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

Abstract

On behalf of the Washington State COVID-19 in Pregnancy Collaborative BACKGROUND: Evidence 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. OBJECTIVE: This 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 DESIGN: Pregnant patients with a polymerase chain reactioneconfirmed 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. RESULTS: The 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 2019eassociated 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, 2.3e5.3);(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, 257e3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7e43.6) 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, À0.3 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). CONCLUSION: Coronavirus disease 2019 hospitalization and casefatality 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...

Higher severe acute respiratory syndrome coronavirus 2 infection rate in pregnant patients

“…Of the WA-CPC cases, 38 (15.8%) were detected in the first trimester of pregnancy, 67 (27.9%) in the second trimester of pregnancy, and 135 (56.3%) in the third trimester of pregnancy, as previously reported. 24 Of the 240 cases, 45 (18.8%) were diag-nosed through asymptomatic screening strategies (preprocedure and universal screening before delivery); this screening strategy excludes patients who were asymptomatic but were tested due to having a known exposure to COVID-19. During the study period, the WA-DOH identified 346 cases of SARS-CoV-2 infections in pregnancy throughout Washington State, but pregnancy status was missing for 35% of the cases in fe-males aged 18 to 50 years.…”

“…In addition, we detected significant disparities in the proportion of pregnant women from racial and ethnic minority groups with SARS-CoV-2 infection, particularly among Hispanic and American Indian or Alaska Native pregnant patients; furthermore, a disproportionate number of pregnant women with SARS-CoV-2 infection received medical care in a non-English language. The higher infection rates in pregnant patients coupled with an elevated risk of severe illness and maternal mortality 16,24,25 because of COVID-19 suggests that pregnancy should be considered a high-risk health condition for COVID-19 vaccine allocation in phase 1B across the United States, similar to some US states (ie, Texas, 26 New Hampshire, 27 New Mexico, 28 Alaska 29 ).…”

Expression map of entry receptors and infectivity factors for pan-coronaviruses in preimplantation and implantation stage human embryos

“…The pandemic of SARS-CoV-2 causing COVID-19 has drawn tremendous attention of researchers globally and it is now clear that COVID-19 during pregnancy is associated with multiple adverse outcomes including mother-to-child transmission [3,4,6,8,10]. Considering the high rate of human-tohuman transmission and viral shedding from both symptomatic and asymptomatic individuals [39], high asymptomatic to symptomatic patient ratio [40] and ability of the viruses to survive on inanimate objects for extended periods and at sub-zero temperatures [41,42], the clinics offering assisted reproduction services are at risk of spreading COVID-19 [43].…”

“…Epidemiologic and clinical evidence suggests that pregnant women with hCoV infection are at a higher risk for severe illness and death, as well as adverse pregnancy outcomes, mother-to-child transmission, and congenital viral syndromes [2][3][4][5][6]. While the placenta protects the developing fetus from maternal infections, we and others have shown that the human S. Colaco, K. Chhabria and D. Singh contributed equally to this work.…”

Maternal-Fetal Immune Responses in Pregnant Women Infected with SARS-CoV-2

“…Regardless, in the first six months of the COVID-19 pandemic, it was documented that pregnant women with SARS-CoV-2 were at an increased risk for hospitalization, mechanical ventilation, intensive care unit admission, and preterm birth 2,3,[6][7][8] , but rates of maternal mortality were reported to be similar between pregnant and non-pregnant women 6 . More recently, it has been clearly shown that pregnant women are at a high risk for severe/critical disease and mortality as well as preterm birth [9][10][11][12] . Therefore, investigating host immune responses in pregnant women infected with SARS-CoV-2, even if they are asymptomatic, is timely.…”