Minding the margins: Evaluating the impact of COVID-19 among Latinx and Black communities with optimal qualitative serological assessment tools.

COVID-19 disproportionately affected minorities, while research barriers to engage underserved communities persist. Serological studies reveal infection and vaccination histories within these communities, however lack of consensus on downstream evaluation methods impede meta-analyses and dampen the broader public health impact. To reveal the impact of COVID-19 and vaccine uptake among diverse communities and to develop rigorous serological downstream evaluation methods, we engaged racial and ethnic minorities in Massachusetts in a cross-sectional study (April-July 2022), screened blood and saliva for SARS-CoV-2 and human endemic coronavirus (hCoV) antibodies by bead-based multiplex assay and point-of-care (POC) test and developed across-plate normalization and classification boundary methods for optimal qualitative serological assessments. Among 290 participants, 91.4% reported receiving at least one dose of a COVID-19 vaccine, while 41.7% reported past SARS-CoV-2 infections, which was confirmed by POC- and multiplex-based saliva and blood IgG seroprevalences. We found significant differences in antigen-specific IgA and IgG antibody outcomes and indication of cross-reactivity with hCoV OC43. Finally, 26.5% of participants reported lingering COVID-19 symptoms, mostly middle-aged Latinas. Hence, prolonged COVID-19 symptoms were common among our underserved population and require public health attention, despite high COVID-19 vaccine uptake. Saliva served as a less-invasive sample-type for IgG-based serosurveys and hCoV cross-reactivity needed to be evaluated for reliable SARS-CoV-2 serosurvey results. The use of the developed rigorous downstream qualitative serological assessment methods will help standardize serosurvey outcomes and meta-analyses for future serosurveys beyond SARS-CoV-2.

Minding the margins: Evaluating the impact of COVID-19 among Latinx and Black communities with optimal qualitative serological assessment tools.

COVID-19 disproportionately affected minorities, while research barriers to engage underserved communities persist. Serological studies reveal infection and vaccination histories within these communities, however lack of consensus on downstream evaluation methods impede meta-analyses and dampen the broader public health impact. To reveal the impact of COVID-19 and vaccine uptake among diverse communities and to develop rigorous serological downstream evaluation methods, we engaged racial and ethnic minorities in Massachusetts in a cross-sectional study (April - July 2022), screened blood and saliva for SARS-CoV-2 and human endemic coronavirus (hCoV) antibodies by bead-based multiplex assay and point-of-care (POC) test and developed across-plate normalization and classification boundary methods for optimal qualitative serological assessments. Among 290 participants, 91.4 % reported receiving at least one dose of a COVID-19 vaccine, while 41.7 % reported past SARS-CoV-2 infections, which was confirmed by POC- and multiplex-based saliva and blood IgG seroprevalences. We found significant differences in antigen-specific IgA and IgG antibody outcomes and indication of cross-reactivity with hCoV OC43. Finally, 26.5 % of participants reported lingering COVID-19 symptoms, mostly middle-aged Latinas. Hence, prolonged COVID-19 symptoms were common among our underserved population and require public health attention, despite high COVID-19 vaccine uptake. Saliva served as a less-invasive sample-type for IgG-based serosurveys and hCoV cross-reactivity needed to be evaluated for reliable SARS-CoV-2 serosurvey results. Using the developed rigorous downstream qualitative serological assessment methods will help standardize serosurvey outcomes and meta-analyses for future serosurveys beyond SARS-CoV-2.

Intrapartum continuous subcutaneous insulin infusion vs intravenous insulin infusion among pregnant individuals with type 1 diabetes mellitus: a randomized controlled trial.

BACKGROUND: Intrapartum glucose management is critical to reducing neonatal hypoglycemia shortly after birth. Although it is known that insulin is required for all pregnant individuals with type 1 diabetes mellitus, the optimal mode of intrapartum glycemic control is not known. OBJECTIVE: This study aimed to compare the effect of intrapartum use of continuous subcutaneous insulin infusion with that of intravenous insulin infusion for glucose management among pregnant individuals with type 1 diabetes mellitus on neonatal blood glucose levels. STUDY DESIGN: This was a randomized controlled trial of pregnant participants with type 1 diabetes mellitus. After written informed consent, participants were randomly allocated to 1 of 2 intrapartum insulin administration strategies: continuation of their continuous subcutaneous insulin infusion or intravenous insulin infusion. The primary outcome was the first neonatal blood glucose level. RESULTS: Between March 2021 and April 2023, 76 participants were approached, and 70 participants were randomized (35 participants in the intravenous insulin infusion group and 35 participants in the continuous subcutaneous insulin infusion group). The groups were similar in terms of age, race/ethnicity, pregravid body mass index, nulliparity, and gestational age at delivery. There was no statistically significant difference in the first neonatal glucose measurement between the 2 groups (50.1±23.4 vs 49.2±22.6; P=.86). In addition, there were no statistically significant differences in any secondary neonatal outcomes. Approximately 57.1% of neonates in the continuous subcutaneous insulin infusion group required either oral, intravenous, or both treatments for hypoglycemia, whereas 51.4% of neonates in the intravenous infusion group required treatment. In both groups, 28.6% of neonates required intravenous treatment for hypoglycemia. CONCLUSION: Pregnant individuals with type 1 diabetes mellitus using either intravenous insulin infusion or continuation of their continuous subcutaneous insulin infusion for intrapartum insulin administration had no difference in the primary outcome of neonatal hypoglycemia. Patients should be given the option of both glycemic management strategies intrapartum.

The microbiota of pregnant women with SARS-CoV-2 and their infants.

BACKGROUND: Infants receive their first bacteria from their birthing parent. This newly acquired microbiome plays a pivotal role in developing a robust immune system, the cornerstone of long-term health. RESULTS: We demonstrated that the gut, vaginal, and oral microbial diversity of pregnant women with SARS-CoV-2 infection is reduced, and women with early infections exhibit a different vaginal microbiota composition at the time of delivery compared to their healthy control counterparts. Accordingly, a low relative abundance of two Streptococcus sequence variants (SV) was predictive of infants born to pregnant women with SARS-CoV-2 infection. CONCLUSIONS: Our data suggest that SARS-CoV-2 infections during pregnancy, particularly early infections, are associated with lasting changes in the microbiome of pregnant women, compromising the initial microbial seed of their infant. Our results highlight the importance of further exploring the impact of SARS-CoV-2 on the infant's microbiome-dependent immune programming. Video Abstract.

Continuous glucose monitor use in type 2 diabetes mellitus in pregnancy and perinatal outcomes: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess whether continuous glucose monitor use in type 2 diabetes mellitus in pregnancy is associated with improved perinatal outcomes. DATA SOURCES: We searched Ovid MEDLINE, Scopus, ClinicalTrials.gov, and Cochrane library from inception through May 9, 2022. STUDY ELIGIBILITY CRITERIA: We included all studies that compared continuous glucose monitor use with fingerstick glucose monitoring in women with type 2 diabetes mellitus. METHODS: The initial search yielded 2463 unique citations that were screened in Covidence by 2 independent reviewers. Study types included randomized controlled trials, cohort studies, and cross-sectional studies. Our outcomes of interest were macrosomia or large-for-gestational-age infants, hemoglobin A1c, cesarean delivery, hypertensive disorders of pregnancy including preeclampsia, gestational age at delivery, and neonatal hypoglycemia. RESULTS: Three randomized controlled trials met the inclusion criteria. We performed random-effects meta-analyses of estimates from 2 studies without risk of significant bias and reported summary adjusted odds ratios and 95% confidence intervals. Meta-analysis of 56 women with continuous glucose monitor use and 53 control women without continuous glucose monitor use showed that there was no difference in the incidence of large-for-gestational-age infants between continuous glucose monitor users and standard-of-care controls (odds ratio, 0.78; 95% confidence interval, 0.34-1.78) with an I2 of 0%. In addition, there was no difference in the development of preeclampsia between continuous glucose monitor users and standard-of-care controls (odds ratio, 1.63; 95% confidence interval, 0.34-7.22) with an I2 of 0%. CONCLUSION: Continuous glucose monitor use was not associated with improved perinatal outcomes as assessed by large-for-gestational-age infants and preeclampsia. This review is limited by the small amount of data available for this population, and further research is needed.

Trends in Screening for Diabetes in Early Pregnancy in the United States.

Objective: The aim of this study was to characterize current diabetes screening practices in the first trimester of pregnancy in the United States, evaluate patient characteristics and risk factors associated with early diabetes screening, and compare perinatal outcomes by early diabetes screening. Methods: This was a retrospective cohort study of US medical claims data of persons diagnosed with a viable intrauterine pregnancy and who presented for care with private insurance before 14 weeks of gestation, without pre-existing pregestational diabetes, from the IBM MarketScan® database for the period January 1, 2016, to December 31, 2018. Univariate and multivariate analyses were used to evaluate perinatal outcomes. Results: A total of 400,588 pregnancies were identified as eligible for inclusion, with 18.0% of persons receiving early screening for diabetes. Of those with laboratory order claims, 53.1% underwent hemoglobin A1c testing, 30.0% underwent fasting glucose testing, and 16.9% underwent oral glucose tolerance testing. Compared with those who did not undergo early diabetes screening, those who did were more likely to be older; obese; having a history of gestational diabetes, chronic hypertension, polycystic ovarian syndrome, or hyperlipidemia; and having a family history of diabetes. In adjusted logistic regression, history of gestational diabetes (adjusted odds ratio 3.99; 95% confidence interval 3.73-4.26) had the strongest association with early diabetes screening. Adverse perinatal outcomes, including a higher rate of cesarean delivery, preterm delivery, preeclampsia, and gestational diabetes, occurred more frequently among women who underwent early diabetes screening. Conclusions: First-trimester early diabetes screening was mostly commonly performed by hemoglobin A1c evaluation, and persons who underwent early diabetes screening were more likely to experience adverse perinatal outcomes.

Investigating demographic differences in patients' decisions to consent to COVID-19 research.

OBJECTIVE: COVID-19 disease severely impacted pregnant persons, resulting in a significant increase in poor maternal health outcomes, with a disproportionate impact on minority populations and individuals with low socioeconomic status. We sought to determine demographic differences between birthing parents with SARS-CoV-2 infections who consented to research study participation versus those who declined. By analyzing demographic differences, we are able to ensure the generalizability of study outcomes and to aid in future prospective research design, with the ultimate goal of recognizing and ameliorating research disparities. METHODS: We conducted a secondary analysis to investigate demographic differences in patients who consented to versus declined study participation, in an effort to confirm the external validity of the study results and ensure minority populations most affected by SARS-CoV-2 infection were accurately represented. An IRB waiver was obtained to conduct retrospective chart review for demographic data collection of all patients approached for the COVID-19 Analysis on Perinatal Specimens Related to ExpoSure (CARES) research study. Pregnant patients with SARS-CoV-2 infection were identified at a single hospital center and approached either in person or via phone, with a translator if primary language listed as non-English. Demographic variables including race, ethnicity, primary language, and insurance type were obtained from the electronic medical record and analyzed via Chi-square to determine significant differences between individuals who consented to participation and those who declined participation. RESULTS: One hundred and fifty-eight pregnant patients with SARS-CoV-2 infection were approached for CARES study participation. Eighty-nine patients consented to study participation, while 69 declined study participation. A retrospective chart review was conducted on all 158 patients. Patients who identified as Black race or non-White race were more likely to decline participation (23.2%, p = .031, 68.1%, p = .026), compared to patients who identified as White (31.9%) (Table 1). Patients with public insurance were also more likely to decline study participation (72.5%, p = .049) compared to those with private insurance (27.5%). There was no significant difference between primary language spoken or ethnicity in patients who participated or declined. There was no difference in study participation between patients who identified as Asian race or Other race, compared to patients who identified as White race. CONCLUSIONS: We found significant differences in race and insurance type between pregnant patients with SARS-CoV-2 infection who consented versus declined research study participation. Our study showed that patients who identify as Black race or have public insurance are less likely to consent to research study participation. However, when demographics of consented patients are compared to county, state, and national demographics of female patients age 18-49 with confirmed SARS-CoV-2 infection obtained from a dataset collected by the Center for Disease Control and Prevention (CDC), there was no significant difference between race representation of patients who consented to study participation. This suggests that though the external validity of the CARES study is confirmed, more efforts need to be made to address racial and socioeconomic disparities in research participation.

Screening test characteristics and comparison of diabetes outcomes among pregnant patients with prediabetes.

This study sought to compare test characteristics of hemoglobin A1c, oral glucose tolerance test and fasting plasma glucose for the development of gestational diabetes among women with prediabetes. Diabetes outcomes were compared by screening test used for prediabetes diagnosis among a retrospective cohort of pregnant patients between 2017-2021. During the study, 8132 patients received diabetes screening and 14.0% met criteria for prediabetes. By screening test, 75.1% were screened with hemoglobin A1c, 10.0% with fasting plasma glucose and 14.9% with a 75-g oral glucose tolerance test. Hemoglobin A1c had the highest positive predictive value (67.2%). Use of hemoglobin A1c was significantly more likely to identify women with GDM than oral glucose tolerance test (aOR 3.94, 95% CI 2.30-6.73). In this study cohort, hemoglobin A1c was able to identify patients that were more likely to develop GDM in an at-risk population.IMPACT STATEMENTWhat is already known on this subject? Prediabetes is becoming more common in the general population; however little is known about prediabetes in pregnancy. Women with prediabetes in pregnancy appear to be at increased risk of developing gestational diabetes mellitus, however there is minimal information about various screening tests performance in pregnancy for detection of prediabetes and subsequent gestational diabetes.What do the results of this study add? The results of this study compare three commonly used screening tests for screening for diabetes. When identifying women with prediabetes, they are at increased risk for developing gestational diabetes mellitus if identified by hemoglobin A1c.What are the implications of these findings for clinical practice and/or further research? The clinical implication of this study is that women can be screened with hemoglobin A1c in early pregnancy for both overt diabetes, but also may be identified as high risk with prediabetes. Among women with prediabetes by hemoglobin A1c, they remain at high risk for developing gestational diabetes mellitus.

Failure to Detect SARS-CoV-2 RNA in the Air During Active Labor in Mothers Who Recently Tested Positive.

The risk of potential SARS-CoV-2 transmission by infected mothers during labor and delivery has not been investigated in-depth. This work collected air samples close to (respiratory droplets) and more distant from (aerosol generation) unvaccinated patients who had previously tested positive for SARS-CoV-2 during labor within 5 days of a positive test. All but one of the patients wore masks during the delivery, and delivery was carried out in either birthing or negative pressure isolation rooms. Our work failed to detect SARS-CoV-2 RNA in any air samples for all of the six patients who gave birth vaginally, despite validation of the limit of detection of the samplers. In sum, this brief report provides initial evidence that the risk of airborne transmission of SARS-CoV-2 during labor may be mitigated by the use of masks and high ventilation rates common in many modern U.S. medical facilities; however more work is needed to fully evaluate the risk of SARS-CoV-2 transmission during labor and maternal pushing.

Prevalence and outcomes of hypertension in pregnancy in non-metropolitan and metropolitan communities.

OBJECTIVES: Hypertension during pregnancy is a leading cause of birthing parent mortality and adverse pregnancy outcomes. Since non-metropolitan communities face higher rates of several risk factors for hypertension in pregnancy and shortages in obstetrical services, persons residing in non-metropolitan areas may be at increased risk for adverse events compared to those living in metropolitan areas. Our study objectives were to examine by non-metropolitan vs. metropolitan birthing parent residence (1) the prevalence of chronic hypertension (cHTN) and hypertensive disorders of pregnancy (HDP), and (2) the prevalence of cesarean delivery, preterm birth, low birth weight, APGAR <7 at 5 min, NICU admission, and stillbirth/neonatal death among the group of birthing parents with cHTN and among the group of birthing parents with HDP. METHODS: Using U.S. Natality data from 2016 to 2018, we described the prevalence of cHTN and HDP and the association of each with several birthing parent and neonatal outcomes, stratified by non-metropolitan versus metropolitan county of birthing parent residence. Multivariable Poisson regression models were used to calculate adjusted prevalence ratios for these adverse outcomes. RESULTS: The prevalence of cHTN among pregnant individuals was 2.2% in non-metropolitan areas and 1.8% in metropolitan areas. For HDP, the prevalence was 7.4% in non-metropolitan areas and 6.6% in metropolitan areas. After adjusting for several sociodemographic characteristics among those with HDP, the prevalence ratio for an APGAR score < 7 at 5 min (aPR 1.34, 95% CI 1.29-1.38) and stillbirth/neonatal death (aPR 1.36, 95% CI 1.15-1.62) was increased among offspring born to birthing parents who resided in non-metropolitan counties. Similar results were seen among those with cHTN. CONCLUSIONS: The prevalence of cHTN and HDP is elevated among birthing parents residing in non-metropolitan areas. Also, the prevalence of APGAR <7 and stillbirth//neonatal death following pregnancies complicated by hypertension were higher among neonates born to birthing parents residing in non-metropolitan areas. Further research should investigate the robustness of these findings using alternate definitions of rural and urban areas and the possible link between low APGAR score, low NICU admission, and stillbirth/neonatal death among birthing parents residing in non-metropolitan counties.

Can sonographic fetal head circumference measurement help predict obstetric anal sphincter injury?

OBJECTIVE: To investigate whether sonographic fetal head circumference (sfHC) size assessed by ultrasound prenatally could help predict OASIS. METHODS: This study is a retrospective cohort study between 2005 and 2016. Antenatal sfHC assessment, maternal demographics, and labor and delivery data were abstracted and compared in women with and without OASIS. RESULTS: Of 2057 pregnant women that had sfHC assessment, 121 (5.8%) had OASIS. In the unadjusted analysis, sfHC above the 90th centile was associated with OASIS (odds ratio [OR] 1.12; 95% confidence interval [CI] 1.02-1.23; P = 0.015). When adjusted for gestational age at delivery, maternal age, race, prolonged second stage, body mass index, infant gender, and intrapartum oxytocin use, sfHC above the 90th centile remained significantly associated with OASIS (OR 1.13, 95% CI 1.00-1.27, P = 0.050). CONCLUSION: In our cohort, sfHC above the 90th centile was associated with a greater risk of OASIS. As OASIS significantly impacts both short-term and long-term health outcomes, such as perineal pain, dyspareunia, and urinary and fecal incontinence, sfHC could be an additional prenatal marker to help clinicians counsel pregnant women about the risk of OASIS.

Morbidity associated with the use of Foley balloon for cervical ripening in women with prior cesarean delivery.

OBJECTIVE: We evaluated the morbidity of Foley balloon for cervical ripening in comparison to oxytocin alone in women with a prior cesarean delivery. STUDY DESIGN: A four-hospital retrospective review of all women with viable singleton pregnancies and history of a single prior cesarean delivery presenting for cervical ripening between 1994 and 2015. Exposure groups were either Foley balloon or oxytocin, at the treating physician's discretion. The primary outcome was defined as maternal morbidity, evaluated by a composite that included hemorrhage, and/or uterine infection, and/or uterine rupture. We defined two secondary outcomes: neonatal morbidity, and vaginal delivery rate. Neonatal morbidity was evaluated by a composite that included five-minute APGAR score <7 and/or NICU admission. We adjusted results for potential confounding variables, including hospital site, maternal age and race, initial cervical dilation, and gestational age at delivery. RESULTS: We identified 688 patients who received ripening, 276 by Foley balloon and 412 by oxytocin. There was no significant difference in the primary outcome of maternal morbidity between groups: 38 (13.8%) in the Foley balloon group and 79 (19.2%) in the oxytocin group (aOR 1.43; 95% CI, 0.90-2.27). There was no significant difference in the secondary outcome of neonatal morbidity: 31 (11.3%) in the Foley balloon group and 51 (12.4%) in the oxytocin group (aOR 1.02; 95% CI, 0.57-1.80). The rate of vaginal delivery was significantly less in the Foley balloon group compared to the oxytocin group: 56.2% vs 64.1%, p = .037. CONCLUSION: When cervical ripening with either Foley balloon or oxytocin was utilized at the physician's discretion in women with prior cesarean, there was no identified difference in maternal and neonatal morbidity, but the rate of successful vaginal delivery was lower.

Optimal timing of the second trimester fetal ultrasound in the obese gravida.

OBJECTIVES: Obesity is increasingly prevalent in the obstetric patient population, becoming one of the most commonly occurring risk factors in obstetric practice. Obesity has implications for maternal and fetal morbidity; in fact, some data suggest it is associated with higher rates of fetal anomaly. Coincident with this, maternal obesity poses an inherent challenge for ultrasound quality. The objective of this study is to investigate the relationship between ultrasound completion rates and advancing gestational age in obese gravidas, and to help identify an ideal gestational age to perform the second trimester ultrasound for fetal evaluation in the obese patient population. We hypothesized that in the obese patient, the odds of a completed scan would increase with each gestational age week, as fetal size increases. METHODS: This is a retrospective cohort study at a single tertiary care center. Inclusion criteria were pregnant women with BMI greater than 30 who had second trimester fetal ultrasound and delivery at our institution. Exclusion criteria were pregnancies without documented BMI, ultrasound not performed between 18 0/6 and 21 6/7 weeks, multiple gestations, or ultrasound performed for indication other than fetal anatomic assessment. Ultrasound reports were considered incomplete if they indicated suboptimal or non-visualization of any anatomic structures included in the comprehensive anatomic survey. Demographic data was compared using Student's t test and chi-square analysis where appropriate. Chi-square analysis was used to compare rates of completed surveys. p < .05 was considered significant. RESULTS: After application of eligibility criteria, our cohort included 1,954 subjects. When comparing subjects with a completed scan to those with an incomplete scan, there were more white subjects in the incomplete group (p = .012), but other analyzed demographics were similar between groups. When using 18 weeks as a referent group, with each additional completed week of gestation, subjects were more likely to have a completed scan, at 19 weeks (OR 1.29, CI 1.05-1.58); at 20 weeks (OR 1.46, CI 1.1-1.95); at 21 weeks (OR 2.12, CI 1.42-3.17) (p < .05 for each). This association persisted when adjusting for demographic factors. To identify the optimal timing for the second trimester ultrasound for fetal evaluation, we re-analyzed the data using each completed week of gestational age as the referent group. When using 19 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, and higher at 21 weeks, but not different at 20 weeks. When using 20 weeks as the referent group, the odds of a complete scan were lower at 18 weeks, but not different at 19 or 21 weeks. Finally, when using 21 weeks as the referent group, the odds of a complete scan were lower at 18 and 19 weeks, but not different at 20 weeks. CONCLUSIONS: In this cohort of obese gravidas, the odds of having a completed anatomic survey continued to improve until 21 weeks gestational age. When comparing completed scans between each week, 18 weeks demonstrated consistently lower odds of a complete scan, however 20 weeks did not differ significantly from 19 weeks. Therefore, consideration should be made to perform the initial second trimester ultrasound for fetal evaluation in obese patients at 19 weeks gestational age to optimize completion rates while minimizing scans performed at advancing gestational ages.

Cardiac and Obstetric Outcomes Associated With Mitral Valve Prolapse.

Mitral valve prolapse (MVP) is the most common valvular heart disease in women of reproductive age. Whether MVP increases the likelihood of adverse outcomes in pregnancy is unknown. The study objective was to examine the cardiac and obstetric outcomes associated with MVP in pregnant women. This retrospective cohort study, using the Healthcare Cost and Utilization Project National Readmission Sample database between 2010 and 2017, identified all pregnant women with MVP using the International Classification of Disease, Ninth and Tenth Revisions codes. The maternal cardiac and obstetric outcomes in pregnant women diagnosed with MVP were compared with women without MVP using multivariable logistic and Cox proportional hazard regression models adjusted for baseline demographic characteristics. There were 23,000 pregnancy admissions with MVP with an overall incidence of 16.9 cases per 10,000 pregnancy admissions. Pregnant women with MVP were more likely to die during pregnancy (adjusted hazard ratio 5.13, 95% confidence interval [CI] 1.09 to 24.16), develop cardiac arrest (adjusted odds ratio [aOR] 4.44, 95% CI 1.04 to 18.89), arrhythmia (aOR 10.96, 95% CI 9.17 to 13.12), stroke (aOR 6.90, 95% CI 1.26 to 37.58), heart failure (aOR 5.81, 95% CI 3.84 to 8.79), or suffer a coronary artery dissection (aOR 25.22, 95% CI 3.42 to 186.07) compared with women without MVP. Pregnancies with MVP were also associated with increased risks of preterm delivery (aOR 1.21, 95% CI 1.02 to 1.44) and preeclampsia/hemolysis, elevated liver enzymes, and low platelets syndrome (aOR 1.22, 95% CI 1.05 to 1.41). In conclusion, MVP in pregnancy is associated with adverse maternal cardiac outcomes and higher obstetric risks.

Comparison of intrapartum glycemic management strategies in pregnant women with type 1 diabetes mellitus.

BACKGROUND: Achieving intrapartum maternal euglycemia in women with type 1 diabetes mellitus (T1DM) is critical to reducing the risk of neonatal hypoglycemia. OBJECTIVE: This study sought to compare the maternal and neonatal outcomes among women with T1DM by different intrapartum glycemic control strategies of continuation of subcutaneous insulin pumps versus intravenous insulin infusion. METHODS: A retrospective cohort study was performed to identify all women with type 1 diabetes mellitus in pregnancy between 1 October 2017 and 1 August 2020 at our tertiary medical center. Medical records were reviewed for sociodemographic, clinical characteristics, and perinatal outcomes. A composite neonatal outcome was created to include one or more of the following outcomes: 5-minute APGAR less than 7, neonatal intensive care unit admission, neonatal hypoglycemia, or respiratory distress. RESULTS: We identified 75 women with T1DM that met inclusion criteria, 27(36%) who remained on their subcutaneous insulin pump and 48(64%) who were transitioned to intravenous insulin infusion intrapartum. Women that continued subcutaneous insulin were more likely to be older (30.5 vs. 28.1, p = .04), multiparous (74% vs. 50%, p = .042), and have a continuous glucose monitor (CGM) (93% vs. 43%, p < .001). There was no difference in maternal hypoglycemic events (14.8% vs. 18.8%, p = .76) or severe hyperglycemia (greater than 250 mg/dL)/development of diabetic ketoacidosis (3.7% vs. 4.2%, p = .99) in labor between both groups. There was no difference in neonatal composite outcome when adjusted for gestational age at delivery, maternal age, parity, and CGM use for both groups (aOR 0.73, 95% CI 0.12-4.43, p = .728). CONCLUSION: Continuation of subcutaneous insulin in the intrapartum period appears to be a reasonable option in women with T1DM, however future, larger studies are needed to confirm this. Both patient and provider must be comfortable with this intrapartum strategy for effective glycemic control.

Early Diagnosis of Prediabetes among Pregnant Women that Develop Gestational Diabetes Mellitus and Its Influence on Perinatal Outcomes.

OBJECTIVE: Purpose of this study was to determine whether early identification of impaired glucose tolerance consistent with prediabetes among pregnant women with gestational diabetes mellitus (GDM) in the first trimester impacts maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of patients who were screened for pregestational diabetes in early pregnancy at a large academic tertiary care center from October 1, 2017, to January 31, 2021, and who subsequently developed GDM. Demographic and perinatal outcomes were compared among women with GDM with a positive early diabetes screen consistent with prediabetes to women who screened negative in the first trimester. Multivariable logistic regression was performed to adjust for baseline demographic differences. RESULTS: During the study period, 260 women screened had negative first trimester diabetes screening and subsequently developed GDM, while 696 screened positive for prediabetes and developed GDM. Women with prediabetes were more likely to require insulin treatment for their GDM compared with those that screened negative (79.5 vs. 45.4%, p < 0.001), while those who screened negative were more likely to take an oral medication of metformin or glyburide for GDM management than those with prediabetes (41.5 vs. 16.4%, p < 0.001). Infants born to mothers who screened positive for prediabetes were more likely to require neonatal intensive care unit (NICU) admission compared with those who screened negative even when adjusted for type of GDM treatment used (adjusted odds ratio [aOR] = 8.5, 95% confidence interval [CI]: 1.5-49.9). CONCLUSION: Women identified as having early impaired glucose tolerance consistent with prediabetes that subsequently develop GDM are more likely to be prescribed insulin treatment and may be at increased risk of adverse neonatal outcomes leading to NICU admission than women with negative first trimester diabetes screening. Future studies should focus on whether different methods of early treatment and/or intervention improve perinatal outcomes. KEY POINTS: · Prediabetes in early pregnancy is associated with higher rates of insulin treatment for GDM.. · Prediabetes in pregnancy increases the risk of developing GDM.. · Prediabetes in early pregnancy is associated with higher rates of NICU admission..

Humoral and Cell-Mediated Immune Response in Colostrum from Women Diagnosed Positive for SARS-CoV-2.

Objective: To evaluate the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in colostrum from women who tested positive for the virus. Methods: Between March and September 2020 we obtained bilateral colostrum samples collected on spot cards within 48 hours of delivery from 15 new mothers who had previously tested positive for SARS-CoV-2. Four of 15 women provided liquid colostrum, which was used for validating results obtained from spot cards. Archived bilateral colostrum samples collected from 8 women during 2011-2013 were used as pre-coronavirus disease 2019 (COVID-19) controls. All samples were tested for reactivity to the receptor binding domain (RBD) of the SARS-CoV-2 spike protein using an enzyme-linked immunosorbent assay that measures SARS-CoV-2 RBD-specific IgA, IgG, and IgM and for levels of 10 inflammatory cytokines (interferon-gamma [IFN-γ], tumor necrosis factor-alpha, interleukin [IL]-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13) using a multiplex electrochemiluminescent sandwich assay. Results: Our validation studies indicate that the levels of SARS-CoV-2-specific antibodies and the associated cytokines measured in liquid colostrum are comparable to levels eluted from spot cards. Bilateral colostrum samples from 73%, 73%, and 33% of the 15 COVID-19 mothers exhibited IgA, IgG, and IgM reactivity to RBD, respectively. In addition, symptomatic COVID-19 mothers had statistically significant elevated levels of 4 of the 10 inflammatory markers (IFN-γ, IL-4, IL-6, and IL-12) compared to asymptomatic COVID-19 mothers. Conclusions: A strong humoral immune response is present in the colostrum of women who were infected with SARS-CoV-2 before delivering. The evolution and duration of the antibody response, as well as dynamics of the cytokine response, remain to be determined. Our results also indicate that future large-scale studies can be conducted with milk easily collected on paper spot cards.

Optimizing Care Preconception for Women With Diabetes and Obesity.

The prevalence of diabetes in reproductive age women has been reported to be as high as 6.8%, with pregestational diabetes affecting 2% of all pregnancies. As cases of diabetes in children and adolescents rise, more patients will be entering reproductive age and pregnancy with diagnoses of obesity, prediabetes, type 2 diabetes. Early interventions of diet modification and exercise to maintain healthy weights can delay or even prevent these complications. It is critical for health care providers to emphasize the importance of preconception counseling in this high-risk patient population to reduce the morbidities associated with obesity and diabetes in pregnancy.

Enoxaparin Effect on Pregnancy Outcomes in a Patient with Elevated Plasminogen Activator Inhibitor-1.

BACKGROUND: Plasminogen activator inhibitor-1 (PAI-1) inhibits tPA and creates a prothrombotic state. Gene polymorphisms of PAI-1 are associated with elevated levels and adverse pregnancy outcomes. CASE: A 36-year-old gravida 6, para 1-1-3-1 with elevated prepregnancy PAI-1 levels, a history of early-onset preeclampsia with severe features superimposed on chronic hypertension, intrauterine growth restriction (IUGR), and recurrent pregnancy loss (RPL), presented with a dichorionic-diamniotic twin gestation. She was managed with aspirin and enoxaparin and delivered appropriately grown twins at 36 weeks and 3 days, due to the development of preeclampsia superimposed on chronic hypertension. She was discharged not on enoxaparin and represented with pulmonary edema on postoperative day 8. CONCLUSION: It is reasonable to consider testing certain patients with recurrent pregnancy loss and/or early preeclampsia with severe features for PAI-1. If levels are elevated, treatment with prophylactic enoxaparin may be beneficial. Further research is needed to determine the effect of this therapy in patients with exceedingly poor perinatal outcomes to better assess for any impact on improved outcomes.

Growth restriction: identifying fetuses at risk.

PURPOSE: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10-20th%, and compare outcomes using umbilical artery Doppler (UAD). MATERIALS AND METHODS: Retrospective, cohort evaluating ultrasound (US) EFW 10-20th%, between 2002 and 2012. Cases were identified with EFW % 10-20. Controls, EFW >20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes. RESULTS: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10-20th% (GA 33.6 ± 3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2-68.7], p < .01), small for gestational age (SGA) (OR 9.2 [6.9-12.3], p < .01), neonatal intensive care unit (NICU) admissions (OR 2.4 [1.6-3.6], p < .01), and composite perinatal morbidity (OR 7.8 [6.0-10.1], p < .01) on adjusted analyses. Abnormal UAD in cases had greater rates of 5 min Apgar <7, NICU admission and composite morbidity (p < .05). CONCLUSIONS: Pregnancies with EFW 10-20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.