Placental Pathology After SARS-CoV-2 Infection in the Pre-Variant of Concern, Alpha / Gamma, Delta, or Omicron Eras.

Objectives.The goal of this study is to describe placental pathology after infection with SARS-CoV-2 before the predominance of variants of concern (pre-VOC) and during eras of predominant transmission of the Alpha & Gamma (co-circulating), Delta, and Omicron variants. Methods. We used county-level variant data to establish population-level variant proportions, SARS-CoV-2 PCR to identify cases, and IgG serology to exclude latent infections from controls and histopathologic examination to identify placental pathology. Results. We report findings in 870 placentas from pregnancies complicated by SARS-CoV-2 including 90 with infection in the Alpha/Gamma era, 60 from the Delta era and 56 from the Omicron era. Features of maternal vascular malperfusion (MVM), including decidual arteriopathy, were significantly more frequent after SARS-CoV-2 infection. The risk of these findings varied over time, with the highest rates in the Delta era. Increased COVID-19 severity and the presence of comorbidities strengthened these associations. Conclusion. MVM is a feature of SARS-CoV-2 infection in pregnancy. Lesion frequency changed with the predominant circulating virus and should be considered with new variants.

The association between the COVID-19 pandemic and postpartum care provision.

BACKGROUND: The COVID-19 pandemic led to a rapid transformation in the healthcare system to mitigate viral exposure. In the perinatal context, one change included altering the prenatal visit cadence and increasing the utilization of telehealth methods. Whether this approach had inadvertent negative implications for postpartum care, including postpartum depression screening and contraceptive utilization, is unknown. OBJECTIVE: This study aimed to examine whether preventative health service utilization, including postpartum depression screening and contraceptive utilization, differed during the COVID-19 pandemic when compared with the prepandemic period. STUDY DESIGN: This retrospective cohort study included all pregnant patients who received prenatal care at 1 of 5 academic obstetrical practices and who delivered at Northwestern Memorial Hospital either before (delivery from September 1, 2018, to January 1, 2019) or during (delivery from February 1, 2020, to May 15, 2020) the COVID-19 pandemic. Completion of postpartum depression screening was assessed by reviewing standardized fields in the documentation associated with the screening in the electronic health record system. The method of contraception used was ascertained from the postpartum clinical documentation. Patients were classified as initiating long-acting reversible contraception use if they received NEXPLANON (etonogestrel implant) or an intrauterine device during the hospitalization for delivery or within 3 months following delivery. Bivariable and multivariable analyses were performed. RESULTS: Of the 2375 pregnant patients included in this study, 1120 (47%) delivered during the COVID-19 pandemic. Pregnant patients who delivered during the COVID-19 pandemic were significantly less likely to have undergone postpartum depression screening (45.5% vs 86.2%; P<.01); this association persisted after adjusting for potential confounders (adjusted odds ratio, 0.13; 95% confidence interval, 0.11-0.16). Pregnant patients who delivered during the COVID-19 pandemic also were significantly less likely to initiate long-acting reversible contraception use within 3 months of delivery (13.5% vs 19.6%; adjusted odds ratio, 0.67; 95% confidence interval, 0.53-0.84). CONCLUSION: The onset of the COVID-19 pandemic was associated with a decrease in the completion of postpartum depression screenings and fewer patients initiating long-acting reversible contraception use overall. These results can inform adaptations in healthcare delivery in the midst of the ongoing COVID-19 pandemic.

Patterns of diverse and changing sentiments towards COVID-19 vaccines: a sentiment analysis study integrating 11 million tweets and surveillance data across over 180 countries.

OBJECTIVES: Vaccines are crucial components of pandemic responses. Over 12 billion coronavirus disease 2019 (COVID-19) vaccines were administered at the time of writing. However, public perceptions of vaccines have been complex. We integrated social media and surveillance data to unravel the evolving perceptions of COVID-19 vaccines. MATERIALS AND METHODS: Applying human-in-the-loop deep learning models, we analyzed sentiments towards COVID-19 vaccines in 11 211 672 tweets of 2 203 681 users from 2020 to 2022. The diverse sentiment patterns were juxtaposed against user demographics, public health surveillance data of over 180 countries, and worldwide event timelines. A subanalysis was performed targeting the subpopulation of pregnant people. Additional feature analyses based on user-generated content suggested possible sources of vaccine hesitancy. RESULTS: Our trained deep learning model demonstrated performances comparable to educated humans, yielding an accuracy of 0.92 in sentiment analysis against our manually curated dataset. Albeit fluctuations, sentiments were found more positive over time, followed by a subsequence upswing in population-level vaccine uptake. Distinguishable patterns were revealed among subgroups stratified by demographic variables. Encouraging news or events were detected surrounding positive sentiments crests. Sentiments in pregnancy-related tweets demonstrated a lagged pattern compared with the general population, with delayed vaccine uptake trends. Feature analysis detected hesitancies stemmed from clinical trial logics, risks and complications, and urgency of scientific evidence. DISCUSSION: Integrating social media and public health surveillance data, we associated the sentiments at individual level with observed populational-level vaccination patterns. By unraveling the distinctive patterns across subpopulations, the findings provided evidence-based strategies for improving vaccine promotion during pandemics.

Maternal Antibody Response and Transplacental Transfer Following SARS-CoV-2 Infection or Vaccination in Pregnancy.

BACKGROUND: Pregnant persons are at increased risk of severe COVID-19 and adverse obstetric outcomes. Understanding maternal antibody response, duration, and transplacental transfer after SARS-CoV-2 infection and COVID-19 vaccination is important to inform public health recommendations. METHODS: This prospective observational cohort study included 351 pregnant people who had SARS-CoV-2 infection or COVID-19 vaccination during pregnancy. IgG and IgM to SARS-CoV-2 S1 receptor binding domain were measured in maternal and cord blood. Antibody levels and transplacental transfer ratios were compared across 1) disease severity for those with SARS-CoV-2 infection and 2) infection versus vaccination. RESULTS: There were 252 individuals with SARS-CoV-2 infection and 99 who received COVID-19 vaccination during pregnancy. Birthing people with more severe SARS-CoV-2 infection had higher maternal and cord blood IgG levels (p = 0.0001, p = 0.0001). Median IgG transfer ratio was 0.87-1.2. Maternal and cord blood IgG were higher after vaccination than infection (p = 0.001, p = 0.001). Transfer ratio was higher after 90 days in the vaccinated group (p < 0.001). Modeling showed higher amplitude and half-life of maternal IgG following vaccination (p < 0.0001). There were no significant differences by fetal sex. CONCLUSIONS: COVID-19 vaccination in pregnancy leads to higher and longer lasting maternal IgG levels, higher cord blood IgG, and higher transfer ratio after 90 days compared to SARS-CoV-2 infection. Greater infection severity leads to higher maternal and cord blood antibodies. Maternal IgG decreases over time following both vaccination and infection, reinforcing the importance of vaccination, even after infection, and vaccine boosters for pregnant patients.

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis.

INTRODUCTION: Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS: We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS: We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS: This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.

Universal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Testing for Obstetric Inpatient Units Across the United States.

BACKGROUND: The purpose of this study was to estimate prevalence of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among patients admitted to obstetric inpatient units throughout the United States as detected by universal screening. We sought to describe the relationship between obstetric inpatient asymptomatic infection rates and publicly available surrounding community infection rates. METHODS: A cross-sectional study in which medical centers reported rates of positive SARS-CoV-2 testing in asymptomatic pregnant and immediate postpartum patients over a 1-3-month time span in 2020. Publicly reported SARS-CoV-2 case rates from the relevant county and state for each center were collected from the COVID Act Now dashboard and the COVID Tracking Project for correlation analysis. RESULTS: Data were collected from 9 health centers, encompassing 18 hospitals. Participating health centers were located in Alabama, California, Illinois, Louisiana, New Jersey, North Carolina, Pennsylvania, Rhode Island, Utah, and Washington State. Each hospital had an active policy for universal SARS-CoV-2 testing on obstetric inpatient units. A total of 10 147 SARS-CoV-2 tests were administered, of which 124 were positive (1.2%). Positivity rates varied by site, ranging from 0-3.2%. While SARS-CoV-2 infection rates were lower in asymptomatic obstetric inpatient groups than the surrounding communities, there was a positive correlation between positivity rates in obstetric inpatient units and their surrounding county (P=.003, r=.782) and state (P=.007, r=.708). CONCLUSIONS: Given the correlation between community and obstetric inpatient rates, the necessity of SARS-CoV-2-related healthcare resource utilization in obstetric inpatient units may be best informed by surrounding community infection rates.

A qualitative examination of the implementation of a perinatal collaborative care program.

AIM: To identify implementation strategies for collaborative care (CC) that are successful in the context of perinatal care. BACKGROUND: Perinatal depression is one of the most common complications of pregnancy and is associated with adverse maternal, obstetric, and neonatal outcomes. Although treating depressive symptoms reduces risks to mom and baby, barriers to accessing psychiatric treatment remain. CC has demonstrated benefit in primary care, expanding access, yet few studies have examined the implementation of CC in perinatal care which presents unique characteristics and challenges. METHODS: We conducted qualitative interviews with 20 patients and 10 stakeholders from Collaborative Care Model for Perinatal Depression Support Services (COMPASS), a perinatal collaborative care (pCC) program implemented since 2017. We analyzed interview data by employing the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to organize empirically selected implementation strategies from Expert Recommendations for Implementing Change (ERIC) to create a guide for the development of pCC programs. FINDINGS: We identified 14 implementation strategies used in the implementation of COMPASS. Strategies were varied, cutting across ERIC domains (eg, plan, educate, finance) and across EPIS contexts (eg, inner context - characteristics of the pCC program). The majority of strategies were identified by patients and staff as facilitators of pCC implementation. In addition, findings show opportunities for improving the implementation strategies used, such as optimal dissemination of educational materials for obstetric clinicians. The implementation of COMPASS can serve as a model for the process of building a pCC program. The identified strategies can support the implementation of this evidence-based practice for addressing postpartum depression.

Low-level SARS-CoV-2 viremia coincident with COVID placentitis and stillbirth.

SARS-CoV-2 infection in pregnancy and COVID placentitis are associated with an increased risk of stillbirth. We sought to investigate the presence of maternal viremia in people with SARS-CoV-2 infection during pregnancy who had histologic placentitis versus those without placentitis. SARS-CoV-2 qRT-PCR was performed on plasma from 6 patients with COVID placentitis and 12 matched controls without placentitis. SARS-CoV-2 infection occurred between 4/2020-1/2021; the latency between SARS-CoV-2 diagnosis and delivery was 0-76 days. Two placentitis cases demonstrated viremia (1 stillbirth and 1 well infant), while 12/12 controls were negative. Future research may consider viremia as a possible marker of COVID placentitis.

Obstetric Outpatient Management During the COVID-19 Pandemic: Prevention, Treatment of Mild Disease, and Vaccination.

The majority of patients with coronavirus disease 2019 will have mild or asymptomatic disease, however, obstetric patients are uniquely at risk for disease progression and adverse outcomes. Preventive strategies including masking, physical distancing, vaccination, and chemoprophylaxis have been well studied, are critical to disease mitigation, and can be used in the pregnant population. High-quality data are needed to assess safety and effectiveness of therapeutics and vaccination in pregnancy, as well as long-term data on maternal and newborn outcomes.

Outcomes from birth to 6 months of publicly insured infants born to mothers with severe acute respiratory syndrome coronavirus 2 infection in the United States.

OBJECTIVES: We evaluated inpatient management, transition to home, breastfeeding, growth, and clinical outcomes of infants born to mothers diagnosed with SARS-CoV-2 infection in pregnancy and followed in a Federally Qualified Health Center (FQHC), that serves a diverse and low-income patient population, from birth through 6 months of life. METHODS: Infants born between 4/3/20 and 7/26/20 at Prentice Women's Hospital with mothers who received prenatal care at Erie Family Health Center (Erie), the second largest FQHC in Illinois, and had confirmed SARS-CoV-2 during pregnancy were included. Data were abstracted from delivery hospital admission and outpatient follow-up appointments between 4/8/20 and 2/4/21. RESULTS: Thirty-three infants met inclusion criteria. Average gestational age was 38.9 weeks (IQR 37.6-40.4), 3 (10%) were premature and 5 (15%) required NICU admission. Nearly all (97%) mothers expressed intent to breastfeed. Outpatient follow-up rates were similar to historical cohorts and 82% (23/28) of infants were vaccination compliant. Growth parameters showed normal distributions at all time points. At 6 months, any and exclusive breast milk feeding rates were lower compared to historic cohorts (18 vs. 36%, p<0.05, 0 vs. 21%, p<0.01). Three infants (10%) received development-related referrals, one carried an underlying genetic diagnosis. Outpatient visits were predominantly face-to-face with telemedicine use comprising only 6% of visits (11/182). CONCLUSIONS: Longitudinal follow-up of 33 publicly insured infants born to mothers with SARS-CoV-2 infection in pregnancy followed in an FQHC showed high rates of follow-up and vaccination compliance, normal growth patterns and reassuring clinical status, and lower than expected rates of breastfeeding.

Neighborhood deprivation and preterm delivery during the coronavirus 2019 pandemic.

BACKGROUND: Prior studies have reported decreases in the preterm delivery incidence during the COVID-19 pandemic. However, the findings are inconsistent. Given the wide disparities in the pandemic's impact across communities, neighborhood deprivation may explain the observed variation in the relationship between the COVID-19 pandemic and preterm delivery. OBJECTIVE: To characterize the changes in the incidence of preterm delivery during the COVID-19 pandemic with attention to the effect modification introduced by neighborhood hardship. STUDY DESIGN: This retrospective cohort study included all the pregnant patients who delivered at an urban tertiary care hospital during the pandemic (April-November 2020) or before the pandemic (April-November 2019). We compared the incidence of preterm delivery, spontaneous preterm delivery, and medically indicated preterm delivery before 37 weeks' gestation across epochs. Planned analyses stratified the cohorts by neighborhood deprivation metrics defined by the residential zip code; the metrics included the median neighborhood household income and the hardship index (a composite index including dependency, educational attainment, unemployment, poverty, per capita income, and crowded housing). The Breslow-Day test for homogeneity assessed the association of the delivery epoch and neighborhood deprivation with the preterm delivery outcomes. RESULTS: Of 16,544 eligible deliveries, 8.7% occurred preterm. The incidences of preterm delivery (8.4% vs 9.0%; P=.17), spontaneous preterm delivery (5.0 vs 5.4%; P=.27), and medically indicated preterm delivery (3.2% vs 3.5%; P=.47) were similar in the pandemic and prepandemic epochs. However, the preterm delivery (odds ratio, 0.78; 95% confidence interval, 0.64-0.96) and spontaneous preterm delivery (odds ratio, 0.76; 95% confidence interval, 0.59-0.99) decreased from the prepandemic to the pandemic epoch in those living in neighborhoods <50th percentile for median income (Breslow-Day P values.047 and.036, respectively). Similarly, the preterm delivery (odds ratio, 0.78; 95% confidence interval, 0.64-0.97) and spontaneous preterm delivery (odds ratio, 0.74; 95% confidence interval, 0.57-0.98) decreased for those inhabiting the neighborhoods in the highest-hardship quartile (Breslow-Day P values.045 and.029, respectively). CONCLUSION: The populations residing in socioeconomically disadvantaged neighborhoods experienced reductions in preterm delivery during the COVID-19 pandemic. Neighborhood-level social determinants of health offer insight into the complex etiologies that contribute to preterm delivery and provide opportunities for public health and equity-focused prevention strategies.

Laboratory analysis of symptomatic and asymptomatic pregnant patients with SARS-CoV-2 infection.

BACKGROUND: Inflammatory biomarkers have been used to portend disease severity in nonpregnant individuals with SARS-CoV-2 infection. However, currently, limited data are available, and with mixed results, to elucidate which inflammatory biomarkers may be most associated with clinical phenotype in pregnant patients. OBJECTIVE: We aimed to compare laboratory findings among pregnant patients with SARS-CoV-2 infection by symptom status and disease severity. STUDY DESIGN: We retrospectively evaluated pregnant patients with positive SARS-CoV-2 infection, confirmed through polymerase chain reaction testing, at an urban academic US hospital between March 2020 and October 2020, performed for reported symptoms or universal screening on admission. In our hospital, all patients with SARS-CoV-2 infection were recommended to have baseline laboratory testing, including leukocyte, neutrophil, and lymphocyte counts; aspartate aminotransferase and alanine aminotransferase; high-sensitivity C-reactive protein; procalcitonin; lactate dehydrogenase; D-dimer; and ferritin. We performed multivariable logistic regression to evaluate peak laboratory abnormalities significantly associated with symptomatic SARS-CoV-2 infection and disease severity with gestational age at diagnosis, maternal age, and obesity as covariates. The sensitivity and specificity of laboratory abnormalities were calculated to identify symptomatic vs asymptomatic infection and severe to critical disease vs mild to moderate disease. RESULTS: We identified 175 pregnant patients with SARS-CoV-2 infection, of whom 100 (57%) were symptomatic; 17 (17%) of those who were symptomatic had a severe to critical disease. Laboratory data were available for 128 patients, of whom 67 (52%) were symptomatic. Compared with asymptomatic individuals, symptomatic individuals were more likely to exhibit elevated high-sensitivity C-reactive protein levels after adjusting for gestational age (adjusted odds ratio, 5.67; 95% confidence interval, 1.42-22.52; sensitivity, 81%; specificity, 43%). In symptomatic individuals, transaminitis (adjusted odds ratio, 5.67; 95% confidence interval, 1.27-25.43), elevated procalcitonin levels (adjusted odds ratio, 16.60; 95% confidence interval, 2.61-105.46), and elevated lactate dehydrogenase levels (adjusted odds ratio, 17.55; 95% confidence interval, 2.51-122.78) were independently associated with severe to critical disease rather than mild to moderate disease after adjusting for maternal age and obesity. For differentiating disease severity, sensitivity rates for transaminitis, procalcitonin elevation, and lactate dehydrogenase elevation were 47%, 87%, and 53%, respectively, whereas the specificity rates were 89%, 63%, and 90%, respectively. CONCLUSION: Inflammatory biomarkers in pregnant patients with SARS-CoV-2 infection exhibited vast heterogeneity, poor discriminative ability, and thereby limited clinical utility. Larger registry studies should evaluate which inflammatory biomarkers may be most useful for risk stratification and prognostication of pregnant patients with SARS-CoV-2 infection, taking into account the physiology of pregnancy.

Risk factors for severe acute respiratory syndrome coronavirus 2 infection in pregnant women.

Background: Risk factors for severe acute respiratory syndrome coronavirus 2 infection in pregnancy remain poorly understood. Identifying and understanding populations at a heightened risk of acquisition is essential to more effectively target outreach and prevention efforts. Objective: This study aimed to compare sociodemographic and clinical characteristics of pregnant women with and without severe acute respiratory syndrome coronavirus 2 infection and, among those with severe acute respiratory syndrome coronavirus 2, to compare characteristics of those who reported coronavirus disease symptoms and those who were asymptomatic at diagnosis. Study Design: This retrospective cohort study includes pregnant women who delivered or intended to deliver at Northwestern Memorial Hospital after initiation of a universal testing protocol on admission (April 8, 2020-May 31, 2020). Women were dichotomized by whether they had a positive test result for severe acute respiratory syndrome coronavirus 2. Among women with a positive test result, women were further dichotomized by whether they reported symptoms of coronavirus disease 2019. Bivariable analysis and parametric tests of trend were used for analyses. Logistic regression was used to control for potential confounders and to examine effect modification between race and ethnicity and any other identified risk factors. Results: During the study period, 1418 women met inclusion criteria, of whom 101 (7.1%) had a positive test result for severe acute respiratory syndrome coronavirus 2. Of the 101 women who had a positive test result, 77 (76.2%) were symptomatic at the time of diagnosis. Compared with women who had a negative test result for severe acute respiratory syndrome coronavirus 2, those with a positive test result were younger and were more likely to have public insurance, to identify as black or African American or Latina, to be unmarried, to be obese, to have preexisting pulmonary disease, and to have living children. An increasing number of living children was associated with an increasing risk of severe acute respiratory syndrome coronavirus 2 infection, and this finding persisted after controlling for potential confounders. There was no effect modification between race or ethnicity and having living children with regard to the risk of infection. There were no significant differences identified between women who were symptomatic and asymptomatic. Conclusion: Many risk factors for severe acute respiratory syndrome coronavirus 2 infection in pregnancy are similar to the social and structural determinants of health that have been reported in the general population. The observed association between severe acute respiratory syndrome coronavirus 2 infection and having children raises the possibility of children themselves being vectors of viral spread or behavior patterns of parents being mediators of acquisition.