(N Engl J Med. 2020;382:2163–2164) The obstetrical population in New York City presents a unique challenge during the current SARS-CoV-2 pandemic, as patients typically interact with the health care system multiple times before eventually being admitted to the hospital for delivery. Following 2 initially asymptomatic but ultimately SARS-CoV-2 positive patients, universal nasopharyngeal swab testing was implemented for all women admitted for delivery at this institution.

IMPORTANCEHypertensive disorders of pregnancy are associated with future cardiovascular disease, perhaps because of subclinical cardiac dysfunction before pregnancy leading to impaired adaptation to pregnancy. Natriuretic peptides are promising biomarkers for detecting subclinical cardiac dysfunction outside of pregnancy.OBJECTIVE To investigate whether higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) in early pregnancy would be associated with hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used data from the The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study, a prospective multicenter observational study. A total of 4103 nulliparous women with complete data and no prepregnancy hypertension or diabetes who were treated at 8 clinical sites were included. Women were followed up with for 2 to 7 years after pregnancy. Data were collected from October 2010 to October 2017, and data were analyzed from August 2020 to November 2021.EXPOSURES NT-proBNP concentration, measured using an electrochemiluminescence immunoassay from a first-trimester blood sample. MAIN OUTCOMES AND MEASURESHypertensive disorders of pregnancy and incident hypertension (systolic blood pressure of 130 mm Hg or diastolic blood pressure of 80 mm Hg or use of antihypertensive agents) at follow-up visit.RESULTS A total of 4103 women met inclusion criteria; the mean (SD) age was 27.0 (5.6) years. Among these women, 909 (22.2%) had an adverse pregnancy outcome, and 817 (19.9%) had hypertension at the follow-up visit. Higher NT-proBNP concentrations were associated with a lower risk of hypertensive disorders of pregnancy (adjusted odds ratio per doubling, 0.81; 95% CI, 0.73-0.91), which persisted after adjustment for age, self-reported race and ethnicity, early-pregnancy body mass index, smoking, and aspirin use. Similarly, higher NT-proBNP concentration in early pregnancy was also associated with a lower risk of incident hypertension 2 to 7 years after delivery (adjusted odds ratio per doubling, 0.84; 95% CI, 0.77-0.93), an association that persisted after controlling for confounders, including hypertensive disorders of pregnancy. CONCLUSIONS AND RELEVANCEIn this cohort study, higher NT-proBNP concentrations in early pregnancy were associated with a lower risk of hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. These findings suggest that normal early-pregnancy cardiovascular physiology, as assessed by NT-proBNP concentration, may provide biologic insights into both pregnancy outcome and cardiovascular disease risk.

Recent additions to the literature provide evidence supporting the use of repeat courses of antenatal steroids. Both human and animal studies offer evidence that repeat courses of corticosteroids improve neonatal pulmonary outcomes, especially for the infants delivered at earlier gestational ages. Although there is also evidence to suggest altered neuronal maturation and intrauterine growth restriction in animals treated with repeat steroids, randomized controlled studies in humans have shown that birth weight reduction was only seen in those infants treated with 4 or more courses of corticosteroids. In addition, the reduction in neonatal birth weight and head circumference seen after multiple courses of antenatal corticosteroids normalizes by the time of hospital discharge. Studies are ongoing to investigate the 24-month post delivery physical and neurodevelopmental outcomes in infants exposed to repeat courses of antenatal corticosteroids. Although there is evidence demonstrating the safety of a single repeat, or 'rescue', dose of antenatal corticosteroids, this must be tempered against the adverse effects seen after multiple courses of weekly repeat steroids. Randomized controlled trials are needed to determine the optimal number of courses of antenatal steroids to reduce the frequency of neonatal respiratory distress syndrome (RDS) without adversely affecting other neonatal outcomes.

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An IRB approved prospective, cohort study including pregnant women at 11-16 weeks gestation, >18 years of age, and carrying a singleton pregnancy conducted from June 2016 to August 2017. Women with a history of prior spontaneous preterm birth and eligible for intramuscular progesterone were compared with healthy, uncomplicated pregnancies. Excluded were women with vaginitis, diabetes mellitus, hypertension, or other chronic diseases affecting the immune response. A sterile vaginal washing was performed and collected at enrollment between 11-16 weeks gestation. Samples underwent semi-quantitative detection of human inflammatory markers (MMP) and tissue inhibitors of MMPs (TIMP). Immunofluorescence pixel density data was analyzed and a p-value < 0.05 was considered significant. RESULTS: There were 48 women included, 16 with a prior spontaneous preterm birth and 32 healthy controls. The baseline demographics and pregnancy outcomes for both groups were similar in age, parity, race, and BMI. The metalloproteinase comparison can be seen in Figure 1. The vaginal MMP-9 value was significantly greater in the high-risk group than in the control group (integrative density 74.94 AE 27.04% vs 49.38 AE 31.08%, p¼0.009). The ratio of MMP-9:TIMP-1 was also 1.8 times higher in the high-risk group than in the control group (integrated density 2.17 AE 2.78% vs 1.21 AE 1.09%, p¼0.099). The ratio of MMP-8:TIMP-2 was similar between the groups. CONCLUSION: There is an increased MMP presence in vaginal washings of women at high-risk for preterm birth compared to healthy controls. Vaginal MMP-9 may have potential as a marker for predicting preterm birth.