Objectives We describe clinical characteristics, pregnancy, and infant outcomes in pregnant people with laboratory‐confirmed SARS‐CoV‐2 infection by trimester of infection. Study Design We analyzed data from the Surveillance for Emerging Threats to Mothers and Babies Network and included people with infection in 2020, with known timing of infection and pregnancy outcome. Outcomes are described by trimester of infection. Pregnancy outcomes included live birth and pregnancy loss (<20 weeks and ≥20 weeks gestation). Infant outcomes included preterm birth (<37 weeks gestation), small for gestational age, birth defects, and neonatal intensive care unit admission. Adjusted prevalence ratios (aPR) were calculated for pregnancy and selected infant outcomes by trimester of infection, controlling for demographics. Results Of 35,200 people included in this analysis, 50.8% of pregnant people had infection in the third trimester, 30.8% in the second, and 18.3% in the first. Third trimester infection was associated with a higher frequency of preterm birth compared to first or second trimester infection combined (17.8% vs. 11.8%; aPR 1.44 95% CI: 1.35–1.54). Prevalence of birth defects was 553.4/10,000 live births, with no difference by trimester of infection. Conclusions There were no signals for increased birth defects among infants in this population relative to national baseline estimates, regardless of timing of infection. However, the prevalence of preterm birth in people with SARS‐CoV‐2 infection in pregnancy in our analysis was higher relative to national baseline data (10.0–10.2%), particularly among people with third trimester infection. Consequences of COVID‐19 during pregnancy support recommended COVID‐19 prevention strategies, including vaccination.
Background Multiple reports have described neonatal SARS‐CoV‐2 infection, including likely in utero transmission and early postnatal infection, but published estimates of neonatal infection range by geography and design type. Objectives To describe maternal, pregnancy and neonatal characteristics among neonates born to people with SARS‐CoV‐2 infection during pregnancy by neonatal SARS‐CoV‐2 testing results. Methods Using aggregated data from the Surveillance for Emerging Threats to Mothers and Babies Network (SET‐NET) describing infections from 20 January 2020 to 31 December 2020, we identified neonates who were (1) born to people who were SARS‐CoV‐2 positive by RT‐PCR at any time during their pregnancy, and (2) tested for SARS‐CoV‐2 by RT‐PCR during the birth hospitalisation. Results Among 28,771 neonates born to people with SARS‐CoV‐2 infection during pregnancy, 3816 (13%) underwent PCR testing and 138 neonates (3.6%) were PCR positive. Ninety‐four per cent of neonates testing positive were born to people with infection identified ≤14 days of delivery. Neonatal SARS‐CoV‐2 infection was more frequent among neonates born preterm (5.7%) compared to term (3.4%). Neonates testing positive were born to both symptomatic and asymptomatic pregnant people. Conclusions Jurisdictions reported SARS‐CoV‐2 RT‐PCR results for only 13% of neonates known to be born to people with SARS‐CoV‐2 infection during pregnancy. These results provide evidence of neonatal infection identified through multi‐state systematic surveillance data collection and describe characteristics of neonates with SARS‐CoV‐2 infection. While perinatal SARS‐CoV‐2 infection was uncommon among tested neonates born to people with SARS‐CoV‐2 infection during pregnancy, nearly all cases of tested neonatal infection occurred in pregnant people infected around the time of delivery and was more frequent among neonates born preterm. These findings support the recommendation for neonatal SARS‐CoV‐2 RT‐PCR testing, especially for people with acute infection around the time of delivery.
Objective We examined the relationship between trimester of SARS-CoV-2 infection, illness severity, and risk for preterm birth. Study design We analyzed data for 6336 pregnant persons with SARS-CoV-2 infection in 2020 in the United States. Risk ratios for preterm birth were calculated for illness severity, trimester of infection, and illness severity stratified by trimester of infection adjusted for age, selected underlying medical conditions, and pregnancy complications. Result Pregnant persons with critical COVID-19 or asymptomatic infection, compared to mild COVID-19, in the second or third trimester were at increased risk of preterm birth. Pregnant persons with moderate-to-severe COVID-19 did not show increased risk of preterm birth in any trimester. Conclusion Critical COVID-19 in the second or third trimester was associated with increased risk of preterm birth. This finding can be used to guide prevention strategies, including vaccination, and inform clinical practices for pregnant persons.
Purpose Opioid overdose death rates rose 36% from 2015 to 2016 in Missouri, indicating a worsening of the opioid overdose epidemic. To better understand urban and rural differences in nonfatal opioid overdoses treated in Missouri emergency departments, this paper analyzed hospital billing data from emergency departments due to opioid overdose from 2012 to 2016. Methods Emergency department records meeting the opioid overdose case definition were aggregated into 6 progressively rural groups using the National Center for Health Statistics (NCHS) urban‐rural county classification from 2013. These data were analyzed to determine significant trends amongst and between the geographic groups. Findings Generally, the magnitude of opioid overdose morbidity decreased as levels of rurality increased, using annual percentage change as the metric of change. Over the study period, Missouri's most urban counties had significantly higher rates of opioid overdose and saw larger percentage increases in rates compared to more rural areas. Statewide, all rural‐urban classifications experienced increases in heroin overdose morbidity; however, there was extreme variation in the trajectory of those increases. Heroin overdose rates were much higher in urban areas than rural areas. Conversely, rural and urban areas saw relatively similar patterns for non‐heroin opioid overdoses, though overall magnitude of these increases was more modest across all geographic groups. Conclusions The results from this analysis can help inform prioritization of strategies and resources to implement activities addressing the opioid overdose epidemic. Using a rich hospital discharge database could allow for further analysis of subpopulations to enhance personalization and customization of care.
Among 10,011 neonates of SARS-CoV-2-infected mothers, 1448 (14%) underwent PCR testing (and 1347 (95%) had mothers with third trimester infections). Fifty-nine (4%) were PCR-positive. Neonates testing positive were born to both symptomatic and asymptomatic women, and nearly all were born to women with infection identified near delivery.
Background: Pregnant persons with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection are at increased risk of preterm birth, and evidence suggests this risk may be higher among pregnant persons with severe coronavirus disease 2019 (COVID-19) or among those infected later in pregnancy. However, the relationship between trimester of SARS-CoV-2 infection, severity of COVID-19, and preterm birth is not fully understood.Objective: This study examined the relationship between trimester of SARS-CoV-2 infection, illness severity, and risk for preterm birth after adjusting for maternal age, selected underlying conditions, and pregnancy complications.Study Design: Using a cohort of 6,396 pregnant persons with SARS-CoV-2 infection in 2020 identified through the Surveillance for Emerging Threats to Mothers and Babies Network, we analyzed data for those with infection at <37 weeks gestation who delivered a singleton liveborn infant. Illness severity groups (asymptomatic infection, mild, moderate-to-severe, and critical) were adapted from National Institutes of Health and World Health Organization criteria. Risk ratios for preterm birth (<37 weeks) were calculated for illness severity categories (referent=mild), trimester of SARS-CoV-2 infection (referent=first trimester), and illness severity stratified by trimester of infection adjusted for age, selected underlying medical conditions, and pregnancy complications.Results: Pregnant persons with critical COVID-19, compared to mild COVID-19, in the second (aRR 3.9; 95% CI: 1.7-9.0) or third (aRR 4.6; 95% CI: 3.2-6.6) trimester were at increased risk of preterm birth. Among persons infected in the second or third trimester, those with critical COVID-19 delivered sooner after infection compared with persons with mild COVID-19 (p<0.001 for second trimester and p=0.02 for third trimester). Nearly half of those with moderate-to-severe or critical COVID-19 delivered by cesarean, with most critical COVID-19 cesarean deliveries as emergent (76.6% weighted [65/96 unweighted]).Conclusion: When infection occurred in the second or third trimester, critical COVID-19 was associated with increased risk of preterm birth, and those with critical COVID-19 delivered sooner after infection compared to those with mild COVID-19. These findings can be used to guide prevention strategies, including vaccination, and inform clinical practices for pregnant persons, particularly those presenting with critical COVID-19 later in pregnancy.
ObjectiveIn this analysis we examine Missouri NAS discharge rates with special focus on the ICD-9-CM/ICD-10-CM transition and changes in code descriptions.IntroductionNeonatal Abstinence Syndrome (NAS) rates have tripled for Missouri residents in the past three years. NAS is a condition infants suffer soon after birth due to withdrawal after becoming opioid-dependent in the womb. NAS has significant immediate health concerns and can have long term effects on child development and quality of life.2 The Missouri Department of Health and Senior Services (MODHSS) maintains the Patient Abstract System (PAS), a database of inpatient, emergency room, and outpatient records collected from non-federal hospitals and ambulatory surgical centers throughout the state. PAS records contain extensive information about the visit, patient, and diagnosis. When examining 2015 annual PAS data for NAS-associated discharges, Missouri analysts noticed a greater than 50% increase in discharges, even larger than anticipated in light of the opioid epidemic. Provisional 2016 data produced similar high rates, dispelling the notion that the trend was a transitional problem. In fact, provisional 2016 rates are 115% higher than NAS rates in 2015. In contrast, percentage change of opioid misuse emergency department visits (as defined by MODHSS) for Missouri women age 18-44 was +13% in 2015 and -12% in 2016.MethodsNAS discharges for Missouri residents under the age of 1 were identified using all available diagnosis fields of the PAS record, using finalized data from 2014 and 2015 and provisional data from 2016. Results were stratified by quarter and ICD-CM code. Rates for each of these stratifications were calculated using Missouri resident live births as the denominator. Adhering to methodology used by MODHSS to calculate significance on its public data query tool, 95% confidence intervals were used to determine statistical significance. Depending on numerator size, either Poisson or the inverse gamma methodology was utilized to analyze changes in discharge rates over time. Two ICD-9-CM codes and four ICD-10-CM codes (identified as equivalents using an in-house crosswalk system) were used as NAS indicators (Figure 1).ResultsAn exploration of the data by quarter and diagnosis code (ICD-9-CM or ICD-10-CM), as well as supporting information from the Centers for Medicare & Medicaid Services, show that definitional changes to ICD-10-CM codes P044 and P0449, (previously 76072 in ICD-9-CM coding), was responsible for the majority of the NAS rate increase in Missouri. Annual rates for 76072 and its equivalents jumped significantly from a rate of 3.82 (per 1,000) to 8.22 Q3 to Q4-2015 (95% CI: 3.39-4.29, 7.57-8.87), while ICD-9-CM code 7795 and its equivalents had a more modest rise, from 5.57 to 6.17, which was not statistically significant (95% CI: 5.04-6.13, 5.62-6.76). Once this anomaly was identified, examination of the code’s description was conducted. This exposed a change in definition, with the words ‘suspected to be’ added to the ICD-10-CM long description, which were not present in the ICD-9-CM equivalent. Further complicating matters is a 2017 revision (effective Q3-2016) deleting the ‘suspected’ language from the description. This reversion to language more closely aligning with prior descriptions may be the reason for the slight decrease in discharges coded to P044 in the provisional Q4-2016 PAS data. Though this dataset is not finalized, there was a decrease in discharges that included code P044 from 27.50 in Q3-2016 to 23.15 in Q4-2016 (Figure 2, Figure 3).ConclusionsWhile NAS discharge rates are undoubtedly increasing in Missouri in tune with the opioid epidemic, the extreme escalation from 2014 to 2016 is, at least partially, the result of a definitional change that came with the transition from ICD-9-CM to ICD-10-CM and not a true indication of profound intensification. Indeed, the definitional change of a single ICD-CM code was responsible, in part, for a greater than three-fold increase in NAS discharge rates in Missouri. This analysis will allow public health program planners to better understand NAS trends and adjust intervention strategies accordingly. Further analysis exploring quarterly trends associated with the 2017 ICD-10-CM revision are ongoing.References1. Centers for Medicare & Medicaid Services. ICD-9-CM and ICD-10. https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.2. Stanford Children’s Health. Neonatal Abstinence Syndrome. http://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387.
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