Background

Pregnant women are at an increased risk of mortality and morbidity owing to COVID-19. Many studies have reported on the association of COVID-19 with pregnancy-specific adverse outcomes, but prediction models utilizing large cohorts of pregnant women are still lacking for estimating the risk of maternal morbidity and other adverse events.

Objective

The main aim of this study was to develop a prediction model to quantify the risk of progression to critical COVID-19 and intensive care unit admission in pregnant women with symptomatic infection.

Study Design

This was a multicenter retrospective cohort study including 8 hospitals from 4 countries (the United Kingdom, Austria, Greece, and Turkey). The data extraction was from February 2020 until May 2021. Included were consecutive pregnant and early postpartum women (within 10 days of birth); reverse transcriptase polymerase chain reaction confirmed SARS-CoV-2 infection. The primary outcome was progression to critical illness requiring intensive care. The secondary outcomes included maternal death, preeclampsia, and stillbirth. The association between the primary outcome and 12 candidate predictors having a known association with severe COVID-19 in pregnancy was analyzed with log-binomial mixed-effects regression and reported as adjusted risk ratios. All the potential predictors were evaluated in 1 model and only the baseline factors in another. The predictive accuracy was assessed by the area under the receiver operating characteristic curves.

Results

Of the 793 pregnant women who were positive for SARS-CoV-2 and were symptomatic, 44 (5.5%) were admitted to intensive care, of whom 10 died (1.3%). The ‘mini-COvid Maternal Intensive Therapy’ model included the following demographic and clinical variables available at disease onset: maternal age (adjusted risk ratio, 1.45; 95% confidence interval, 1.07–1.95; P=.015); body mass index (adjusted risk ratio, 1.34; 95% confidence interval, 1.06–1.66; P=.010); and diagnosis in the third trimester of pregnancy (adjusted risk ratio, 3.64; 95% confidence interval, 1.78–8.46; P=.001). The optimism-adjusted area under the receiver operating characteristic curve was 0.73. The ‘full-COvid Maternal Intensive Therapy’ model included body mass index (adjusted risk ratio, 1.39; 95% confidence interval, 1.07–1.95; P=.015), lower respiratory symptoms (adjusted risk ratio, 5.11; 95% confidence interval, 1.81–21.4; P=.007), neutrophil to lymphocyte ratio (adjusted risk ratio, 1.62; 95% confidence interval, 1.36–1.89; P<.001); and serum C-reactive protein (adjusted risk ratio, 1.30; 95% confidence interval, 1.15–1.44; P<.001), with an optimism-adjusted area under the receiver operating characteristic curve of 0.85. Neither model showed signs of a poor fit. Categorization as high-risk by either model was associated with a shorter diagnosis to intensive care unit admission interval (log-rank test P<.001, both), higher maternal death (5.2% vs 0.2%; P<.001), and preeclampsia (5.7% vs 1.0%; P<.001). A spreadsheet calculator is available for risk estimation.

Conclusion

At presentation with symptomatic COVID-19, pregnant and recently postpartum women can be stratified into high- and low-risk for progression to critical disease, even where resources are limited. This can support the nature and place of care. These models also highlight the independent risk for severe disease associated with obesity and should further emphasize that even in the absence of other comorbidities, vaccination is particularly important for these women. Finally, the model also provides useful information for policy makers when prioritizing national vaccination programs to quickly protect those at the highest risk of critical and fatal COVID-19.

中文翻译：

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一个内部验证的有症状孕妇重症 COVID-19 感染和重症监护病房入院的预测模型

背景

由于 COVID-19，孕妇的死亡和发病风险增加。许多研究报告了 COVID-19 与妊娠特异性不良结果的关联，但仍缺乏利用大量孕妇的预测模型来估计产妇发病率和其他不良事件的风险。

客观的

本研究的主要目的是开发一个预测模型，以量化有症状感染的孕妇进展为危急 COVID-19 和重症监护病房的风险。

学习规划

这是一项多中心回顾性队列研究，包括来自 4 个国家（英国、奥地利、希腊和土耳其）的 8 家医院。数据提取时间为 2020 年 2 月至 2021 年 5 月。包括连续怀孕和产后早期妇女（出生 10 天内）；逆转录酶聚合酶链反应证实了 SARS-CoV-2 感染。主要结果是进展为需要重症监护的危重疾病。次要结局包括孕产妇死亡、先兆子痫和死产。使用对数二项式混合效应回归分析了主要结果与 12 个已知与妊娠期严重 COVID-19 相关的候选预测因子之间的关联，并报告为调整后的风险比。在一个模型中评估了所有潜在的预测因子，而在另一个模型中仅评估了基线因子。

结果

在 SARS-CoV-2 呈阳性且有症状的 793 名孕妇中，44 人（5.5%）被送入重症监护室，其中 10 人死亡（1.3%）。“mini-COvid 孕产妇强化治疗”模型包括以下疾病发作时可用的人口统计学和临床​​变量：孕产妇年龄（调整后的风险比，1.45；95% 置信区间，1.07-1.95；P =.015）；体重指数（调整后的风险比，1.34；95% 置信区间，1.06-1.66；P =.010）；和妊娠晚期的诊断（调整后的风险比，3.64；95% 置信区间，1.78-8.46；P=.001)。受试者工作特征曲线下的乐观调整面积为 0.73。“全 COvid 孕产妇强化治疗”模型包括体重指数（调整后的风险比，1.39；95% 置信区间，1.07-1.95；P =.015）、下呼吸道症状（调整后的风险比，5.11；95% 置信区间, 1.81–21.4；P =.007)，中性粒细胞与淋巴细胞的比率（调整后的风险比，1.62；95% 置信区间，1.36–1.89；P <.001）；和血清 C 反应蛋白（调整后的风险比，1.30；95% 置信区间，1.15-1.44；P<.001)，接受者操作特征曲线下的乐观调整面积为 0.85。两种模型都没有表现出不合适的迹象。任一模型归类为高风险与更短的重症监护病房入院间隔诊断相关（对数秩检验P <.001，两者）、更高的孕产妇死亡率（5.2% 对 0.2%；P <.001）和先兆子痫（5.7% 对 1.0%；P <.001）。电子表格计算器可用于风险评估。

结论

在出现症状性 COVID-19 时，即使在资源有限的情况下，孕妇和最近产后的妇女也可以分为进展为危重疾病的高风险和低风险。这可以支持护理的性质和地点。这些模型还强调了与肥胖相关的严重疾病的独立风险，并应进一步强调，即使没有其他合并症，疫苗接种对这些女性尤为重要。最后，该模型还为政策制定者在优先考虑国家疫苗接种计划以快速保护那些处于严重和致命 COVID-19 风险最高的人群时提供了有用的信息。