Decision-making for congenital anomalies diagnosed during pregnancy: a narrative review.

PURPOSE: The purpose of this narrative review was to assess the limited literature on fetal anomalies diagnosed in the second trimester of pregnancy and parental decision-making and identify sources of information deemed as facilitators and barriers to medical decisions. METHODS: This was a literature review of source material and information about fetal anomalies diagnosed in the second trimester of pregnancy, decision-making, decision tools or aids, and sources of information for anomalies. The search string used explored related peer-reviewed publications and systematic reviews between 2007 and 2024. We also reviewed references from publications meeting inclusion criteria. The search was conducted between June 2022 and February 2024. Exclusion criteria included conference abstracts, non-peer reviewed literature, and articles not available in English language. A total of 77 publications were identified by searching multiple databases using a predefined search string. The search encompassed full text articles from 2007 to 2024 and 11 full-text publications were ultimately included in the review. A list of 45 co-occurring keywords was generated from the included texts, with each keyword having a minimum of two co-occurrences. RESULTS: Key themes identified included (1) the role of the clinician and need for development of professional knowledge and empathy surrounding discussion of fetal anomalies with patients; (2) information gathering, with individuals reporting use of multiple strategies to obtain information; while the majority found information satisfying, they preferred more details on diagnosis, long-term outcomes of the fetus/child and management of the pregnancy or termination process; and (3) decision-making, the path and process of how individuals made decisions about the pregnancy including quality of life, future fertility, and seeking other people's experiences. CONCLUSION: Many factors contribute to an individual's decision-making after a diagnosis of a fetal anomalies diagnosed in the second trimester of pregnancy, ranging from personal beliefs and goals to shared experiences of others and access to care. Understanding how sources of information may be deemed both as facilitators and barriers to different individuals during the decision-making process is important for healthcare providers in order to understand how to most effectively support patients. There is a dearth of information on training healthcare professionals to provide support to patients facing these decisions.

Association between Peripartum Mean Arterial Pressure and Postpartum Readmission for Preeclampsia with Severe Features.

OBJECTIVE: This study aimed to evaluate the relationship between peripartum mean arterial pressure (MAP) and postpartum readmission for preeclampsia with severe features. STUDY DESIGN: This is a retrospective case-control study comparing adult parturients readmitted for preeclampsia with severe features to matched nonreadmitted controls. Our primary objective was to evaluate the association between MAP at three time points during the index hospitalization (admission, 24-hour postpartum, and discharge) and readmission risk. We also evaluated readmission risk by age, race, body mass index, and comorbidities. Our secondary aim was to establish MAP thresholds to identify the population at highest risk of readmission. Multivariate logistic regression and chi-squared tests were used to determine the adjusted odds of readmission based on MAP. Receiver operating characteristic analyses were performed to evaluate risk of readmission relative to MAP; optimal MAP thresholds were established to identify those at highest risk of readmission. Pairwise comparisons were made between subgroups after stratifying for history of hypertension, with a focus on readmitted patients with new-onset postpartum preeclampsia. RESULTS: A total of 348 subjects met inclusion criteria, including 174 controls and 174 cases. We found that elevated MAP at both admission (adjusted odds ratio [OR]: 1.37 per 10 mm Hg, p < 0.0001) and 24-hour postpartum (adjusted OR: 1.61 per 10 mm Hg, p = 0.0018) were associated with increased risk of readmission. African American race and hypertensive disorder of pregnancy were independently associated with increased risk of readmission. Subjects with MAP > 99.5 mm Hg at admission or >91.5 mm Hg at 24-hour postpartum had a risk of at least 46% of requiring postpartum readmission for preeclampsia with severe features. CONCLUSION: Admission and 24-hour postpartum MAP correlate with risk of postpartum readmission for preeclampsia with severe features. Evaluating MAP at these time points may be useful for identifying women at higher risk for postpartum readmission. These women may otherwise be missed based on standard clinical approaches and may benefit from heightened surveillance. KEY POINTS: · Existing literature focuses on management of antenatal hypertensive disorders of pregnancy.. · Elevated peripartum MAP is associated with increased odds of readmission for preeclampsia.. · Peripartum MAP may predict readmission risk for de novo postpartum preeclampsia..

Acceptance of Routine Vaccines in Pregnancy during the COVID-19 Pandemic.

OBJECTIVE: This study aimed to evaluate the rates of vaccination against infectious diseases (Tetanus, Diphtheria, and Pertussis [Tdap] and influenza) in pregnancy during the coronavirus disease 2019 (COVID-19) pandemic compared to contemporary historical controls. STUDY DESIGN: This was a retrospective cohort study comparing rates of Tdap and influenza vaccination in pregnant people who received care at NYU Langone Health and delivered from September 1, 2020, to January 31, 2021 ("COVID cohort") to the same period the prior year ("2019 cohort"). Demographic information, trimester of initiation of prenatal care, insurance status, and medical comorbidities were evaluated. Outcomes were analyzed using chi-square, Fisher's exact test, and multivariable logistic regression, with significance of p < 0.05. RESULTS: In total, 1,713 pregnant people were included. Compared to historical controls, the COVID cohort differed in age, race, timing of initiation of prenatal care, insurance status, and medical comorbidities. After adjusting for these covariates, pregnant people were significantly more likely to accept influenza vaccine in the COVID cohort (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.27-2.29) and had similar Tdap acceptance (aOR 1.5, 95% CI 0.99-2.17). However, this trend was not observed for the entire obstetric population; public insurance status and medical comorbidities were associated with lower vaccine rates during the pandemic. For those who had public insurance, rates of influenza vaccination decreased from 83% in 2019 to 40% during COVID (aOR 0.16, 95% CI 0.10-0.24) and for Tdap rates decreased from 93 to 54% (aOR 0.13, 95% CI 0.08-0.21). CONCLUSION: During the COVID-19 pandemic era, pregnant people at large were more likely to accept the influenza vaccine. However, this trend did not apply to Tdap, and high-risk groups with public insurance and medical comorbidities. This study highlights potential disparities in vaccination rates, which need to be accounted for when evaluating national vaccine trends. These data support increased efforts in vaccine counseling for high-risk populations. KEY POINTS: · Antenatal flu vaccination increased during the pandemic.. · Antenatal Tdap vaccination was unchanged during the pandemic.. · High-risk pregnant patients had decreased vaccine uptake.. · High-risk subgroups were not included in overarching vaccination trends..

Comparing outcomes of fetal growth restriction defined by estimated fetal weight versus isolated abdominal circumference.

PURPOSE: The objective of this study was to compare maternal and neonatal outcomes when the diagnosis of FGR was based on isolated abdominal circumference < 10th percentile for gestational age (GA) (iAC group) versus overall estimated fetal weight < 10th percentile (EFW group). METHODS: This was a retrospective cohort study of singleton gestations who underwent growth ultrasounds and delivered at a single health system from 1/1/19-9/4/20. The study group was comprised of patients with AC < 10th percentile and EFW ≥ than the 10th percentile (iAC group). The control group included patients with overall EFW < 10th percentile (EFW group). Outcomes evaluated included GA at delivery, mode of delivery, fetal and neonatal outcomes. Data was analyzed using Mann Whitney U, X2, and Fisher exact tests with significance defined as p < 0.05. RESULTS: 635 women met the inclusion criteria, 259 women in the iAC group and 376 women in the EFW group. The iAC group was noted to have a later GA at diagnosis and delivery. iAC was associated with lower rates of preterm birth (PTB), NICU admission, SGA at delivery and umbilical artery cord gas < 7.0. CONCLUSION: Using iAC as a definition of FGR increased the number of FGR cases by 1.69-fold over EFW criteria alone. However, obstetrical and neonatal outcomes for the iAC group appear to be significantly better than those in the EFW group, with low rates of PTB, NICU admission, and umbilical artery cord gas < 7.0.

Pregnant women with severe or critical coronavirus disease 2019 have increased composite morbidity compared with nonpregnant matched controls.

BACKGROUND: In March 2020, as community spread of severe acute respiratory syndrome coronavirus 2 became increasingly prevalent, pregnant women seemed to be equally susceptible to developing coronavirus disease 2019. Although the disease course usually appears mild, severe and critical cases of coronavirus disease 2019 seem to lead to substantial morbidity, including intensive care unit admission with prolonged hospital stay, intubation, mechanical ventilation, and even death. Although there are recent reports regarding the impact of coronavirus disease 2019 on pregnancy, there is a lack of information regarding the severity of coronavirus disease 2019 in pregnant vs nonpregnant women. OBJECTIVE: We aimed to describe the outcomes of severe and critical cases of coronavirus disease 2019 in pregnant vs nonpregnant, reproductive-aged women. STUDY DESIGN: This is a multicenter, retrospective, case-control study of women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection hospitalized with severe or critical coronavirus disease 2019 in 4 academic medical centers in New York City and 1 in Philadelphia between March 12, 2020, and May 5, 2020. The cases consisted of pregnant women admitted specifically for severe or critical coronavirus disease 2019 and not for obstetrical indications. The controls consisted of reproductive-aged, nonpregnant women admitted for severe or critical coronavirus disease 2019. The primary outcome was a composite morbidity that includes the following: death, a need for intubation, extracorporeal membrane oxygenation, noninvasive positive pressure ventilation, or a need for high-flow nasal cannula O2 supplementation. The secondary outcomes included intensive care unit admission, length of stay, a need for discharge to long-term acute care facilities, and discharge with a home O2 requirement. RESULTS: A total of 38 pregnant women with severe acute respiratory syndrome coronavirus 2 polymerase chain reaction-confirmed infections were admitted to 5 institutions specifically for coronavirus disease 2019, 29 (76.3%) meeting the criteria for severe disease status and 9 (23.7%) meeting the criteria for critical disease status. The mean age and body mass index were markedly higher in the nonpregnant control group. The nonpregnant cohort also had an increased frequency of preexisting medical comorbidities, including diabetes, hypertension, and coronary artery disease. The pregnant women were more likely to experience the primary outcome when compared with the nonpregnant control group (34.2% vs 14.9%; P=.03; adjusted odds ratio, 4.6; 95% confidence interval, 1.2-18.2). The pregnant patients experienced higher rates of intensive care unit admission (39.5% vs 17.0%; P<.01; adjusted odds ratio, 5.2; 95% confidence interval, 1.5-17.5). Among the pregnant women who underwent delivery, 72.7% occurred through cesarean delivery and the mean gestational age at delivery was 33.8±5.5 weeks in patients with severe disease status and 35±3.5 weeks in patients with critical coronavirus disease 2019 status. CONCLUSION: Pregnant women with severe and critical coronavirus disease 2019 are at an increased risk for certain morbidities when compared with nonpregnant controls. Despite the higher comorbidities of diabetes and hypertension in the nonpregnant controls, the pregnant cases were at an increased risk for composite morbidity, intubation, mechanical ventilation, and intensive care unit admission. These findings suggest that pregnancy may be associated with a worse outcome in women with severe and critical cases of coronavirus disease 2019. Our study suggests that similar to other viral infections such as severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, pregnant women may be at risk for greater morbidity and disease severity.

Differential Uptake of Telehealth for Prenatal Care in a Large New York City Academic Obstetrical Practice during the COVID-19 Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic in New York City, telehealth was rapidly implemented for obstetric patients. Though telehealth for prenatal care is safe and effective, significant concerns exist regarding equity in access among low-income populations. We performed a retrospective cohort study evaluating utilization of telehealth for prenatal care in a large academic practice in New York City, comparing women with public and private insurance. We found that patients with public insurance were less likely to have at least one telehealth visit than women with private insurance (60.9 vs. 87.3%, p < 0.001). After stratifying by borough, this difference remained significant in Brooklyn, one of the boroughs hardest hit by the pandemic. As COVID-19 continues to spread around the country, obstetric providers must work to ensure that all patients, particularly those with public insurance, have equal access to telehealth. KEY POINTS: · Telehealth for prenatal care is frequently utilized during the COVID-19 pandemic.. · Significant concerns exist regarding equity in access among lower-income populations.. · Women with public insurance in New York City were less likely to access telehealth for prenatal care..

Disparate Rates of Cesarean Delivery in Term Nulliparous Women with Hypertensive Disorders of Pregnancy.

OBJECTIVE: To evaluate the prevalence of cesarean delivery in women with hypertensive disorders of pregnancy (HDP), and explore whether maternal, sociodemographic, or obstetric comorbidities contribute to cesarean delivery rates. STUDY DESIGN: This is a retrospective cohort study of nulliparous, term, singleton, vertex women using the 2013 U.S. National Vital Statistics Report. We compared prevalence of risk factors for cesarean delivery between women with and without HDP, and then calculated probabilities of cesarean delivery after controlling for these risk factors. RESULTS: In this cohort of 1,439,977 women, the unadjusted probability of cesarean delivery in women with HDP was 39.5 versus 26.8% in those without the diagnosis (p < 0.01). Hypertensive women had more risk factors for cesarean delivery, most notably morbid obesity (9.0 vs. 3.1%, p < 0.01), diabetes (9.9 vs. 4.4%, p < 0.01), and induction of labor (59.2 vs. 26.9%, p < 0.01). Despite this, after controlling for these risk factors, hypertensive women remained significantly more likely to undergo cesarean delivery (35.1 vs. 26.4%, p < 0.01). CONCLUSION: Even after controlling for multiple comorbidities, hypertension remained a significant risk factor for cesarean delivery in nulliparous women at term. Hypertensive women may therefore represent an important target population in efforts aimed at reduction of cesarean rates.

Adolescent Pregnancies in the United States: How Obstetric and Sociodemographic Factors Influence Risk of Cesarean Delivery.

Objective To determine how an adolescent's risk of cesarean varies by maternal age and race/ethnicity, and evaluate the contribution of obstetric and sociodemographic factors to mode of delivery. Study Design This is a retrospective cohort study of 604,287 births to women aged 13 to 23 years. Regression techniques were used to determine maternal ages at lowest risk of primary cesarean in each major racial/ethnic group before and after adjustment for various cesarean risk factors. Results Adolescent age was associated with lower risk of cesarean compared with young adults (17.2% at age 13 years vs 24.8% at age 23 years, p < 0.05). After stratification by race/ethnicity, Non-Hispanic Black women had the highest probability of cesarean, while Asian/Pacific Islanders had the lowest probability across all ages. When compared with young adults of the same race/ethnicity, young adolescents continued to have a lower risk of cesarean, decreased by at least 30% until age 18 years (White) and 17 years (other racial/ethnic groups). These associations persisted after adjustment for obstetric and sociodemographic risk factors. Conclusion Young maternal age is protective against cesarean delivery in all racial/ethnic groups. Adolescents also experience racial/ethnic disparities in mode of delivery similar to those observed in adults, which were unexplained by either obstetric or sociodemographic factors.

Easy as ABC: A System to Stratify Category II Fetal Heart Rate Tracings.

Objective To evaluate whether a subcategory system for category II tracings can improve team communication and perinatal outcomes. Study Design We collected data prospectively for 15 months, first using the NICHD system, followed by the ABC system, which divides category II tracings into subcategories A, B, and C, each representing increased risk for metabolic acidemia. We surveyed providers about communication effectiveness and agreement on tracing interpretation for each system. In cases where the communication system was used to alert an off-site physician about a category II tracing, we compared arrival to L&D and NICU admissions. Results The ABC system was preferred (69%, n = 152) and considered a more effective tool for communicating concerning fetal status (80% vs. 43%, p < 0.01). Participants also reported greater agreement on tracing interpretation (79% for ABC vs. 64% for NICHD, p = 0.046). When an off-site physician was contacted about a category II tracing (n = 95), they were more likely to arrive to L&D (44% vs. 20%, p < 0.01) and have fewer NICU admissions (0% vs. 6%, p < 0.01) with the ABC system. Conclusion The ABC system resulted in improved team communication, increased physician response, and decreased NICU admissions. Using standardized communication may offer a useful strategy for identifying and expediting care.

Respiratory distress syndrome is associated with increased morbidity and mortality in late preterm births.

BACKGROUND: Respiratory distress syndrome is strongly associated with prematurity, including late preterm births. Respiratory distress syndrome has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births. OBJECTIVE: We sought to determine the association between respiratory distress syndrome and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates. STUDY DESIGN: This is a retrospective cohort study using California's linked vital statistics and patient discharge data (2008-2019). We included singleton, nonanomalous births with a gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal sepsis, length of hospital stay, neonatal death, and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of respiratory distress syndrome with outcomes at each gestational age. Adjusted risk ratio and 95% confidence interval values were estimated. RESULTS: A total of 242,827 births were included, of which 11,312 (4.7%) had respiratory distress syndrome. We found that among neonates with respiratory distress syndrome, necrotizing enterocolitis was higher at 35 weeks (adjusted risk ratio, 3.97 [95% confidence interval, 1.88-8.41]) and 36 weeks (adjusted risk ratio, 4.53 [95% confidence interval, 1.45-14.13]). Intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, and length of hospital stay were significantly higher at 34-36 weeks of gestation in neonates with respiratory distress syndrome. Neonatal death was significantly higher among neonates with respiratory distress syndrome at 35 weeks (adjusted risk ratio, 3.04 [95% confidence interval, 1.58-5.85]) and 36 weeks (adjusted risk ratio, 3.25; 95% confidence interval, 1.59-6.68). In addition, infant death was significantly higher at 35 weeks (adjusted risk ratio, 2.27 [95% confidence interval, 1.43-3.61]) and 36 weeks (adjusted risk ratio, 2.60 [95% confidence interval, 1.58-4.28]). CONCLUSION: We found that respiratory distress syndrome was associated with intraventricular hemorrhage, retinopathy of prematurity, and sepsis at 34-36 weeks of gestation, whereas respiratory distress syndrome was associated with neonatal death, infant death, and necrotizing enterocolitis at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing, the potential benefits of antenatal steroids in pregnancies in the late preterm period, and the management of respiratory distress syndrome in late preterm neonates.

A Pregnant Adolescent with COVID-19 and Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children (MIS-C), a new condition related to coronavirus disease 2019 (COVID-19) in the pediatric population, was recognized by physicians in the United Kingdom in April 2020. Given those up to the age of 21 years can be affected, pregnant adolescents and young adults are susceptible. However, there is scant information on how MIS-C may affect pregnancy and whether the presentation differs in the pregnant population. We report a case of a pregnant adolescent with COVID-19 and MIS-C with a favorable outcome. This case highlights the considerations in managing a critically ill pregnant patient with a novel illness and the importance of a multidisciplinary team in coordinating care.

A Case of Vein of Galen Aneurysmal Malformation Diagnosed Prenatally in a Monochorionic-Diamniotic Twin Pregnancy.

We present a case of a vein of Galen aneurysmal malformation (VGAM), a rare congenital arteriovenous malformation, in one fetus of a monochorionic-diamniotic twin pregnancy. The diagnosis was made with color Doppler ultrasonography at 28 weeks and the affected fetus was found to have worsening cardiomegaly on subsequent fetal echocardiograms. She was emergently delivered at 32 weeks for abnormal fetal heart rate tracing of the affected twin. Magnetic resonance imaging of the brain findings after delivery demonstrated severe neurological injury; therefore, postnatal embolization was not performed. The neonate died on day of life 9. The cotwin survived without neurological complications. This is the first case in the literature of a VGAM diagnosed prenatally in a monochorionic-diamniotic twin pregnancy and demonstrates the challenge of delivery timing with prenatal diagnosis in a twin pregnancy.

Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum.

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

Postpartum readmissions for hypertensive disorders in pregnancy during the COVID-19 pandemic.

BACKGROUND: Hypertensive disorders in pregnancy are one of the most common causes of readmission in the postpartum period. Because of the COVID-19 pandemic, early hospital discharge was encouraged for patients who were medically stable, because hospitalization rates among SARS-CoV-2-infected patients steadily increased in 2020. The impact of an early discharge policy on postpartum readmission rates among patients with hypertensive disorders in pregnancy is unknown. OBJECTIVE: This study aimed to compare the postpartum readmission rates of patients with hypertensive disorders in pregnancy before and after implementation of an early discharge policy owing to the COVID-19 pandemic. STUDY DESIGN: This was a quality improvement, retrospective cohort study of postpartum patients with antenatal hypertensive disorders in pregnancy who delivered and were readmitted because of hypertensive disorders in pregnancy at the New York University Langone Health medical center from March 1, 2019 to February 29, 2020 (control cohort) and from April 1, 2020 to March 31, 2021 (COVID-19 cohort). During the pandemic, our institution introduced an early discharge policy for all postpartum patients to be discharged no later than 2 days postpartum during the delivery admission if deemed medically appropriate. The reduction in postpartum length of stay was accompanied by the continuation of patient education, home blood pressure monitoring, and outpatient follow-up. The primary outcome was the comparison of the readmission rates for patients with postpartum hypertensive disorders in pregnancy. Data were analyzed using Fisher's Exact tests, chi-square tests, and Wilcoxon rank-sum tests with significance defined as P<.05. RESULTS: There was no statistical difference in the readmission rates for patients with postpartum hypertensive disorders in pregnancy before vs after implementation of an early discharge policy (1.08% for the control cohort vs 0.59% for the COVID-19 cohort). The demographics in each group were similar, as were the median times to readmission (5.0 days; interquartile range, 4.0-6.0 days vs 6.0 days; interquartile range, 5.0-6.0 days; P=.13) and the median readmission length of stay (3.0 days; interquartile range, 2.0-4.0 days vs 3.0 days; interquartile range, 2.0-4.0 days; P=.45). There was 1 intensive care unit readmission in the COVID-19 cohort and none in the control cohort (P=.35). There were no severe maternal morbidities or maternal deaths. CONCLUSION: These findings suggest that policies calling for a reduced postpartum length of stay, which includes patients with hypertensive disorders in pregnancy, can be implemented without impacting the hospital readmission rate for patients with hypertensive disorders in pregnancy. Continuation of patient education and outpatient surveillance during the pandemic was instrumental for the outpatient postpartum management of the study cohort. Further investigation into best practices to support early discharges is warranted.

Association of SARS-CoV-2 placental histopathology findings with maternal-fetal comorbidities and severity of COVID-19 hypoxia.

OBJECTIVE: SARS-CoV-2 is known to impact multiple organ systems, with growing data to suggest the potential for placental infection and resultant pathology. Understanding how maternal COVID-19 disease can affect placental histopathology has been limited by small study cohorts with mild disease, review by multiple pathologists, and potential confounding by maternal-fetal comorbidities that can also influence placental findings. This study aims to identify pathologic placental findings associated with COVID-19 disease and severity, as well as to distinguish them from changes related to coexisting maternal-fetal comorbidities. METHODS: This is an observational study of 61 pregnant women with confirmed SARS-CoV-2 infection who delivered and had a placental histological evaluation at NYU Langone Health between March 19, 2020 and June 30, 2020. Primary outcomes were the prevalence of placental histopathologic features and their association with maternal-fetal comorbidities and severity of COVID-19 related hypoxia. Analysis was performed using Fisher's exact test and t-test with p < 0.05 considered significant. RESULTS: Sixty-one placentas were included in the study cohort, 71% from pregnancies complicated by at least one maternal-fetal comorbidity. Twenty-five percent of placentas were small for gestational age and 77% exhibited at least one feature of maternal vascular malperfusion. None of the histopathologic features in the examined placentas were associated with the presence of any specific maternal-fetal comorbidity. Thirteen percent of the cohort required maternal respiratory support for COVID-19 related hypoxia. Villous trophoblast necrosis was associated with maternal supplemental oxygen requirement (67 vs. 33%, p = 0.04) and intubation (67 vs. 33%, p = 0.01). CONCLUSION: In pregnancies complicated by COVID-19 disease, there was a high prevalence of placental histopathologic changes identified, particularly features of maternal vascular malperfusion, which could not be attributed solely to the presence of maternal-fetal comorbidities. The significantly increased prevalence of villous trophoblast necrosis in women needing respiratory support suggests a connection to the severity of COVID-19 illness.

Predictors of severe and critical disease in pregnant women with SARS-CoV-2.

BACKGROUND/OBJECTIVE: SARS-CoV-2 continues to spread widely in the US and worldwide. Pregnant women are more likely to develop severe or critical illness than their non-pregnant counterparts. Known risk factors for severe and critical disease outside of pregnancy, such as asthma, diabetes, and obesity have not been well-studied in pregnancy. We aimed to determine which clinical and pregnancy-related factors were associated with severe and critical COVID illness in pregnancy. STUDY DESIGN: This was a retrospective cohort study of women with confirmed intrauterine pregnancy and positive nasopharyngeal swab for SARS-CoV-2 who presented to an academic medical center in New York City from 1 March 2020 to 1 July 2020. Severe and critical COVID-19 disease was defined by World Health Organization criteria. Women with severe/critical disease were compared to women with asymptomatic/mild disease. Continuous variables were compared with Mann-Whitney or t-test and categorical variables were compared using chi-square and Fisher's exact. Statistical significance was set at p < .05. Multivariable logistic regression was performed including variables that were significantly different between groups. RESULTS: Two hundred and thirty-three patients were included, 186 (79.8%) with asymptomatic/mild disease and 47 (20.2%) with severe/critical disease. Women with asymptomatic/mild disease were compared to those with severe/critical disease. Women with severe/critical disease were more likely to have a history of current or former smoking (19.6 vs. 5.4%, p = .004), COVID-19 diagnosis in the 2nd trimester (42.6 vs. 11.8%, p = .001), and asthma or other respiratory condition (21.3 vs. 7.0%, p = .01). Women with severe/critical disease were more likely to have cesarean delivery (35.5 vs. 15.6%, p < .01) and preterm delivery <37 weeks (25.8 vs. 3.8%, p < .01). After adjustment, history of smoking remained significantly predictive of severe/critical disease [aOR 3.84 (95% CI, 1.25-11.82)]. CONCLUSION: Pregnant women with a history of smoking, asthma, or other respiratory condition, and COVID-19 diagnosis in the second trimester of pregnancy were more likely to develop severe/critical disease. These findings may be useful in counseling women on their individual risk of developing the severe or critical disease in pregnancy and may help determine which women are good candidates for vaccination during pregnancy.

COVID-19 vaccination in pregnancy: early experience from a single institution.

OBJECTIVE: Pregnant women are at increased risk for morbidity owing to infection with the COVID-19 virus.1 Vaccination presents an important strategy to mitigate illness in this population. However, there is a paucity of data on vaccination safety and pregnancy outcomes because pregnant women were excluded from the initial phase III clinical trials. Our objective was to describe the maternal, neonatal, and obstetrical outcomes of women who received a messenger RNA (mRNA) COVID-19 vaccination while pregnant during the first 4 months of vaccine availability. STUDY DESIGN: This was an institutional review board-approved descriptive study of pregnant women at New York University Langone Health who received at least 1 dose of an mRNA COVID-19 vaccination approved by the US Food and Drug Administration (FDA) (Pfizer-BioNTech or Moderna) from the time of the FDA Emergency Use Authorization to April 22, 2021. Eligible women were identified via search of the electronic medical record (EMR) system. Vaccine administration was ascertained via immunization records from the New York State Department of Health. Women were excluded if they were vaccinated before conception or during the postpartum period. Charts were reviewed for maternal demographics and pregnancy outcomes. Descriptive analyses were performed using the R software version 4.0.2 (The R Foundation, Boston, MA). RESULTS: We identified 424 pregnant women who received an mRNA vaccination. Of those, 348 (82.1%) received both doses and 76 (17.9%) received only 1 dose. The maternal characteristics and vaccination information are shown in Table 1. Of the included women, 4.9% had a history of a confirmed COVID-19 diagnosis before vaccination. After vaccination, no patient in our cohort was diagnosed with COVID-19. In terms of the pregnancy outcomes, 9 women had spontaneous abortions, 3 terminated their pregnancies, and 327 have ongoing pregnancies. Of the women included, 85 delivered liveborn infants. There were no stillbirths in our population. Of the 9 spontaneous abortions, 8 occurred during the first trimester at a range of 6 to 13 weeks' gestation. There was 1 second trimester loss. The rate of spontaneous abortion among women vaccinated in the first trimester was 6.5%. The 327 women with ongoing pregnancies have been followed for a median of 4.6 weeks (range, 0-17 weeks) following their most recent dose. A total of 113 (34.6%) women, initiated vaccination during the first trimester, 178 (54.4%) initiated vaccination during the second trimester, and 36 (11.0%) during the third trimester. Following the vaccination, 2 fetuses (0.6%) developed intrauterine growth restriction, whereas 5 (1.5%) were diagnosed with anomalies. Outcomes for the 85 women who delivered are shown in Table 2. Of the women who delivered, 18.8% were diagnosed with a hypertensive disorder of pregnancy. The rate of preterm birth was 5.9%. One preterm delivery was medically indicated, whereas the remaining 3 were spontaneous. A total of 15.3% of neonates required admission to the neonatal intensive care unit (NICU). Of the NICU admissions, 61.5% were because of hypoglycemia or an evaluation for sepsis. Other reasons for admission included prematurity, hypothermia, and transient tachypnea of the newborn. Of all the neonates, 12.2% were small for gestational age (SGA) per the World Health Organization standards. CONCLUSION: This series describes our experience with women who received an mRNA COVID-19 vaccine during pregnancy. In line with other published findings,2 we observed no concerning trends. There were no stillbirths. Our 6.5% rate of spontaneous abortion is within the expected rate of 10%,3 and our preterm birth rate of 5.9% is below the national average of 9.5%.4 Our rate of pregnancy-related hypertensive disorders is higher than our baseline institutional rate of 9.5%, however, this may be because of the underlying characteristics of our study population or skewing of our small sample size. Our 12.2% rate of SGA neonates is near the expected value based on the definition that 10% of neonates will be SGA at birth. The NICU admission rate is at par with our institutional rate of 12%. To date, most women in this series have had uncomplicated pregnancies and have delivered at-term. Strengths of this study include using the EMR system to identify subjects and gather data. We did not rely on self-enrollment and self-report, thereby reducing selection and recall bias. By performing manual chart reviews, we obtained detailed and reliable information about individual patients. One limitation of this study is the lack of a matched control group consisting of unvaccinated pregnant women and therefore direct conclusions could not be drawn about the relative risks of complications. In addition, our cohort is small and may not be generalizable. Finally, many women included are healthcare workers who had early access to vaccinations. As more pregnant women become eligible for the COVID-19 vaccinations, there is an urgent need to report on the maternal, neonatal, and obstetrical outcomes of COVID-19 vaccinations during pregnancy. The results of this study can be used to counsel and reassure pregnant patients facing this decision.

Acute Respiratory Decompensation Requiring Intubation in Pregnant Women with SARS-CoV-2 (COVID-19).

There is a current paucity of information about the obstetric and perinatal outcomes of pregnant novel coronavirus disease 2019 (COVID-19) patients in North America. Data from China suggest that pregnant women with COVID-19 have favorable maternal and neonatal outcomes, with rare cases of critical illness or respiratory compromise. However, we report two cases of pregnant women diagnosed with COVID-19 in the late preterm period admitted to tertiary care hospitals in New York City for respiratory indications. After presenting with mild symptoms, both quickly developed worsening respiratory distress requiring intubation, and both delivered preterm via caesarean delivery. These cases highlight the potential for rapid respiratory decompensation in pregnant COVID-19 patients and the maternal-fetal considerations in managing these cases.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.