Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis

Analysis of SARS-CoV-2 vertical transmission during pregnancy

The impact of SARS-CoV-2 infection during gestation remains unclear. Here, we analyse the viral genome on maternal and newborns nasopharyngeal swabs, vaginal swabs, maternal and umbilical cord plasma, placenta and umbilical cord biopsies, amniotic fluids and milk from 31 mothers with SARS-CoV-2 infection. In addition, we also test specific anti-SARS-CoV-2 antibodies and expression of genes involved in inflammatory responses in placentas, and in maternal and umbilical cord plasma. We detect SARS-CoV-2 genome in one umbilical cord blood and in two at-term placentas, in one vaginal mucosa and in one milk specimen. Furthermore, we report the presence of specific anti-SARS-CoV-2 IgM and IgG antibodies in one umbilical cord blood and in one milk specimen. Finally, in the three documented cases of vertical transmission, SARS-CoV-2 infection was accompanied by a strong inflammatory response. Together, these data support the hypothesis that in utero SARS-CoV-2 vertical transmission, while low, is possible. These results might help defining proper obstetric management of COVID-19 pregnant women, or putative indications for mode and timing of delivery.

Outcomes in COVID-19 Positive Neonates and Possibility of Viral Vertical Transmission: A Narrative Review

OBJECTIVE

Novel coronavirus disease 2019 (COVID-19) seems to affect adults and pediatric patients differently. While neonates are a special population, little is known about the neonatal outcomes. This study aimed to investigate the outcomes in COVID-19 positive neonates and incidence of vertical transmission of the virus by reviewing available literature.

STUDY DESIGN

This study is a narrative review of available literature on "COVID-19 in neonates," for which PubMed and Google Scholar were used to search the published articles.

RESULTS

We summarized the data from 39 published studies that are comprised of 326 COVID-19 positive peripartum mothers with respective neonatal outcomes. Twenty-three neonates have been reported to be COVID-19 positive. Male neonates were affected significantly more (79%) than female neonates. Approximately 3% neonates acquired infection through suspected vertical transmission. Strict infection prevention measures during the perinatal time can significantly reduce the chance of horizontal transmission of the virus. Overall, neonates were asymptomatic or mildly symptomatic regardless of gestational age at birth and required only supportive measures. There was 0% mortality in COVID-19 positive neonates.

CONCLUSION

From available published data to date, we can conclude that the prognosis of COVID-19 positive neonates is good with no mortality. There appears to be minimal vertical transmission of the infection.

KEY POINTS

· Majority of COVID-19 positive neonates showed mild clinical signs and symptoms with no mortality.. · Most COVID-19 positive neonates require only supportive measures.. · Possibility of viral vertical transmission is very low..

Clinical characteristics, prognostic factors, and maternal and neonatal outcomes of SARS-CoV-2 infection among hospitalized pregnant women: A systematic review

BACKGROUND

Pregnant women represent a potentially high-risk population in the COVID-19 pandemic.

OBJECTIVE

To summarize clinical characteristics and outcomes among pregnant women hospitalized with COVID-19.

SEARCH STRATEGY

Relevant databases were searched up until May 29, 2020.

SELECTION CRITERIA

Case series/reports of hospitalized pregnant women with laboratory-confirmed COVID-19.

DATA COLLECTION AND ANALYSIS

PRISMA guidelines were followed. Methodologic quality was assessed via NIH assessment tools.

MAIN RESULTS

Overall, 63 observational studies of 637 women (84.6% in third trimester) with laboratory-confirmed SARS-CoV-2 infection were included. Most (76.5%) women experienced mild disease. Maternal fatality, stillbirth, and neonatal fatality rates were 1.6%, 1.4%, and 1.0%, respectively. Older age, obesity, diabetes mellitus, and raised serum D-dimer and interleukin-6 were predictive of poor outcomes. Overall, 33.7% of live births were preterm, of which half were iatrogenic among women with mild COVID-19 and no complications. Most women underwent cesarean despite lacking a clear indication. Eight (2.0%) neonates had positive nasopharyngeal swabs after delivery and developed chest infection within 48 hours.

CONCLUSIONS

Advanced gestation, maternal age, obesity, diabetes mellitus, and a combination of elevated D-dimer and interleukin-6 levels are predictive of poor pregnancy outcomes in COVID-19. The rate of iatrogenic preterm birth and cesarean delivery is high; vertical transmission may be possible but has not been proved.

COVID-19 and pregnancy: A review of clinical characteristics, obstetric outcomes and vertical transmission

BACKGROUND

Since its emergence in December 2019, COVID-19 has spread to over 210 countries, with an estimated mortality rate of 3-4%. Little is understood about its effects during pregnancy.

AIMS

To describe the current understanding of COVID-19 illness in pregnant women, to describe obstetric outcomes and to identify gaps in the existing knowledge.

METHODS

Medline Ovid, EMBASE, World Health Organization COVID-19 research database and Cochrane COVID-19 in pregnancy spreadsheet were accessed on 18/4, 18/5 and 23/5 2020. Articles were screened via Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following were excluded: reviews, opinion pieces, guidelines, articles pertaining solely to other viruses, single case reports.

RESULTS

Sixty articles were included in this review. Some pregnant participants may have been included in multiple publications, as admission dates overlap for reports from the same hospital. However, a total of 1287 confirmed SARS-CoV-2 positive pregnant cases are reported. Where universal testing was undertaken, asymptomatic infection occurred in 43.5-92% of cases. In the cohort studies, severe and critical COVID-19 illness rates approximated those of the non-pregnant population. Eight maternal deaths, six neonatal deaths, seven stillbirths and five miscarriages were reported. Nineteen neonates were SARS-CoV-2 positive, confirmed by reverse transcription polymerase chain reaction of nasopharyngeal swabs. [Correction added on 2 September 2020, after first online publication: the number of neonates indicated in the preceding sentence has been corrected from 'Thirteen' to 'Nineteen'.] CONCLUSIONS: Where universal screening was conducted, SARS-CoV-2 infection in pregnancy was often asymptomatic. Severe and critical disease rates approximate those in the general population. Vertical transmission is possible; however, it is unclear whether SARS-CoV-2 positive neonates were infected in utero, intrapartum or postpartum. Future work should assess risks of congenital syndromes and adverse perinatal outcomes where infection occurs in early and mid-pregnancy.

Covid-19 pandemic and pregnancy

At the end of 2019, a new coronavirus disease, COVID-19, emerged and quickly spread around the world. Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), the causative virus of this disease, belongs to the β-coronavirus family, together with SARS and middle east respiratory syndrome, and has similar biological characteristics to these viruses. For obstetricians, the susceptibility and prognoses of pregnant women and the effects of the infection on the fetus have been the focus of attention; however, at present, the seriousness of the disease in pregnant women is not apparent, and COVID-19 does not increase the rate of miscarriage, stillbirth, preterm labor or teratogenicity. Even so, carriers might transmit SARS-CoV-2 to pregnant women. Thus, we must keep in mind that all medical personnel must understand and maintain standard precautions in their clinical and laboratory practices.

The clinical course of SARS-CoV-2 positive neonates

The COVID-19 pneumonia was firstly reported in Wuhan, China, in December 2019. The disease had a rapid spread all over the word becoming an international public health emergency. Limited data were available on COVID-19 positive neonates. We reviewed relevant literature to understand the clinical course of disease and transmission routes in affected neonates. The aim of the study was evaluating the clinical course and prognosis of SARS-CoV-2 positive neonates. Based on current literature, the hypothesis of vertical transmission of SARS-CoV-2, though conceivable, remains unproven. A research conducted on PubMed database from December 2019 to April 27, 2020 revealed that were reported 25 neonates affected by SARS-CoV-2. Main symptoms were fever, cough, or shortness of breath but often these neonates did not show other symptoms during length stay in hospital. No deaths occurred.

Coronavirus-2019 Disease (COVID-19) in Children

COVID-19 disease affects all ages, but severe cases of the disease and mortality are very rarely seen among children. In most cases, they acquire the virus from their parents or from an another infected person. The exact reasons why the disease has a milder course in children is unknown but high numbers of Angiotensin Converting Enzyme-2 (ACE2) receptors, underdeveloped immune responses, cross-reaction with other viruses, protective effect of fetal hemoglobin and fewer outdoor activities as well as journeys, and nonexposure to air pollution, and smoking. Although many cases are asymptomatic, they can still shed the virus. Materno-fetal vertical transmission has not been shown so far. In symptomatic cases, clinical findings include fever and respiratory symptoms, followed by diarrhea and vomiting. There are signs indicating a possible association between Kawasaki disease and COVID-19. Clinical findings and diagnostic procedures in newborns, and older children are similar. Supportive therapy is essential and antiviral agents are not required in most cases. During cytokine storm, anti-inflammatory treatments may be tried. There is no evidence for transmission through breastmilk; therefore infected mothers should breastfeed their infants by taking all precautions. Routine immunizations of children should not be deferred during COVID-19 outbreak period. Psychological support for children who need to stay at home and for healthcare personnel should be provided.

Placental barrier against COVID-19

Vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and possible induction of pregnancy complications, including miscarriage, fetal malformations, fetal growth restriction and/or stillbirth, are serious concerns for pregnant individuals with COVID-19. According to clinical information, the incidence of vertical transmission of SARS-CoV-2 is limited to date. However, even if a neonate tests negative for SARS-CoV-2, frequent abnormal findings, including fetal and maternal vascular malperfusion, have been reported in cases of COVID-19-positive mothers. Primary receptor of SARS-CoV-2 is estimated as angiotensin-converting enzyme 2 (ACE2). It is highly expressed in maternal-fetal interface cells, such as syncytiotrophoblasts, cytotrophoblasts, endothelial cells, and the vascular smooth muscle cells of primary and secondary villi. However other route of transplacental infection cannot be ruled out. Pathological examinations have demonstrated that syncytiotrophoblasts are often infected with SARS-CoV-2, but fetuses are not always infected. These findings suggest the presence of a placental barrier, even if it is not completely effective. As the frequency and molecular mechanisms of intrauterine vertical transmission of SARS-CoV-2 have not been determined to date, intensive clinical examinations by repeated ultrasound and fetal heart rate monitoring are strongly recommended for pregnant women infected with COVID-19. In addition, careful investigation of placental samples after delivery by both morphological and molecular methods is also strongly recommended.

SARS-CoV-2 infections with emphasis on pediatric patients: a narrative review

This narrative review summarizes the main aspects underlying the new coronavirus SARS-CoV-2, its epidemiology, pathophysiology, pointing to differences of SARS-CoV-2 main receptors ACE2, in terms of expression and the amount of soluble ACE2 in the circulation of children, men and women, and also in those with risk factors such as the smokers and pregnant women or presenting with comorbidities (diabetes, obesity, hypertension and other cardiovascular diseases, renal and CNS pre-existing diseases). Clinical manifestations in adults and children were also described, emphasizing the particularities already seen in children, regarding signs, symptoms, viral excretion time and the involvement of all organs and systems. The COVID-19 in the pediatric population was divided into two sections: one dedicated to previously healthy children and adolescents with COVID-19, and the other to those who live with comorbidities and acquired COVID-19. A few paragraphs were reserved to the recently described severe multisystemic inflammatory syndrome associated with COVID-19 (MIS-C) that shares certain characteristics with Kawasaki disease. Some studies on the infection in pregnant and postpartum women, as well as neonates were shown. This review has also covered the laboratory diagnosis of COVID-19, passing through the imaging diagnosis made by the chest tomography revealing ground glass patching opacities, and results of non-specific exams such as the total blood with lymphopenia, the coagulation tests with increased prothrombin times, as well as marked increments of the D-dimer, troponin and proinflammatory cytokines. In the section devoted to the specific laboratory diagnosis of COVID-19, the most used RT-PCR protocols were described and some studies on the serological diagnosis with IgA, IgM and IgG detection were detailed, including the use of rapid immunochromatographic assays and discussing the ideal period after the onset of symptoms to perform each type of test. In the end, the management of pediatric patients with COVID-19 based mainly on supportive measures has been briefly commented.

Retrospective Description of Pregnant Women Infected with Severe Acute Respiratory Syndrome Coronavirus 2, France

Fix data are available on the management of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We conducted a retrospective study of 100 pregnant women with SARS-CoV-2 infection in 4 obstetric units in the Paris metropolitan area of France during March 12-April 13, 2020. Among patients, 52 (52%) were hospitalized, 10 (10%) in intensive care units (ICUs). Women with higher body mass indexes (BMIs; median 30.7 kg/m2) were more likely to be hospitalized in ICUs than other women (median BMI 26.2 kg/m2). Women hospitalized in ICUs had lower lymphocyte count at diagnosis (median 0.77 × 109 cells/L) than women not hospitalized in ICUs (median lymphocyte count 1.15 × 109 cells/L). All women requiring oxygen >5 L/min were intubated. Clinical and laboratory evaluation of SARS-CoV-2-positive pregnant women at the time of diagnosis can identify patients at risk for ICU hospitalization.

MS, pregnancy and COVID-19

Concerns regarding infection with the novel coronavirus SARS-CoV-2 leading to COVID-19 are particularly marked for pregnant women with autoimmune diseases such as multiple sclerosis (MS). There is currently a relative paucity of information to guide advice given to and the clinical management of these individuals. Much of the limited available data around COVID-19 and pregnancy derives from the obstetric literature, and as such, neurologists may not be familiar with the general principles underlying current advice. In this article, we discuss the impact of potential infection on the pregnant woman, the impact on her baby, the impact of the current pandemic on antenatal care, and the interaction between COVID-19, MS and pregnancy. This review provides a framework for neurologists to use to guide the individualised advice given to both pregnant women with MS, and those women with MS who are considering pregnancy. This includes evidence derived from previous novel coronavirus infections, and emerging evidence from the current pandemic.

Maternal and neonatal characteristics and outcomes among COVID-19 infected women: An updated systematic review and meta-analysis

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has become a global pandemic and may adversely affect pregnancy outcomes. We estimated the adverse maternal and neonatal characteristics and outcomes among COVID-19 infected women and determined heterogeneity in the estimates and associated factors.

STUDY DESIGNS

PubMed search was performed of confirmed COVID-19 pregnant cases and related outcomes were ascertained prior to July 8, 2020, in this systematic review and meta-analysis. Studies reporting premature birth, low birth weight, COVID-19 infection in neonates, or mode of delivery status were included in the study. Two investigators independently performed searches, assessed quality of eligible studies as per the Cochrane handbook recommendations, extracted and reported data according to PRISMA guidelines. Pooled proportions of maternal and neonatal outcomes were estimated using meta-analyses for studies with varying sample sizes while a systematic review with descriptive data analysis was performed for case report studies. Maternal and neonatal outcomes included C-section, premature birth, low birth weight, adverse pregnancy events and COVID transmission in neonates.

RESULTS

A total of 790 COVID-19 positive females and 548 neonates from 61 studies were analyzed. The rates of C-section, premature birth, low birth weight, and adverse pregnancy events were estimated as 72 %, 23 %, 7 %, and 27 % respectively. In the heterogeneity analysis, the rate of C-section was substantially higher in Chinese studies (91 %) compared to the US (40 %) or European (38 %) studies. The rates of preterm birth and adverse pregnancy events were also lowest in the US studies (12 %, 15 %) compared to Chinese (17 %, 21 %), and European studies (19 %, 19 %). In case reports, the rates of C-section, preterm birth, and low birth weight were estimated as 69 %, 56 %, and 35 %, respectively. Adverse pregnancy outcomes were associated with infection acquired at early gestational ages, more symptomatic presentation, myalgia symptom at presentation, and use of oxygen support therapy.

CONCLUSIONS

Adverse pregnancy outcomes were prevalent in COVID-19 infected females and varied by location, type, and size of the studies. Regular screening and early detection of COVID-19 in pregnant women may provide more favorable outcomes.

Covid-19 in pregnant women and babies: What pediatricians need to know

Beginning in late 2019, a novel coronavirus labeled SARS-CoV-2 spread around the world, affecting millions. The impact of the disease on patients and on health care delivery has been unprecedented. Here, we review what is currently known about the effects of the virus and its clinical condition, Covid-19 in areas of relevance to those providing care to neonates. While aspects of pregnancy, including higher expression of the cell receptor for the virus, ACE2, could put these women at higher risk, preliminary epidemiological information does not support this. Viral carriage prevalence based on universal screening show that rates vary from 13% in "hot spots" such as New York City, to 3% in areas with lower cases. Vertical transmission risks are unknown but 3.1% of 311 babies born to mothers with Covid-19 were positive within a week of birth. The clinical description of 26 neonates <30 days of age showed no deaths and only one requiring intensive care. Risks for breast-feeding and for milk banks are discussed.

Vertical Transmission of SARS-CoV-2 (COVID-19): Are Hypotheses More than Evidences?

In spite of the increasing, accumulating knowledge on the novel pandemic coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), questions on the coronavirus disease-2019 (COVID-19) infection transmission from mothers to fetuses or neonates during pregnancy and peripartum period remain pending and have not been addressed so far. SARS-CoV-2, a RNA single-stranded virus, has been detected in the amniotic fluid, in the cord blood and in the placentas of the infected women. In the light of these findings, the theoretical risk of intrauterine infection for fetuses, or of peripartum infection occurring during delivery for neonates, has a biological plausibility. The extent of this putative risk might, however, vary during the different stages of pregnancy, owing to several variables (physiological modifications of the placenta, virus receptors' expression, or delivery route). This brief review provides an overview of the current evidence in this area. Further data, based on national and international multicenter registries, are needed not only to clearly assess the extent of the risk for vertical transmission, but also to ultimately establish solid guidelines and consistent recommendations. KEY POINTS: · Questions on the COVID-19 infection transmission from mothers to fetuses or neonates during pregnancy and peripartum period remain pending so far.. · The theoretical risk of intrauterine infection for fetuses, or of neonatal infection during delivery for neonates, has a biological plausibility.. · A caution is recommended in the interpretation of clinical and laboratory data in neonates..

A Systematic Review of Treatment and Outcomes of Pregnant Women With COVID-19-A Call for Clinical Trials

BACKGROUND

Data pertaining to COVID-19 in pregnancy are limited; to better inform clinicians, we collated data from COVID-19 cases during pregnancy and summarized clinical trials enrolling this population.

METHODS

We performed a systematic literature review of PubMed/MEDLINE to identify cases of COVID-19 in pregnancy or the postpartum period and associated outcomes. We then evaluated the proportion of COVID-19 clinical trials (from ClinicalTrials.gov) excluding pregnant or breastfeeding persons (both through June 29, 2020).

RESULTS

We identified 11 308 published cases of COVID-19 during pregnancy. Of those reporting disease severity, 21% (416/1999) were severe/critical. Maternal and neonatal survival were reassuring (98% [10 437/10 597] and 99% [1155/1163], respectively). Neonatal disease was rare, with only 41 possible cases of infection reported in the literature. Of 2351 ongoing COVID-19 therapeutic clinical trials, 1282 were enrolling persons of reproductive age and 65% (829/1282) excluded pregnant persons. Pregnancy was an exclusion criterion for 69% (75/109) of chloroquine/hydroxychloroquine, 80% (28/35) of lopinavir/ritonavir, and 48% (44/91) of convalescent plasma studies. We identified 48 actively recruiting or completed drug trials reporting inclusion of this population.

CONCLUSIONS

There are limited published reports of COVID-19 in pregnancy despite more than 14 million cases worldwide. To date, clinical outcomes appear reassuring, but data related to important long-term outcomes are missing or not yet reported. The large number of clinical trials excluding pregnant persons, despite interventions with safety data in pregnancy, is concerning. In addition to observational cohort studies, pregnancy-specific adaptive clinical trials could be designed to identify safe and effective treatments.

Care recommendations for parturient and postpartum women and newborns during the COVID-19 pandemic: a scoping review

Objective to map the current knowledge on recommendations for labor, childbirth, and newborn (NB) care in the context of the novel coronavirus. Method scoping review of papers identified in databases, repositories, and reference lists of papers included in the study. Two researchers independently read the papers' full texts, extracted and analyzed data, and synthesized content. Results 19 papers were included, the content of which was synthesized and organized into two conceptual categories: 1) Recommendations concerning childbirth with three subcategories - Indications to anticipate delivery, Route of delivery, and Preparation of the staff and birth room, and 2) Recommendations concerning postpartum care with four categories - Breastfeeding, NB care, Hospital discharge, and Care provided to NB at home. Conclusion prevent the transmission of the virus in the pregnancy-postpartum cycle, assess whether there is a need to interrupt pregnancies, decrease the circulation of people, avoid skin-to-skin contact and water births, prefer epidural over general anesthesia, keep mothers who tested positive or are symptomatic isolated from NB, and encourage breastfeeding. Future studies are needed to address directed pushing, instrumental delivery, delayed umbilical cord clamping, and bathing NB immediately after birth.

Clinical update on COVID-19 in pregnancy: A review article

The data pertaining to the COVID-19 pandemic has been rapidly evolving since the first confirmed case in December 2019. This review article presents a comprehensive analysis of the current data in relation to COVID-19 and its effect on pregnant women, including symptoms, disease severity and the risk of vertical transmission. We also review the recommended management of pregnant women with suspected or confirmed COVID-19 and the various pharmacological agents that are being investigated and may have a role in the treatment of this disease. At present, it does not appear that pregnant women are at increased risk of severe infection than the general population, although there are vulnerable groups within both the pregnant and nonpregnant populations, and clinicians should be cognizant of these high-risk groups and manage them accordingly. Approximately 85% of women will experience mild disease, 10% more severe disease and 5% critical disease. The most common reported symptoms are fever, cough, shortness of breath and diarrhea. Neither vaginal delivery nor cesarean section confers additional risks, and there is minimal risk of vertical transmission to the neonate from either mode of delivery. We acknowledge that the true effect of the virus on both maternal and fetal morbidity and mortality will only be evident over time. We also discuss the impact of social isolation can have on the mental health and well-being of both patients and colleagues, and as clinicians, we must be mindful of this and offer support as necessary.

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.

Clinical update on COVID-19 in pregnancy: A review article

The data pertaining to the COVID-19 pandemic has been rapidly evolving since the first confirmed case in December 2019. This review article presents a comprehensive analysis of the current data in relation to COVID-19 and its effect on pregnant women, including symptoms, disease severity and the risk of vertical transmission. We also review the recommended management of pregnant women with suspected or confirmed COVID-19 and the various pharmacological agents that are being investigated and may have a role in the treatment of this disease. At present, it does not appear that pregnant women are at increased risk of severe infection than the general population, although there are vulnerable groups within both the pregnant and nonpregnant populations, and clinicians should be cognizant of these high-risk groups and manage them accordingly. Approximately 85% of women will experience mild disease, 10% more severe disease and 5% critical disease. The most common reported symptoms are fever, cough, shortness of breath and diarrhea. Neither vaginal delivery nor cesarean section confers additional risks, and there is minimal risk of vertical transmission to the neonate from either mode of delivery. We acknowledge that the true effect of the virus on both maternal and fetal morbidity and mortality will only be evident over time. We also discuss the impact of social isolation can have on the mental health and well-being of both patients and colleagues, and as clinicians, we must be mindful of this and offer support as necessary.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis

OBJECTIVE

To report mode of delivery and immediate neonatal outcome in women infected with COVID-19.

DESIGN

Retrospective study.

SETTING

Twelve hospitals in northern Italy.

PARTICIPANTS

Pregnant women with COVID-19-confirmed infection who delivered.

EXPOSURE

COVID 19 infection in pregnancy.

METHODS

SARS-CoV-2-infected women who were admitted and delivered from 1 to 20 March 2020 were eligible. Data were collected from the clinical records using a standardised questionnaire on maternal general characteristics, any medical or obstetric co-morbidity, course of pregnancy, clinical signs and symptoms, treatment of COVID 19 infection, mode of delivery, neonatal data and breastfeeding.

MAIN OUTCOME AND MEASURES

Data on mode of delivery and neonatal outcome.

RESULTS

In all, 42 women with COVID-19 delivered at the participating centres; 24 (57.1%, 95% CI 41.0-72.3) delivered vaginally. An elective caesarean section was performed in 18/42 (42.9%, 95% CI 27.7-59.0) cases: in eight cases the indication was unrelated to COVID-19 infection. Pneumonia was diagnosed in 19/42 (45.2%, 95% CI 29.8-61.3) cases: of these, 7/19 (36.8%, 95% CI 16.3-61.6) required oxygen support and 4/19 (21.1%, 95% CI 6.1-45.6) were admitted to a critical care unit. Two women with COVID-19 breastfed without a mask because infection was diagnosed in the postpartum period: their newborns tested positive for SARS-Cov-2 infection. In one case, a newborn had a positive test after a vaginal operative delivery.

CONCLUSIONS

Although postpartum infection cannot be excluded with 100% certainty, these findings suggest that vaginal delivery is associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

TWEETABLE ABSTRACT

This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.

Perinatal transmission with SARS-CoV-2 and route of pregnancy termination: a narrative review

OBJECTIVE

Analyze newborns diagnosed with SARS-CoV-2 performed with RT-PCR at birth or during the first days of birth and to look for an association with the route of birth.

METHODS

We conducted a comprehensive literature search for newborns diagnosed with COVID-19 using PubMed, LILACS and Google scholar until May 15, 2020, looking for published articles with pregnancy, vertical transmission, intrauterine transmission, neonates, delivery.

RESULTS

There were found 10 articles with a total of 15 newborn infected with SARS-CoV-2 according to positive PCR at birth or in the first days of birth. Eleven newborn birth by cesarean section and 4 vaginally. Of the 11 cases with cesarean section, two presented premature rupture of the membranes. Seven newborns developed pneumonia, of which two had ruptured membranes and one was born by vaginal delivery.

CONCLUSION

This review shows that there is perinatal or neonatal infection with SARS-CoV-2 by finding a positive PCR in the first days of birth. In addition, that there is more possibility of neonatal infection if the birth is vaginal or if there is premature rupture of the membranes before cesarean section. Vaginal delivery and premature rupture of membranes should be considered as risk factors for perinatal infection.

A Message from the Human Placenta: Structural and Immunomodulatory Defense against SARS-CoV-2

The outbreak of the coronavirus disease 2019 (COVID-19) pandemic has caused a global public health crisis. Viral infections may predispose pregnant women to a higher rate of pregnancy complications, including preterm births, miscarriage, and stillbirth. Despite reports of neonatal COVID-19, definitive proof of vertical transmission is still lacking. In this review, we summarize studies regarding the potential evidence for transplacental transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), characterize the expression of its receptors and proteases, describe the placental pathology and analyze virus-host interactions at the maternal-fetal interface. We focus on the syncytium, the barrier between mother and fetus, and describe in detail its physical and structural defense against viral infections. We further discuss the potential molecular mechanisms, whereby the placenta serves as a defense front against pathogens by regulating the interferon type III signaling, microRNA-triggered autophagy and the nuclear factor-κB pathway. Based on these data, we conclude that vertical transmission may occur but rare, ascribed to the potent physical barrier, the fine-regulated placental immune defense and modulation strategies. Particularly, immunomodulatory mechanisms employed by the placenta may mitigate violent immune response, maybe soften cytokine storm tightly associated with severely ill COVID-19 patients, possibly minimizing cell and tissue damages, and potentially reducing SARS-CoV-2 transmission.

Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: a systematic review and critical analysis

Background

Early reports of COVID‐19 in pregnancy described management by caesarean, strict isolation of the neonate and formula feeding. Is this practice justified?

Objective

To estimate the risk of the neonate becoming infected with SARS‐CoV‐2 by mode of delivery, type of infant feeding and mother‐infant interaction.

Search strategy

Two biomedical databases were searched between September 2019 and June 2020.

Selection criteria

Case reports or case series of pregnant women with confirmed COVID‐19, where neonatal outcomes were reported.

Data collection and analysis

Data were extracted on mode of delivery, infant infection status, infant feeding and mother–infant interaction. For reported infant infection, a critical analysis was performed to evaluate the likelihood of vertical transmission.

Main results

Forty nine studies included information on mode of delivery and infant infection status for 655 women and 666 neonates. In all, 28/666 (4%) tested positive postnatally. Of babies born vaginally, 8/292 (2.7%) tested positivecompared with 20/374 (5.3%) born by Caesarean. Information on feeding and baby separation were often missing, but of reported breastfed babies 7/148 (4.7%) tested positive compared with 3/56 (5.3%) for reported formula fed ones. Of babies reported as nursed with their mother 4/107 (3.7%) tested positive, compared with 6/46 (13%) for those who were reported as isolated.

Conclusions

Neonatal COVID‐19 infection is uncommon, rarely symptomatic, and the rate of infection is no greater when the baby is born vaginally, breastfed or remains with the mother.

Tweetable abstract

Risk of neonatal infection with COVID‐19 by delivery route, infant feeding and mother‐baby interaction.

Risk of neonatal infection with COVID‐19 by delivery route, infant feeding and mother‐baby interaction.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights16362

Vertical transmission of SARS CoV-2: a systematic review

OBJECTIVE

The aim of this study is to review the current evidence on the vertical transmission of SARS CoV-2.

METHODS

Combination of the following keywords; COVID-19, SARS CoV-2, placenta, vertical transmission, intrauterine infection, breast milk were searched in databases.

RESULTS

In the 50 studies included, 17 newborns testing positive for SARS CoV-2 by RT-PCR were reported. In three neonates, SARS-CoV-2 IgG and IgM levels were elevated. Eight placental tissues testing positive for the virus were reported. Three positive RT-PCR results of test of breast milk have been reported recently. One amniotic fluid testing positive was reported.

CONCLUSION

Possible vertical transmission of SARS CoV-2 has been observed in some studies currently. More RT-PCR tests on amniotic fluid, placenta, breast milk and cord blood are required.

COVID-19 infection in pregnant women, preterm delivery, birth weight, and vertical transmission: a systematic review and meta-analysis

In less than four months, the total of confirmed cases of COVID-19 was 1,684,833 worldwide. Outcomes among the public of pregnant women with COVID-19 are still unclear. We performed a systematic review and meta-analysis to analyze whether COVID-19 in pregnant women is related to premature birth and birth weight, and to summarize the diagnostic results of neonates born to mothers with COVID-19 for investigating the possibility of vertical transmission. Searches were performed in PubMed, Scopus, LILACS, Web of Science, Google Scholar, Preprints, bioRxiv, and medRxiv. We used the odds ratio (OR) and mean difference (MD) as measure of analysis. Summary estimates were calculated using random effects models. 38 studies were included; data from 279 women were analyzed; 60 patients were diagnosed with COVID-19. The meta-analysis showed no significant association between COVID-19 and preterm delivery (OR = 2.25; 95%CI: 0.96, 5.31; p = 0.06; I² = 0%). No significant relationship was found between birth weight and COVID-19 (MD = -124.16; 95%CI: -260.54, 12.22; p = 0.07; I² = 0%). Among 432 newborns, 10 were reported with positive results for early SARS-CoV-2. Due to the characteristics of the studies, the level of evidence of this meta-analysis was considered very low. COVID-19 in pregnant women may not be associated with the occurrence of preterm deliveries or the birth weight of the newborn children, however the evidence to date is very uncertain. A few reports suggest vertical transmission of SARS-CoV-2 to newborn is possible, but evidence is still uncertain.

On the potential role of exosomes in the COVID-19 reinfection/reactivation opportunity

We propose here that one of the potential mechanisms for the relapse of the COVID-19 infection could be a cellular transport pathway associated with the release of the SARS-CoV-2-loaded exosomes and other extracellular vesicles. It is possible that this “Trojan horse” strategy represents possible explanation for the re-appearance of the viral RNA in the recovered COVID-19 patients 7–14 day post discharge, suggesting that viral material was hidden within such exosomes or extracellular vesicles during this “silence” time period and then started to re-spread again.

Communicated by Ramaswamy H. Sarma

Effect of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcome: systematic review

OBJECTIVE

To evaluate the effect of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcome by performing a systematic review of available published literature on pregnancies affected by COVID-19.

METHODS

We performed a systematic review to evaluate the effect of COVID-19 on pregnancy, perinatal and neonatal outcome. We conducted a comprehensive literature search using PubMed, EMBASE, the Cochrane Library, China National Knowledge Infrastructure Database and Wan Fang Data up to and including 20 April 2020 (studies were identified through PubMed alert after that date). For the search strategy, combinations of the following keywords and medical subject heading (MeSH) terms were used: 'SARS-CoV-2', 'COVID-19', 'coronavirus disease 2019', 'pregnancy', 'gestation', 'maternal', 'mother', 'vertical transmission', 'maternal-fetal transmission', 'intrauterine transmission', 'neonate', 'infant' and 'delivery'. Eligibility criteria included laboratory-confirmed and/or clinically diagnosed COVID-19, patient being pregnant on admission and availability of clinical characteristics, including at least one maternal, perinatal or neonatal outcome. Exclusion criteria were non-peer-reviewed or unpublished reports, unspecified date and location of the study, suspicion of duplicate reporting and unreported maternal or perinatal outcomes. No language restrictions were applied.

RESULTS

We identified a high number of relevant case reports and case series, but only 24 studies, including a total of 324 pregnant women with COVID-19, met the eligibility criteria and were included in the systematic review. These comprised nine case series (eight consecutive) and 15 case reports. A total of 20 pregnant patients with laboratory-confirmed COVID-19 were included in the case reports. In the combined data from the eight consecutive case series, including 211 (71.5%) cases of laboratory-confirmed and 84 (28.5%) of clinically diagnosed COVID-19, the maternal age ranged from 20 to 44 years and the gestational age on admission ranged from 5 to 41 weeks. The most common symptoms at presentation were fever, cough, dyspnea/shortness of breath, fatigue and myalgia. The rate of severe pneumonia reported amongst the case series ranged from 0% to 14%, with the majority of the cases requiring admission to the intensive care unit. Almost all cases from the case series had positive computed tomography chest findings. All six and 22 cases that had nucleic-acid testing in vaginal mucus and breast milk samples, respectively, were negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Only four cases of spontaneous miscarriage or termination were reported. In the consecutive case series, 219/295 women had delivered at the time of reporting and 78% of them had Cesarean section. The gestational age at delivery ranged from 28 to 41 weeks. Apgar scores at both 1 and 5 min ranged from 7 to 10. Only eight neonates had birth weight < 2500 g and nearly one-third of neonates were transferred to the neonatal intensive care unit. There was one case of neonatal asphyxia and death. In 155 neonates that had nucleic-acid testing in throat swab, all, except three cases, were negative for SARS-CoV-2. There were no cases of maternal death in the eight consecutive case series. Seven maternal deaths, four intrauterine fetal deaths (one with twin pregnancy) and two neonatal deaths (twin pregnancy) were reported in a non-consecutive case series of nine cases with severe COVID-19. In the case reports, two maternal deaths, one neonatal death and two cases of neonatal SARS-CoV-2 infection were reported.

CONCLUSIONS

Despite the increasing number of published studies on COVID-19 in pregnancy, there are insufficient good-quality data to draw unbiased conclusions with regard to the severity of the disease or specific complications of COVID-19 in pregnant women, as well as vertical transmission, perinatal and neonatal complications. In order to answer specific questions in relation to the impact of COVID-19 on pregnant women and their fetuses, through meaningful good-quality research, we urge researchers and investigators to present complete outcome data and reference previously published cases in their publications, and to record such reporting when the data of a case are entered into one or several registries. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

[Infection by SARS-CoV-2 in pregnancy and possibility of transmission to neonates: A systematic revision]

En este trabajo se revisan los artículos publicados sobre COVID-19, embarazo y afectación del neonato hasta el 30 de abril de 2020. Se han encontrado un total de 33 publicaciones que se refieren a 553 gestantes y 456 partos. Los síntomas más frecuentes en la embarazada fueron fiebre, tos y disnea. Cerca de tercios de los partos se realizaron por cesárea; el 5,9% de las mujeres requirieron ingreso en la UCI y el 4% requirieron ventilación mecánica. No se produjo ninguna muerte materna. Hubo prematuridad en el 22,3% de los partos y el neonato requirió ingreso en la UCI en el 38,3%. Solo se informó de una muerte neonatal (0,4%) y de 13 casos de COVID-19 neonatal (3,4%). La información disponible no permite asegurar que la transmisión se produjera por vía transplacentaria.

Effects of COVID-19 Infection during Pregnancy and Neonatal Prognosis: What Is the Evidence?

BACKGROUND

This study's aims are to assess the current evidence presented in the literature regarding the potential risks of COVID-19 infection among pregnant women and consequent fetal transmission.

METHODS

a systematic literature review assessing papers published in the most comprehensive databases in the field of health intended to answer the question, "What are the effects of COVID-19 infection during pregnancy, and what is the neonatal prognosis?"

RESULTS

49 papers published in 2020 were eligible, presenting low levels of evidence. A total of 755 pregnant women and 598 infants were assessed; more than half of pregnant women had C-sections (379/65%). Only 493 (82%) infants were tested for SARS-CoV-2, nine (2%) of whom tested positive. There is, however, no evidence of vertical transmission based on what has been assessed so far, considering there are knowledge gaps concerning the care provided during and after delivery, as well as a lack of suitable biological samples for testing SARS-CoV-2.

CONCLUSIONS

We cannot rule out potential worsening of the clinical conditions of pregnant women infected with SARS-CoV-2, whether the infection is associated with comorbidities or not, due to the occurrence of respiratory disorders, cardiac rhythm disturbances, and acid-base imbalance, among others. We recommend relentless monitoring of all pregnant women in addition to testing them before delivery or the first contact with newborns.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): a review

In recent years, the prevalence and spread of coronavirus has had a huge impact on global public health. Due to the incomplete understanding of the pathogenic mechanism of the virus, it is difficult for humans to fight against the virus quickly and effectively once the outbreak occurs. In early 2020, a novel coronavirus was discovered in Wuhan, China. Soon after, similar cases were found in other countries around the world, and the number of infected people increased rapidly. So far, the global cumulative number of infected people has exceeded 3 million, and more than 200,000 people have died, which has had a huge impact on global human health and economic development. Every outbreak of disease makes a deep impression on mankind. Herein, we summarize the virology, epidemiology, clinical manifestations, diagnosis, treatment and prevention of SARS-CoV-2, and hope that countries can control the outbreak as soon as possible to minimize the loss.

Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has substantially impacted maternity care provision worldwide. Studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. The objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers.

METHODS

We conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in 12 languages. Information was collected between 24 March and 10 April 2020 on respondents' background, preparedness for and response to COVID-19 and their experience during the pandemic. An optional module sought information on adaptations to 17 care processes. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (LMICs) and high-income countries (HICs).

RESULTS

We analysed responses from 714 maternal and newborn health professionals. Only one-third received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, 47% of participants in LMICs and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices.

CONCLUSIONS

Substantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information-sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses.

Incidence and clinical profiles of COVID-19 pneumonia in pregnant women: A single-centre cohort study from Spain

BACKGROUND

Information regarding the incidence and characteristics of COVID-19 pneumonia amongst pregnant women is scarce.

METHODS

Single-centre experience with 32 pregnant women diagnosed with COVID-19 between March 5 to April 5, 2020 at Madrid, Spain.

FINDINGS

COVID-19 pneumonia was diagnosed in 61·5% (32/52) women. Only 18·7% (6/32) had some underlying condition (mostly asthma). Supplemental oxygen therapy was required in 18 patients (56·3%), with high-flow requirements in six (18·7%). Eight patients (25·0%) fulfilled the criteria for acute distress respiratory syndrome. Invasive mechanical ventilation was required in two patients (6·2%). Tocilizumab was administered in five patients (15·6%). Delivery was precipitated due to COVID-19 in three women (9·4%). All the newborns had a favourable outcome, with no cases of neonatal SARS-CoV-2 transmission. Severe cases of pneumonia requiring supplemental oxygen were more likely to exhibit bilateral alveolar or interstitial infiltrates on chest X-ray (55·6% vs. 0·0%; P-value = 0·003) and serum C-reactive protein (CRP) levels >10 mg/dL (33·0% vs. 0·0%; P-value = 0·05) at admission than those with no oxygen requirements.

INTERPRETATION

Pregnant women with COVID-19 have a high risk of developing pneumonia, with a severe course in more than half of cases. The presence of bilateral kung infiltrates and elevated serum CRP at admission may identify women at-risk of severe COVID-19 pneumonia.

FUNDING

Instituto de Salud Carlos III (COV20/00,181), Spanish Ministry of Science and Innovation.

Safe Perinatal Management of Neonates Born to SARS-CoV-2 Positive Mothers at the Epicenter of the Italian Epidemic

Introduction: 2019-novel Coronavirus Disease (COVID-19) pandemic has recently struck Northern Italy. Limited data are available about COVID-19 during pregnancy and infancy, mostly from China. Herein, our experience on a safe perinatal management of neonates born to COVID-19 mothers is reported. Method: Since late February through May 15, 2020, 375 pregnant women delivered at our City Hospital in Piacenza, at the epicenter of the Italian epidemic. Of these, 144 were tested via a SARS-CoV-2 quantitative rRT-PCR nasopharyngeal swab prior to delivery, firstly on the basis of epidemiological and clinical criteria, then adopting a universal screening approach. All newborns from SARS-CoV-2 positive mothers were tested via nasopharyngeal swab at birth, on day 3 and/or day 7. In case of positive result, they were re-tested on day 14. Results: Fifteen women tested positive for SARS-CoV-2 infection. All newborns except one were born at term. All of them were non-infected at birth, irrespective of mode of delivery; 13 out 15 remained negative; the two positive neonates became negative by day 14 of life. All of them have always remained asymptomatic. All newborns except two were allowed to have immediate bonding, permanent rooming-in, and direct breastfeeding. Conclusions: Our study supports the claim that COVID-19 in pregnancy is not associated with worse clinical outcomes compared to non-COVID-19 pregnant women and/or with higher rates of preterm birth and intrauterine growth restriction. Intrauterine vertical transmission of SARS-CoV-2 seems to be unlikely. Breastfeeding appears to be safe and protective for the neonate, once appropriate preventive measures are adopted.

Manifestations of COVID-19 in pregnant women with focus on gastrointestinal symptoms: a systematic review

AIM

This review study was conducted to evaluate the symptoms of COVID-19 in pregnant women with a focus on gastrointestinal symptoms.

BACKGROUND

COVID-19 is a fatal respiratory disease caused by a novel coronavirus that quickly became a pandemic. Although the main symptoms of this disease include respiratory symptoms, gastrointestinal manifestations have also been observed in some patients suffering from COVID-19. Pregnant women are among the most vulnerable groups in the community to infectious diseases.

METHODS

Scientific databases were searched for articles published up to May 8, 2020. Any type of study investigating the manifestations of COVID-19 in pregnant women was included. Symptoms of the disease in pregnant women with an emphasis on gastrointestinal symptoms were assessed.

RESULTS

The search resulted in 852 titles and abstracts, which were narrowed down to 43 studies involving 374 women. The most common symptoms of patients were fever (59.1%) and cough (48.4%), respectively. Gastrointestinal symptoms included diarrhea (4.5%), abdominal pain (1.6%), nausea (0.8%), and loss of appetite (0.3%), respectively. In studies on pregnant women with gastrointestinal symptoms, 13 fetal abortions occurred, most of which were induced abortions due to the risks posed by COVID-19.In thirty cases, and infected pregnant women reported a history of chronic pregnancy-related diseases.

CONCLUSION

COVID-19 in pregnant women, similar to the general population, can present with gastrointestinal manifestations. The gastrointestinal tract can be a potential route for infection with the novel coronavirus.