Association of SARS-CoV-2 Infection With Serious Maternal Morbidity and Mortality From Obstetric Complications
Torri D. Metz, Rebecca G. Clifton, Brenna L. Hughes, Grecio J. Sandoval, William A. Grobman, George R. Saade, Tracy A. Manuck, Monica Longo, Amber Sowles, Kelly Clark, Hyagriv N. Simhan, Dwight J. Rouse, Hector Mendez‐Figueroa, Cynthia Gyamfi‐Bannerman, Jennifer L. Bailit, Maged M. Costantine, Harish M. Sehdev, Alan Tita, George A. Macones, M. Bickus, Francesca Facco, J. Grant, Amy M. Leath, Anna Bartholomew, Mark B. Landon, Kara M. Rood, Patrick Schneider, Heather A. Frey, Amanda L. Nelson, Sean Esplin, Michael W. Varner, Donna Allard, Janet Rousseau, Janet Milano, Lisa Early, Sabine Bousleiman, Ronald J. Wapner, Desmond Sutton, Haley Manchon, Ashley H. Salazar, Luis D. Pacheco, Shannon Clark, Hassan Harirah, Sangeeta Jain, Gayle Olson, Antonio F. Saad, Lindsey Allen, Guillermina Carrington, Jennifer Cornwell, Jennifer D. DeVolder, Wendy Dalton, Amanda Tyhulski, Ashley Mayle, Suneet P. Chauhan, Felecia Ortiz, John M. Thorp, S. Timlin, Lena Fried, Hannah Byers, Jennifer Ferrara, Aimee Williams, Gail Mallett, M. Ramos-Brinson, Samuel Parry, Meaghan McCabe, Christina Fazio, Anna Filipczak, Jennifer Craig, Lucia Muzzarelli, Abigail Roche, Elizabeth Thom, Crystal Nwachuku, V. Lynn Flowers-Fanomezantsoa, Monica Longo, Menachem Miodovnik, Stephanie Wilson Archer
Abstract
Importance: It remains unknown whether SARS-CoV-2 infection specifically increases the risk of serious obstetric morbidity. Objective: To evaluate the association of SARS-CoV-2 infection with serious maternal morbidity or mortality from common obstetric complications. Design, Setting, and Participants: Retrospective cohort study of 14 104 pregnant and postpartum patients delivered between March 1, 2020, and December 31, 2020 (with final follow-up to February 11, 2021), at 17 US hospitals participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Gestational Research Assessments of COVID-19 (GRAVID) Study. All patients with SARS-CoV-2 were included and compared with those without a positive SARS-CoV-2 test result who delivered on randomly selected dates over the same period. Exposures: SARS-CoV-2 infection was based on a positive nucleic acid or antigen test result. Secondary analyses further stratified those with SARS-CoV-2 infection by disease severity. Main Outcomes and Measures: The primary outcome was a composite of maternal death or serious morbidity related to hypertensive disorders of pregnancy, postpartum hemorrhage, or infection other than SARS-CoV-2. The main secondary outcome was cesarean birth. Results: Of the 14 104 included patients (mean age, 29.7 years), 2352 patients had SARS-CoV-2 infection and 11 752 did not have a positive SARS-CoV-2 test result. Compared with those without a positive SARS-CoV-2 test result, SARS-CoV-2 infection was significantly associated with the primary outcome (13.4% vs 9.2%; difference, 4.2% [95% CI, 2.8%-5.6%]; adjusted relative risk [aRR], 1.41 [95% CI, 1.23-1.61]). All 5 maternal deaths were in the SARS-CoV-2 group. SARS-CoV-2 infection was not significantly associated with cesarean birth (34.7% vs 32.4%; aRR, 1.05 [95% CI, 0.99-1.11]). Compared with those without a positive SARS-CoV-2 test result, moderate or higher COVID-19 severity (n = 586) was significantly associated with the primary outcome (26.1% vs 9.2%; difference, 16.9% [95% CI, 13.3%-20.4%]; aRR, 2.06 [95% CI, 1.73-2.46]) and the major secondary outcome of cesarean birth (45.4% vs 32.4%; difference, 12.8% [95% CI, 8.7%-16.8%]; aRR, 1.17 [95% CI, 1.07-1.28]), but mild or asymptomatic infection (n = 1766) was not significantly associated with the primary outcome (9.2% vs 9.2%; difference, 0% [95% CI, -1.4% to 1.4%]; aRR, 1.11 [95% CI, 0.94-1.32]) or cesarean birth (31.2% vs 32.4%; difference, -1.4% [95% CI, -3.6% to 0.8%]; aRR, 1.00 [95% CI, 0.93-1.07]). Conclusions and Relevance: Among pregnant and postpartum individuals at 17 US hospitals, SARS-CoV-2 infection was associated with an increased risk for a composite outcome of maternal mortality or serious morbidity from obstetric complications.