Listeriosis During Pregnancy: Maternal and Neonatal Consequences-A Case Report.

Listeriosis is a rare but extremely dangerous infection for both mother and fetus. This pathogen can spread in humans' bodies by consumption of contaminated food. The main high-risk groups of people for being infected are immunosuppressed and especially pregnant women. We present a case of materno-neonatal listeriosis illustrating that empiric antimicrobial therapy of chorioamnionitis during labor and neonate postpartum can also cover listeriosis which was not diagnosed prior to obtaining cultures.

A Cryptic Case of an Anaerobic Hepatic Abscess Following a Cesarean Section.

Postpartum infectious complications can present with a wide range of nonspecific symptoms. Herein, we describe a complicated late postpartum presentation of recurrent fever following a cesarean delivery complicated by chorioamnionitis. Following discharge, the patient experienced cyclical fever and was treated with antipyretics as an outpatient. The patient continued to experience symptoms and reported to the hospital for further evaluation. Initially thought to be septic pelvic thrombophlebitis, the patient was trialed on clindamycin and gentamycin without resolution of symptoms. After extensive evaluation, the fevers were found to be the result of an infected periuterine hematoma and a concomitant subcapsular inferior hepatic abscess. Bacterial cultures isolated two rare anaerobic organisms: Peptoniphilus ssp. and Finegoldia magna. Source control was achieved by drainage of the two abscesses followed by antibiotic treatment with ertapenem and metronidazole, and the patient recovered successfully. This is the first reported case, to the authors' knowledge, of this complicated postpartum picture due to these anaerobic organisms.

Invited Speaker Talks

S-01.5 Impact of aging on the frequency, phenotype, and function of CD4+ T cells in the human... Zheng Shen SP 1 sp , Mickey V. Patel SP 1 sp , Landon G. vom Steeg SP 1 sp , Marta Rodriguez-Garcia SP 2 sp , Charles R. Wira SP 1 sp I SP 1 sp Geisel School of Medicine at Dartmouth, Lebanon, NH, USA, SP 2 sp Tufts University School of Medicine, Boston, MA, USA i B Problem b : Since CD4+ T cells are essential for regulating adaptive immune responses and for long lasting mucosal protection, changes in CD4+ T cells are likely to affect protective immunity. S-02.2 Impact of SARS-CoV-2 infection in pregnancy on fetal immune state Leena B. Mithal I Northwestern University, Feinberg School of Medicine;Lurie Children's Hospital Chicago, IL, USA i SARS-CoV-2 infection during pregnancy is associated with increased risk of adverse maternal and pregnancy outcomes. The objectives including: 1) review treatment considerations during pregnancy and postpartum, pregnancy outcomes and postpartum challenges in women with established rheumatoid arthritis, 2) review treatment considerations during pregnancy and postpartum, pregnancy outcomes and pregnancy challenges in women with established lupus, and 3) review treatment considerations during pregnancy and postpartum and pregnancy outcomes in women with established antiphospholipid antibody syndrome. S-15.6 Longitudinal expression of serum immune markers across pregnancy and fetal growth rest... Shailaja Sopory, Khushboo Kaushal, Ayushi Ayushi, Nikhil Sharma, Shinjini Bhatnagar, Bapu Koundinya Desiraju, Ramachandran Thiruvengadam I Translational Health Science and Technology Institute, Faridabad, India i B Problem b : Pregnancy is a delicate balance of pro and anti-inflammatory cytokines that are appropriately expressed during different stages of pregnancy. [Extracted from the article] Copyright of American Journal of Reproductive Immunology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Repeat Doses of Sotrovimab for Recurrence of COVID-19 in a High-Risk Pregnancy

Background: Myasthenia gravis (MG) is an autoimmune disorder leading to variable degrees of skeletal muscle weakness. During pregnancy, infections can trigger exacerbations and should be treated promptly and aggressively.(1) Sotrovimab is a monoclonal antibody used as monotherapy in high-risk, symptomatic non-hospitalized patients at risk of developing COVID-19 disease. (2) It is thought to have retained activity against SARS-CoV-2 omicron variant. (3) Limited data are available on its use in pregnancy. Case: A 39-year-old woman with severe generalized MG, was referred to our joint neuro-obstetric multidisciplinary service. Her two previous pregnancies were complicated by severe exacerbations of MG necessitating intensive care admissions, and preterm labour. Her long-term therapy included high dose steroids, intravenous immune globulin (IVIG) and plasma exchanges. In this pregnancy, she additionally received rituximab in the first-trimester, allowing her prednisolone to be weaned to 20 mg daily, with ongoing 3-weekly IVIG. She received 3 doses of the Pfizer COVID-19 vaccine. At 19 weeks she developed mild coryzal symptoms, sore throat and myalgia. Lateral flow and polymerase chain reaction tests in the community confirmed infection with SARS-CoV-2. She was treated with sotrovimab with uneventful recovery at home. At 31 weeks, she again tested positive for SARS-CoV-2, after reporting mild COVID-19 symptoms. She received a second dose of sotrovimab and had a quick recovery. Subsequent SARS-CoV-2 genotyping indicated she had contracted the Omicron-BA.2 variant. Fetal surveillance for growth (SARS-CoV-2) and arthrogryposis (MG) did not raise concerns. At 35+3 weeks, she went into spontaneous labour and was delivered by caesarean section for evolving chorioamnionitis, with uneventful recovery for mother and baby. Discussion(s): We report a case of repeated treatment with sotrovimab (in second and third trimesters) of a high-risk, non-hospitalized pregnant woman, who was re-infected with SARS-CoV-2. We identified no immediate maternal, fetal or neonatal complications following two doses of sotrovimab for mild COVID-19.

Changing Laboratory Practice for Early Detection of a Fetal Inflammatory Response: A Contemporary Approach.

Neonates born with the fetal inflammatory response (FIR) are at risk of complications such as early-onset neonatal sepsis, meningitis, and pneumonia. Providing an early histopathological diagnosis of FIR is important to guide management but can be a challenge in busy laboratories. This is a retrospective cross-sectional study over a four-month duration recruiting all placental cases with histological chorioamnionitis in our institution. The diagnostic performance of the umbilical cord (UC) section in identifying FIR, relative to the corresponding subsequent placental sections, was assessed. Clinical predictors of umbilical cord FIR were also investigated. A total of 390 UC sections were analyzed, of which 206 (52.8%) were found positive for FIR: 111 cases (53.9%) stage 1, 87 (42.2%) stage 2, and 8 (3.9%) stage 3. Our data revealed a good diagnostic sensitivity, specificity, positive predictive value, and accuracy of 76.2% (95%CI: 68.6-82.7%), 82.4% (95%CI: 65.5-93.2%), 95.0% (95%CI: 90.2-97.6%), and 77.3% (95%CI: 70.6-83.1%) respectively, in cases when clinical chorioamnionitis, fever and/or prolonged rupture of membrane (PROM) were suspected, with the area under the curve of 0.793. A maternal inflammatory response (MIR) was correlated with FIR (p < 0.001). Multivariate logistic regression analysis indicated that the higher the gestational age, clinical suspicion of chorioamnionitis, fever, and/or PROM, and the higher the stage of MIR significantly increased the odds of FIR (p < 0.001). UC section diagnosis of FIR is reasonably accurate in cases with clinical chorioamnionitis, fever, and/or PROM. Changing current laboratory practice to rapid processing of UC ahead of the rest of the other placental sections can be recommended in busy pathology departments.

Peripartum Outcomes Associated With COVID-19 Vaccination during Pregnancy: A Systematic Review and Meta-analysis

Background. The risk and benefits of coronavirus disease 2019 (COVID-19) vaccination during pregnancy are under investigation. Pooled evidence regarding neonatal and maternal outcomes in relation to COVID-19 vaccination during pregnancy is scarce. Methods. We searched PubMed and EMBASE databases in April 2022 without language restrictions. We included Prospective trials and observational studies comparing the women who received at least one COVID-19 vaccination during pregnancy with those who did not and reporting neonatal outcomes. Two independent investigators extracted relevant data from each study. Odds ratios (ORs) were calculated using random-effects models. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The primary outcomes were the neonatal outcomes, including preterm birth, small-for-gestational-age (SGA), low Apgar score (< 7 at 5 min), neonatal intensive care units (NICU) admission, and intrauterine fetal death (IFD). The secondary outcomes were maternal outcomes, including maternal SARS-CoV-2 infection, cesarean delivery, postpartum hemorrhage, and chorioamnionitis. Results. Nine observational studies involving 81,349 vaccinated (mean age, 32.0 +/-4.6 years) and 255,346 unvaccinated women during pregnancy (mean age, 30.5+/-5.1 years) were included. COVID-19 vaccination during pregnancy was associated with lower risk of NICU admission (OR, 0.88;95% confidence intervals [CI], 0.80-0.97) and IFD (OR, 0.73;95% CI, 0.57-0.94), whereas it was not associated with preterm birth (OR, 0.89;95% CI, 0.76-1.04), SGA (OR, 0.99;95% CI, 0.94-1.04), and low Apgar score (OR, 0.94;95% CI, 0.87-1.02). COVID-19 vaccination during pregnancy was associated with a lower risk of maternal SARS-CoV-2 infection (OR, 0.46;95% CI, 0.22-0.93), but not associated with increased risk of cesarean delivery (OR, 1.05;95% CI, 0.93-1.20), postpartum hemorrhage (OR, 0.95;95% CI, 0.83-1.07), and chorioamnionitis (OR, 0.95;95% CI, 0.83-1.07). Flowchart of study selection Forest plots showing the odds ratio of neonatal outcomes a: neonatal intensive care units admission, b: intrauterine fetal death, c: preterm birth, d: small for gestational age, e: low Apgar score Forest plots showing the odds ratio of maternal outcomes a: maternal SARS-CoV-2 infection, b: cesarean delivery, c: postpartum hemorrhage, d: chorioamnionitis Conclusion. COVID-19 vaccination during pregnancy did not increase the risk of peripartum outcomes but decreased the risk of NICU admission, IFD, and maternal COVID-19 infection. COVID-19 vaccination should be encouraged for pregnant women.

Histopathological finding of 5 cases of CAOS without genital bleeding

Objective: Chronic Abruption Oligohydramnios Sequence (CAOS) is known as a disease with a poor perinatal prognosis characterized by placental marginal hematoma and genital bleeding, associated with fetal growth restriction, hemorrhagic amniotic fluid, oligohydramnios and chronic lung disease in the newborn. We reviewed the placental pathology of five cases diagnosed as CAOS without genital bleeding. Method(s): Pregnant women with CAOS without genital bleeding between April 2020 and July 2022 were identified. Five of these cases were clinically suspected as CAOS. Therefore, we evaluate the presence of hemorrhagic amniotic fluid and/or posterior placental hematoma by MRI;one case could not perform MRI because of COVID-19 infection. Placentas were examined histopathological and reviewed for the four Amsterdam classification groups, presence of diffuse chorioamniotic hemosiderosis (DCH), and other special findings. Result(s): The median age of the patients was 31 years and the median number of weeks of delivery was 24 weeks, including 2 cases of artificial abortion, 1 case of vaginal delivery, and 2 cases of cesarean section. The main complaints were FGR in 2 cases, amniotic fluid depletion in 2 cases, and suspected fetal congenital anomaly in 1 case. In histopathologic examination, 4 cases show DCH, 3 cases show maternal vascular marperfusion, and all cases had Acute chorioamnionitis. Conclusion(s): Four of the five patients had DCH, which suggest that the chorion and amnion are exposed to hematoma over a long period of time. This finding provides the basis for a final diagnosis in cases of clinically suspected CAOS. Our cases suggested that CAOS may be established before the appearance of genital hemorrhage. MRI or other tests should be performed aggressively in cases of clinically suspected CAOS without genital hemorrhage, and the patient should be strictly managed. Copyright © 2022

Peripartum Outcomes Following COVID-19 Vaccination in Late Pregnancy: Findings from a Population-Based Retrospective Cohort Study in Ontario, Canada

Objectives: Evaluate peripartum outcomes following COVID-19 vaccination during pregnancy. Methods: Ontario population-based retrospective cohort between December 14, 2020 and September 30, 2021 using linkage of provincial birth registry and COVID-19 immunization databases. Poisson regression was used to generate risk ratios (RR) and 95% confidence intervals (CI), adjusted for temporal, socio-demographic, and clinical factors using propensity scores. Obstetric (postpartum hemorrhage, chorioamnionitis, cesarean birth) and newborn (NICU admission and 5-minute Apgar<7) outcomes were compared for those who received ≥1 dose of COVID-19 vaccine during pregnancy with 2 unexposed groups—Group 1: individuals vaccinated postpartum, Group 2: never vaccinated. Results: Among 97 590 individuals, 22 660 (23%) received ≥1 dose of vaccine during pregnancy (64% received dose 1 in 3rd trimester). Compared with those vaccinated postpartum, we found no increased risks of postpartum hemorrhage (aRR 0.91, 95% CI 0.82–1.02);chorioamnionitis (aRR 0.92, 95% CI 0.70–1.21);or cesarean (aRR 0.92, 95% CI 0.89–0.95) following COVID-19 vaccination, nor any increased risk of NICU admission or 5-minute Apgar <7. All findings were similar when compared with individuals who did not receive COVID-19 vaccination at any point. We did not observe any difference according to vaccine product, number of doses received during pregnancy, or trimester of dose 1. Conclusions: As of late 2021, there is limited evidence from comparative studies in large populations on outcomes following COVID-19 vaccination during pregnancy. Our study of births up to September 30, 2021 did not identify any increased adverse peripartum outcomes associated with later pregnancy COVID-19 vaccination. Once more individuals vaccinated earlier in pregnancy deliver, we will report on other important obstetric and perinatal outcomes. Keywords: COVID-19 vaccine;pregnancy;epidemiology

Suspected Neonatal COVID-19 Infection in an Extremely Premature Infant

Introduction: The COVID-19 pandemic has been widely described, however, there is limited data regarding neonatal infection. We present an extremely premature neonate with suspected COVID-19 pneumonia treated with Remdesivir. Case Description: Our patient is an infant born via emergency cesarean section for chorioamnionitis at 24 weeks gestational age with extremely low birth weight (ELBW). Mother is a 23-yearold primigravid female whose pregnancy was complicated by asymptomatic COVID-19 infection diagnosed by nasopharyngeal PCR ten days prior to delivery. Antenatal steroids were given for imminent premature delivery. Infant was intubated during initial resuscitation then extubated to non-invasive positive pressure ventilation (NIPPV) on day three of life. On day seven of life, she developed increasing apneic spells and feeding intolerance. Empiric antibiotics were initiated while awaiting blood and cerebrospinal fluid cultures. Blood culture grew Serratia marcescens and antibiotic coverage was tailored to cefepime monotherapy. Our patient remained stable on non-invasive respiratory support seven days into her sepsis event. Around this time, histopathological analysis of the placenta revealed acute villitis and intervillositis highly suggestive of COVID-19 placentitis. A positive nasopharyngeal COVID-19 PCR was noted on day ten of life. Our patient remained stable on non-invasive respiratory support until day fourteen of life, when she suddenly developed refractory hypoxemia requiring intubation. This coincided with acute changes in her chest x-ray (Fig 1). The negative bacterial respiratory culture, timing of clinical deterioration, and placental findings increased our suspicion for symptomatic co-infection with COVID-19. Patient continued to have refractory hypoxia and poor ventilation despite maximum settings and inhaled nitric oxide. After an extensive multidisciplinary discussion, patient received Remdesivir as a compassionate measure. Neonatal dosage was well tolerated with no adverse effects at 5 mg/kg loading dose followed by four days of maintenance dosing at 2.5 mg/kg. Significant clinical improvement was noted after the second day by decreasing FiO2 requirements. COVID-19 PCR remained positive ten days after Remdesivir treatment was completed. Patient was extubated to NIPPV on day thirty-six of life and is currently requiring no respiratory support at 37 weeks corrected age. Discussion: We present an ELBW neonate with placental findings typical of COVID-19 infection and refractory hypoxemia likely due to COVID-19 pneumonia. To date, the mechanism for this infant's infection is unclear. Based on the Acharya et al. Classification for Maternal-Fetal-Neonatal SARS-CoV-2 infection, our patient fits into probable neonatal infection acquired post-partum category. We have strong evidence of infection but lack of absolute proof to confirm congenital disease as no testing was done at birth. We acknowledge that part of the clinical course was complicated by sepsis, however, the peak of illness correlates with the typical clinical course for COVID-19 infection. Conclusion: To our knowledge, this may be the youngest patient documented to have COVID-19 pneumonia and received Remdesivir treatment.

USE OF TOCILIZUMAB IN COVID-19 POSITIVE PREGNANT WOMEN

Background: Tocilizumab reduces the need for mechanical ventilation and improves survival in COVID-19 patients. There is limited evidence on Tocilizumab use in pregnant patients with COVID-19. Methods: Case series of pregnant patients with COVID-19 treated with Tocilizumab during hospitalisation between June to November 2021. Demographic data, maternal morbidity and neonatal outcomes were collected. Results: Ten pregnant patients received Tocilizumab. Six patients received a single dose of 800 mcg, 2 patients received a single dose of 600 mcg, and 2 patients received a double dose of 800 mcg and 600 mcg respectively. Three patients received Tocilizumab postpartum, with 6 receiving it in the second and third trimester (mean gestational age 29.5 +/- 3.9 weeks). Antenatal patients received Tocilizumab at a median of 84 (IQR 63) days before delivery. In five patients, there was a trend in improvement of respiratory rate following administration of Tocilizumab (Table1). Birth outcomes were available for 8 patients. There were no significant adverse maternal outcomes or opportunistic infections, with only 1 patient experiencing chorioamnionitis with no long term sequalae. All neonates were born with Apgar of 91 and 95. One infant was identified as having Lenticulostriatal vasculopathy and another was diagnosed with gastroenteritis, but no causative bacterial or viral organism was identified. One infant tested positive for COVID-19 on Day 5. Out of the 8 neonates who were born, 7 were breastfed and none of the neonates in this study experienced any adverse outcomes until discharge. Conclusions: Tocilizumab is efficacious and safe for COVID- 19 in pregnancy for the women and neonates. (Table Presented).

Life After Amsterdam: Placental Pathology Consensus Recommendations and Beyond.

The Amsterdam Placental Workshop Group Consensus Statement on Sampling and Definitions of Placental Lesions has become widely accepted and is increasingly used as the universal language to describe the most common pathologic lesions found in the placenta. This review summarizes the most salient aspects of this seminal publication and the subsequent emerging literature based on Amsterdam definitions and criteria, with emphasis on publications relating to diagnosis, grading, and staging of placental pathologic conditions. We also provide an overview of the recent expert recommendations on the pathologic grading of placenta accreta spectrum, with insights on their clinical context. Finally, we discuss the emerging entity of SARS-CoV2 placentitis.

PROVISION OF HUMAN MILK AT NICU DISCHARGE FOR PRETERM INFANTS DURING THE COVID-19 PANDEMIC

Purpose of Study To investigate the impact of the COVID-19 pandemic on provision of human milk (HM) at the time of discharge (DC) home from the NICU in a cohort of survivors born < 34 weeks gestational age. Methods Used Retrospective analysis of prospectively collected data from the Women & Infants Follow-up Clinic database. 532 preterm (PT) infants born between 1/1/2019 and 3/30/ 2021 who survived to DC are included. Infants born during the COVID-19 period (defined as 3/1/20 to 4/30/21) were compared to infants born pre-COVID (defined as 1/1/19 to 2/ 29/20), and the primary outcome was the provision of any HM at NICU DC. Secondary analyses were performed by public and private insurance. Multivariable regression analyses were run for the total cohort and by health insurance, adjusting for socio-economic demographics and medical risks. An interaction term for public insurance and COVID-19 period was also tested. Summary of Results Infants born during COVID-19 pandemic were larger than infants born pre-COVID (table 1). There were more mothers who identified as single prior to pandemic onset, and more cases of chorioamnionitis after pandemic onset (table 1). Rates of public insurance were similar between groups (55% pre-COVID and 50% COVID). There was no change in provision of any HM at DC between time periods, 63% to 71%;p=0.08 (table 1). Provision of any HM at DC increased from 77% to 88%;p=0.02 for those on private insurance and remained unchanged for infants on public insurance;52% to 53%;p=0.92 (table 1). In regression analyses, mothers with private insurance were twice as likely to provide HM at DC during the COVID period compared to pre- COVID. OR;CI (2.07;1.06-4.03);p=0.03 (table 2). For those on public insurance, the odds for HM provision during COVID versus pre-COVID were 0.95;0.55-1.66;p=0.85 NS, with a 2% decrease in odds for each day in the NICU (table 2). The interaction term showed lower odds of HM for public vs private insurance during the COVID-19 period (OR 0.41;0.17-0.98;p=0.05). Conclusions Mothers with private insurance were twice as likely to provide HM at DC during the COVID-19 pandemic, whereas there was no change in provision among families with public insurance. We speculate that both the dedication of our lactation support team and health care disparities contributed to this difference in outcomes by insurance status. (Table Presented).

MATERNAL SARS-COV-2 INFECTION IN THE SECOND TRIMESTER AND VENTRICULOMEGALY AND DEVELOPMENTAL DELAY IN AN INFANT

Case Report History: Mother is a 23 year old gravida 4 para 1021, with a history of type 1 diabetes since 12 years of age. Prenatal sonogram at 20 weeks of gestation showed normal fetal anatomy with an EFW 21st percentile & 2-vessel cord. She was admitted at 23 weeks of gestation for acute hypoxic respiratory failure secondary to SARS-CoV-2 pneumonia, diabetic ketoacidosis & acute kidney failure. She refused intubation in spite of saturations in low 80s & was treated with high flow nasal cannula, non-rebreather mask, & nasal CPAP. She received convalescent plasma, Remdesivir, Tocilizumab, steroids, hydroxychloroquine, ceftriaxone & azithromycin, and was discharged home on oxygen after 29 days. Prenatal sonogram at 29 weeks of gestation demonstrated severe IUGR (abdominal & head circumference, fetal weight and femur length all < 3rd percentile), ventriculomegaly & a 2-vessel cord. Fetal MRI showed severe lateral ventriculomegaly of the brain, diffuse white matter parenchymal edema, bilateral germinal matrix & intraventricular hemorrhage & severe parenchymal volume loss. Mother was lost to follow up until time of delivery. Physical examination An infant female was born at 39 weeks of gestation via repeat cesarean-section. She was admitted to NICU for severe IUGR. The newborn's birth weight was 2126 g, head circumference 30 cm, length 43.5 cm (all <3rd percentile). Baby had mild hypertonia and tremors, rest of the exam was normal. The newborn was treated for TTN with NCPAP, hypoglycemia requiring IVF and hyperbilirubinemia requiring phototherapy and was extremely slow to feed. Diagnostic work-up CBC, BMP, LFT & CSF microscopy were normal, SARS-CoV-2 PCR was negative. SARS-CoV-2 IgM was negative in serum & CSF, but IgG was positive in serum & CSF. Baby's titers were slightly higher than mother's. US & MRI confirmed ventriculomegaly due to volume loss, a component of hydrocephalus was suspected due to presence of intraventricular hemorrhage, however there was no evidence of raised ICP. Retinal exam, hearing and BAER were normal. Chromosome analysis was normal & Zika titers were negative. The newborn was discharged home after 20 days with weighing 2580 g and head circumference of 32 cm. Placental was 222 g with <10% infarction and moderate acute chorioamnionitis. Infant has significant developmental delay at 1 year of age. Discussion There is definitive evidence of adverse neonatal outcomes in third trimester maternal SARS-CoV-2 infection, effects of earlier infections are not well reported. In our case the neurological injury can't be attributed definitively to fetal SARS-CoV-2 infection as IgM was negative, but the interval of 16 weeks between maternal infection and delivery need to be taken into account. Maternal illness likely contributed to severe acute on chronic fetal hypoxia which resulted in IUGR and in utero IVH with resultant CNS tissue loss and ventriculomegaly. (Figure Presented).

Histopathological and Clinical Analysis of 19 Placentas in Patients Diagnosed with COVID-19 Infection

Background: Although there are many studies examining the clinical outcomes of women and their infants diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, during pregnancy, the reasons causing the possible adverse outcomes remain unclear1. This study examines placental pathology from women who contracted COVID-19 during pregnancy at this university hospital institution. Design: This study was centered around all 19 placenta specimens from patients infected with COVID-19 at this university hospital. The American College of Obstetricians and Gynecologists (ACOG) allow for the judgement of the Obstetrics physician to be the predominant factor in the decision of sending the placenta specimen for pathology evaluation. Therefore ACOG and CRICO (a risk retention group for medical practitioners) work in conjunction to recommend that placentas be sent for pathology evaluation when clinically indicated. All 19 placenta specimens that were submitted in this study met at least one of these recommendations and therefore 19 age matched controls without COVID-19 infection were reviewed in order to outline any significant clinical trends. The age matched controls were selected within the same time frame as the COVID-19 specimens, which was June 2020 to August 2021. Results: The interval of initial COVID-19 diagnosis and time of placenta evaluation was documented in each case, with the median time interval being 2 days (minimum 1day to maximum 91 days). The gestational age for each patient was calculated, and the average gestational age was a full term pregnancy of 37.2 weeks. 90% of the patients were identified to be of Hispanic ethnicity and heritage, while the other two patients were of Caucasian descent. 63% of the placental weights from the COVID specimens were 25th percentile or lower, whereas only 21% of the age matched controls were 25th percentile or lower. 63% of the cases were recognized to contain histopathological abnormalities, 10.5% in aged matched controls. 4 cases were found to have intra-placental infarction (figure 1), 2 cases were identified to have chorangiosis, 1 case of villous ischemic change, 1 case of decidual laminar necrosis, 1 case of meconium, and 2 cases of acute chorioamnionitis. Conclusions: In this study on average the placenta weight was identified to be lower than age matched controls and placental abnormalities were identified more often in patients infected with COVID 19 (63% vs. 10.5%). (Table Presented).

Loss of CXC-Chemokine Receptor 1 Expression in Chorioamnionitis Is Associated with Adverse Perinatal Outcomes.

BACKGROUND: Chorioamnionitis complicates about 1-5% of deliveries at term and causes about one-third of stillbirths. CXC-chemokine receptor 1 (CXCR1) binds IL-8 with high affinity and regulates neutrophil recruitment. We aimed to determine the immunoexpression of CXCR1 in placentas with chorioamnionitis, and its association with adverse perinatal outcomes. METHODS: A total of 101 cases of chorioamnionitis and 32 cases of non-chorioamnionitis were recruited over a period of 2 years. CXCR1 immunohistochemistry was performed, and its immunoexpression in placentas was evaluated. The adverse perinatal outcomes included intrauterine death, poor APGAR score, early neonatal death, and respiratory complications. RESULTS: Seventeen cases (17/101, 16.8%) with chorioamnionitis presented as preterm deliveries. Lung complications were more common in mothers who were >35 years (p = 0.003) and with a higher stage in the foetal inflammatory response (p = 0.03). Notably, 24 cases (23.8%) of histological chorioamnionitis were not detected clinically. Interestingly, the loss of CXCR1 immunoexpression in the umbilical cord endothelial cells (UCECs) was significantly associated with foetal death (p = 0.009). CONCLUSION: The loss of CXCR1 expression in UCECs was significantly associated with an increased risk of adverse perinatal outcomes and could be used as a biomarker to predict adverse perinatal outcomes in chorioamnionitis. Further study is warranted to study the pathophysiology involved in the failure of CXCR1 expression in these cells.

Acute postpartum care utilization after expedited postpartum discharge

Objective: During the COVID-19 pandemic, many hospitals provided expedited postpartum discharge (EPD) for patients wishing to leave the hospital soon after birth. This study was performed to assess whether acute postpartum care utilization increased after EPD during COVID-19. Study Design: Birth hospitalization data from a single teaching hospital from two 6-week periods (3/22-4/30/19 and 3/22-4/30/20) were used for this retrospective cohort study. EPD, defined as discharge on postpartum day 1 or 2 following vaginal or cesarean birth, respectively, was the primary exposure. The primary outcome was acute postpartum care utilization defined as emergency or obstetrical triage unit visits within 6 weeks of delivery. Secondary outcomes included 6-week postpartum readmission. We fit logistic regression models to assess the risk for the primary and secondary outcomes. Categorical comparisons were made with the chi square test. Results: Of 1,358 deliveries in the study, 5.0% of deliveries in 2019 (n=36) compared to 60.3% of deliveries in 2020 (n=388) underwent EPD (p< 0.01). Rates of acute postpartum care utilization were 8.8% and 5.6% for 2019 and 2020, respectively (Figure 1). In 2020, patients with hypertensive disorders of pregnancy (HDP), chorioamnionitis/endometritis, or a positive COVID test were less likely to be discharged early (Table 1). There were no significant differences in rates of acute postpartum care utilization (OR 0.9, 95% CI 0.5, 1.8) or readmissions (OR 1.3, 95% CI 0.5, 3.6) between patients with EPD as compared to routine discharge. Among patients with HDP, readmission risk was significantly higher among those who had early discharge as compared to routine discharge (OR 6.1, 95% CI 2.1, 17.3). Conclusion: Rates of EPD were significantly higher in 2020 compared to 2019 with no impact on acute postpartum care utilization or readmission rates. Among patients with hypertensive disorders of pregnancy, expedited discharge was associated with higher risk of readmission. EPD discharge does not appear to be associated with increased acute postpartum care utilization among low-risk patients. [Formula presented] [Formula presented]

Systematic review and meta-analysis of the effect of pertussis vaccine in pregnancy on the risk of chorioamnionitis, non-pertussis infectious diseases and other adverse pregnancy outcomes.

BACKGROUND: Several countries have introduced maternal immunisation with pertussis vaccine to provide protection against pertussis in early infancy. There is increasing interest in non-specific effects of vaccines including that non-live vaccines may enhance susceptibility to non-targeted infections in females. Some studies have shown increased risk of chorioamnionitis among women receiving pertussis vaccine during pregnancy. We aimed to conduct a systematic review and meta-analysis of the effect of maternal pertussis immunisation on the risk of chorioamnionitis, as well as the secondary outcomes of non-pertussis infections in women, non-pertussis infections in infants, spontaneous abortion or stillbirth, maternal death and infant death. METHODS: We searched PubMed and Embase for articles published until January 14, 2021. We screened articles for eligibility and extracted data using Covidence. Quality was assessed using Cochrane RoB tool and Newcastle-Ottawa Scale. Data were imported into RevMan for pooling and conduction of a meta-analysis stratified by study type. Outcomes are presented as risk ratios. RESULTS: We identified 13 observational studies and six randomized controlled trials eligible for inclusion. We pooled data on chorioamnionitis from six observational studies and found maternal pertussis vaccine (mostly compared with other maternal immunizations with non-live vaccines) to be associated with an increased risk among the pertussis vaccinated women, RR = 1.27 [CI 95%: 1.14-1.42]. We found no difference in the analysis of our secondary outcomes of non-pertussis infections, spontaneous abortion or stillbirth and death. CONCLUSION: We found an increased risk of chorioamnionitis among women who received pertussis vaccine in pregnancy. The large number of women receiving pertussis vaccine during pregnancy, as well as the growing evidence of non-live vaccines causing increased susceptibility to infections, indicates a need for further randomised trials to assess potential adverse effects of maternal immunisation with pertussis-containing vaccines.

ACE2 Is Expressed in Immune Cells That Infiltrate the Placenta in Infection-Associated Preterm Birth.

COVID-19 is associated with increased incidence of preterm birth (PTB). We assessed pathways by which SARS-CoV-2 could access the placenta. Placentae, from PTB with or without chorioamnionitis (ChA), or from term pregnancies (n = 12/13/group) were collected. Peripheral blood was collected from healthy pregnant women (n = 6). Second trimester placental explants (16-20 weeks, n = 5/group) were treated with lipopolysaccharide (LPS, to mimic bacterial infection) and ACE2, CCL2, IL-6/8 and TNFα mRNA was assessed. ChA-placentae exhibited increased ACE2 and CCL2 mRNA expression (p < 0.05). LPS increased cytokine and ACE2 mRNA in placental explants. Placental ACE2 protein localized to syncytiotrophoblast, fetal endothelium, extravillous trophoblast and in immune cells-subsets (M1/M2 macrophage and neutrophils) within the villous stroma. Significantly increased numbers of M1 macrophage and neutrophils were present in the ChA-placenta (p < 0.001). Subsets of peripheral immune cells from pregnant women express the ACE2 mRNA and protein. A greater fraction of granulocytes was positive for ACE2 protein expression compared to lymphocytes or monocytes. These data suggest that in pregnancies complicated by ChA, ACE2 positive immune cells in the maternal circulation have the potential to traffic SARS-CoV-2 virus to the placenta and increase the risk of vertical transmission to the placenta/fetus.