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Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers

Our take —

This case-series followed 241 pregnant women with COVID-19 who delivered in 5 New York City hospitals. It demonstrated that 31% developed severe or critical disease, 7% required ICU admission, and 14.6% (34) of births were preterm. Obesity was a strong risk factor associated with COVID-19 severity among this sample of pregnant women, consistent with a body of evidence in the general population. Though the observed levels of preterm birth and cesarean birth were higher among those with severe disease than those with asymptomatic/mild disease, the comparisons did not account for the higher proportion of other independent risk factors in the former group, and limit inferences about a causal effect of COVID-19 severity.

Study design

Case Series

Study population and setting

This study included 241 pregnant women with evidence of SARS-CoV-2 infection who delivered in five hospitals in New York City between March 13 and April 12, 2020. The authors collected demographic, medical comorbidity, COVID-19 signs, symptoms, and course, maternal and neonatal outcomes, and laboratory and radiographic information from the electronic medical record. All included women had confirmed SARS-CoV-2 by virologic test at hospital admission— although notably testing criteria was not uniform across hospitals and during the study period — and were characterized as having asymptomatic, mild, severe, or critical COVID-19 based on World Health Organization criteria. Finally, the authors assessed obstetric, maternal, and neonatal outcomes by COVID-19 severity (dichotomized to asymptomatic and mild versus severe and critical) using Chi-squared tests for categorical variables and Cochran-Armitage tests for trend for ordinal variables.

Summary of Main Findings

The women had a median age of 32 years (IQR 27-36), median body mass index of 30.5 (IQR 27-34), 74.1% were parous, and 61.2% were insured through Medicaid (61.2%). Participants identified as Latinx (43.9%), non-Hispanic white (30.3%), non-Hispanic Black (10.9%), and other race/ethnicity(14.9%), and were predominantly English speaking (73.4%). On admission, 148 women (61.4%) were asymptomatic, however, by the end of the study 102 (42.3%) were asymptomatic, 64 (26.5%) met criteria for mild COVID-19, 63 (26.1%) for severe COVID-19, and 12 (5%) for critical COVID-19. A small minority of mothers required ICU admission (n=17, 7.1%) or intubation (n=9, 3.7%), and no mothers died. In unadjusted comparisons, severe or critical disease was more common among pregnant women with higher BMI, occurring among 57.1% of those with BMI >=40, 41.7% among BMI 30-39, 27% among BMI 25-29 and 11.8% among BMI <25 (p=0.001). Severe/critical disease was also more common among those with compared to without hypertensive disorders and glucose intolerance, though these differences were not statistically significant. Most of the pregnancies ended in live birth (99.2%), although 14.6% (34) of the births were preterm (< 37 weeks) and 4.3% (10) were early preterm (< 34 weeks); 41.5% of births were cesareans. There were 2 stillbirths. Patients with more severe COVID-19 were more likely than the asymptomatic/mild group to require cesarean delivery and experience preterm birth.

Study Strengths

This study has detailed information on all participants and, importantly, includes data on maternal comorbidities, presenting symptoms, COVID-19 severity, vitals and laboratory findings, and patient characteristics by COVID-19 severity in the online appendix.

Limitations

Patient testing criteria, and therefore participant selection, was different across study sites and, at one site, changed during data collection, which likely undercounted asymptomatic pregnant women and may have overestimated the differences between asymptomatic and symptomatic women if the asymptomatic women delivering at the sites without universal testing who were not included in the analysis had worse outcomes than the asymptomatic women at the sites with universal testing, which the authors noted had less representation of Latinx and Black women. Importantly, there is no control group to compare the outcomes of pregnant women without COVID-19 during the same time period and the small sample size limited the authors’ ability to control for confounders in the relationship between COVID-19 and adverse maternal or neonatal outcomes. Finally, this study examined outcomes in women exposed to SARS-CoV-2 during the third trimester and does not provide information on infection earlier in pregnancy.

Value added

This study was one of the largest to date describing the symptoms, severity, and obstetric outcomes among pregnant women with COVID-19 in the United States at the time of its publication.

This review was posted on: 30 October 2020