Including Pregnancy Complications Research Articles

Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State

BackgroundEvidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown.ObjectiveThis study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality.Study DesignPregnant patients with a polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery.ResultsThe principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019–associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3–5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257–3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7–43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, −0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001).ConclusionCoronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.

Maternal and child-health outcomes in pregnancies following Assisted Reproductive Technology (ART): a prospective cohort study

BackgroundStudies comparing the outcome of spontaneous versus assisted reproductive technologies (ART) pregnancies report heterogeneous results. Despite the success of ART to overcome infertility, concern is growing regarding both its safety and its effect on maternal and child health. The objective of this study was to compare maternal and child-health outcomes after ART relative to natural conception.MethodsA population-based birth cohort study was carried out among pregnant women expected to deliver in 2015 in Pelotas, southern Brazil. Maternal outcomes included pregnancy complications and gestational weight gain. Gestational age, weight, intrauterine growth restriction, length and head circumference, and 1-min and 5-min Apgar, as well as health problems at birth and breastfeeding were defined as offspring outcomes. Statistical analyses were performed using linear and logistic regression. G-formula was used to perform mediation analysis.ResultsThe study included 4252 babies born by spontaneously pregnancies and 23 babies born after ART. Adjusted analyses showed that children conceived from ART presented lower means of gestational age (p = 0.001), birth weight (p = 0.002), length (p < 0.001), and head circumference at birth (p = 0.02). However, more than 90% of the effect of ART over these outcomes was mediated by multiple pregnancy.ConclusionOur findings suggest that the possible negative effect on the child-health outcomes is due mainly to the higher incidence of multiple pregnancies and not because of ART. The reasons for the increase in adverse pregnancy outcomes associated with ART singleton pregnancies are still uncertain and warrants further research. Further large-population studies are needed to confirm these results.

1618. Public Health at the United States/Mexico Border: Evaluation of the County of San Diego Health and Human Services Agency’s Health Screening Assessment of Asylum-Seeking Families at the San Diego Rapid Response Network Shelter

BackgroundMany families arrive at the United States–Mexico border seeking asylum. Jewish Family Service and the San Diego Rapid Response Network operate a shelter in San Diego that provides shelter, food, clothing, legal services and travel coordination for asylum-seeking families. Two local federally qualified health centers provide on-site urgent care.MethodsIn late December 2018, the County of San Diego expanded public health efforts by conducting health screenings of guests upon entry to the shelter with the goal of identifying health issues requiring urgent or emergent evaluation and preventing the spread of communicable disease. University of California San Diego Health physicians contracted by the County of San Diego Health and Human Services Agency (HHSA) nurses and ancillary staff provide daily on-site services to all shelter entrants including: health screening for diseases of public health significance, treatment and/or referral of urgent conditions, and medical clearance for shelter entry or medical isolation as needed. Official tracking of screening outcomes from January 2 to April 24, 2019 were collected using standardized surveys and analyzed for program evaluation and surveillance purposes.ResultsDuring that time a total of 9,124 asylum-seekers were screened, averaging 81 guests daily, identifying: 42 influenza-like illness, 645 lice, 330 scabies, 8 varicella, and 0 hepatitis A cases. Chest radiography for suspected tuberculosis was performed for 29 guests. Only one chest x-ray was abnormal. Sputum specimens for acid-fast stain (n = 3) and nucleic acid testing (n = 2) were all negative and no tuberculosis cases were diagnosed. Emergency department referrals were made for <1% of guests (n = 90) for conditions including pregnancy complications, asthma, dysentery, hemoptysis and fractures. No deaths or outbreaks of communicable disease occurred.ConclusionCoordination among local partner agencies resulted in early identification of communicable and acute health conditions prior to shelter entry allowing evaluation, treatment and off-site isolation, and minimizing stress on the emergency medical services system. This approach provides a successful model for health screening of asylum-seeking families arriving at the United States–Mexico border. Disclosures All authors: No reported disclosures.

Common Diagnoses among Refugee Populations: Linked Results with Statewide Hospital Discharge Database.

Background:According to the U.S. State Department’s Refugee Processing Center and the U.S. Census Bureau, in the fiscal year 2016, among all states in the United States, Nebraska resettled the highest number of refugees per capita.Objectives:The objectives of this study were to determine the most common reasons for refugees utilizing hospital services in Nebraska between January 2011 and September 2015, and to examine whether refugee patients had increased risks for adverse health conditions compared to non-refugee patients.Methods:Statewide linkage was performed between Nebraska Medicaid Program’s immigration data, and 2011–2015 Nebraska hospital discharge data inpatient and outpatient files. The linkage produced 3017, 5460, and 775 cases for emergency department visits, outpatient clinic visits, and inpatient care for the refugee sample, respectively.Findings:Refugee patients were at increased risk for a number of diagnoses or medical conditions, including pregnancy complications, abdominal pain, upper respiratory infections, viral infections, mood disorders, disorders of teeth and jaw, deficiency and anemia, urinary system disorders, headache, nausea and vomiting, limb fractures, spondylosis, essential hypertension, and uncomplicated diabetes mellitus.Conclusions:The findings suggest a greater emphasis on preventive healthcare, especially in areas of maternal health and perinatal outcomes, psychological counseling, screening for infectious diseases, nutrition and healthy eating, and oral health. Additionally, culturally appropriate measures to address prevention, health screening, and treatments should be adopted by health providers who care for refugees.

Cardiovascular Risk Factors in Women with History Hypertensive Disorder of Pregnancy Seen at Post Partum Maternal Health Clinic: A Retrospective Study

Cardiovascular disease is the leading cause of death in Canadian women. Women have unique risk factors for cardiovascular disease (CVD) including pregnancy complications such as hypertensive disorders of pregnancy, gestational diabetes, idiopathic preterm birth, and intrauterine growth restriction which impact close to 20% of women. Hypertensive Disorders of Pregnancy (HDP) were identified as risk factor for CVD in the 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Sunnybrook Health Science Centre implemented an inter-professional post-partum maternal health clinic (4P Maternal Health Clinic) in 2014 for women whose pregnancy was complicated by a HDP.

Women Postpartum Cardiovascular Health: What Do Women Need to Know About Their Heart Health When Meeting Their Family Physician After Pregnancy?

Due to transitions between community and inpatient care, family physicians are often unaware of their patients’ pregnancy history that may include pregnancy complications associated with early cardiovascular disease. A postcard containing targeted information on pregnancy risk factors was developed to determine whether patient education material could help both patients and family doctors to better manage women’s cardiovascular health after pregnancy.

Pregnancy outcomes after liver transplantation in Finland.

Pregnancy after liver transplantation is possible but associated with increased risk of obstetrical complications. We report here for the first time the pregnancy outcomes after liver transplantation in Finland. All of the 25 pregnancies ending in deliveries after liver transplantation in Finland in 1998-2015 were analyzed. The data were collected from the mothers' medical records. The main outcome measures included pregnancy complications and the mode of delivery. Neonatal outcome measures were birthweight, 5-min Apgar score and umbilical artery pH. Twenty-six infants were born. Of all deliveries, 76% occurred at the ≥37 weeks of gestation and the average birthweight was 3040 g. Apgar scores were ≥7 in 25/26 (96%) of the infants and cases of birth asphyxia (umbilical artery pH ≤ 7.05) were not detected. Cesarean section rate was 32%. Preeclampsia occurred in 12% of the women and the preterm delivery rate was 24%. Co-morbidities (hypertension, intrahepatic cholestasis of pregnancy, Hodgkin's disease, colitis ulcerosa, epileptic attacks, cholangitis, splenic artery rupture, renal insufficiency and graft rejection) complicated 52% of pregnancies. Pregnancies after liver transplantation in Finland result in good perinatal outcome with healthy, mostly full-term, normally grown offspring; however, serious maternal complications related to underlying liver pathology, transplant surgery and immunosuppressive medication occur frequently.

Self-Reported Oil Spill Exposure and Pregnancy Complications: The GROWH Study.

Adverse infant outcomes often rise in the aftermath of disaster, but few studies have assessed the effects of disaster on maternal health. 1091 southern Louisiana women were interviewed about their pregnancy history, including pregnancy complications. Associations between oil spill exposures and gestational diabetes, hypertensive disorders, and nausea/vomiting were assessed for all reported pregnancies. 631 women had a pregnancy both before and after the oil spill. Generalized estimating equations (logistic regression) with adjustment for confounders were used. To assess possible unmeasured confounding, instead of considering oil spill exposure as a time-varying exposure, women were defined as oil spill-exposed or not. If oil spill-exposed women were equally prone to complications in pregnancies that occurred prior to the oil spill as after it, it was considered that any associations were likely due to selection or reporting issues. Women who reported oil spill exposure, particularly loss of use of the coast, were more likely to report gestational diabetes; however, the level of association was similar for pregnancies before and after the spill (p for interaction >0.10 and odds ratios (ORs) for pregnancies prior to the spill > than those after the spill). No associations were found between oil spill exposure and hypertensive disorders. This analysis does not suggest an increased risk of pregnancy complications associated with exposure to the oil spill; however, future studies should assess exposure and outcomes prospectively and clinically instead of relying on self-report.

Risk Factors for Pregnancy-Associated Stroke in Women With Preeclampsia.

Preeclampsia affects 3% to 8% of pregnancies and increases risk of pregnancy-associated stroke (PAS). Data are limited on which women with preeclampsia are at highest risk for PAS. Using billing data from the 2003 to 2012 New York State Department of Health inpatient database, we matched women with preeclampsia and PAS 1:3 to preeclamptic controls based on age and race/ethnicity. Pre-defined PAS risk factors included pregnancy complications, infection present on admission, vascular risk factors, prothrombotic states, and coagulopathies. We constructed multivariable conditional logistic regression models to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for independent risk factors for PAS. Among women aged 12 to 55 years admitted to New York State hospitals for any reason during the study period (n=3 373 114), 88 857 had preeclampsia, and 197 of whom (0.2%) had PAS. In multivariable analysis, women with preeclampsia and stroke were more likely than controls to have severe preeclampsia or eclampsia (OR, 7.2; 95% confidence interval [CI], 4.6-11.3), infections present on admission (OR, 3.0; 95% CI, 1.6-5.8), prothrombotic states (OR, 3.5; 95% CI, 1.3-9.2), coagulopathies (OR, 3.1; 95% CI, 1.3-7.1), or chronic hypertension (OR, 3.2; 95% CI, 1.8-5.5). Additional analyses matched and stratified by severity of preeclampsia confirmed these results. Infections, chronic hypertension, coagulopathies, and underlying prothrombotic conditions increase PAS risk in women with preeclampsia. These women may warrant closer monitoring.

Interventions for treating hyperemesis gravidarum.

Interventions for treating hyperemesis gravidarum.

MTHFR deficiency or reduced intake of folate or choline in pregnant mice results in impaired short-term memory and increased apoptosis in the hippocampus of wild-type offspring

Genetic or nutritional disturbances in one-carbon metabolism, with associated hyperhomocysteinemia, can result in complex disorders including pregnancy complications and neuropsychiatric diseases. In earlier work, we showed that mice with a complete deficiency of methylenetetrahydrofolate reductase (MTHFR), a critical enzyme in folate and homocysteine metabolism, had cognitive impairment with disturbances in choline metabolism. Maternal demands for folate and choline are increased during pregnancy and deficiencies of these nutrients result in several negative outcomes including increased resorption and delayed development. The goal of this study was to investigate the behavioral and neurobiological impact of a maternal genetic deficiency in MTHFR or maternal nutritional deficiency of folate or choline during pregnancy on 3-week-old Mthfr+/+ offspring. Mthfr+/+ and Mthfr+/− females were placed on control diets (CD); and Mthfr+/+ females were placed on folate-deficient diets (FD) or choline-deficient diets (ChDD) throughout pregnancy and lactation until their offspring were 3weeks of age. Short-term memory was assessed in offspring, and hippocampal tissue was evaluated for morphological changes, apoptosis, proliferation and choline metabolism. Maternal MTHFR deficiency resulted in short-term memory impairment in offspring. These dams had elevated levels of plasma homocysteine when compared with wild-type dams. There were no differences in plasma homocysteine in offspring. Increased apoptosis and proliferation was observed in the hippocampus of offspring from Mthfr+/− mothers. In the maternal FD and ChDD study, offspring also showed short-term memory impairment with increased apoptosis in the hippocampus; increased neurogenesis was observed in ChDD offspring. Choline acetyltransferase protein was increased in the offspring hippocampus of both dietary groups and betaine was decreased in the hippocampus of FD offspring. Our results reveal short-term memory deficits in the offspring of dams with MTHFR deficiency or dietary deficiencies of critical methyl donors. We suggest that deficiencies in maternal one-carbon metabolism during pregnancy can contribute to hippocampal dysfunction in offspring through apoptosis or altered choline metabolism.

Bridging the gaps: An early integrated support collaborative for at risk mothers in rural Maine.

The antecedents that contribute to health disparities in maternal child health populations begin before birth and extend into the early prenatal and gestational growth periods. Mothers and infants living in rural poverty in particular are at considerable risk for problems associated with reproductive health, including pregnancy complications and premature births. The aim of this manuscript is thus two-fold, to describe the epidemiologic makeup of the community and the intervention model of the Community Caring Collaborative. Innovative models of early-integrated care for high-risk mothers and children are showing promise for long-term outcomes. They foster environments that enable mothers to trust health systems while maintaining a workforce of high functioning health workers who understand the mechanisms that underpin maternal and child health disparities. The Community Caring Collaborative in Washington County, Maine developed one such model that has made inroads in bridging such gaps. This manuscript explicates a case study of how the Community Caring Collaborative came into being and why it established the Bridging model of comprehensive care. The focus of this manuscript is thus two-fold, the community and the intervention model. The "bridging model" develops trust-based relationships between high-risk mothers with the health system and its multiple resources. Community members with advanced training provide the support and care linkages that are critical for family success. Innovative models of collaborative care impact the health of vulnerable mothers and their children working toward a marked decrease in health related disparities.

Prenatal Screening Using Maternal Markers.

Maternal markers are widely used to screen for fetal neural tube defects (NTDs), chromosomal abnormalities and cardiac defects. Some are beginning to broaden prenatal screening to include pregnancy complications such as pre-eclampsia. The methods initially developed for NTDs using a single marker have since been built upon to develop high performance multi-maker tests for chromosomal abnormalities. Although cell-free DNA testing is still too expensive to be considered for routine application in public health settings, it can be cost-effective when used in combination with existing multi-maker marker tests. The established screening methods can be readily applied in the first trimester to identify pregnancies at high risk of pre-eclampsia and offer prevention though aspirin treatment. Prenatal screening for fragile X syndrome might be adopted more widely if the test was to be framed as a form of maternal marker screening.

Genetically induced oxidative stress in mice causes thrombocytosis, splenomegaly and placental angiodysplasia that leads to recurrent abortion

Historical data in the 1950s suggests that 7%, 11%, 33%, and 87% of couples were infertile by ages 30, 35, 40 and 45, respectively. Up to 22.3% of infertile couples have unexplained infertility. Oxidative stress is associated with male and female infertility. However, there is insufficient evidence relating to the influence of oxidative stress on the maintenance of a viable pregnancy, including pregnancy complications and fetal development. Recently, we have established Tet-mev-1 conditional transgenic mice, which can express the doxycycline-induced mutant SDHCV69E transgene and experience mitochondrial respiratory chain dysfunction leading to intracellular oxidative stress. In this report, we demonstrate that this kind of abnormal mitochondrial respiratory chain-induced chronic oxidative stress affects fertility, pregnancy and delivery rates as well as causes recurrent abortions, occasionally resulting in maternal death. Despite this, spermatogenesis and early embryogenesis are completely normal, indicating the mutation's effects to be rather subtle. Female Tet-mev-1 mice exhibit thrombocytosis and splenomegaly in both non-pregnant and pregnant mice as well as placental angiodysplasia with reduced Flt-1 protein leading to hypoxic conditions, which could contribute to placental inflammation and fetal abnormal angiogenesis. Collectively these data strongly suggest that chronic oxidative stress caused by mitochondrial mutations provokes spontaneous abortions and recurrent miscarriage resulting in age-related female infertility.

Prevalence of Trichomonas vaginalis and HIV co-infection among asymptomatic pregnant women in Zaria, northern Nigeria

Background: Trichomonas vaginalis infection is the most common curable, sexually transmitted infection worldwide. Serious adverse reproductive health outcomes including pregnancy complications, pelvic inflammatory disease, and an increased risk of human immunodeficiency virus (HIV) acquisition have been linked to T. vaginalis infection. Objective: To determine the prevalence of T. vaginalis in asymptomatic pregnant women and their HIV status in Ahmadu Bello University Teaching Hospital, Zaria, northern Nigeria. Materials and Methods: This was a prospective cross-sectional descriptive study conducted using a proforma to obtain demographic and reproductive health information from consenting pregnant women attending the antenatal clinic. Vaginal swab and blood samples were taken and analyzed for T. vaginalis and HIV, respectively. Data were analyzed using Statistical Package for Social Science (SPSS) V17, with the level of significance set at 5% . Results: The overall prevalence of T. vaginalis was 19.2%. There was an inverse relationship between the level of education and acquisition of T. vaginalis infection in pregnancy; women having no formal education had a higher prevalence of the T. vaginalis infection (7.5%) as against those who had tertiary education (1.7%). The 26-30 years age group had the highest prevalence of both HIV infection (5.0%) and T. vaginalis infection (5.8%), strongly suggesting the possibility of co-infection between the two agents. There was a statistically significant association between T. vaginalis infection and HIV infection with a P value of 0.0003. The relative risk (RR) of acquiring HIV in the presence of T. vaginalis infection was 4 (RR: 4.193; Confidence Interval: 1.756-10.01). Conclusion: Improvement of the socioeconomic status and education of women, especially sexual health; will reduce the prevalence of T. vaginalis and HIV co-infection.

Oxidative status shifts in uterine cervical incompetence patients

Uterine cervical incompetence (UCI) is a pregnancy complication affecting about 10% of the pregnancies in the western world. Studying the etiology of the UCI requires a specific approach adequate for this highly heterogenous syndrome. Oxidative status disorders are associated with various pathologies, including pregnancy complications. As such, general oxidative status profiling is a promising methodology to treat UCI. We aimed at assaying the closely interrelated oxidative status markers in the uterine cervical incompetence patients by means of the systems biology-oriented approach. Chemiluminescent assay, circulating thioredoxin 1 protein, uric acid, and homocysteine level measurements were used to assess the character of the oxidative status regulation in the UCI patients. We found UCI to be associated with the atypical plasma oxidative status deregulation; UCI plasma samples demonstrated lowered proneness to the pro-oxidative processes, and this was not due to the excessive antioxidant activity. There were neither signs of oxidative stress nor destructive pro-oxidant feedforward circuit locking in the UCI group. We also report increased circulating levels of uric acid in the UCI patients.

Celiac disease serum markers and recurrent pregnancy loss

Celiac disease has been associated with numerous unfavorable health outcomes, including pregnancy complications such as infertility, preterm birth, and preeclampsia. However, the association between celiac disease and recurrent pregnancy loss (RPL) remains uncertain. Our purpose was to compare serum markers of celiac disease in women with and without RPL. Therefore, we performed a case–control study of 116 women with unexplained recurrent pregnancy loss and 116 age-matched controls. Maternal sera were analyzed for immunoglobulin A (IgA) and immunoglobulin G (IgG) tissue transglutaminase (tTG) antibodies and endomysial (EM) antibodies. Groups were similar with regard to age, race and ethnicity, and BMI. One case and one control tested positive (≥20Units) for IgA tTG antibodies and mean levels of IgA tTG antibodies were similar in cases and controls (5.5±2.86 versus 6.0±12.45; p=0.16). No cases or controls were positive for IgG tTG antibodies. However, cases had higher levels of IgG tTG antibody compared with controls (4.0±2.40 versus 3.3±1.30; p=0.0064). One subject (a control) tested positive for IgA EM antibodies and no subjects tested positive for IgG EM antibodies. In conclusion, positive results for tTG and EM antibodies were similar in women with and without RPL. Given these results, testing for occult celiac disease is not recommended in the evaluation of women with idiopathic RPL.

Sexually transmitted infections and women’s sexual and reproductive health

Sexually transmitted infections (STIs) are widespread globally and result in a large burden of sexual and reproductive health consequences that disproportionately affect women, including pregnancy complications, cancer, infertility, and enhanced HIV transmission. A new WHO publication, available online, outlines key points of action and new and future technologies for global STI prevention and control. Highlights from the WHO publication are described in the present article.

Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies.

Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection worldwide. Annually, 7.4 million new infections are estimated in the United States, which is greater than combined new cases of Chlamydia, gonorrhea, and syphilis. Serious adverse reproductive health outcomes including pregnancy complications, pelvic inflammatory disease, and an increased risk of HIV acquisition have been linked to TV infection. There are several sensitive and specific diagnostic tests available, including a newly approved nucleic acid amplification test (NAAT) that utilizes the same instrumentation platform and clinical sample as Chlamydia and gonorrhea tests. In this article, we review TV pathogenicity, adverse reproductive health outcomes, detection, and treatment followed by clinical scenarios for which TV diagnosis may prove useful in obstetrics and gynecology practice.

OBSTETRIC ANTIPHOSPHOLIPID SYNDROME - A REVIEW

The Antiphospholipid syndrome (APS) is one of the current hot topics embracing rheumatology and obstetrics.The first clinical description of APS was in 1983. Venous or arterial thrombosis, abortion and cerebral manifestations along with circulating antibodies were the first described hallmarks of the syndrome. In the following years other clinical features, which include pregnancy complications, such as recurrent miscarriages (RM), pre-eclampsia or severe placental insufficiency were described.