Post-COVID Conditions at the Delivery Hospitalization

doi:10.21203/rs.3.rs-3307419/v1

This study describes the frequency of post-COVID conditions and other co-occurring health outcomes at the delivery hospitalization. PCC diagnoses occurred in 0.02% of delivery hospitalizations and were more frequent in pregnant people who were White, had private health insurance, and delivered preterm.

Infectious Diseases

Obstetrics & Gynecology

Post-COVID conditions

Long COVID

COVID-19

pregnancy

Following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, some individuals experience symptoms ≥ 4 weeks after acute infection that vary in severity and impact a wide range of body systems (1). Post-COVID conditions (PCC), also referred to as Long COVID, affect approximately 15% of infected individuals, with higher rates in women (2). To date, few studies have characterized the use of the PCC International Classification of Diseases (ICD) code for pregnant people to provide an estimate of overall burden. This study describes the prevalence of recorded PCC diagnosis and assesses the frequency of underlying health conditions, maternal, and pregnancy outcomes that co-occur with PCC and COVID-19 diagnoses at delivery hospitalization.

A cross-sectional analysis was performed comparing the prevalence of demographic, comorbid conditions, and maternal and pregnancy outcomes between three groups at the delivery hospitalization: patients with PCC diagnosis, patients with COVID-19 diagnosis, and patients with neither. PCC, COVID-19, comorbidities, and pregnancy outcomes were identified using ICD, 10th revision diagnostic and procedure codes.* Data from October 2021 to February 2023 were obtained from the Premier Healthcare Database** and restricted to females aged 12–55 years with one delivery hospitalization and a singleton live birth or stillbirth (3). Poisson regression models with robust standard errors were used to calculate adjusted prevalence ratios (aPRs).

A total of 990,250 pregnant women were included: 231 (0.02%) with a PCC diagnosis, 26,521 (2.7%) with a COVID-19 diagnosis, and 963,498 (97.3%) with neither (Table).*** The frequency of PCC diagnosis and COVID-19 diagnosis varied across racial groups. Compared to non-Hispanic White women, non-Hispanic Black women were 33% less likely to have a PCC diagnosis at delivery hospitalization (PR: 0.67 [95% CI: 0.44, 1.03]), despite being 34% more likely to be diagnosed with COVID-19 (1.34 [1.29, 1.3]). Although not statistically significant, women with private health insurance were 19% more likely to be diagnosed with PCC than those with Medicaid (1.19 [0.91, 1.56]), despite being 31% less likely to be diagnosed with COVID-19 at the delivery hospitalization than those with Medicaid (0.69 [0.67, 0.70]). Women with a preterm birth were 72% more likely to have a PCC diagnosis (< 37 weeks gestation) (1.72 [1.20, 2.45]) compared to women without a preterm birth. Prevalence of PCC diagnosis was higher in those with pre-pregnancy diabetes, obesity, depression, and anxiety than those without those conditions. Those receiving mechanical ventilation and ICU admission at delivery were also more likely to receive a PCC diagnosis.

In this large cross-sectional study, PCC diagnosis was uncommon but was more frequent in those with a preterm birth, maternal comorbidities, or pregnancy complications. These findings should be interpreted with caution. These results based on a diagnosis code may be an underestimate given that about 15% of U.S. adults reported ever experiencing PCC (2). However, one study in the U.S. found that the use of the PCC ICD-19 code had a good positive predictive value, 65% of 300 PCC cases were correctly classified as PCC but varied by PCC definition (4). Given that PCC is still not well characterized and guidance for diagnosing PCC is not clear, further studies are needed to assess the timing of SARS-CoV-2 infection and development of PCC in pregnant people, as well as the risks associated with PCC in pregnant people (5).

*(PCC: U09.9, COVID-19: U07.1 & B97.29). The ICD code for PCC was first introduced October 1, 2021. Codes used to identify pregnancy, pregnancy outcomes, and maternal comorbidities have been listed elsewhere (6).

**The Premier Healthcare Database is a U.S. hospital-based, service-level, all-payor database representing approximately 20% of U.S. inpatient admissions, from geographically varied healthcare facilities (3).

***Four individuals had records with both PCC and COVID-19 codes but were categorized as PCC to make categories mutually exclusive in the analysis.

Conflict of Interest Disclosure: Authors report no conflicts.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy; the activity was determined to meet the requirements of public health surveillance as defined in 45 CFR 46.102(l)(2).

Biographical Sketch: Dr. Carlson is an Epidemiologist at Eagle Global Scientific and a contractor with the Centers for Disease Control and Prevention. His interests include prenatal exposures and developmental and maternal health outcomes.

Post-COVID Conditions [Internet]. Centers for Disease Control and Prevention. 2022 [cited 2023 May 15]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html
Long COVID - Household Pulse Survey - COVID-19 [Internet]. 2023 [cited 2023 May 15]. Available from: https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm
Premier Healthcare Database (COVID-19): data that informs and performs: Premier Applied Sciences®, Premier; 2020 [p. 3]. Available from: https://learn.premierinc.com/white-papers/premier-healthcaredatabase.
Zhang HG, Honerlaw JP, Maripuri M, Samayamuthu MJ, Beaulieu-Jones BR, Baig HS, et al. Characterizing the use of the ICD-10 Code for Long COVID in 3 US Healthcare Systems [Internet]. medRxiv; 2023 [cited 2023 Aug 15]. p. 2023.02.12.23285701. Available from: https://www.medrxiv.org/content/10.1101/2023.02.12.23285701v1
Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, et al. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA. 2023 Jun 13;329(22):1934–46.
Ko JY, DeSisto CL, Simeone RM, Ellington S, Galang RR, Oduyebo T, et al. Adverse Pregnancy Outcomes, Maternal Complications, and Severe Illness Among US Delivery Hospitalizations With and Without a Coronavirus Disease 2019 (COVID-19) Diagnosis. Clinical Infectious Diseases. 2021 Jul 15;73(Supplement_1):S24–31.

Table. Demographic characteristics, comorbidities, delivery outcomes, and pregnancy complications of pregnant women by PCC and COVID-19 diagnosis, Premier Healthcare Database October 2021-February 2023

				PRs (95% CIs)
	PCC	COVID-19	Neither	PCC v. Neither	COVID-19 v. Neither
Characteristics
Total deliveries	N=231	N=26521	N=963498
Length of stay in days (mean, SD)	3.03 (2.56)	2.79 (3.91)	2.49 (2.68)	1.00 (1.00, 1.01)	1.00 (1.00, 1.01)
Maternal age in years (mean, SD)	30.9 (5.57)	28.9 (5.93)	29.3 (5.76)	1.05 (1.03, 1.07)	0.99 (0.99, 0.99)
Maternal race and ethnicity no. (%)
Non-Hispanic White	138 (59.7%)	11727 (44.2%)	501028 (52.0%)	REF	REF
Hispanic	42 (18.2%)	6852 (25.8%)	201383 (20.9%)	0.76 (0.54, 1.07)	1.44 (1.40, 1.48)
Non-Hispanic Asian	7 (3.0%)	1219 (4.6%)	46421 (4.8%)	0.55 (0.26, 1.17)	1.12 (1.06, 1.19)
Non-Hispanic Black	25 (10.8%)	4269 (16.1%)	135459 (14.1%)	0.67 (0.44, 1.03)	1.34 (1.29, 1.38)
Non-Hispanic Other	14 (6.1%)	1371 (5.2%)	45151 (4.7%)	1.13 (0.65, 1.95)	1.29 (1.22, 1.36)
Missing	5 (2.1%)	1083 (4.1%)	34279 (3.5%)
Census region no. (%)
Midwest	72 (31.2%)	6030 (22.7%)	218908 (22.7%)	REF	REF
Northeast	35 (15.2%)	4971 (18.7%)	131561 (13.7%)	0.81 (0.54, 1.21)	1.36 (1.31, 1.41)
South	83 (35.9%)	10246 (38.6%)	422923 (43.9%)	0.60 (0.44, 0.82)	0.88 (0.86, 0.91)
West	38 (16.5%)	4972 (18.7%)	174363 (18.1%)	0.66 (0.45, 0.98)	1.03 (1.00, 1.07)
Missing	3 (1.3%)	302 (1.1%)	15743 (1.6%)
Hospital location no. (%)
Rural	32 (13.9%)	3227 (12.2%)	122643 (12.7%)	REF	REF
Urban	196 (84.8%)	22992 (86.7%)	825112 (85.6%)	0.91 (0.63, 1.32)	1.06 (1.02, 1.10)
Payor type n (%)
Medicaid	90 (39.0%)	13784 (52.0%)	409508 (42.5%)	REF	REF
Private	129 (55.8%)	11227 (42.3%)	491443 (51.0%)	1.19 (0.91, 1.56)	0.69 (0.67, 0.70)
Self-pay/other	12 (5.2%)	1510 (5.7%)	62547 (6.5%)	0.87 (0.48, 1.59)	0.72 (0.69, 0.76)
Maternal comorbidities no. (%)
Hypertensive disorders of pregnancy*	64 (27.7%)	5432 (20.5%)	182417 (18.9%)	1.34 (0.96, 1.86)	1.12 (1.09, 1.16)
Chronic hypertension^†	17 (7.4%)	1000 (3.8%)	37564 (3.9%)	1.69 (1.02, 2.80)	0.97 (0.91, 1.03)
Pre-pregnancy diabetes^†	11 (4.8%)	472 (1.8%)	15227 (1.6%)	2.94 (1.61, 5.37)	1.08 (0.98, 1.18)
Obesity^†	61 (26.4%)	4626 (17.4%)	156680 (16.3%)	1.85 (1.38, 2.49)	1.06 (1.02, 1.09)
Depression^†	32 (13.9%)	1420 (5.4%)	54777 (5.7%)	2.64 (1.80, 3.86)	0.98 (0.92, 1.03)
Anxiety disorder^†	48 (20.8%)	1881 (7.1%)	75268 (7.8%)	3.01 (2.16, 4.19)	0.97 (0.93, 1.02)
Smoking (tobacco) complicating childbirth^†,‡	13 (5.6%)	1169 (4.4%)	40153 (4.2%)	1.34 (0.75, 2.42)	1.02 (0.96, 1.08)
Delivery/birth outcome no. (%)
Stillbirth*^,§	2 (0.9%)	219 (0.8%)	5020 (0.5%)	1.72 (0.42, 6.95)	1.52 (1.33, 1.73)
Preterm birth*^,§	39 (16.9%)	3558 (13.4%)	91611 (9.5%)	1.72 (1.20, 2.45)	1.42 (1.37, 1.47)
Pregnancy complications n (%)
Prolonged labor*	4 (1.7%)	258 (1.0%)	9784 (1.0%)	1.72 (0.64, 4.61)	0.98 (0.86, 1.11)
Cesarean delivery*	93 (40.3%)	8530 (32.2%)	303761 (31.5%)	1.20 (0.92, 1.57)	1.03 (1.01, 1.06)
ICU admission*	12 (5.2%)	892 (3.4%)	16250 (1.7%)	2.68 (1.50, 4.80)	1.93 (1.81, 2.07)
Mechanical ventilation*	3 (1.3%)	202 (0.8%)	915 (0.1%)	10.20 (3.26, 31.87)	6.53 (5.75, 7.42)
In hospital death*	1 (0.4%)	27 (0.1%)	48 (0.0%)	78.45 (10.71, 574.59)	13.16 (9.76, 17.74)

Abbreviations: n=number; SD=standard deviation; PR=prevalence ratio; COVID-19=coronavirus disease 2019; PCC=post-COVID conditions; ICU=intensive care unit. (PCC: U09.9, COVID-19: U07.1 & B97.29). The ICD code for PCC was first introduced October 1, 2021. Codes used to identify pregnancy, pregnancy outcomes, and maternal comorbidities have been listed elsewhere (5).

*Adjusted for age, obesity, diabetes, asthma, and chronic hypertension, race/ethnicity, and payor type

^†Adjusted for age, race/ethnicity, and payor type

^‡Abstracted using ICD code O99.33

^§Additionally adjusted for smoking (tobacco) complicating childbirth

Post-COVID Conditions at the Delivery Hospitalization

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Version 1

Abstract

Objective

Study Design

Results

Conclusions

Declarations

References

Table

Status:

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