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Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State.
Am J Obstet Gynecol. 2021 07; 225(1):77.e1-77.e14.AJ

Abstract

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 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.

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 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).

CONCLUSION

Coronavirus 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.

Authors+Show Affiliations

Department of Global Health, University of Washington, Seattle, WA; Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.University of Washington School of Medicine, Seattle, WA.Department of Epidemiology, University of Washington, Seattle, WA.Yakima Valley Farm Workers Clinic, Yakima, WA.Swedish Maternal and Fetal Specialty Center-First Hill, Seattle, WA; Obstetrix Medical Group of Washington, Seattle, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Elson S. Floyd College of Medicine, Washington State University, Spokane, WA.MultiCare Health System, Tacoma, WA.MultiCare Regional Maternal-Fetal Medicine, Tacoma, WA.Department of Pediatrics, University of Washington, Seattle, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.University of Washington School of Medicine, Seattle, WA.Department of Obstetrics and Gynecology, PeaceHealth St. Joseph Medical Center, Bellingham, WA.University of Washington School of Medicine, Seattle, WA.University of Washington School of Medicine, Seattle, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Yakima Valley Farm Workers Clinic, Yakima, WA.Yakima Valley Farm Workers Clinic, Yakima, WA.Yakima Valley Farm Workers Clinic, Yakima, WA.Virginia Mason Memorial, Yakima, WA.University of Washington School of Medicine, Seattle, WA.Quality Department, EvergreenHealth Medical Center Kirkland, Kirkland, WA.Department of Obstetrics and Gynecology, PeaceHealth St. Joseph Medical Center, Bellingham, WA.Eastside Maternal-Fetal Medicine, EvergreenHealth Medical Center Kirkland, Kirkland, WA; Obstetrix Medical Group of Washington, Bellevue, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA; Women's and Children's Health, Confluence Health, Wenatchee, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Yakima Valley Farm Workers Clinic, Yakima, WA.Department of Obstetrics and Gynecology, Vancouver Clinic, Vancouver, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.University of Washington School of Medicine, Seattle, WA; Elson S. Floyd College of Medicine, Washington State University, Spokane, WA; Jefferson Healthcare, Port Townsend, WA.Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.Legacy Medical Group-Maternal-Fetal Medicine, Legacy Health, Vancouver, WA.Eastside Maternal-Fetal Medicine, EvergreenHealth Medical Center Kirkland, Kirkland, WA; Obstetrix Medical Group of Washington, Bellevue, WA.Department of Global Health, University of Washington, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA.Department of Global Health, University of Washington, Seattle, WA; Department of Obstetrics and Gynecology, University of Washington, Seattle, WA. Electronic address: adamsk@uw.edu.No affiliation info available

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

33515516

Citation

Lokken, Erica M., et al. "Disease Severity, Pregnancy Outcomes, and Maternal Deaths Among Pregnant Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Washington State." American Journal of Obstetrics and Gynecology, vol. 225, no. 1, 2021, pp. 77.e1-77.e14.
Lokken EM, Huebner EM, Taylor GG, et al. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol. 2021;225(1):77.e1-77.e14.
Lokken, E. M., Huebner, E. M., Taylor, G. G., Hendrickson, S., Vanderhoeven, J., Kachikis, A., Coler, B., Walker, C. L., Sheng, J. S., Al-Haddad, B. J. S., McCartney, S. A., Kretzer, N. M., Resnick, R., Barnhart, N., Schulte, V., Bergam, B., Ma, K. K., Albright, C., Larios, V., ... Adams Waldorf, K. M. (2021). Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. American Journal of Obstetrics and Gynecology, 225(1), e1-e14. https://doi.org/10.1016/j.ajog.2020.12.1221
Lokken EM, et al. Disease Severity, Pregnancy Outcomes, and Maternal Deaths Among Pregnant Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Washington State. Am J Obstet Gynecol. 2021;225(1):77.e1-77.e14. PubMed PMID: 33515516.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. AU - Lokken,Erica M, AU - Huebner,Emily M, AU - Taylor,G Gray, AU - Hendrickson,Sarah, AU - Vanderhoeven,Jeroen, AU - Kachikis,Alisa, AU - Coler,Brahm, AU - Walker,Christie L, AU - Sheng,Jessica S, AU - Al-Haddad,Benjamin J S, AU - McCartney,Stephen A, AU - Kretzer,Nicole M, AU - Resnick,Rebecca, AU - Barnhart,Nena, AU - Schulte,Vera, AU - Bergam,Brittany, AU - Ma,Kimberly K, AU - Albright,Catherine, AU - Larios,Valerie, AU - Kelley,Lori, AU - Larios,Victoria, AU - Emhoff,Sharilyn, AU - Rah,Jasmine, AU - Retzlaff,Kristin, AU - Thomas,Chad, AU - Paek,Bettina W, AU - Hsu,Rita J, AU - Erickson,Anne, AU - Chang,Andrew, AU - Mitchell,Timothy, AU - Hwang,Joseph K, AU - Erickson,Stephen, AU - Delaney,Shani, AU - Archabald,Karen, AU - Kline,Carolyn R, AU - LaCourse,Sylvia M, AU - Adams Waldorf,Kristina M, AU - ,, Y1 - 2021/01/27/ PY - 2020/11/10/received PY - 2020/12/20/revised PY - 2020/12/30/accepted PY - 2021/1/31/pubmed PY - 2021/7/16/medline PY - 2021/1/30/entrez KW - COVID-19 KW - SARS-CoV-2 KW - case fatality KW - coronavirus KW - fetus KW - maternal mortality KW - pneumonia KW - pregnancy KW - preterm birth SP - 77.e1 EP - 77.e14 JF - American journal of obstetrics and gynecology JO - Am J Obstet Gynecol VL - 225 IS - 1 N2 - 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 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. 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 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). CONCLUSION: Coronavirus 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. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/33515516/Disease_severity_pregnancy_outcomes_and_maternal_deaths_among_pregnant_patients_with_severe_acute_respiratory_syndrome_coronavirus_2_infection_in_Washington_State_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9378(21)00033-8 DB - PRIME DP - Unbound Medicine ER -