ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals

Clinical Features and Maternal-fetal Results of Pregnant Women in COVID-19 Times

OBJECTIVE

 Coronavirus disease 2019 (COVID-19) is a disease caused by a newly discovered coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which usually leads to non-specific respiratory symptoms. Although pregnant women are considered at risk for respiratory infections by other viruses, such as SARS and Middle East respiratory syndrome (MERS), little is known about their vulnerability to SARS-CoV-2. Therefore, this study aims to identify and present the main studies on the topic, including the postpartum period.

METHODS

 In this narrative review, articles were searched in various databases, organizations, and health entities using keywords compatible with medical subject headings (MeSH), such as: COVID-19, pregnancy, vertical transmission, coronavirus 2019, and SARS-CoV-2.

RESULTS

 The review of the scientific literature on the subject revealed that pregnant women with COVID-19 did not present clinical manifestations significantly different from those of non-pregnant women; however, there are contraindicated therapies. Regarding fetuses, studies were identified that reported that infection by SARS-CoV-2 in pregnant women can cause fetal distress, breathing difficulties and premature birth, but there is no substantial evidence of vertical transmission.

CONCLUSION

 Due to the lack of adequate information and the limitations of the analyzed studies, it is necessary to provide detailed clinical data on pregnant women infected with SARS-CoV-2 and on the maternal-fetal repercussions caused by this infection. Thus, this review may contribute to expand the knowledge of professionals working in the area as well as to guide more advanced studies on the risk related to pregnant women and their newborns. Meanwhile, monitoring of confirmed or suspected pregnant women with COVID-19 is essential, including in the postpartum period.

Evaluation of clinical outcomes of neonates born to mothers with coronavirus (COVID-19) in Shahid Beheshti Hospitals

BACKGROUND

The coronavirus, which is caused by acute respiratory syndrome, appeared in Wuhan, China, in December 2019 and gradually spread around the world until almost all countries became infected with the coronavirus. In Iran, the outbreak of coronavirus began on February 21, 2020, with the report of infection of two people in the city of Qom. The aim of this study is to evaluate the clinical findings of neonates born to pregnant women with corona disease.

MATERIALS AND METHODS

During this case study (February 21 to November 30, 2020), out of 88 pregnant mothers who referred to the hospitals of Shahid Beheshti University of Medical Sciences, 44 live neonates were born from 42 pregnant women with COVID-19, who were evaluated for clinical signs by studying their files and reported as a case series, due to limited samples, No statistical analysis of the study was performed.

RESULTS

In studies of clinical records of hospitalized mothers and infants, among the polymerase chain reactions (PCRs) provided for all infants, one PCR was reported positive 2 days after birth, whereas this infant 10 min after birth, immediately after routine procedures, due to positive mother's PCR was isolated from the operating room. However, all of the infant's clinical symptoms were normal during the 3-day hospital stay for routine postpartum care. Twenty-eight days after birth, the baby was reevaluated for clinical, laboratory, and chest X-ray symptoms, all of which were normal. The PCR of other neonates was negative, and five intubated neonates, two twin, and two single died, and the other neonates were discharged. In evaluating the clinical records of mothers of these infants, the mean age is 30 years, and the average gestational age is 35 weeks, 32 cases of caesarean section, and 10 cases of normal delivery.

CONCLUSION

We describe epidemiological data, demographics, signs and symptoms on admission, laboratory results, comorbidities, infection COVID-19 in the mothers and neonates, chest radiography and computed tomography findings, treatment received for COVID-19, and clinical maternal, fetal, and neonatal outcomes. Due to the fact that the study population is small consist of 42 mothers with COVID-19 infection, among all PCR samples from infants born to COVID-19 positive mothers, the PCR result of one case was positive, and the rest of was negative. Therefore, vertical transmission of COVID-19 through the placenta to the fetus cannot be confirmed or denied, nor can the COVID-19 confirmed or denied the baby's postnatal complication during pregnancy.

COVID-19: changing the care process for women's health-the patient's perspective

OBJECTIVE

Assess women's perceptions of the impact of COVID-19 on their health care and well-being, access to and satisfaction with medical care due to the changes in delivery of care triggered by the pandemic.

METHODS

An online survey of women having health care appointments in the outpatient facilities across all divisions of a Department of Obstetrics and Gynecology at a tertiary care referral center in North Central Florida. Patients had outpatient appointments that were scheduled, canceled or rescheduled, in person or by telemedicine, between 11 March 2020 and 11 May 2020, a time during which a COVID-19 stay-at-home order was enacted across our state. A total of 6,697 visits were planned. Patients with multiple visits were unified, leaving 6,044 unique patients to whom the survey was emailed between 20 July 2020 and 31 July 2020. The survey was closed on 21 August 2020. Analyses were focused on simple descriptive statistics to assess frequency of responses. Analyses of variance and chi-square analyses were conducted to compare outcomes when all cells were ≥ 10, based on sub-specialty and insurance status; otherwise, frequencies were examined for the entire sample only. Missing data were excluded listwise.

RESULTS

A total of 6044 patients were contacted. Completed surveys numbered 1,083 yielding a response rate of 17.9%. The most common sub-specialty visit was gynecology (56.7%) followed by obstetrics (31.5%,), pelvic floor disorders (4.8%), gynecological oncology (2.9%,), and reproductive endocrinology (0.5%). A substantial percentage of women had visits canceled (19.2%), rescheduled (32.8%) or changed (42.1%) to telemedicine. In our patient population, 32.6% were worried about visiting the clinic and 48.1% were worried about visiting the hospital. COVID-19 triggered changes were perceived to have a negative impact by 26.1% of respondents. Refusal of future telemedicine visits was by 17.2%, however, 75.2% would prefer to use both in-person and telemedicine visits.

CONCLUSION

During the initial COVID-19 surge with lockdown, the majority of survey respondents were following public health precautions. However, there were significant concerns amongst women related to obstetric and gynecologic medical appointments scheduled during that period. During pandemics, natural disasters and similar extreme circumstances, digital communication and telemedicine have the potential to play a critical role in providing reassurance and care. Nevertheless, given the concerns expressed by survey respondents, communication and messaging tools are needed to increase comfort and ensure equity with the rapidly changing methods of care delivery.

COVID-19 Impacts, Diagnosis and Possible Therapeutic Techniques: A Comprehensive Review

BACKGROUND

The spread of COVID-19 has become a growing cause of mortalities over the globe since its major outbreak in December 2019. The scientific and medical communities are rallying to study different strains and probable mutations to develop more rapid and reliable molecular diagnostic tests and possible therapeutic approaches for SARS-CoV-2.

INTRODUCTION

In the first section, following the introductory part, we shed light on structural and pathogenic features of SARS-CoV-2 and risk factors related to age, gender, neonatal and comorbidities. The next section summarizes the current diagnostic tests for COVID-19, such as nucleic acid and computed tomography (CT) techniques, with further emphasis on emerging diagnostic approaches for COVID-19.

METHODS

Further, we also review the ongoing therapeutic practices which can block virus-host interaction, cease viral proliferation or inhibit hyperbolic host immune response with subsections on drug therapy, cell therapy, immunotherapy and herbal medicines that are being used for the possible treatment of patients.

RESULTS AND CONCLUSION

Among the different promising drugs, remdesivir, by inhibiting the RNA-dependent RNA-Polymerase activity, gives much better results, including declined viral load and quick lung tissue recovery. The long-lasting repercussions of COVID-19 have also been discussed at the end. In this review, we have also critically discussed the progress in several vaccines that are under development.

COVID-19 Disease During Pregnancy and Peripartum Period: A Cardiovascular Review

Pregnancy with various physiological effects on cardiovascular system, makes mothers with borderline cardiovascular reserve at significant risk for adverse events during labor and early postpartum period. Cardiac imaging modalities, have shown that Coronavrus Disease 2019 disease is associated with subclinical myocardial injury in significant numbers of infected people, even in mild or asymptomatic disease and previous healthy ones. Herein, we have discussed the cardiovascular aspects of prepartum pregnant women with Coronavrus Disease 2019, especially patients with moderate to severe illness. Also, we have proposed how to handle the hemodynamic load during labor and the first 48 hours postpartum in the hypoxemic overloaded parturients with possible subclinical myocardial injury.

Relationship of COVID-19 with pregnancy

COVID-19 a pandemic disease caused by the SARS-CoV2 virus, which has been emerged in Wuhan city China from early December 2019 which subsequently spreading globally. As a consequence of the physiological adaptive changes and immunosuppressive condition during pregnancy are more susceptible to respiratory tract infection and pneumonia that perhaps makes them more at risk to COVID-19. There is scarce information available on COVID-19 pregnancy and no reliable evidence for vertical transmission. It is a concern that newborns are risk from postpartum contamination. Meanwhile, there was no vaccine and specific therapeutic drugs for COVID19. The Multidisciplinary team will manage by close supervision, isolated negative pressure room, and routinely fetal monitoring. The timing and mode of delivery depend on the critical condition of the mother and fetal. The newborns need a14 days period of precautionary isolation. In the present study, addressed the most recent data on 149 pregnant women and 96 newborns with typical symptoms and planning of management which response to COVID-19 that will help for frontline doctor to the management of COVID-19 associated pregnancy and newborns baby. Repeated testing, contact tracing and self-isolation will assist to control the spread of SARS-CoV2 infection and COVID-19 disease until specific vaccine and pharmaceuticals drugs of COVID-19 are available.

Pregnant women with COVID-19: the placental involvement and consequences

SARS-CoV-2, the leading cause of COVID-19 pandemic, was detected for the first time in Wuhan. In this study, we investigated the potential undesirable maternal and feto-neonatal consequences of COVID-19, and the related pathophysiological alterations in mother, neonate, and especially in the placenta as a vital organ, were reviewed. Also, the possibility of vertical transmission of virus and placental abnormalities were evaluated. The pregnant women were a vulnerable population for COVID-19, and several obstetric consequences were reported following SARS-CoV-2 infection. The higher risk of abruption, preterm labor, maternal death, stillbirth, intrauterine growth restriction, and newborns with fetal distress were adverse pregnancy and perinatal outcomes of COVID-19. Despite the ACE2 expression on placental components was confirmed, there is no agreement on the mother-child vertical transmission of this virus. Therefore, feto-neonatal consequences might be associated with placental abnormalities. The placental abnormalities are characterized by feto-maternal vascular malperfusion. Additionally, these adverse consequences lead to early termination of pregnancy in some cases, mostly via cesarean section. The pregnant women screening, coordination between healthcare personnel and neonatal unit, and infected women quarantine may decrease the risk of maternal and neonatal death after delivery.

Management and Prevention of COVID-19 in Pregnancy and Pandemic Obstetric Care: A Review of Current Practices

Constant accumulation of data results in continuous updates of guidelines and recommendations on the proper management of pregnant women with COVID-19. This study aims to summarize the up-to-date information about the prevention and management of suspected/confirmed SARS-CoV-2 infection in obstetric patients and obstetric care during prenatal, intrapartum, and postpartum periods. We conducted a comprehensive literature search in PubMed for relevant English-written full-text reviews. We also included relevant guidelines and recommendations. In women with a low risk for infection and uncomplicated pregnancy, elective and non-urgent appointments should be postponed or completed through telehealth. Vaccination should be discussed and distance and personal hygiene preventive measures should be recommended. Routine ultrasound examinations should be adjusted in order to minimize exposure to the virus. Standardized criteria should evaluate the need for admission. Women with moderate/high-risk for infection should be isolated and tested with RT-PCR. The mode and timing of delivery should follow routine obstetric indications. In case of infection, glucocorticoids are recommended in critically ill pregnant women, after individualized evaluation. During labor and concomitant infection, the duration of the first two stages should be reduced as possible to decrease aerosolization, while minimization of hemorrhage is essential during the third stage. Close maternal monitoring and adequate oxygenation when necessary always remain a prerequisite. Discharge should be considered on the first or second day postpartum, also depending on delivery mode. Breastfeeding with protective equipment is recommended, as its benefits outweigh the risks of neonatal infection. Recommendations are currently based on limited available data. More original studies on infected pregnant women are needed to establish totally evidence-based protocols of care for these patients.

Effects of COVID-19 on Pregnant women: Evidence-based review

Corona virus infection (COVID-19) is increasing exponentially globally. It is also affecting pregnant women among others. Complications arising during pregnancy because of COVID-19 must be considered a health issue. The objective of the study was to analyse symptoms of pregnant women affected with COVID-19 based on the available literature. The articles were searched from Medline/PubMed, Scopus which were published till June 2020 and reviewed for the determined outcomes. The review demonstrated that common symptoms were fever, cough, nausea and myalgia. Vertical transmission of Corona virus infection was not found in any of the articles reviewed. Multicenter studies are important to better understand the pathogenesis and treatment planning for COVID-19 affected pregnant women.

COVID-19 guidelines for pregnant women and new mothers: A systematic evidence review

BACKGROUND

Nearly a year after COVID-19 was initially detected, guidance for pregnant and new mothers remains varied.

OBJECTIVE

The goal of this systematic review is to summarize recommendations for three areas of maternal and fetal care-breastfeeding, post-partum social distancing, and decontamination.

SEARCH STRATEGY

We searched PubMed, Embase and Web of Science spanning from inception to November 9, 2020.

SELECTION CRITERIA

Articles were included if they focused on COVID-positive mothers, commented on at least one of the three areas of interest, and were published in English.

DATA COLLECTION AND ANALYSIS

Our combined database search yielded 385 articles. After removing duplicates and articles that did not cover the correct populations or subject matter, a total of 74 articles remained in our analysis.

MAIN RESULTS

Most articles recommended direct breastfeeding with enhanced precaution measures. Recommendations regarding post-partum social distancing varied, although articles published more recently often recommended keeping the mother and newborn in the same room when possible. Decontamination recommendations emphasized mask wearing, good hand hygiene, and proper cleaning of surfaces.

CONCLUSION

In general, there was a focus on shared decision making when approaching topics such as breastfeeding and post-partum social distancing. Guidelines for decontamination were fairly uniform.

SARS-CoV-2 from Urban to Rural Water Environment: Occurrence, Persistence, Fate, and Influence on Agriculture Irrigation. A Review

The novel coronavirus disease (COVID-19), originating from China, has rapidly crossed borders, infecting people worldwide. While its transmission may occur predominantly via aerosolization of virus-laden droplets, the possibility of other routes of contagion via the environment necessitates considerable scientific consideration. SARS-CoV-2 viral RNA has been detected in the feces of infected persons, and studies also have reported its occurrence in wastewater and surface water bodies. Therefore, water may be a possible route of virus outbreaks. Agricultural irrigation is the largest use of water globally, accounting for 70% of water use worldwide. Ensuring adequate water quality within irrigation practices is fundamental to prevent harm to plants and soils, maintain food safety, and protect public health. This review aims to gather information on possible SARS-CoV-2 transmission routes within urban and rural water environments, looking into the detection, persistence, and fate of SARS-CoV-2. Based on published literature, the effect of current treatment technologies in wastewater treatment plants (WWTPs) on SARS-CoV-2 inactivation has also been investigated. Preliminary research efforts that concentrated on SARS-CoV-2 indicate that the risk of virus transmission from the aquatic environment may currently be non-existent, although a few studies have reported the presence of SARS-CoV RNA in soils, whereas there are still no studies on the detection of SARS-CoV-2 in crops.

Delivery and breastfeeding in pregnant patients with COVID-19 (Review)

COVID-19 infection has rapidly become a global issue that has brought essential changes in the daily life of patients and doctors. The pandemic outbreak represents a significant burden on humankind; yet, life still moves on with approximately 350,000 babies being born every day around the world (UNICEF-2018). Some of these mothers will have other conditions, including COVID-19 infection. As healthcare providers, it is our responsibility to treat all women equal no matter what illness they have and to offer them the best possible conditions to give birth vaginally or via Caesarian section, in a safe environment for them and their babies. The main concern is represented by the limitation of the disease transmission to pregnant patients and newborns while managing maternal or fetal emergencies. We have limited information regarding COVID-19 infection, and the data are constantly changing and evolving. New information is brought to light almost on a weekly basis. This review aims to synthesize the recommendations and current experience regarding the birth method for infected women, labor management, Caesarian section management, and breastfeeding indications in these cases.

A Review on Mode of Delivery during COVID-19 between December 2019 and April 2020

OBJECTIVE

This study aims to review the published literature to determine mode of delivery in pregnant women with coronavirus disease 2019 (COVID-19) and the indications reported for cesarean section early in the pandemic to add information to the current narrative and raise awareness of trends discovered.

STUDY DESIGN

A systematic review was conducted by searching PubMed, Scopus, and ScienceDirect databases for articles published between December 2019 and April 29, 2020 using a combination of the keywords such as COVID-19, coronavirus 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), pregnancy, vaginal delivery, cesarean section, vertical transmission, management, and guidelines. Peer-reviewed case studies with confirmed SARS-CoV-2 women who delivered were included to determine mode of delivery, indications for cesarean section, and maternal and neonatal characteristics.

RESULTS

A review of 36 total articles revealed deliveries in 203 SARS-CoV-2 positive pregnant women. A comparable severity of disease in pregnant versus nonpregnant women was noted, as previously determined. Overall, 68.9% of women delivered via cesarean section, with COVID-19 status alone being a common indication. Maternal COVID-19 may also be associated with increased risk of preterm labor, although neonatal outcomes were generally favorable. Despite eight of 206 newborns testing positive for SARS-CoV-2, there remains no definitive evidence of vertical transmission.

CONCLUSION

COVID-19 status alone became a common indication for cesarean delivery early in the pandemic, despite lack of evidence for vertical transmission. The increase in cesarean rate in this data may reflect obstetricians attempting to serve their patients in the best way possible given the current climate of constantly evolving guidelines on safest mode of delivery for the mother, infant, and provider. Upholding current recommendations from trusted organizations as new data are published, while also providing individualized support to expecting mothers on most appropriate mode of delivery, will reduce the amount of unnecessary, unplanned cesarean sections and could lessen the psychological impact of delivering during the COVID-19 pandemic.

KEY POINTS

· COVID-19 may result in an increased rate of cesarean delivery for SARS-CoV-2 positive pregnant women.. · COVID-19 is a commonly reported indication for cesarean section, despite management guidelines urging against this.. · Although eight neonates tested positive for SARS-CoV-2, all additional fluid and tissue samples tested negative..

Pregnant women with SARS-CoV-2 infection are at higher risk of death and pneumonia: propensity score matched analysis of a nationwide prospective cohort (COV19Mx)

OBJECTIVE

There are limited, unmatched data reporting low complication rates in pregnant women with coronavirus disease 2019 (COVID-19). The aim of this study was to compare COVID-19-related outcomes between pregnant and non-pregnant women after adjusting for potential risk factors for severe outcomes.

METHODS

Data were obtained from the COVID-19 National Data Registry of Mexico, which is an ongoing prospective cohort of people of any age with clinically suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and admitted to 475 monitoring hospitals. This study included pregnant and non-pregnant women of reproductive age (15-45 years) with COVID-19 confirmed by reverse transcription polymerase chain reaction. To adjust for underlying risk factors, propensity score matching was conducted for chronic obstructive pulmonary disease, asthma, smoking, hypertension, cardiovascular disease, obesity, diabetes, chronic renal disease, immunosuppression, age, language, nationality and level of health insurance. The primary outcome was death. Secondary outcomes were pneumonia, intubation and intensive care unit (ICU) admission.

RESULTS

The cohort comprised 5183 pregnant and 175 905 non-pregnant women with COVID-19. The crude (unmatched) rates of death, pneumonia, intubation and ICU admission in pregnant compared with non-pregnant women were 1.5% vs 1.5%, 9.9% vs 6.5%, 8.1% vs 9.9% and 13.0% vs 6.9%, respectively. After propensity score matching (5183 pregnant and 5183 non-pregnant matched women), pregnant women had a higher odds of death (odds ratio (OR), 1.84; 95% CI, 1.26-2.69), pneumonia (OR, 1.86; 95% CI, 1.60-2.16) and ICU admission (OR, 1.86; 95% CI, 1.41-2.45) than non-pregnant women, but similar odds of intubation (OR, 0.93; 95% CI, 0.70-1.25).

CONCLUSION

After adjusting for background demographic and medical factors, pregnancy is a risk factor for death, pneumonia and ICU admission in SARS-CoV-2-infected women of reproductive age. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

COVID-19 Preventive Measure Practices and Knowledge of Pregnant Women in Guraghe Zone Hospitals

BACKGROUND

The COVID-19 pandemic is caused by a severe acute respiratory syndrome coronavirus which emerged in Wuhan. Recently this virus has rapidly spread throughout Ethiopia. The current preventive measure practices and knowledge have gaps. Therefore this study aimed to assess COVID-19 preventive measure practices and knowledge of pregnant women in Guraghe Zone hospitals.

METHODS AND MATERIALS

This cross-sectional study was conducted from July 27-August 27, 2020 among pregnant women in Guraghe zone hospitals. Systematic random sampling technique were employed to select 403 participants. Data were checked manually for completeness, cleaned, and stored in Epi Data and exported to SPSS for further analysis. Variables which have a P-value less than 0.25 on bivariate analysis were taken to multivariate analysis. A P-value of less than 0.05 and 95% confidence level was used as a cut-off point for presence of association in multivariate analysis.

RESULTS

COVID-19 preventive measure practice and knowledge of pregnant women visiting Guraghe Zone hospitals was 76.2% and 54.84%, respectively. Those aged 20-24 (AOR=1.22, 95% CI=1.15-22.24), 25-29 (AOR=1.32, 95% CI=1.20-20.25), and 30-34 (AOR=2.57, 95% CI-2.32-43.38) were more likely to practice COVID-19 preventive measures. Those residing in urban area (AOR=2.16, 95% CI=1.24-3.77) and perceiving that COVID-19 is worst for people with chronic disease (AOR=5.12, 95% CI=1.73-15.17) were more likely to practice COVID-19 preventive measures.

CONCLUSION

COVID-19 preventive measure practices and knowledge were low. Age, residence, and perception of COVID-19 on chronic disease were independent factors associated with preventive measure practices. Pregnant women aged ≥35 need to be counseled on practices of preventing COVID-19 by their healthcare providers.

Modes of Transmission of Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) and Factors Influencing on the Airborne Transmission: A Review

The multiple modes of SARS-CoV-2 transmission including airborne, droplet, contact, and fecal-oral transmissions that cause coronavirus disease 2019 (COVID-19) contribute to a public threat to the lives of people worldwide. Herein, different databases are reviewed to evaluate modes of transmission of SARS-CoV-2 and study the effects of negative pressure ventilation, air conditioning system, and related protection approaches of this virus. Droplet transmission was commonly reported to occur in particles with diameter >5 µm that can quickly settle gravitationally on surfaces (1-2 m). Instead, fine and ultrafine particles (airborne transmission) can stay suspended for an extended period of time (≥2 h) and be transported further, e.g., up to 8 m through simple diffusion and convection mechanisms. Droplet and airborne transmission of SARS-CoV-2 can be limited indoors with adequate ventilation of rooms, by routine disinfection of toilets, using negative pressure rooms, using face masks, and maintaining social distancing. Other preventive measures recommended include increasing the number of screening tests of suspected carriers of SARS-CoV-2, reducing the number of persons in a room to minimize sharing indoor air, and monitoring people's temperature before accessing a building. The work reviews a body of literature supporting the transmission of SARS-CoV-2 through air, causing COVID-19 disease, which requires coordinated worldwide strategies.

How can we build and maintain the resilience of our health care professionals during COVID-19? Recommendations based on a scoping review

OBJECTIVE

To explore how to build and maintain the resilience of frontline healthcare professionals exposed to COVID-19 outbreak working conditions.

DESIGN

Scoping review supplemented with expert interviews to validate the findings.

SETTING

Hospitals.

METHODS

We searched PubMed, Embase, PsycINFO, CINAHL, bioRxiv and medRxiv systematically and grey literature for articles focusing on the impact of COVID-19-like working conditions on the physical and/or mental health of healthcare professionals in a hospital setting. Articles using an empirical design about determinants or causes of physical and/or mental health and about interventions, measures and policies to preserve physical and/or mental health were included. Four experts were interviewed to reflect on the results from the scoping review.

RESULTS

In total, 4471 records were screened leading to an inclusion of 73 articles. Recommendations prior to the outbreak fostering resilience included optimal provision of education and training, resilience training and interventions to create a feeling of being prepared. Recommendations during the outbreak consisted of (1) enhancing resilience by proper provision of information, psychosocial support and treatment (eg, create enabling conditions such as forming a psychosocial support team), monitoring the health status of professionals and using various forms and content of psychosocial support (eg, encouraging peer support, sharing and celebrating successes), (2) tasks and responsibilities, in which attention should be paid to kind of tasks, task mix and responsibilities as well as the intensity and weight of these tasks and (3) work patterns and working conditions. Findings of the review were validated by experts.

CONCLUSIONS

Recommendations were developed on how to build and maintain resilience of frontline healthcare professionals exposed to COVID-19 outbreak working conditions. These practical and easy to implement recommendations can be used by hospitals and other healthcare organisations to foster and preserve short-term and long-term physical and mental health and employability of their professionals.

Human Coronavirus Infections and Pregnancy

Human coronavirus (HCoV) causes potentially fatal respiratory disease. Pregnancy is a physiological state that predisposes women to viral infection. In this review, we aim to present advances in the pathogenesis, clinical features, diagnosis, and treatment in HCoV in pregnancy. We retrieved information from the Pubmed database up to June 2020, using various search terms and relevant words, including coronaviruses, severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus, 2019 coronavirus disease, and pregnancy. Both basic and clinical studies were selected. We found no evidence that pregnant women are more susceptible to HCoV infection or that those with HCoV infection are more prone to developing severe pneumonia. There is also no confirmed evidence of vertical mother-to-child transmission of HcoV infection during maternal HCoV infection. Those diagnosed with infection should be promptly admitted to a negative-pressure isolation ward, preferably in a designated hospital with adequate facilities and multi-disciplinary expertise to manage critically ill obstetric patients. Antiviral treatment has been routinely used to treat pregnant women with HCoV infection. The timing and mode of delivery should be individualized, depending mainly on the clinical status of the patient, gestational age, and fetal condition. Early cord clamping and temporary separation of the newborn for at least 2 weeks is recommended. All medical staff caring for patients with HCoV infection should use personal protective equipment. This review highlights the advances in pathogenesis, maternal-fetal outcome, maternal-fetal transmission, diagnosis and treatment in HCoV including severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus, and coronavirus disease 2019 in pregnancy.

Coronavirus disease 2019 in pregnancy was associated with maternal morbidity and preterm birth

BACKGROUND

Despite the mainly reassuring outcomes for pregnant women with coronavirus disease 2019 reported by previous case series with small sample sizes, some recent reports of severe maternal morbidity requiring intubation and of maternal deaths show the need for additional data about the impact of coronavirus disease 2019 on pregnancy outcomes.

OBJECTIVE

This study aimed to report the maternal characteristics and clinical outcomes of pregnant women with coronavirus disease 2019.

STUDY DESIGN

This retrospective, single-center study includes all consecutive pregnant women with confirmed (laboratory-confirmed) or suspected (according to the Chinese management guideline [version 7.0]) coronavirus disease 2019, regardless of gestational age at diagnosis, admitted to the Strasbourg University Hospital (France) from March 1, 2020, to April 3, 2020. Maternal characteristics, laboratory and imaging findings, and maternal and neonatal outcomes were extracted from medical records.

RESULTS

The study includes 54 pregnant women with confirmed (n=38) and suspected (n=16) coronavirus disease 2019. Of these, 32 had an ongoing pregnancy, 1 had a miscarriage, and 21 had live births: 12 vaginal and 9 cesarean deliveries. Among the women who gave birth, preterm deliveries were medically indicated for their coronavirus disease 2019-related condition for 5 of 21 women (23.8%): 3 (14.3%) before 32 weeks' gestation and 2 (9.5%) before 28 weeks' gestation. Oxygen support was required for 13 of 54 women (24.1%), including high-flow oxygen (n=2), noninvasive (n=1) and invasive (n=3) mechanical ventilation, and extracorporeal membrane oxygenation (n=1). Of these, 3, aged 35 years or older with positive test result for severe acute respiratory syndrome coronavirus 2 using reverse transcription polymerase chain reaction, had respiratory failure requiring indicated delivery before 29 weeks' gestation. All 3 women were overweight or obese, and 2 had an additional comorbidity.

CONCLUSION

Coronavirus disease 2019 in pregnancy was associated with maternal morbidity and preterm birth. Its association with other well-known risk factors for severe maternal morbidity in pregnant women with no infection, including maternal age above 35 years, overweight, and obesity, suggests further studies are required to determine whether these risk factors are also associated with poorer maternal outcome in these women.

COVID-19, neutrophil extracellular traps and vascular complications in obstetric practice

An issue of the novel coronavirus infection spreading is currently in the first place among others in the list of the international medical community. Due to lack of information, conflicting research findings, multicomponent effect of the virus on the body host, as well as various consequences that the virus triggers in the body, now every medical specialty does study the viral attack pathogenesis. Recent months showed that vascular complications are the most severe in the Coronavirus Disease 2019 (COVID-19) and are the main cause of death in the patients. The mechanisms of vascular complications are complex and affect both the hemostatic system and immune responses, "inflammatory storm", disorders of the renin-angiotensin-aldosterone system, endotheliopathy, etc. Due to the leading role of vascular complications in the viral infection pathogenesis, several groups of patients are at extra risk, including pregnant women, patients with a burdened obstetric history, with hereditary thrombophilia and antiphospholipid syndrome, and patients after in vitro fertilization (IVF). In this category of pregnant women, use of low-molecular-weight heparins (LMWH) is particularly important for both prevention of vascular and obstetric complications, and for pathogenetic therapy of COVID-19.

COVID-19 in obstetrics 2020: the experience at a New York City medical center

The global spread of the SARS-CoV-2 virus during the early months of 2020 was rapid and exposed vulnerabilities in health systems throughout the world. Obstetric SARS-CoV-2 disease was discovered to be largely asymptomatic carriage but included a small rate of severe disease with rapid decompensation in otherwise healthy women. Higher rates of hospitalization, Intensive Care Unit (ICU) admission and intubation, along with higher infection rates in minority and disadvantaged populations have been documented across regions. The operational gymnastics that occurred daily during the Covid-19 emergency needed to be translated to the obstetrics realm, both inpatient and ambulatory. Resources for adaptation to the public health crisis included workforce flexibility, frequent communication of operational and protocol changes for evaluation and management, and application of innovative ideas to meet the demand.

COVID-19 does not stop obstetrics: what we need to change to go on safely birthing. The experience of a University Obstetrics and Gynecology Department in Milan

Since SARS-COV-2 appeared in Wuhan City, China and rapidly spread throughout Europe, a real revolution occurred in the daily routine and in the organization of the entire health system. While non-urgent clinical services have been reduced as far as possible, all kind of specialists turned into COVID-19 specialists. Obstetric assistance cannot be suspended and, at the same time, safety must be guaranteed. In addition, as COVID-19 positive pregnant patients require additional care, some of the clinical habits need to be changed to face emerging needs for a vulnerable but unstoppable kind of patients. We report the management set up in an Obstetrics and Gynecology Unit during the COVID-19 era in a University Hospital in Milan, Italy.

Pregnancy and Breastfeeding During COVID-19 Pandemic: A Systematic Review of Published Pregnancy Cases

Background: The COVID-19 pandemic is an emerging concern regarding the potential adverse effects during pregnancy. This study reviews knowledge on the impact of COVID-19 on pregnancy and describes the outcome of published cases of pregnant women diagnosed with COVID-19. Methods: Searches were conducted in PubMed®, Scopus®, Web of Science®, and MedRxiv® up to 26th June 2020, using PRISMA standards, to identify original published studies describing pregnant women at any gestational age diagnosed COVID-19. There were no date or language restrictions on the search. All identified studies were included irrespective of assumptions on study quality. Results: We identified 161 original studies reporting 3,985 cases of pregnant women with COVID-19 (1,007 discharged while pregnant). The 2,059 published cases with pregnancy outcomes resulted in 42 abortions, 21 stillbirths, and 2,015 live births. Preterm birth occurred in 23% of cases. Around 6% of pregnant women required admission to an intensive care unit and 28 died. There were 10 neonatal deaths. From the 163 cases with amniotic fluid, placenta, and/or cord blood analyzed for the SARS-CoV-2 virus, 10 were positive. Sixty-one newborns were positive for SARS-CoV-2. Four breast milk samples from 92 cases showed evidence of SARS-CoV-2. Conclusion: Emerging evidence suggests that vertical transmission is possible, however, there is still a limited number of reported cases with intrapartum samples. Information, counseling and adequate monitoring are essential to prevent and manage adverse effects of SARS-CoV-2 infection during pregnancy.

Changes in the obstetrical emergency department profile during the COVID-19 pandemic

BACKGROUND

The COVID-19 outbreak caused persons to be reluctant to seek medical care due to fear of contracting the infection.

OBJECTIVES

To evaluate the effect of the COVID-19 pandemic on admission rates to the delivery room and the feto-maternal unit, and to assess the effect on the nature of presenting obstetrical complaints to the emergency department.

STUDY DESIGN

A retrospective cohort study in one medical center. The population was women > 20 weeks pregnant who presented to the obstetrical emergency department with self-complaints during 29 days at the peak of the pandemic outbreak, and a matched group during the exact period in the previous year. We compared between the groups: clinical, obstetrical, and demographic data, including age, area of residence, gravidity, parity, previous cesarean deliveries, high-risk pregnancy follow-up, the last 30 days admissions to the obstetrical emergency department, gestational age, chief complaints, cervical dilatation, cervical effacement, admissions to the delivery room or feto-maternal unit, time from admissions to the delivery room to birth, if applicable, and acute obstetrical complications diagnosed at the emergency department.

RESULTS

During the pandemic outbreak, 398 women met study inclusion criteria, compared to 544 women in the matched period of the previous year. During the COVID-19 period, women visited the obstetrical emergency department at a more advanced mean gestational age (37.6 ± 3.7 vs. 36.7 ± 4.6, p = .001). Higher proportions of women in the COVID-19 cohort presented in active labor, defined by cervical dilation of at least 5 cm on admission to the labor ward [37 (9.3%) vs 28 (5.1%), p = .013)] and with premature rupture of membranes [82 (20.6%) vs 60 (11.0%), p < .001)], and consequently with more admissions to the delivery room [198 (49.7%) vs 189 (34.7%), p < .001)]. We also recorded a significant increase in urgent obstetrical events in the emergency department during the recorded COVID-19 pandemic [23 (5.8%) vs 12 (2.2%)), p = .004]. However, the rates of neonatal and maternal morbidity did not change. During the outbreak the proportion of visits during the night was higher than during the matched period of the previous year: [138 (34.7%) vs 145 (26.6%)), p = .008]. In a multivariate logistic regression, the higher rates of admission to the delivery room during active labor and of urgent events during the pandemic outbreak compared to the matched period in the previous year remained statistically significant.

CONCLUSIONS

The pandemic outbreak of COVID-19 caused a behavioral change among women who presented to the obstetrical emergency department. This was characterized by delayed arrival to the obstetrical emergency department and the delivery room, which led to a significant increase in urgent and acute interventions. The change in behavior did not affect the rates of maternal and neonatal morbidity.

Guidelines for Pregnancy Management During the COVID-19 Pandemic: A Public Health Conundrum

Pregnant women seem to be at risk for developing complications from COVID-19. Given the limited knowledge about the impact of COVID-19 on pregnancy, management guidelines are fundamental. Our aim was to examine the obstetrics guidelines released from December 2019 to April 2020 to compare their recommendations and to assess how useful they could be to maternal health workers. We reviewed 11 guidelines on obstetrics management, assessing four domains: (1) timeliness: the time between the declaration of pandemics by WHO and a guideline release and update; (2) accessibility: the readiness to access a guideline by searching it on a common browser; (3) completeness: the amount of foundational topics covered; and (4) consistency: the agreement among different guidelines. In terms of timeliness, the Royal College of Obstetricians and Gynaecologists (RCOG) was the first organization to release their recommendation. Only four guidelines were accessible with one click, while only 6/11 guidelines covered more than 80% of the 30 foundational topics we identified. For consistency, the study highlights the existence of 10 points of conflict among the recommendations. The present research revealed a lack of uniformity and consistency, resulting in potentially challenging decisions for healthcare providers.

Managing pregnancy in COVID-19 pandemic: A review article

The outbreak Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a highly contagious and lethal beta coronavirus SARS-CoV-2, which has spread fast to encroach the entire globe and hence declare pandemic. Pregnancy alters body physiology and immune systems, can have worse effects of some respiratory infections and due to limited research and published data we still are in dilemma of appropriate management guidelines This article covers the updated guidelines for infection prevention and control (IPC), screening, sampling, antenatal visit schedules, risk scoring, triaging, supportive care, delivery, postpartum care and care of the newborn. This article aims to provide up-to-date information as per recent guidelines of various association which would serve as guidance in managing pregnant women and newborn with suspected or confirmed COVID-19. All the published papers till date, NCPRE, WHO Interim guidelines, RCOG, FOGS GCPRI, Medical Council of India, ICMR, MOFHW, CDC, ACOG guidelines are referred to compile this article to reach to a conclusion of evidence based management of pregnant ladies during COVID-19 pandemic. This article covers the not only infection prevention and control (IPC) guidelines, but also screening and sampling guidelines, antenatal visit schedules, risk scoring, triaging but also in-patient supportive care, delivery, postpartum care and care of the newborn. Data are very limited and hence very difficult to accurately define clinical management strategies and needs to be constantly updated.

A review of newborn outcomes during the COVID-19 pandemic

As the COVID-19 pandemic continues to spread worldwide, it is crucial that we determine populations that are at-risk and develop appropriate clinical care policies to protect them. While several respiratory illnesses are known to seriously impact pregnant women and newborns, preliminary data on the novel SARS-CoV-2 Coronavirus suggest that these groups are no more at-risk than the general population. Here, we review the available literature on newborns born to infected mothers and show that newborns of mothers with positive/suspected SARS-CoV-2 infection rarely acquire the disease or show adverse clinical outcomes. With this evidence in mind, it appears that strict postnatal care policies, including separating mothers and newborns, discouraging breastfeeding, and performing early bathing, may be more likely to adversely impact newborns than they are to reduce the low risk of maternal transmission of SARS-CoV-2 or the even lower risk of severe COVID-19 disease in otherwise healthy newborns.

A case of delivery of a pregnant woman with COVID-19 infection in Daegu, Korea

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is affiliated with the β-coronavirus subgroup, which includes SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), but is far more infectious than the 2. Because it is potentially life-threatening to infants and pregnant women with weak immune systems, clinical manifestations and vertical transmission of COVID-19 are matters of interest. Staff of the obstetrics department of university hospitals in Daegu and of the Daegu metropolitan government designated Daegu Fatima Hospital for the delivery of pregnant women with suspected and confirmed SARS-CoV-2 infection. Thirteen pregnant women with laboratory-confirmed COVID-19 were identified. Among them was a 28-year-old pregnant woman who had recovered from COVID-19 and had given birth to a healthy girl at 38 weeks of gestational age. We present our uncommon experience with a brief review of literatures.

A pandemic center's experience of managing pregnant women with COVID-19 infection in Turkey: A prospective cohort study

OBJECTIVE

To evaluate the course and effect of coronavirus disease 2019 (COVID-19) on pregnant women followed up in a Turkish institution.

METHODS

A prospective, single tertiary pandemic center cohort study was conducted on pregnant women with confirmed or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Positive diagnosis was made on a real-time polymerase chain reaction (RT-PCR) assay of a nasopharyngeal and oropharyngeal specimen. Demographic features, clinical characteristics, and maternal and perinatal outcomes were evaluated.

RESULTS

SARS-CoV-2 was suspected in 100 pregnant women. Of them, 29 had the diagnosis confirmed by RT-PCR. Eight of the remaining 71 cases had clinical findings highly suspicious for COVID-19. Ten (34.5%) of the confirmed cases had co-morbidities. Cough (58.6%) and myalgia (51.7%) were the leading symptoms. COVID-19 therapy was given to 10 (34.5%) patients. There were no admissions to the intensive care unit. Pregnancy complications were present in 7 (24.1%) patients. Half of the births (5/10) were cesarean deliveries. None of the neonates were positive for SARS-CoV-2. Samples of breastmilk were also negative for the virus. Three neonates were admitted to the neonatal intensive care unit.

CONCLUSION

The clinical course of COVID 19 during pregnancy appears to be mild in the present study.

Obstetrics and Neonatal Outcomes in Pregnant Women with COVID-19: A Systematic Review

BACKGROUND

Considering that the obstetricians and pediatricians need to comprehensive information about the obstetric and neonatal effect of COVID-19, this review study was conducted to investigate the impact of COVID-19 on obstetrics and neonatal outcomes.

METHODS

In this systematic review the international search databases following PubMed, Web of Science, Scopus, ProQuest and Embase and Google scholar were searched. All articles were reviewed by two independent researchers until 10 April 2020. After quality assessment of included studies the finding reported in 2 sections obstetrics and neonatal outcomes.

RESULTS

The sixteen studies with a sample size of 123 pregnant women with a definitive diagnosis of COVID-19 and their neonates were evaluated. The range of gestational age was 25-40 weeks. There was no death associated with COVID-19 in pregnant women. The obstetric outcomes in pregnant women with COVID-19 include decreased fetal movement, intrauterine fetal distress, anemia, PROM, preterm labor, Multiple Organ Dysfunction Syndrome (MODS) and etc. The most common delivery mode in women affect with COVID-19 was cesarean section. Expect for one case with MODS, in the majority of the studies reviewed, no severe morbidity or mortality occurred. The neonatal outcomes were stillbirth, prematurity, asphyxia, fetal distress, low birth weight, small for gestational age, large for gestational age, multiple organ dysfunction syndrome, disseminated intravascular coagulation and neonatal death. In addition, five neonates born to mothers with COVID-19 were positive for SARS-CoV-2. However, the studies report these outcomes but the exact causes of theme are not known.

CONCLUSION

In this systematic review, we summarize the diverse results of studies about the obstetrics and neonatal outcomes following COVID-19. This infection may cause negative outcomes in both mothers and neonates. However, there were evidence about neonate infected with COVID-19, but there is controversial information about the vertical transmission of COVID-19.

DORSCON Orange: An Approach to Challenges in a Busy Antenatal Diagnostic Centre in the Midst of a Global Pandemic

The WHO declared the coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020. Lessons from SARS epidemic led Singapore to develop stringent infection control protocols in preparation for future pandemics. However, unlike SARS, COVID-19 appears to be more transmissible and is predicted to continue for longer. As of 14 June 2020, there have been 40,197 positive cases with 26 deaths in Singapore, and KK Women’s and Children’s Hospital (KKH) has managed a total of 73 cases. Obstetrics ultrasound is an indispensable medical service and must continue to operate during a pandemic. A key balance must be struck between keeping patients and healthcare workers safe while being able to provide quality and prompt obstetric care. Our Antenatal Diagnostic Centre (ADC) in KKH developed new strategies to adapt to the pandemic when the national Disease Outbreak Response System Condition (DORSCON) was raised from yellow to orange on 7 February 2020. In this paper, we discuss our clinical workflow to reduce the risk of transmission amongst patients and staff while minimising disruption to our services.

SARS-CoV-2 and Pregnancy: A Review of the Facts

OBJECTIVE

 The present comprehensive review aims to show the full extent of what is known to date and provide a more thorough view on the effects of SARS-CoV2 in pregnancy.

METHODS

 Between March 29 and May, 2020, the words COVID-19, SARS-CoV2, COVID-19 and pregnancy, SARS-CoV2 and pregnancy, and SARS and pregnancy were searched in the PubMed and Google Scholar databases; the guidelines from well-known societies and institutions (Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG], International Society of Ultrasound in Obstetrics & Gynecology [ISUOG], Centers for Disease Control and Prevention [CDC], International Federation of Gynecology and Obstetrics [FIGO]) were also included.

CONCLUSION

 The COVID-19 outbreak resulted in a pandemic with > 3.3 million cases and 230 thousand deaths until May 2^nd. It is caused by the SARS-CoV2 virus and may lead to severe pulmonary infection and multi-organ failure. Past experiences show that unique characteristics in pregnancy make pregnant women more susceptible to complications from viral infections. Yet, this has not been reported with this new virus. There are risk factors that seem to increase morbidity in pregnancy, such as obesity (body mass index [BMI] > 35), asthma and cardiovascular disease. Current reports describe an increased rate of preterm birth and C-section. Vertical transmission is still a possibility, due to a few reported cases of neonatal positive real-time polymerase chain reaction (RT-PCR) in nasal swab, amniotic fluid, and positive immunoglobulin M (IgM) in neonatal blood. Treatments must be weighed in with caution due to the lack of quality trials that prove their effectiveness and safety during pregnancy. Medical staff must use personal protective equipment in handling SARS-CoV2 suspected or positive patients and be alert for respiratory decompensations.

Management of the mother-infant dyad with suspected or confirmed SARS-CoV-2 infection in a highly epidemic context

In the context of SARS-CoV-2 pandemic, the hospital management of mother-infant pairs poses to obstetricians and neonatologists previously unmet challenges. In Lombardy, Northern Italy, 59 maternity wards networked to organise the medical assistance of mothers and neonates with suspected or confirmed SARS-CoV-2 infection. Six “COVID-19 maternity centres” were identified, the architecture and activity of obstetric and neonatal wards of each centre was reorganised, and common assistance protocols for the management of suspected and proven cases were formulated. Here, we present the key features of this reorganization effort, and our current management of the mother-infant dyad before and after birth, including our approach to rooming-in practice, breastfeeding and neonatal follow-up, based on the currently available scientific evidence. Considered the rapid diffusion of COVID-19 all over the world, we believe that preparedness is fundamental to assist mother-infant dyads, minimising the risk of propagation of the infection through maternity and neonatal wards.

Performance of an extended triage questionnaire to detect suspected cases of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in obstetric patients: Experience from two large teaching hospitals in Lombardy, Northern Italy

Objectives

1. To assess the performance of an extended questionnaire in identifying cases of SARS-CoV-2 infection among obstetric patients. 2. To evaluate the rate of infection among healthcare workers involved in women’s care.

Study design

A prospective cohort study of obstetric patients admitted to MBBM Foundation and Buzzi Hospital (Lombardy, Northern Italy) from March 16^th to May 22^nd, 2020. Women were screened on admission by a questionnaire investigating major and minor symptoms of infection and high-risk contacts in the last 14 days. SARS-CoV-2 assessment was performed by RT-PCR on nasopharyngeal swabs. Till April 7^th, a targeted SARS-CoV-2 testing triggered by a positive questionnaire was used; from April 8^th, a universal testing approach was implemented.

Results

There were 1,177 women screened by the questionnaire, which yielded a positive result in 130 (11.0%) cases. SARS-CoV-2 RT-PCR was performed in 865 (73.5%) patients, identifying 51 (5.9%) infections. During the first period, there were 29 infected mothers, 4 (13.8%) of whom had a negative questionnaire. After universal testing implementation, there were 22 (3%, 95% CI 1.94% - 4.04%) infected mothers, 13 (59.1%) of whom had a negative questionnaire; rate of infection among asymptomatic women was 1.9%. Six of the 17 SARS-CoV-2-positive women with a negative questionnaire reported symptoms more than 14 but within 30 days before admission. Isolated olfactory or taste disorders were identified in 15.7% of infected patients. Rate of infection among healthcare workers was 5.8%.

Conclusions

An exhaustive triage questionnaire can effectively discriminate women at low risk of SARS-CoV-2 infection in the context of a targeted and a universal viral testing approach. In 15.7% of infected women, correct classification as a suspected case of infection was due to investigation of olfactory and taste disorders. Extension of the assessed time-frame to 30 days may be worth considering to increase the questionnaire’s performance.

The effect of coronavirus infection (SARS-CoV-2, MERS-CoV, and SARS-CoV) during pregnancy and the possibility of vertical maternal-fetal transmission: a systematic review and meta-analysis

BACKGROUND

Coronavirus is challenging the global health care system from time to time. The pregnant state, with alterations in hormone levels and decreased lung volumes due to a gravid uterus and slightly immunocompromised state may predispose patients to a more rapidly deteriorating clinical course and can get a greater risk of harm for both the mother and fetus. Therefore, this systematic review was aimed to assess the effect of coronavirus infection (SARS-CoV-2, MERS-CoV, and SARS-CoV) during pregnancy and its possibility of vertical maternal-fetal transmission.

METHODS

A systematic search was conducted on PubMed, Web of Science, Embase, Google Scholar and the Cochrane Library until the end of April. All authors independently extracted all necessary data using excel spreadsheet form. Only published articles with fully accessible data on pregnant women infected with SARS-CoV, MARS-CoV, and SARS-CoV-2 were included. Data on clinical manifestations, maternal and perinatal outcomes were extracted and analyzed.

RESULT

Out of 879 articles reviewed, 39 studies involving 1316 pregnant women were included. The most common clinical features were fever, cough, and myalgia with prevalence ranging from 30 to 97%, while lymphocytopenia and C-reactive protein were the most common abnormal laboratory findings (55-100%). Pneumonia was the most diagnosed clinical symptom of COVID-19 and non-COVID-19 infection with prevalence ranged from 71 to 89%. Bilateral pneumonia (57.9%) and ground-glass opacity (65.8%) were the most common CT imaging reported. The most common treatment options used were hydroxychloroquine (79.7%), ribavirin (65.2%), and oxygen therapy (78.8%). Regarding maternal outcome, the rate of preterm birth < 37 weeks of gestation was 14.3%, preeclampsia (5.9%), miscarriage (14.5%, preterm premature rupture of membranes (9.2%) and fetal growth restriction (2.8%). From the total coronavirus infected pregnant women, 56.9% delivered by cesarean, 31.3% admitted to ICU, while 2.7% were died. Among the perinatal outcomes, fetal distress rated (26.5%), neonatal asphyxia rated (1.4%). Only, 1.2% of neonates had apgar score < 7 at 5 min. Neonate admitted to ICU was rated 11.3%, while the rate of perinatal death was 2.2%. In the current review, none of the studies reported transmission of CoV from the mother to the fetus in utero during the study period.

CONCLUSION

Coronavirus infection is more likely to affect pregnant women. Respiratory infectious diseases have demonstrated an increased risk of adverse maternal obstetrical complications than the general population due to physiological changes occurred during pregnancy. None of the studies reported transmission of CoV from the mother to the fetus in utero, which may be due to a very low expression of angiotensin-converting enzyme-2 in early maternal-fetal interface cells.

Clinical, molecular, and epidemiological characterization of the SARS-CoV-2 virus and the Coronavirus Disease 2019 (COVID-19), a comprehensive literature review

Coronaviruses are an extensive family of viruses that can cause disease in both animals and humans. The current classification of coronaviruses recognizes 39 species in 27 subgenera that belong to the family Coronaviridae. From those, at least 7 coronaviruses are known to cause respiratory infections in humans. Four of these viruses can cause common cold-like symptoms. Those that infect animals can evolve and become infectious to humans. Three recent examples of these viral jumps include SARS CoV, MERS-CoV and SARS CoV-2 virus. They are responsible for causing severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and the most recently discovered coronavirus disease during 2019 (COVID-19). COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, was declared a pandemic by the World Health Organization (WHO) on 11 March 2020. The rapid spread of the disease has taken the scientific and medical community by surprise. Latest figures from 20 May 2020 show more than 5 million people had been infected with the virus, causing more than 330,000 deaths in over 210 countries worldwide. The large amount of information received daily relating to COVID-19 is so abundant and dynamic that medical staff, health authorities, academics and the media are not able to keep up with this new pandemic. In order to offer a clear insight of the extensive literature available, we have conducted a comprehensive literature review of the SARS CoV-2 Virus and the Coronavirus Diseases 2019 (COVID-19).

Providing high-quality care remotely to patients with rare bone diseases during COVID-19 pandemic

During the COVID-19 outbreak, the European Reference Network on Rare Bone Diseases (ERN BOND) coordination team and Italian rare bone diseases healthcare professionals created the "COVID-19 Helpline for Rare Bone Diseases" in an attempt to provide high-quality information and expertise on rare bone diseases remotely to patients and healthcare professionals. The present position statement describes the key characteristics of the Helpline initiative, along with the main aspects and topics that recurrently emerged as central for rare bone diseases patients and professionals. The main topics highlighted are general recommendations, pulmonary complications, drug treatment, trauma, pregnancy, children and elderly people, and patient associations role. The successful experience of the "COVID-19 Helpline for Rare Bone Diseases" launched in Italy could serve as a primer of gold-standard remote care for rare bone diseases for the other European countries and globally. Furthermore, similar COVID-19 helplines could be considered and applied for other rare diseases in order to implement remote patients' care.

Clinical Findings and Disease Severity in Hospitalized Pregnant Women With Coronavirus Disease 2019 (COVID-19)

OBJECTIVE

To investigate the clinical evolution of coronavirus disease 2019 (COVID-19) in hospitalized pregnant women and potential factors associated with severe maternal outcomes.

METHODS

We designed a prospective multicenter cohort study of pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who were admitted to 12 Italian maternity hospitals between February 23 and March 28, 2020. Clinical records, laboratory and radiologic examinations, and pregnancy outcomes were collected. A subgroup of patients with severe disease was identified based on intensive care unit (ICU) admission, delivery for respiratory compromise, or both.

RESULTS

Seventy-seven patients were included, 14 of whom had severe disease (18%). Two thirds of the patients in the cohort were admitted during the third trimester, and 84% were symptomatic on admission. Eleven patients underwent urgent delivery for respiratory compromise (16%), and six were admitted to the ICU (8%). One woman received extracorporeal membrane oxygenation; no deaths occurred. Preterm delivery occurred in 12% of patients, and nine newborns were admitted to the neonatal intensive care unit. Patients in the severe subgroup had significantly higher pregestational body mass indexes (BMIs) and heart and respiratory rates and a greater frequency of fever or dyspnea on admission compared with women with a nonsevere disease evolution.

CONCLUSION

In our cohort, one in five women hospitalized with COVID-19 infection delivered urgently for respiratory compromise or were admitted to the ICU. None, however, died. Increased pregestational BMI and abnormal heart and respiratory rates on admission were associated with severe disease.

COVID-19 During Pregnancy and Puerperium - A Review by the Austrian Society of Gynaecology and Obstetrics (OEGGG)

After the first case of COVID-19 pneumonia was reported in Wuhan, Hubei Province, China, in December 2019, the infection quickly spread to the rest of China and then to the wider world. The available information on pregnant women infected with COVID-19 is now significantly greater. There are now several case series and systematic reviews of cohorts, some of which include more than 100 cases. This review evaluates the scientific literature available until May 1, 2020 and discusses common questions about COVID-19 in the context of pregnancy and the postpartum period.

SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes

BACKGROUND

Perform a systematic review and meta-analysis of SARS-CoV-2 infection and pregnancy.

METHODS

Databases (Medline, Embase, Clinicaltrials.gov, Cochrane Library) were searched electronically on 6th April and updated regularly until 8th June 2020. Reports of pregnant women with reverse transcription PCR (RT-PCR) confirmed COVID-19 were included. Meta-analytical proportion summaries and meta-regression analyses for key clinical outcomes are provided.

FINDINGS

86 studies were included, 17 studies (2567 pregnancies) in the quantitative synthesis; other small case series and case reports were used to extract rarely-reported events and outcome. Most women (73.9%) were in the third trimester; 52.4% have delivered, half by caesarean section (48.3%). The proportion of Black, Asian or minority ethnic group membership (50.8%); obesity (38.2%), and chronic co-morbidities (32.5%) were high. The most commonly reported clinical symptoms were fever (63.3%), cough (71.4%) and dyspnoea (34.4%). The commonest laboratory abnormalities were raised CRP or procalcitonin (54.0%), lymphopenia (34.2%) and elevated transaminases (16.0%). Preterm birth before 37 weeks' gestation was common (21.8%), usually medically-indicated (18.4%). Maternal intensive care unit admission was required in 7.0%, with intubation in 3.4%. Maternal mortality was uncommon (~1%). Maternal intensive care admission was higher in cohorts with higher rates of co-morbidities (beta=0.007, p<0.05) and maternal age over 35 years (beta=0.007, p<0.01). Maternal mortality was higher in cohorts with higher rates of antiviral drug use (beta=0.03, p<0.001), likely due to residual confounding. Neonatal nasopharyngeal swab RT-PCR was positive in 1.4%.

INTERPRETATION

The risk of iatrogenic preterm birth and caesarean delivery was increased. The available evidence is reassuring, suggesting that maternal morbidity is similar to that of women of reproductive age. Vertical transmission of the virus probably occurs, albeit in a small proportion of cases.

FUNDING

N/A.

SARS-CoV-2 Infection and COVID-19 During Pregnancy: A Multidisciplinary Review

The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), has been associated with worse outcomes in several patient populations, including the elderly and those with chronic comorbidities. Data from previous pandemics and seasonal influenza suggest that pregnant women may be at increased risk for infection-associated morbidity and mortality. Physiologic changes in normal pregnancy and metabolic and vascular changes in high-risk pregnancies may affect the pathogenesis or exacerbate the clinical presentation of COVID-19. Specifically, SARS-CoV-2 enters the cell via the angiotensin-converting enzyme 2 (ACE2) receptor, which is upregulated in normal pregnancy. Upregulation of ACE2 mediates conversion of angiotensin II (vasoconstrictor) to angiotensin-(1-7) (vasodilator) and contributes to relatively low blood pressures, despite upregulation of other components of the renin-angiotensin-aldosterone system. As a result of higher ACE2 expression, pregnant women may be at elevated risk for complications from SARS-CoV-2 infection. Upon binding to ACE2, SARS-CoV-2 causes its downregulation, thus lowering angiotensin-(1-7) levels, which can mimic/worsen the vasoconstriction, inflammation, and pro-coagulopathic effects that occur in preeclampsia. Indeed, early reports suggest that, among other adverse outcomes, preeclampsia may be more common in pregnant women with COVID-19. Medical therapy, during pregnancy and breastfeeding, relies on medications with proven safety, but safety data are often missing for medications in the early stages of clinical trials. We summarize guidelines for medical/obstetric care and outline future directions for optimization of treatment and preventive strategies for pregnant patients with COVID-19 with the understanding that relevant data are limited and rapidly changing.

Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes

BACKGROUND

There is limited information related to COVID-19 in pregnancy.

OBJECTIVES

Evaluate the impact of COVID-19 during pregnancy.Search strategy: Searches were systematically carried out in PubMed, Scopus database and WHO database.Selection criteria: Studies with information related to the effects of COVID-19 in pregnancy, concerning maternal, obstetric, and neonatal outcomes were included.Data collection and analysis: Data were extracted for systematic review following PRISMA guidelines. CARE and STROBE were used to evaluate the quality of data.Main Results: A total of 8 studies involving 95 pregnant women and 51 neonates were included. Overall, the quality was considered good in four studies, moderate in three and poor in one. Among pregnant women, 26% had a history of epidemiological exposure to SARS-CoV-2. The most common symptoms presented were fever (55%), cough (38%) and fatigue (11%). In 50 deliveries, 94% were cesarean sections and 35% were preterm births. Of the 51 neonates, 20% had low birth weight and 1 tested positive for Sars-CoV-2. There was 1 neonatal death, not related to the viral infection, and no cases of severe neonatal asphyxia.

CONCLUSIONS

The information compiled in this systematic review may help healthcare providers administer the best possible care.

Breastfeeding during the COVID-19 pandemic: Suggestions on behalf of woman study group of AMD

SARS-Cov2 infection has recently spread to Italy with important consequences on pregnancy management, mother and child health and mother-child contact. Breastfeeding improves the health of mother and child and reduces risk of neonatal infection with other pathogens that are likely to cause serious illness. To date no evidence confirmed COVID-19 vertical transmission from infected pregnant mother to their fetus. However it is well known that an infected mother can transmit the COVID-19 virus through respiratory droplets during breastfeeding or intimate contact. Thus, the mothers with known or suspected COVID-19 should adhere to standard and contact precautions during breastfeeding. Woman Study Group of AMD, after reviewing current knowledge about COVID-19 vertical transmission and the compatibility of breastfeeding in COVID-19 mother, the available recommendations from Health Care Organizations and main experts opinions, issued the following suggestions on breastfeeding during the COVID-19 pandemic, addressed both to mothers with and without diabetes. It should be considered that following suggestions may change in the future when more evidence is acquired regarding SARS-Cov2 infection.

Breastfeeding and coronavirus disease-2019: Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies

The recent COVID-19 pandemic has spread to Italy with heavy consequences on public health and economics. Besides the possible consequences of COVID-19 infection on a pregnant woman and the fetus, a major concern is related to the potential effect on neonatal outcome, the appropriate management of the mother-newborn dyad, and finally the compatibility of maternal COVID-19 infection with breastfeeding. The Italian Society on Neonatology (SIN) after reviewing the limited scientific knowledge on the compatibility of breastfeeding in the COVID-19 mother and the available statements from Health Care Organizations has issued the following indications that have been endorsed by the Union of European Neonatal & Perinatal Societies (UENPS). If a mother previously identified as COVID-19 positive or under investigation for COVID-19 is asymptomatic or paucisymptomatic at delivery, rooming-in is feasible, and direct breastfeeding is advisable, under strict measures of infection control. On the contrary, when a mother with COVID-19 is too sick to care for the newborn, the neonate will be managed separately and fed fresh expressed breast milk, with no need to pasteurize it, as human milk is not believed to be a vehicle of COVID-19. We recognize that this guidance might be subject to change in the future when further knowledge will be acquired about the COVID-19 pandemic, the perinatal transmission of SARS-CoV-2, and clinical characteristics of cases of neonatal COVID-19.