Objective: To assess the frequency and associated characteristics of COVID-19 vaccine hesitancy among pregnant and postpartum individuals.

OBJECTIVE To examine the association between initial COVID‐19 vaccine hesitancy and subsequent vaccination among pregnant and postpartum individuals. DESIGN Prospective cohort SETTING A Midwestern tertiary care academic medical center. Individuals completed a baseline vaccine hesitancy assessment from 03/22/21 to 04/02/21, with subsequent ascertainment of vaccination status at 3 to 6 months follow‐up. METHODS We used multivariable Poisson regression to estimate the relative risk of vaccination by baseline vaccine hesitancy status, and then characteristics associated with vaccination. MAIN OUTCOMES Self‐report of COVID‐19 vaccination, and secondarily, consideration of COVID‐19 vaccination among those not vaccinated. RESULTS Of 456 individuals (93% pregnant, 7% postpartum) initially surveyed, 290 individuals (64%; 23% pregnant, 77% postpartum) provided subsequent vaccination status (median=17 weeks). Forty percent (116/290) reported COVID‐19 vaccine hesitancy at enrollment, of whom 52% reported subsequent vaccination at follow‐up. Few individuals transitioned during the study period from vaccine hesitant to vaccinated (10%); in comparison, 80% of those who were not vaccine hesitant were vaccinated at follow‐up (aRR: 0.19; 95% CI: 0.11, 0.33). Among those who remained unvaccinated at follow‐up, 38% who were vaccine hesitant at baseline were considering vaccination compared to 71% who were not vaccine hesitant (aRR: 0.48; 95% CI: 0.33, 0.67). Individuals who were older, parous, employed, and of higher educational attainment were more likely to be vaccinated, and those who identified as non‐Hispanic Black, were Medicaid beneficiaries, and still pregnant at follow‐up were less likely to be vaccinated. CONCLUSIONS COVID‐19 vaccine hesitancy persisted over time in the peripartum period, and few individuals who reported hesitancy at baseline were later vaccinated. Interventions that address vaccine hesitancy in pregnancy are needed. FUNDING Ms. Germann was supported by the New York Academy of Medicine David E. Rogers Fellowship Program. Dr. Venkatesh was supported by the Care Innovation and Community Improvement Program and the Division of Maternal Fetal Medicine at The Ohio State University Wexner Medical Center.

Objective To evaluate the accuracy of antenatal diagnosis of congenital heart disease (CHD) using screening methods including a combination of elevated hemoglobin A1c, detailed anatomy ultrasound, and fetal echocardiography. Study Design This is a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each screening regimen. The incremental cost-effectiveness ratio (ICER) was calculated for each regimen with effectiveness defined as additional CHD diagnosed. Results A total of 378 patients met inclusion criteria with an overall prevalence of CHD of 4.0% (n = 15). When compared with a detailed ultrasound, fetal echocardiography had a higher sensitivity (73.3 vs. 40.0%). However, all cases of major CHD were detected by detailed ultrasound (n = 6). Using an elevated early A1c > 7.7% and a detailed ultrasound resulted in a sensitivity and specificity of 60.0 and 99.4%, respectively. The use of selective fetal echocardiography for an A1c > 7.7% or abnormal detailed anatomy ultrasound would result in a 63.3% reduction in cost per each additional minor CHD diagnosed (ICER: $18,290.52 vs. $28,875.67). Conclusion Fetal echocardiography appears to have limited diagnostic value in women with pregestational diabetes. However, these results may not be generalizable outside of a high-volume academic setting.

To evaluate the association between community-level social vulnerability and achieving glycemic control (defined as hemoglobin A 1c [Hb A 1c ] less than 6.0% or less than 6.5%) among individuals with pregestational diabetes. METHODS:We conducted a retrospective cohort of individuals with pregestational diabetes with singleton gestations from 2012 to 2016 at a tertiary care center. Addresses were geocoded using ArcGIS and then linked at the census tract to the Centers for Disease Control and Prevention's 2018 SVI (Social Vulnerability Index), which incorporates 15 Census variables to produce a composite score and four scores across thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). Scores range from 0 to 1, with higher values indicating greater community-level social vulnerability. The primary outcome was Hb A 1c less than 6.0%, and, secondarily, Hb A 1c less than 6.5%, in the second or third trimesters. Multivariable Poisson regression with robust error variance was used to evaluate the association between SVI score as a continuous measure and target Hb A 1c .RESULTS: Among 418 assessed pregnant individuals (33.0% type 1; 67.0% type 2 diabetes), 41.4% (173/418) achieved Hb A 1c less than 6.0%, and 56.7% (237/418) Hb A 1c less than 6.5% at a mean gestational age of 29.5 weeks (SD 5.78). Pregnant individuals with a higher SVI score were less likely to achieve Hb A 1c less than 6.0% compared with those with a lower SVI score. For each 0.1-unit increase in SVI score, the risk of achieving Hb A 1c less than 6.0% decreased by nearly 50% (adjusted risk ratio [aRR] 0.53; 95% CI 0.36-0.77), and by more than 30% for Hb A 1c less than 6.5% (adjusted odds ratio 0.67; 95% CI 0.51-0.88). With regard to specific SVI domains, those who scored higher on socioeconomic status (aRR 0.50; 95% CI 0.35-0.71) as well as on household composition and disability (aRR 0.55; 95% CI 0.38-0.79) were less likely to achieve Hb A 1c less than 6.0%.CONCLUSION: Pregnant individuals with pregestational diabetes living in an area with higher social vulnerability were less likely to achieve glycemic control, as measured by HgbA1c levels. Interventions are needed to assess whether addressing social determinants of health can improve glycemic control in pregnancy.

OBJECTIVE: To evaluate differences between fasting and nonfasting bile acid levels in asymptomatic and symptomatic pregnant women. METHODS: This is a report of two prospective cohort studies describing bile acid levels in the fasting and nonfasting state in pregnancy. The first cohort included asymptomatic women with singleton pregnancies. Women with a diagnosis of cholestasis, symptoms of cholestasis, or intolerance to components of a standardized meal were excluded. Bile acid levels were measured during the second and third trimesters after fasting and again 2 hours after a standardized meal. The second cohort included symptomatic women with singleton pregnancies in whom fasting and nonfasting bile acid levels were measured at the time of symptom evaluation. A cutoff of 10 micromoles/L was used for diagnosis. RESULTS: A total of 27 women were included in the asymptomatic cohort. Median [interquartile range] fasting bile acid levels were significantly lower than nonfasting levels in both the second trimester (4.65 micromoles/L [1.02–29.57] vs 13.62 micromoles/L [2.03–40.26]; P<.001) and third trimester (8.31 micromoles/L [1.14–51.26] vs 17.35 micromoles/L [1.77–62.93]; P<.001). Bile acid levels exceeded 10 micromoles/L in 21% of the fasting samples and in 58% of the nonfasting samples in the third trimester. A total of 26 women were included in the symptomatic cohort. Median [interquartile range] fasting bile acid levels were significantly lower than nonfasting values (11.5 micromoles/L [7–56] vs 13.5 micromoles/L [9–142]; P<.001). Six patients in the symptomatic cohort (23%) had nonfasting bile acid levels greater than 10 micromoles/L that dropped below 10 micromoles/L when fasting. CONCLUSION: Fasting bile acid levels are significantly lower when compared with nonfasting values in both asymptomatic and symptomatic pregnant women. In asymptomatic women, nonfasting bile acid levels often exceeded 10 micromoles/L whereas fasting values did not. In symptomatic women, fasting bile acid levels resulted in 23% fewer diagnoses of cholestasis when compared with nonfasting values. These findings suggest that fasting evaluation of bile acid levels or a higher threshold for diagnosis of cholestasis should be considered.

Aims: To determine whether a net decline in glycosylated haemoglobin (HbA 1c ) from early to late pregnancy is associated with lower risk of adverse perinatal outcomes at delivery among women with pregestational diabetes. Methods:A retrospective analysis from 2012 to 2016 at a tertiary care centre. The exposure was the net change in HbA 1c from early (<20 weeks gestation) to late pregnancy (≥20 weeks gestation). Primary outcomes were large for gestational age (LGA) and neonatal hypoglycaemia. The association between outcomes per 6 mmol/mol (0.5%) absolute decrease in HbA 1c was evaluated using modified Poisson regression, and adjusted for age, body mass index, White Class, early HbA 1c and haemoglobin and gestational age at HbA 1c measurement and delivery.Results: Among 347 women with pregestational diabetes, HbA 1c was assessed in early (9 weeks [IQR 7,13]) and late pregnancy (31 weeks [IQR 29,34]). Mean HbA 1c decreased from early (59 mmol/mol [7.5%]) to late (47 mmol/mol [6.5%]) pregnancy. Each 6 mmol/mol (0.5%) absolute decrease in HbA 1c was associated with a 12% reduced risk of LGA infant (30%, aRR:0.88; 95% CI:0.81,0.95), and a 7% reduced risk of neonatal hypoglycaemia (35%, aRR:0.93; 95% CI:0.87,0.99). Preterm birth (36%, aRR:0.93; 95% CI:0.89,0.98) and neonatal intensive care unit admission (55%, aRR:0.95; 95% CI:0.91,0.98) decreased with a net decline in HbA 1c , but not caesarean delivery, pre-eclampsia, shoulder dystocia and respiratory distress syndrome. Conclusions:Women with pregestational diabetes with a reduction in HbA 1c may have fewer infants born LGA or with neonatal hypoglycaemia. Repeated assessment of HbA 1c may provide an additional measure of glycaemic control.

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