation of the data, exposing people to violations of their fundamental rights. Both issues are sensitive to Latin America and the Caribbean, a region that today is presented itself not only as the epicenter of the pandemic but also of inequalities. The contribution that bioethical reflection and deliberation can make in this matter, acquires special relevance with a view to generating a new covenant for the treatment of data

Els avenços de les Tecnologies de la Informació I la Comunicació (TIC) permeten accedir en temps real a una quantitat ingent de dades, a través dels quals és possible conèixer el comportament de fets socials. En aquest escenari, l'actual pandèmia per SARS-CoV-2 ha permès, sota qüestionables criteris d'immediatesa I urgència, circular informació que genera realitat I impacta en la presa de decisions; i, a més, ha afavorit l'apropiació de la dada, exposant a les persones a violacions dels seus drets fonamentals. Tots dos assumptes són sensibles per a Amèrica Llatina I el Carib, regió que avui es presenta no només com l'epicentre de la pandèmia sinó també de les desigualtats. La contribució que des de la reflexió I deliberació bioètica pot realitzarse en aquesta matèria, adquireix especial rellevància amb vistes a generar un nou pacte per al tractament de les dades

Percepción de los alumnos de quinto año de medicina sobre algunas de sus competencias clínicas / Fifth year medical students perception about their clinical competences

Introducción. Un grupo de docentes del Departamentode Pediatría de la Facultad de Medicina,dependiente de la Universidad de Buenos Airesefectuó una investigación de tipo descriptivo entrelos alumnos de quinto año que cursan esta asignatura,ya próximos al final de su carrera.El objetivo fue conocer, mediante una encuesta, laspercepciones de los alumnos acerca de sus competenciasy habilidades clínicas para realizar un examenfísico y ciertos procedimientos para determinarel estado de salud de un paciente.Población, material y métodos. Se definieron 71maniobras y 30 procedimientos clínicos básicosque se realizan con finalidad exploratoria,diagnóstica o terapéutica y se propuso a los 80alumnos que en marzo de 2003 ingresaban acursar Pediatría en las Unidades docentes delárea Norte del Departamento, responder en formaanónima si se sentían capaces de efectuarlase interpretar los hallazgos.Resultados. Expresados en porcentaje de respuestasafirmativas, los resultados oscilaron entre el 100 por ciento en la exploración de adenopatías axilares y el 18,75 por ciento en el reconocimiento de un opistótonos. En la competencia para realizar procedimientos básicos losresultados oscilaron entre el 86,25 por ciento para la toma de los pulsos periféricos y la tensión arterial y el 6,25 por ciento para la prescripción de una indicación terapéutica.Conclusiones: El trabajo muestra que en la percepciónde los estudiantes sometidos a la encuestaexisten graves deficiencias en sus competencias clínicaspara realizar un examen físico y determinar elestado de salud de un paciente

Percepción de los alumnos de quinto año de medicina sobre algunas de sus competencias clínicas / Fifth year medical students perception about their clinical competences

Introducción. Un grupo de docentes del Departamentode Pediatría de la Facultad de Medicina,dependiente de la Universidad de Buenos Airesefectuó una investigación de tipo descriptivo entrelos alumnos de quinto año que cursan esta asignatura,ya próximos al final de su carrera.El objetivo fue conocer, mediante una encuesta, laspercepciones de los alumnos acerca de sus competenciasy habilidades clínicas para realizar un examenfísico y ciertos procedimientos para determinarel estado de salud de un paciente.Población, material y métodos. Se definieron 71maniobras y 30 procedimientos clínicos básicosque se realizan con finalidad exploratoria,diagnóstica o terapéutica y se propuso a los 80alumnos que en marzo de 2003 ingresaban acursar Pediatría en las Unidades docentes delárea Norte del Departamento, responder en formaanónima si se sentían capaces de efectuarlase interpretar los hallazgos.Resultados. Expresados en porcentaje de respuestasafirmativas, los resultados oscilaron entre el 100 por ciento en la exploración de adenopatías axilares y el 18,75 por ciento en el reconocimiento de un opistótonos. En la competencia para realizar procedimientos básicos losresultados oscilaron entre el 86,25 por ciento para la toma de los pulsos periféricos y la tensión arterial y el 6,25 por ciento para la prescripción de una indicación terapéutica.Conclusiones: El trabajo muestra que en la percepciónde los estudiantes sometidos a la encuestaexisten graves deficiencias en sus competencias clínicaspara realizar un examen físico y determinar elestado de salud de un paciente(AU)