Impact of the Coronavirus Infection in Pregnancy: A Preliminary Study of 141 Patients

Biochemical profiles of patients with COVID-19 during the first and second waves in Ethiopia

Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2. Nasopharyngeal swabs (NP swabs) were used for patients with COVID-19 who demonstrated serious clinical symptoms and disturbances in biochemical parameters. The biochemical profiles of these patients remain ambiguous and differ from wave to wave of COVID-19 infections. Herein, we conducted a multicenter retrospective cohort study with 538 patients with COVID-19 at six COVID-19 treatment centers in Ethiopia. Professional data collectors collected the data. Descriptive statistics were used to summarize the data, and independent t-tests and chi-square tests were used to assess the relationships between the continuous and categorical variables across waves, respectively. In total, 240 and 298 patients were included from the first and second waves, respectively. Men and individuals aged 53-69 years were more likely to be infected in each wave. The mean alkaline phosphatase (p < 0.001) and sodium levels (p = 0.035) significantly differed between patients across the two waves of COVID-19; the significant difference in the alkaline phosphatase levels of patients between the two waves was -45.425. All the symptoms of COVID-19 were significantly (p < 0.05) associated with the waves of the pandemic. Patients in both waves had no chronic disease comorbidities. This study showed that the mean alkaline phosphatase and sodium levels differed significantly across the first two waves of the pandemic at six COVID-19 treatment centers in Ethiopia while all clinical symptoms of COVID-19 were associated with the first two waves of the pandemic.

The coronavirus disease 2019 infection in pregnancy and adverse pregnancy outcomes: a systematic review and meta-analysis

The coronavirus disease 2019 (COVID-19) outbreak which started in December 2019 rapidly developed into a global health concern. Pregnant women are susceptible to respiratory infections and can experience adverse outcomes. This systematic review and meta-analysis compared pregnancy outcomes according to COVID-19 disease status. The MEDLINE, EMBASE, and Cochrane Library databases were searched for relevant articles published between December 1, 2019, and October 19, 2022. Main inclusion criterion was any population-based, cross-sectional, cohort, or case-control study that assessed pregnancy outcomes in women with or without laboratory-confirmed COVID-19. Sixty-nine studies including 1,606,543 pregnant women (39,716 [2.4%] diagnosed with COVID-19) were retrieved. COVID-19-infected pregnant women had a higher risk of preterm birth (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.42-1.78), preeclampsia (OR, 1.41; 95% CI, 1.30-1.53), low birth weight (OR, 1.52; 95% CI, 1.30-1.79), cesarean delivery (OR, 1.20; 95% CI, 1.10-1.30), stillbirth (OR, 1.71; 95% CI, 1.39-2.10), fetal distress (OR, 2.49; 95% CI, 1.54-4.03), neonatal intensive care unit admission (OR, 2.33; 95% CI, 1.72-3.16), perinatal mortality (OR, 1.96; 95% CI, 1.15-3.34), and maternal mortality (OR, 6.15; 95% CI, 3.74-10.10). There were no significant differences in total miscarriage, preterm premature rupture of membranes, postpartum hemorrhage, cholestasis, or chorioamnionitis according to infection. This review demonstrates that COVID-19 infection during pregnancy can lead to adverse pregnancy outcomes. This information could aid researchers and clinicians in preparing for another pandemic caused by newly discovered respiratory viruses. The findings of this study may assist with evidence-based counseling and help clinicians manage pregnant women with COVID-19.

The impact of the COVID-19 pandemic on the mental health of new mothers in China: A qualitative study of mothers with infants aged 0–1 year old

Background

China has implemented a strict epidemic control policy (ECP) for 3 years during the COVID-19 pandemic. New mothers are under great psychological pressure to protect themselves against the virus, following the ECP, as well as taking on the main responsibility of raising their children. However, the mental health of this group has been neglected by the public. This article aims to understand the mental health of new mothers during the COVID-19 pandemic.

Method

Qualitative research methods were adopted in this study. From 1 October to 1 November 2022, we conducted in-depth interviews with 36 new mothers in Guiyang, Guizhou, China, and used thematic analysis to examine their emotional status, as well as the origins of their negative and positive emotions.

Results

(1) New mothers are chronically depressed, feeling anxious, and upset. (2) Negative emotions are caused either by the virus or by the ECP. (3) New mothers are mainly anxious about their children's physical health, feeding options, childcare, and family income. (4) Positive emotions are reflected by tight parent–child bonds, a better understanding of childcare, and an increased ability to perceive risks.

Conclusion

The anxiety of new mothers has revealed the shortcomings of the Chinese health system in the emergency management of the mother and child. At the same time, the outbreak is an opportunity to improve the response management capacity of the health system in order to prevent the recurrence of similar problems for mothers and infants.

Impact of COVID-19 during pregnancy on placental pathology, maternal and neonatal outcome - A cross-sectional study on anemic term pregnant women from a tertiary care hospital in southern India

Background

SARS-CoV-2 infection during pregnancy may cause adverse maternal, neonatal and placental outcomes. While tissue hypoxia is often reported in COVID-19 patients, pregnant women with anemia are suspected to be more prone to placental hypoxia-related injuries.

Methods

This hospital-based cross-sectional study was conducted between August-November 2021, during COVID-19 second wave in India. Term pregnant women (N=212) admitted to hospital for delivery were enrolled consecutively. Since hospital admission mandated negative RT-PCR test for SARS-CoV-2 virus, none had active infection. Data on socio-demography, COVID-19 history, maternal, obstetric, and neonatal outcomes were recorded. Pre-delivery maternal and post-delivery cord blood samples were tested for hematological parameters and SARS-CoV-2 IgG. Placentae were studied for histology.

Results

Of 212 women, 122 (58%) were seropositive for SARS-CoV-2 IgG, but none reported COVID-19 history; 134 (63.2%) were anemic. In seropositive women, hemoglobin (p=0.04), total WBC (p=0.009), lymphocytes (p=0.005) and neutrophils (p=0.02) were significantly higher, while ferritin was high, but not significant and neutrophils to lymphocytes (p=0.12) and platelets to lymphocytes ratios (p=0.03) were lower. Neonatal outcomes were similar. All RBC parameters and serum ferritin were significantly lower in anemic mothers but not in cord blood, except RDW that was significantly higher in both, maternal (p=0.007) and cord (p=0.008) blood from seropositive anemic group compared to other groups. Placental histology showed significant increase in villous hypervascularity (p=0.000), dilated villous capillaries (p=0.000), and syncytiotrophoblasts (p=0.02) in seropositive group, typically suggesting placental hypoxia. Maternal anemia was not associated with any histological parameters. Univariate and multivariate logistic regression analyses of placental histopathological adverse outcomes showed strong association with SARS-CoV-2 seropositivity but not with maternal anemia. When adjusted for several covariates, including anemia, SARS-CoV-2 seropositivity emerged as independent risk factor for severe chorangiosis (AOR 8.74, 95% CI 3.51-21.76, p<0.000), dilated blood vessels (AOR 12.74, 95% CI 5.46-29.75, p<0.000), syncytiotrophoblasts (AOR 2.86, 95% CI 1.36-5.99, p=0.005) and villus agglutination (AOR 9.27, 95% CI 3.68-23.32, p<0.000).

Conclusion

Asymptomatic COVID-19 during pregnancy seemed to be associated with various abnormal placental histopathologic changes related to placental hypoxia independent of maternal anemia status. Our data supports an independent role of SARS-CoV-2 in causing placental hypoxia in pregnant women.

To Compare the Maternal and Fetal Outcomes of COVID-19-Affected Expectant Mothers During the First and Second COVID-19 Waves: Data From a Tertiary Care Referral Hospital in Punjab

BACKGROUND

Coronavirus 2019 (COVID-19) infection, declared pandemic in March 2020 by the World Health Organization, paved the way for newer research in the field of medicine. The second wave, beginning in March 2021, appeared to be more devastating. The purpose of this study is to evaluate the clinical characteristics, effects of COVID-19 infection in pregnancy, and obstetric and perinatal outcomes in the first and second waves.

MATERIALS AND METHODS

This study was conducted from January 2020 to August 2021 at the Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab. The patients were enrolled immediately after each infected woman was identified as per the inclusion and exclusion criteria. Demographic details of the patients, associated comorbid conditions, intensive care unit (ICU) admission, and treatment details were noted. Neonatal outcomes were recorded. The testing of pregnant women was done as per the Indian Council of Medical Research (ICMR) guidelines.

RESULTS

There were 3421 obstetric admissions and 2132 deliveries during this period. Group 1 had 123 COVID-19-positive admissions, while group 2 had 101 admissions. The incidence of COVID-19 infection in pregnancy was 6.54%. In both groups, the majority of patients were between the ages of 21 and 30. About 80(66%) of the admissions in group 1 and 46(46%) in group 2 were in the gestational age of 29-36 weeks. Multiparity was more common in both groups, with 58% of cases in group 1 and 79% of cases in group 2. Obstetric comorbidities were common in both groups, seen in 46% of cases in group 1 and 78% of cases in group 2. The majority of patients were asymptomatic in group 1, with an 89% incidence, whereas only 33% of patients in group 2 were without symptoms. In biological data, D-dimers, prothrombin time, and platelet count were altered in 11%, 14%, and 17% of cases, respectively, in group 2, with almost normal data in group 1. Most cases in group 2 (52%) were critical cases in the moderate and severe categories requiring intensive care unit (ICU) treatment, whereas there was only single ICU admission in group 1. The overall case fatality rate (CFR) in group 2 was found to be 19.8(20/101).  Delivery by cesarean section was done in 38.2% of cases in group 1, while in 33% of cases in group 2, with a significant p-value of 0.001. About 29% of cases in group 1 and 34% of cases in group 2 underwent vaginal delivery. The rate of abortion was almost similar in both groups. Only two cases in group 1 and nine cases in group 2 had intrauterine fetal death. Observations of neonatal outcomes suggested that five cases in group 2 and two cases in group 1 had severe birth asphyxia. Only one case in group 1 and four cases in group 2 had positive COVID-19 status. Maternal mortality was significantly higher in group 2 with 20 cases, while only one case was in group 1. Anemia and pregnancy-induced hypertension were the chief comorbidities in this group.

CONCLUSION

COVID-19 infection during pregnancy may be associated with maternal mortality while having a minimal effect on neonatal morbidity and mortality. The possibility of maternal-fetal transmission cannot be ruled out completely. The severity and characteristics of COVID-19 may vary in each wave, and we need to modify treatment strategies. More studies or meta-analyses reports are required to authenticate this transmission.

COVID-19 suspicion and diagnosis in pregnancy: A big conundrum!

Introduction

This article aims to discuss all the challenges faced in the diagnosis of coronavirus disease 2019 (COVID-19) in pregnancy, isolation of suspected and positive patients, their management, and the strategies to prevent the transmission of infection among the healthy population and medical fraternity. The diagnosis of COVID in pregnancy is influenced by many factors, including normal physiological changes in pregnancy, comorbid conditions associated with pregnancy, and the presence of asymptomatic infection in patients. Suspicion of COVID-19 in pregnant females is of utmost importance at a primary health center for risk mitigation of exposure to medical personnel.

Material and Methods

A retrospective study was carried out in the labour room in a tertiary care center in India. Two groups were made, suspected COVID and confirmed COVID in pregnant patients. The case records were analysed.

Results

Out of a total of 5164 admissions, 95 patients were admitted as suspected (1.8%), but only two patients were COVID-positive amongst them. 84% of COVID-positive patients were asymptomatic. Fever was the most common symptom in both groups (P-value: 0.15). Preeclampsia and anaemia were the most common comorbidities in both groups, not statistically significant. There were 32% of intensive acre unit (ICU) admissions in suspected COVID patients, and 77% of them were having respiratory distress.

Conclusion

COVID-19 presents as an asymptomatic infection in most pregnant patients. Physiological changes to the cardiorespiratory and immune systems along with associated comorbidities in pregnancy, increase a woman's susceptibility and delay diagnosis. Consideration of patients as suspected COVID at triage stations on the basis of only contact or travel history poses a great burden on the health care system. Although triage is an essential tool to identify symptomatic COVID patients, universal testing strategies should continue simultaneously. Streamlining medical care professionals into self-sufficient teams ensures adequate clinical coverage amongst the suspected COVID, confirmed COVID, and routine labour room admissions.

Impact of SARS-CoV-2 infection on risk of prematurity, birthweight and obstetric complications: A multivariate analysis from a nationwide, population-based retrospective cohort study

OBJECTIVE

To determine the impact of maternal coronavirus disease 2019 (COVID-19) on prematurity, birthweight and obstetric complications.

DESIGN

Nationwide, population-based retrospective cohort study.

SETTING

National Programme de Médicalisation des Systèmes d'Information database in France.

POPULATION

All single births from March to December 2020: 510 387 deliveries, including 2927 (0.6%) with confirmed COVID-19 in the mother and/or the newborn.

METHODS

The group with COVID-19 was compared with the group without COVID-19 using the chi-square test or Fisher's exact test, and the Student's t test or Mann-Whitney U test. Logistic regressions were used to study the effect of COVID-19 on the risk of prematurity or macrosomia (birthweight ≥4500 g).

MAIN OUTCOME MEASURES

Prematurity less than 37, less than 28, 28-31, or 32-36 weeks of gestation; birthweight; obstetric complications.

RESULTS

In singleton pregnancies, COVID-19 was associated with obstetric complications such as hypertension (2.8% versus 2.0%, p < 0.01), pre-eclampsia (3.6% versus 2.0%, p < 0.01), diabetes (18.8% versus 14.4%, p < 0.01) and caesarean delivery (26.8% versus 19.7%, p < 0.01). Among pregnant women with COVID-19, there was more prematurity between 28 and 31 weeks of gestation (1.3% versus 0.6%, p < 0.01) and between 32 and 36 weeks of gestation (7.7% versus 4.3%, p < 0.01), and more macrosomia (1.0% versus 0.7%, p = 0.04), but there was no difference in small-for-gestational-age newborns (6.3% versus 8.7%, p = 0.15). Logistic regression analysis for prematurity showed an adjusted odds ratio (aOR) of 1.77 (95% CI 1.55-2.01) for COVID-19. For macrosomia, COVID-19 resulted in non-significant aOR of 1.38 (95% CI 0.95-2.00).

CONCLUSIONS

COVID-19 is a risk factor for prematurity, even after adjustment for other risk factors.

TWEETABLE ABSTRACT

The risk of prematurity is twice as high in women with COVID-19 after adjustment for factors usually associated with prematurity.

Effect of restrictions imposed due to COVID-19 pandemic on the antenatal care and pregnancy outcomes: a prospective observational study from rural North India

OBJECTIVES

To assess the difficulties faced by the pregnant women in seeking appropriate antenatal care due to the restrictions imposed during the COVID-19 pandemic; assess the difficulties encountered during delivery and postpartum period; the suitability of the teleconsultation services offered; effect of COVID-19 infection on pregnancy outcomes and the effect of restrictions on the nutrition profile of the pregnant women.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

We included 1374 pregnant women from the rural areas of three districts of Punjab, India registered at government health centres before the implementation of lockdown due to the COVID-19 pandemic on 24 March 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the difficulties faced by the women during their pregnancies due to restrictions imposed during the lockdown. The secondary outcomes included the effect of COVID-19 infections on pregnancy outcomes, satisfaction from the telemedicine services and restrictions on the nutrition profile of the pregnant women.

RESULTS

One-third of the women (38.4%) considered their last pregnancy unplanned. Women faced difficulties due to the restrictions in getting adequate nutrition (76.5%), accessing transportation facilities (35.4%), consultations from doctors (22.4%) or getting an ultrasonography scan (48.7%). One-fifth (21.9%) of women could not access safe abortion services. Only 3.6% of respondents ever took any teleconsultation services offered by the government. Most of them felt unsatisfied compared with routine visits (77.5%). COVID-19-infected women were primarily asymptomatic (76.1%), but there was a high incidence of preterm birth (42.8%). Frontline workers could visit 64.3% of the women in the postpartum period despite restrictions.

CONCLUSIONS

Lockdown compromised the antenatal care in our study area while the frontline workers attempted to minimise the inconvenience. Telemedicine services did not prove to be of many benefits to pregnant women and should only work as a supplement to the existing protocols of antenatal care.

Preeclampsia in COVID-19: A Masquerading Errant-An Exploration of Foeto-Maternal Outcome from a Tertiary Care Hospital In India

Background

COVID-19 pandemic has shown that the multisystem involvement in COVID-infected patients is beyond the usual clinical manifestations of other respiratory viral illnesses. This study aims to evaluate the upshots of COVID-19 in women with preeclampsia.

Methodology

This descriptive study was conducted in department of Obstetrics & Gynaecology at VMMC & Safdarjung Hospital (May–November 2020), wherein a retrospective review of the medical records of laboratory confirmed SARS CoV2-positive pregnant women (as per ICMR), with preeclampsia (as defined by ACOG guidelines), was done in the dedicated COVID labour ward. Primary outcome was incidence of preeclampsia in SARS CoV2 positive gravid females. Secondary outcomes were socio-demographic and maternal characteristics, severity of COVID-19 and foeto-maternal outcome.

Results

During these 7 months, 38/302 (12.58%) SARS COV2-positive women presented with pre-eclampsia, either before or at the time of admission; amongst them 47.37% were primigravida. Severe preeclampsia was chronicled in 65.71% women. Around 20% women had severe COVID-19. All women with severe COVID19 required ICU stay, 5 requiring intubation. Three of these patients succumbed to their illness. Out of the 40 babies born to these women (including 2 twin pregnancies), 36.84% were premature deliveries. Seventeen (42.50%) babies had low birth weight. Although 82.50% were live births, five (12.50%) were intrauterine demise and 2 were early neonatal deaths.

Conclusion

Gravid women with preeclampsia infected with SARS CoV2 have comparative more severe illness, requiring more intensive care requirement and high maternal and neonatal morbidity.

Clinical Outcome of Neonates Born to SARS-CoV-2 Positive Mothers in India: A Systematic Review and Meta-Analysis

During the SARS-CoV-2 pandemic, India accounted for 10-50% of cases reported across the world. Perinatal care from a developing country during this period has its own importance. This study was conducted to evaluate the health outcome of neonates born to SARS-CoV-2 positive mothers in India from the published literature by a systematic review and meta-analysis. Articles reporting neonates born from SARS-CoV-2 confirmed mothers in India, published in PubMed, Scopus®, and Embase® databases, were analyzed. After registration with the International Prospective Register of Systematic Reviews (PROSPERO), the study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes were the mode of delivery, perinatal asphyxia, preterm birth, breastfeeding, neonatal mortality, SARS-CoV-2 infectivity among neonates of SARS-CoV-2 mothers. The pooled rate was expressed with a 95% confidence interval. Heterogeneity and study level effect size were assessed using I² statistics and DerSimonian and Laird random effect method of meta-analysis. Data analysis was made by Stata 15.1 (StataCorp LLC, College Station, Texas, USA). Total 3,551 neonates born from 3,542 SARS-CoV-2 positive mothers were included from 14 studies (four prospective and 10 retrospective studies). The pooled rates of premature birth, Caesarean delivery, breastfeeding, and neonatal mortality were 18.89%, 55.89%, 67.79%, respectively, with 12.64/1000 live births. SARS-CoV-2 positivity rate was 5.28%; 11.76% were symptomatic, and five (1.7%) died from 281 SARS-CoV-2 positive neonates. There was an increase in the number of Caesarean delivery, premature birth, and lower mortality among neonates born to SARS-CoV-2 positive mothers compared to the Indian neonatal database. Around five percent of neonates delivered to SARS-CoV-2 positive mothers were infected, and the majority of them had good clinical outcomes.

Adverse Perinatal Outcomes in COVID-19 Infected Pregnant Women: A Systematic Review and Meta-Analysis

The impact of COVID-19 virus infection during pregnancy is still unclear. This systematic review and meta-analysis aimed to quantitatively pool the evidence on impact of COVID-19 infection on perinatal outcomes. Databases of Medline, Embase, and Cochrane library were searched using the keywords related to COVID-19 and perinatal outcomes from December 2019 to 30 June 2021. Observational studies comparing the perinatal outcomes of COVID-19 infection in pregnancy with a non-infected comparator were included. The screening process and quality assessment of the included studies were performed independently by two reviewers. Meta-analyses were used to pool the comparative dichotomous data on perinatal outcomes. The database search yielded 4049 results, 1254 of which were duplicates. We included a total of 21 observational studies that assessed the adverse perinatal outcomes with COVID-19 infection. The odds of maternal death (pooled OR: 7.05 [2.41−20.65]), preeclampsia (pooled OR: 1.39 [1.29−1.50]), cesarean delivery (pooled OR: 1.67 [1.29−2.15]), fetal distress (pooled OR: 1.66 [1.35−2.05]), preterm birth (pooled OR: 1.86 [1.34−2.58]), low birth weight (pooled OR: 1.69 [1.35−2.11]), stillbirth (pooled OR: 1.46 [1.16−1.85]), 5th minute Apgar score of less than 7 (pooled OR: 1.44 [1.11−1.86]) and admissions to neonatal intensive care unit (pooled OR: 2.12 [1.36−3.32]) were higher among COVID-19 infected pregnant women compared to non-infected pregnant women.

Insights on Epidemiology, Pathogenesis, Diagnosis and Possible Treatment of COVID-19 Infection

The sudden outbreak of the novel coronavirus infection (COVID-19, SARS-CoV-2 virus) is posing a significant threat by affecting millions of people across the globe showing mild to severe symptoms of pneumonia and acute respiratory distress. The absence of precise information on primary transmission, diagnosis, prognosis, and therapeutics for patients with COVID-19 makes prevention and control tough. In the current scenario, only supportive treatment is available, which in turn possess a biggest challenge for scientists to develop specific drugs and vaccines for COVID-19. Further, India, with the second largest populated country and fluctuating climatic conditions quarterly, has high vulnerability towards COVID-19 infection. Thus, this highlights the importance of a better understanding of the COVID-19 infection, pathology, diagnosis and its treatment. The present review article has been intended to discuss the COVID-19 biology, mechanism of infection in humans with primary effects on pregnancy, the nervous system, diabetes, and cardiovascular disease. The article will also discuss the drug repurposing strategy as an alternative line of treatment and clinical practices recommended by the World Health Organization and other government agencies and represent the COVID-19 scenario with the Indian context.

[Current evidence of SARS-CoV-2 infection in pregnancy: A scoping reviewEvidencias atuais sobre a infecto pelo SARS-COV-2 na gravidez: revisao do escopo]

Introduction

SARS-CoV-2 is a betacoronavirus as well as SARS-CoV and MERS-CoV, both associated with spontaneous miscarriage, preterm birth, maternal morbidity and mortality and a higher number of ICU admissions for pregnant women. Being a new virus, its effects on pregnancy are little known. This review aims to analyze the available evidence on SARS-CoV-2 in pregnancy.

Materials and Methods

A literature review was conducted in PubMed, ProQuest, Scopus, BVS and SciElo. Evidence criticism and information extraction were conducted using two instruments from the Joanna Briggs Institute, following the PRISMA-ScR guidelines.

Results

85 articles were included evidencing that most pregnant women with SARS-COV-2 suffered mild to moderate disease and were at a higher risk of death and complications compared to non-pregnant patients. Low risk of vertical transmission was documented and adverse perinatal outcomes were associated with severe maternal clinical manifestations. The effectiveness of treatment was inconclusive.

Discussion

Clinical presentation of infection in pregnant women, vertical transmission, treatment, disease severity and neonatal outcomes were discussed.

Conclusions

COVID-19 during pregnancy is a complication that generates greater morbidity and mortality, for which it is vital to develop further research on the understanding of the behavior, physiological and emotional implications and possible treatment. This review makes a rigorous analysis of the quality of studies and provides valuable information from evidence.

A Clinical Retrospective Study on the Transmission of COVID-19 From Mothers to Their Newborn and Its Outcome

Introduction India is the second most populated country in the world. The declaration of the COVID-19 pandemic has caused significant morbidity and mortality in pregnant women and newborns. Due to the decreased lung volume and immunocompromised state, pregnant women are more prone to rapid clinical deterioration. Regarding the transmission of COVID-19 infection to newborns, there is no clear-cut evidence regarding the intrauterine or vertical transmission of COVID-19 from the affected pregnant women to their neonates. Aim This study aimed to assess the outcome of neonates born to mothers with COVID-19 in a tertiary care hospital in Puducherry, India. Methods This retrospective case record-based study was conducted among all neonates born to COVID-19-positive mothers at a tertiary care institution in Puducherry from April 2020 to June 2020. All the newborns born to COVID-19-positive mothers during the specified period of time were included in the study. Results A total of 98 COVID-positive mothers were included in the study. Of these, 13.27% showed mild upper respiratory infection, and one had a moderate category. The mean gestational age was 38.4+1.12 weeks. About 53.06% of COVID-19-positive mothers had C-sections, 45.92% had a normal vaginal delivery, and only one had an instrumental vaginal delivery. All the mothers gave birth to singleton neonates; of 98 newborns, 51 were female, and 47 were male with the mean birth weight of 3.1 ± 0.4 kg. Among the 98 neonates, only six developed COVID-19 infection. Among the six, four acquired infections during the first to second week of the postnatal period and two acquired infections during the fourth week. Three neonates born by normal vaginal delivery only had a fever; two neonates manifested fever, cough, and increased respiratory rate; and only one neonate developed hypoxia. Conclusion The study showed that vertical transmission from the mother to the newborn is extremely minimal. In our study, six neonates acquired infection mostly due to the close contact of the newborn with the mother during rooming-in and breastfeeding.

Obstetric and perinatal outcomes in pregnant women with COVID-19: an interim analysis

The coronavirus disease (COVID-19) has affected the health-care system worldwide. The effect of COVID-19 on obstetric and perinatal outcomes is yet to be completely ascertained. A hospital-based prospective observational study was conducted at the Department of Obstetrics & Gynecology, AIIMS Rishikesh from July to December 2020. A total of 60 COVID-positive pregnant women were included. Obstetric and perinatal outcomes were compared with 60 COVID-negative pregnant women. A subgroup comparison was also performed between symptomatic and asymptomatic pregnant women with COVID-19. Majority of COVID-positive pregnant women were asymptomatic (81.7%). Eleven patients were symptomatic, out of which 9 (15%) had mild disease and only 2 (3.3%) had severe pneumonia. There was an increased likelihood of early pregnancy loss (5%), oligohydramnios (21.7%), preterm birth (31.7%), and cesarean section (53.3%). The occurrence of preterm birth was significantly higher in symptomatic women than asymptomatic women (p = .01). Oligohydramnios was significantly more frequent in COVID-positive than COVID-negative pregnant women (p = .048). Preterm birth and cesarean rate were slightly higher in COVID-positive group but the difference was not statistically significant. Other obstetric outcomes were comparable in both groups. The majority of women with COVID-19 infection in pregnancy remain asymptomatic or have mild symptoms. Still, it may lead to maternal death and poor fetal outcomes in form of early pregnancy loss, prematurity, oligohydramnios, intrapartum fetal distress, and increased cesarean rate. Therefore, COVID-19 preventive measures should be strictly implemented and followed.

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND

The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies.

OBJECTIVE

To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic.

METHODS

We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality.

RESULTS

The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda.

CONCLUSIONS

Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development.

COVID-19 and miscarriage: From immunopathological mechanisms to actual clinical evidence

The association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the first half of pregnancy and pregnancy loss is still unknown. Infections by other coronaviruses, such as severe acute respiratory syndrome coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV), appear to increase the risk of miscarriage. The purpose of this study is to assess whether SARS-CoV-2 infection increases the risk of miscarriage. Firstly, a narrative review of the literature on animal and human studies was performed to analyze the immunopathological mechanisms of SARS-CoV-2 infection during preconception and early pregnancy, by which it may increase the risk of miscarriage. Secondly, a systematic review/meta-analysis of studies was conducted to assess the prevalence of miscarriage in COVID-19 patients diagnosed during pregnancy. Meta-analysis of proportions was used to combine data, and pooled proportions were reported. Seventeen case series and observational studies and 10 prevalence meta-analyses were selected for the review. The estimate of the overall miscarriage rate in pregnant women with COVID-19 was 15.3 % (95 % CI 10.94-20.59) and 23.1 (95 % CI 13.17-34.95) using fixed and random effect models, respectively. Based on the data in the current literature, the miscarriage rate (<22 weeks gestation) in women with SARS-CoV-2 infection is in the range of normal population. Well-designed studies are urgently needed to determine whether SARS-CoV-2 infection increases the risk of miscarriage during periconception and early pregnancy.

Preliminary Results from the FOGSI's National Registry on Pregnancy with COVID-19

Background/purpose of the study

The obstetric population is believed to be more susceptible to adverse consequences of coronavirus disease COVID-19 as compared to the general populace. Clinical characteristics and outcomes data related to COVID-19 infection in obstetric cases are limited and evolving. Most importantly, studies reporting Indian data are strikingly few and of single centre. The objective of our study was thus to address these lacunae using data registered in the FOGSI’s National registry on COVID-19 infection in pregnancy (FOGSI COVID registry).

Methods

We conducted an observational study using data retrieved from the FOGSI COVID registry. Fifty-three hospital departments participating in the registry populated data related to laboratory confirmed and hospitalized COVID-19 obstetric patients. Data for the period of 28 April 2020 to 28 August 2020 were extracted from the registry. A subset of the data was formatted, curated, standardized and harmonized. Descriptive analysis was carried out, and results reported.

Results

Of the 989 cases analyzed, 956 women were pregnant and 33 women were in the postpartum period. A total of 569 women (61.71%, n = 922) were multi-gravida, and 713 women (72.98%, n = 977) belonged to the 21–30 years age group. A total of 492 cases (52.73%, n = 966) had a gestational age > 37 weeks. A total of 754 women (83.41%, n = 904) were asymptomatic, and 32 cases (3.54%, n = 904) had severe acute respiratory infection (SARI). Fifty-six women (7.19%, n = 779) required critical care and ten women (1.01%, n = 989) died. A total of 771 pregnant women (97.23%, n = 793) gave birth of which 455 cases (59.01%) underwent a lower segment caesarean section (LSCS). There were 749 cases (95.17%, n = 771) of live birth that included eight cases of twin deliveries. 195 infants (28.34%, n = 688) were admitted to the NICU, and 13 infants (2.99%, n = 435) tested COVID-19 positive in the neonatal period. Twelve infants (1.54%, n = 779) died.

Conclusion

83.41% pregnant women were asymptomatic. COVID-19 infection in obstetric cases from India led to 59.01% LSCS procedures which are lower than many other countries. COVID-19 infection led to a higher maternal mortality and IUFD rate as compared to pregnant women that did not have COVID-19 infection in India. Vertical transmission rate is 2.99% and at par with other countries.

Is the Immunization of Pregnant Women against COVID-19 Justified?

Maternal immunization against some infectious diseases can offer significant advantages for women, preventing maternal morbidity and mortality, or for offspring, preventing fetal disease and conferring passive immunity to neonates. Recently, clinical trials specifically to evaluate the immunogenicity, safety, and tolerability of some of the available coronavirus disease 2019 (COVID-19) vaccines in pregnant and lactating women have been planned, initiated and, in some cases, completed. This paper discusses whether the immunization of pregnant women against COVID-19 is justified and presents knowledge about the immunogenicity and safety of mRNA COVID-19 vaccines for these subjects. The results of recent studies indicate that pregnant women are at increased risk of developing severe disease compared with nonpregnant women of the same age. Studies carried out with mRNA vaccines indicate that the immunogenicity, safety and tolerability of these preventive measures in pregnant women are not different from those in nonpregnant women of the same age. Moreover, antibodies are efficiently transferred through the placenta and can be detected in breastmilk, suggesting a potential prevention of infection in the child. All these findings authorize the use of mRNA vaccines in pregnant women to protect both the mother and the child. However, further studies with larger sample size and with follow-up of the pregnant women vaccinated during different periods of pregnancy and their children are needed to better characterize the immune response of pregnant women, to define when these vaccines should be administered to obtain the best protection, and to measure vaccine efficacy against virus variants in both mothers and infants. COVID-19 vaccines based on different technological platforms cannot presently be used, and their role in pregnant women should be clarified.

Death from COVID-19 in a Hispanic postpartum woman and review of the literature

There is still much we do not know about the impact of COVID-19 on the health of pregnant and postpartum women and pregnancy outcomes. Current evidence suggests that there is biological plausibility for worse outcomes among this population. This case report details the clinical care given to a postpartum Hispanic and obese woman diagnosed with COVID-19 in April 2020. We report the care she and her newborn received and her progression through the virus. We discuss the current knowledge surrounding COVID-19 among pregnant and postpartum women. While research supports COVID-19 outcomes being comparable to the general population, there is limited research in this area. Clinical trials, acting on the side of caution, have tended to exclude pregnant women from participation. Therefore, there is a need for further research that can inform evidence-based policy decisions related to COVID-19 in pregnant and postpartum women.

SARS-CoV-2 infection during pregnancy and pregnancy-related conditions: Concerns, challenges, management and mitigation strategies-a narrative review

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health problem. The SARS-CoV-2 triggers hyper-activation of inflammatory and immune responses resulting in cytokine storm and increased inflammatory responses on several organs like lungs, kidneys, intestine, and placenta. Although SARS-CoV-2 affects individuals of all age groups and physiological statuses, immune-compromised individuals such as pregnant women are considered as a highly vulnerable group. This review aims to raise the concerns of high risk of infection, morbidity and mortality of COVID-19 in pregnant women and provides critical reviews of pathophysiology and pathobiology of how SARS-CoV-2 infection potentially increases the severity and fatality during pregnancy. This article also provides a discussion of current evidence on vertical transmission of SARS-CoV-2 during pregnancy and breastfeeding. Lastly, guidelines on management, treatment, preventive, and mitigation strategies of SARS-CoV-2 infection during pregnancy and pregnancy-related conditions such as delivery and breastfeeding are discussed.

Pregnancy Outcomes With COVID-19 Lessons Learned From the Pandemic

Background Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) that causes Coronavirus disease has caused one of the most damaging pandemics in the recorded human history. Objective To assess pregnancy outcomes with COVID-19 lessons learned from the pandemic. Study design This retrospective observational study was conducted at Teerthanker Mahaveer Medical College and Research Centre, Moradabad, a level 3 COVID hospital in Northern India, with a patient pool of all the antenatal females diagnosed COVID 19 positive via a positive quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) test of maternal pharyngeal and nasal swab samples in the given time period of three months and ten days, i.e., May 25, 2020 to September 3, 2020. In conjunction with maternal outcomes, neonatal outcomes including evidence of perinatal transmission of SARS-CoV-2 was assessed by testing neonatal pharyngeal swab samples. Results Out of 100 COVID-19 positive patients, the average age of women was 26.2 years, 73 women (73%) were asymptomatic, and 50 patients (50%) women had associated co-morbidities such as anaemia in 38 (38%) women, gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH) in four patients (4%) each, respectively. No case of spontaneous abortion in early gestation was reported. Out of 100 patients, 32 (32%) patients delivered during their stay, out of which 17 women (53.1%) delivered via cesarean section which was performed mainly due to obstetric indications. One maternal death was reported due to antepartum eclampsia which was unrelated to COVID-19 complications. Five neonates were born prematurely, out of which three were delivered followed by spontaneous premature preterm rupture of membranes (PPROM). The Appearance Pulse Grimace Activity Respiration (APGAR) score was recorded to be ≥9 at the five minutes mark in 28 out of 30 live babies (93.3%) and the birth weight of the babies ranged from 1.8 to 3.5 kg) with an average birth weight of 2.71 kg. Two neonatal deaths were reported due to respiratory distress. There were two documented intrauterine demise (IUD) cases both due to PIH. Furthermore, all 30 live neonates tested for SARS CoV-2 had negative results. Conclusion The spectrum of Coronavirus infection leans more towards asymptomatic and mild symptomatic clinical presentation. Favourably, the likelihood of spontaneous preterm birth was not escalated in our current study and remained low. The rate of intrauterine fetal demise and neonatal death were less. As none of the neonates tested positive for COVID-19, there is no corroborative proof of vertical perinatal transmission.

A systematic review and meta-analysis of data on pregnant women with confirmed COVID-19: Clinical presentation, and pregnancy and perinatal outcomes based on COVID-19 severity

BACKGROUND

We determined the clinical presentation, risk factors, and pregnancy and perinatal outcomes in pregnant women with confirmed COVID-19 and identified if these are different based on COVID-19 severity.

METHODS

We included all observational studies on pregnant women with confirmed COVID-19 reporting clinical presentation, risk factors, and pregnancy and perinatal outcomes. We included all studies published between Dec/2019-Feb/2021 in Medline, Embase, the WHO COVID-19 databases, and clinicaltrials.gov. The methodological quality of cohort and case-series was assessed using NHLBI criteria.

RESULTS

31 016 pregnant women from 62 studies were included. Women were an average of 30.9 years of age, most (77.7%) were in the third trimester, and 16.4% developed severe COVID-19. Nearly half were asymptomatic, while the most commonly reported symptoms were cough, fever, fatigue, and anosmia/ageusia. About 7% were admitted to the intensive care unit (ICU), 8% required mechanical ventilation, and 2% of the women died. Almost 80% of women delivered; 48.4% had cesarean births. Among newborns, 23.4% were preterm (<37 weeks), 16.6% were low birth weight, and 23.7% were admitted to neonatal ICU. A total of 21 stillbirths (1.6%) and 24 neonatal deaths (1.6%) were recorded, while 50 babies (3.5%) were COVID-19 positive. Studies comparing pregnant women with severe and non-severe COVID-19 showed that women with severe COVID-19 were 3.7 years older and the risk of severe COVID-19 was 1.5 times higher among women >35 years. The risk of severe COVID-19 was significantly higher among women who were obese, had smoked, diabetic, and had pre-eclampsia. The risk of preterm birth was almost 2.4 folds among women with severe COVID-19.

CONCLUSIONS

Our review suggests a heightened risk of COVID-19 severity and adverse pregnancy and perinatal outcomes among women with certain demographic and health profiles. These findings can inform the formation of current guidelines; however, these should be constantly updated as the global COVID-19 scenario unfolds.

REGISTRATION

PROSPERO: CRD42020182048.

COVID-19 positivity associated with traumatic stress response to childbirth and no visitors and infant separation in the hospital

As the novel coronavirus (COVID-19) has spread globally, a significant portion of pregnant and delivering women were infected with COVID-19. While emerging studies examined birth outcomes in COVID-19 positive women, knowledge of the psychological experience of childbirth and maternal wellness remains lacking. This matched-control survey-based study included a sample of women recruited during the first wave of the pandemic in the US who gave birth in the previous six months. Women reporting confirmed/suspected COVID-19 (n = 68) during pregnancy or childbirth were matched on background factors with women reporting COVID-19 negativity (n = 2,276). We found nearly 50% of COVID positive women endorsed acute traumatic stress symptoms at a clinical level in response to childbirth. This group was more than twice as likely to endorse acute stress and to have no visitors during maternity hospitalization than COVID negative women; they were also less likely to room-in with newborns. The COVID positive group reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Our findings suggest COVID-19 affected populations are at increased risk for traumatic childbirth and associated risk for psychiatric morbidity. Attention to delivering women's wellbeing is warranted during the pandemic.

One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19

Obstetric guidelines have rapidly evolved to incorporate new data and research on the novel coronavirus disease (COVID-19), with data on perinatal mental health building over the last year. Our aim in the present manuscript is to provide a systematic review of mental health outcomes in pregnant and postpartum women during the COVID-19 pandemic in the context of neonatal and obstetric guidelines addressing symptoms and complications of COVID-19 during pregnancy, mother-to-neonate transmission, Cesarean-section delivery, neonatal prematurity, maternal/neonate mortalities, maternal-neonatal separation, and breastfeeding. We summarize data from 81 mental health studies of pregnant and postpartum women and underscore protective and risk factors identified for perinatal mental health outcomes amidst the COVID-19 pandemic. Data reviewed here suggest increased psychological symptoms, especially depressive and anxiety symptoms, in pregnant and postpartum women during COVID-19. Our systematic review integrates the most current obstetric and neonate guidelines, along with perinatal mental health outcomes associated with COVID-19, highlighting the best available data for the care of women and their neonates amidst the current COVID-19 pandemic.

Incidence de la COVID-19 sur les issues de grossesse: examen systématique et méta-analyse

Contexte:

La nature exacte des répercussions de la maladie à coronavirus 2019 (COVID-19) sur la santé maternelle et néonatale reste à préciser. Nous avons cherché à évaluer l’association entre l’infection par le coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) pendant la grossesse et les issues défavorables de la grossesse.

MÉTHODES:

Nous avons réalisé une revue systématique et une méta-analyse d’études observationnelles fournissant des données comparatives sur l’infection par le SRAS-CoV-2 et la gravité de la COVID-19 pendant la grossesse. Nous avons sélectionné les études admissibles à partir des bases de données MEDLINE, Embase, ClinicalTrials.gov , medRxiv et Cochrane au 29 janvier 2021, en utilisant les Medical Subject Headings (vedettes matière en médecine) et les expressions clés « severe acute respiratory syndrome coronavirus 2 OR SARS-CoV-2 OR coronavirus disease 2019 OR COVID-19 » (coronavirus du syndrome respiratoire aigu sévère 2 ou SRAS-CoV-2 ou maladie à coronavirus 2019 ou COVID-19) AND « pregnancy » (grossesse). Nous avons ensuite évalué la qualité méthodologique de toutes les études retenues avec l’échelle de Newcastle–Ottawa. Les issues primaires étaient la prééclampsie et la naissance prématurée. Les issues secondaires incluaient la mortinaissance et le diabète gestationnel, ainsi que d’autres issues de grossesse. Nous avons calculé des rapports de cotes (RC) sommaires ou des différences moyennes pondérées avec des intervalles de confiance (IC) à 95 % par méta-analyse à effets aléatoires.

RÉSULTATS:

Nous avons retenu 42 études portant sur 438 548 personnes enceintes. Comparativement à une absence d’infection par le SRAS-CoV-2 pendant la grossesse, le diagnostic de COVID-19 a été associé à la prééclampsie (RC 1,33; IC à 95 % 1,03–1,73), à la naissance prématurée (RC 1,82; IC à 95 % 1,38–2,39) et à la mortinaissance (RC 2,11; IC à 95 % 1,14–3,90). Par rapport à la COVID-19 légère, la COVID-19 grave était fortement associée à la prééclampsie (RC 4,16; IC à 95 % 1,55–11,15), à la naissance prématurée (RC 4,29; IC à 95 % 2,41–7,63), au diabète gestationnel (RC 1,99; IC à 95 % 1,09–3,64) et au faible poids à la naissance (RC 1,89; IC à 95 % 1,14–3,12).

INTERPRÉTATION:

La COVID-19 pourrait être associée à un risque accru de prééclampsie, de naissance prématurée et d’autres issues défavorables de la grossesse.

A snapshot of the prevalence of endocrine disorders in pregnancies complicated by coronavirus disease 2019: A narrative review with meta-analysis

Background

Some maternal characteristics indicate worse prognosis in pregnant women with coronavirus disease 2019 (COVID‐19).

Objective

To describe the prevalence of endocrine disorders in pregnancies involving COVID‐19, and its impact on maternal outcomes.

Search strategy

Search terms were “pregnancy” and “COVID‐19”.

Selection

PubMed, Embase, medRxiv, and Cochrane worksheet from February to July 2020 were searched.

Data collection and analysis

Articles describing endocrine disorders in pregnancies with and without COVID‐19 involvement were considered. We performed meta‐analyses of prevalence using random‐effect models and estimated relative risk and 95% confidence intervals (CI) of maternal outcomes relative to presence of endocrine disorders.

Main results

Articles included (n = 141) were divided into three data sets: individual (119 articles, 356 women), case series (17 articles, 1064 women), and national registries (7 articles, 10 178 women). Prevalence of obesity ranged from 16% to 46% and hyperglycemia in pregnancy (HIP) ranged from 8% to 12%. In data set 1, HIP and obesity were risk factors for severe disease in crude and age‐adjusted models, although not for intensive care unit admission. In data from two national registries, risk of dying was 5.62 (95% CI 0.30–105.95) in women with diabetes and 2.26 (95% CI 1.03–4.96) in those with obesity.

Conclusion

Obesity and HIP were prevalent in pregnant women with severe COVID‐19.

In pregnant women with COVID‐19, obesity and hyperglycemia were prevalent and associated with adverse maternal outcomes.

Maternal death related to COVID-19: A systematic review and meta-analysis focused on maternal co-morbidities and clinical characteristics

Background

Besides reducing the quality of obstetric care, the direct impact of COVID‐19 on pregnancy and postpartum is uncertain.

Objective

To evaluate the characteristics of pregnant women who died due to COVID‐19.

Search strategy

Cochrane Library, Embase, MEDLINE, Scopus, and Google Scholar were searched from inception to February 2021.

Selection criteria

Studies that compared deceased and survived pregnant women with COVID‐19.

Data collection and analysis

Relevant data were extracted and tabulated. The primary outcome was maternal co‐morbidity.

Main results

Thirteen studies with 154 deceased patients were included. Obesity doubled the risk of death (relative risk [RR] 2.48, 95% confidence interval [CI] 1.41–4.36, I² = 0%). No differences were found for gestational diabetes (RR 5.71; 95% CI 0.77–42.44, I² = 94%) or asthma (RR 2.05, 95% CI 0.81–5.15, I² = 0%). Overall, at least one severe co‐morbidity showed a twofold increased risk of death (RR 2.26, 95% CI 1.77–2.89, I² = 76%). Admission to intensive care was related to a fivefold increased risk of death (RR 5.09, 95% CI 2.00–12.98, I² = 56%), with no difference in need for respiratory support (RR 0.53, 95% CI 0.23–1.48, I² = 95%) or mechanical ventilation (RR 4.34, 95% CI 0.96–19.60, I² = 58%).

Conclusion

COVID‐19 with at least one co‐morbidity increases risk of intensive care and mortality.

Pregnant women with COVID‐19 infection and at least one severe co‐morbidity experience increased risk of death and admission to the intensive care unit.

Clinical characteristics, outcomes, & mortality in pregnant women with COVID-19 in Maharashtra, India: Results from PregCovid registry

Background & objectives

The PregCovid registry was established to document the clinical presentations, pregnancy outcomes and mortality of pregnant and post-partum women with COVID-19.

Methods

The PregCovid registry prospectively collects information in near-real time on pregnant and post-partum women with a laboratory-confirmed diagnosis of SARS-CoV-2 from 19 medical colleges across the State of Maharashtra, India. Data of 4203 pregnant women collected during the first wave of the COVID-19 pandemic (March 2020-January 2021) was analyzed.

Results

There were 3213 live births, 77 miscarriages and 834 undelivered pregnancies. The proportion of pregnancy/foetal loss including stillbirths was six per cent. Five hundred and thirty-four women (13%) were symptomatic, of which 382 (72%) had mild, 112 (21%) had moderate, and 40 (7.5%) had severe disease. The most common complication was preterm delivery (528, 16.3%) and hypertensive disorders in pregnancy (328, 10.1%). A total of 158 (3.8%) pregnant and post-partum women required intensive care, of which 152 (96%) were due to COVID-19 related complications. The overall case fatality rate (CFR) in pregnant and post-partum women with COVID-19 was 0.8 per cent (34/4203). Higher CFR was observed in Pune (9/853, 1.1%), Marathwada (4/351, 1.1%) regions as compared to Vidarbha (9/1155, 0.8%), Mumbai Metropolitan (11/1684, 0.7%), and Khandesh (1/160, 0.6%) regions. Comorbidities of anaemia, tuberculosis and diabetes mellitus were associated with maternal deaths.

Interpretation & conclusions

The study demonstrates the adverse outcomes including severe COVID-19 disease, pregnancy loss and maternal death in women with COVID-19 in Maharashtra, India.

The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis

BACKGROUND

The impact of coronavirus disease 2019 (COVID-19) on maternal and newborn health is unclear. We aimed to evaluate the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and adverse pregnancy outcomes.

METHODS

We conducted a systematic review and meta-analysis of observational studies with comparison data on SARS-CoV-2 infection and severity of COVID-19 during pregnancy. We searched for eligible studies in MEDLINE, Embase, ClinicalTrials.gov, medRxiv and Cochrane databases up to Jan. 29, 2021, using Medical Subject Headings terms and keywords for "severe acute respiratory syndrome coronavirus 2 OR SARS-CoV-2 OR coronavirus disease 2019 OR COVID-19" AND "pregnancy." We evaluated the methodologic quality of all included studies using the Newcastle-Ottawa Scale. Our primary outcomes were preeclampsia and preterm birth. Secondary outcomes included stillbirth, gestational diabetes and other pregnancy outcomes. We calculated summary odds ratios (ORs) or weighted mean differences with 95% confidence intervals (CI) using random-effects meta-analysis.

RESULTS

We included 42 studies involving 438 548 people who were pregnant. Compared with no SARS-CoV-2 infection in pregnancy, COVID-19 was associated with preeclampsia (OR 1.33, 95% CI 1.03 to 1.73), preterm birth (OR 1.82, 95% CI 1.38 to 2.39) and stillbirth (OR 2.11, 95% CI 1.14 to 3.90). Compared with mild COVID-19, severe COVID-19 was strongly associated with preeclampsia (OR 4.16, 95% CI 1.55 to 11.15), preterm birth (OR 4.29, 95% CI 2.41 to 7.63), gestational diabetes (OR 1.99, 95% CI 1.09 to 3.64) and low birth weight (OR 1.89, 95% CI 1.14 to 3.12).

INTERPRETATION

COVID-19 may be associated with increased risks of preeclampsia, preterm birth and other adverse pregnancy outcomes.

Adverse Pregnancy Outcomes Among Individuals With and Without Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Systematic Review and Meta-analysis

Individuals with and without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had similar rates of intrauterine fetal death, neonatal death, and Apgar score less than 7 at 5 minutes.

To compare the risk of intrauterine fetal death (20 weeks of gestation or later) and neonatal death among individuals who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared with those who tested negative for SARS-CoV-2 on admission for delivery.

A Translational Perspective of Maternal Immune Activation by SARS-CoV-2 on the Potential Prenatal Origin of Neurodevelopmental Disorders: The Role of the Cholinergic Anti-inflammatory Pathway

The emergent Coronavirus Disease 2019 (COVID-19) caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) could produce a maternal immune activation (MIA) via the inflammatory response during gestation that may impair fetal neurodevelopment and lead to postnatal and adulthood mental illness and behavioral dysfunctions. However, so far, limited evidence exists regarding long-term physiological, immunological, and neurodevelopmental modifications produced by the SARS-CoV-2 in the human maternal-fetal binomial and, particularly, in the offspring. Relevant findings derived from epidemiological and preclinical models show that a MIA is indeed linked to an increased risk of neurodevelopmental disorders in the offspring. We hypothesize that a gestational infection triggered by SARS-CoV-2 increases the risks leading to neurodevelopmental disorders of the newborn, which can affect childhood and the long-term quality of life. In particular, disruption of either the maternal or the fetal cholinergic anti-inflammatory pathway (CAP) could cause or exacerbate the severity of COVID-19 in the maternal-fetal binomial. From a translational perspective, in this paper, we discuss the possible manifestation of a MIA by SARS-CoV-2 and the subsequent neurodevelopmental disorders considering the role of the fetal-maternal cytokine cross-talk and the CAP. Specifically, we highlight the urgent need of preclinical studies as well as multicenter and international databanks of maternal-fetal psychophysiological data obtained pre-, during, and post-infection by SARS-CoV-2 from pregnant women and their offspring.

Current trends and geographical differences in therapeutic profile and outcomes of COVID-19 among pregnant women - a systematic review and meta-analysis

BACKGROUND

Coronavirus disease (COVID-19) has been associated with adverse pregnancy outcomes. Due to the lack of effective treatments for COVID-19, it becomes imperative to assess the geographical differences and trends in the current clinical care and outcomes of COVID-19 in pregnant women.

METHODS

A PubMed search was performed to screen articles reporting therapeutics and outcomes of confirmed COVID-19 in pregnant women prior to August 27, 2020. We performed searches, quality assessments of eligible studies, extracted and reported data according to PRISMA guidelines. Meta-analyses and cumulative meta-analyses of proportions were performed for estimating each outcome and their pattern over time respectively.

RESULTS

One thousand two hundred thirty nine pregnant women with COVID-19 from 66 studies were analyzed. In case series analysis reflecting average-risk patients, the proportion of oxygen support, antibiotics, antivirals, and plasma therapy administration except for hydroxychloroquine was substantially higher in Asian studies (55, 78, 80, 6, and 0%) compared to the US (7, 1, 12, 0, and 7%) or European (33, 12, 14, 1, and 26%) studies, respectively. The highest preterm birth and the average length of hospital stay (35%, 11.9 days) were estimated in Asian studies compared to the US studies (13%, 9.4 days) and European studies (29%, 7.3 days), respectively. Even in case reports reflecting severe cases, the use of antivirals and antibiotics was higher in Asian studies compared to the US, Latin American, and European studies. A significant decline in the use of most therapeutics along with adverse outcomes of COVID-19 in pregnant women was observed.

CONCLUSIONS

Geographical differences in therapeutic practice of COVID-19 were observed with differential rates of maternal and clinical outcomes. Minimizing the use of some therapeutics particularly antibiotics, antivirals, oxygen therapy, immunosuppressants, and hydroxychloroquine by risk stratification and careful consideration may further improve maternal and clinical outcomes.

A Comprehensive Analysis of Maternal and Newborn Disease and Related Control for COVID-19

The maternal-fetal/newborn unit is established at risk for COVID-19 infection. This narrative review summarizes the contemporary and cumulative publications which detail maternal infection, antenatal and newborn infections, and maternal/fetal/newborn management and prevention. There is a wide spectrum of maternal disease, but the potential for severe disease albeit in a minority is confirmed. COVID-19 carries risk for preterm delivery. Pregnant females can suffer multisystem disease, and co-morbidities play a significant role in risk. Congenital infection has been supported by several anecdotal reports, but strong confirmatory data are few. No typical congenital dysmorphisms are evident. Nevertheless, placental vascular compromise must be considered a risk for the fetus during advanced maternal infections. Clinical manifestations of newborn infection have been mild to moderate and relatively uncommon. Proven antiviral therapy is of yet lacking. The mode of delivery is a medical decision that must include patient risk assessment and patient directives. Both presymptomatic and asymptomatic mothers and offspring can complicate infection control management with the potential for spread to others in several regards. In the interim, infections of the maternal-fetal-newborn unit must be taken seriously both for the disease so caused and the potential for further dissemination of disease.

Preterm care during the COVID-19 pandemic: A comparative risk analysis of neonatal deaths averted by kangaroo mother care versus mortality due to SARS-CoV-2 infection

BACKGROUND

COVID-19 is disrupting health services for mothers and newborns, particularly in low- and middle-income countries (LMIC). Preterm newborns are particularly vulnerable. We undertook analyses of the benefits of kangaroo mother care (KMC) on survival among neonates weighing ≤2000 g compared with the risk of SARS-CoV-2 acquired from infected mothers/caregivers.

METHODS

We modelled two scenarios over 12 months. Scenario 1 compared the survival benefits of KMC with universal coverage (99%) and mortality risk due to COVID-19. Scenario 2 estimated incremental deaths from reduced coverage and complete disruption of KMC. Projections were based on the most recent data for 127 LMICs (~90% of global births), with results aggregated into five regions.

FINDINGS

Our worst-case scenario (100% transmission) could result in 1,950 neonatal deaths from COVID-19. Conversely, 125,680 neonatal lives could be saved with universal KMC coverage. Hence, the benefit of KMC is 65-fold higher than the mortality risk of COVID-19. If recent evidence of 10% transmission was applied, the ratio would be 630-fold. We estimated a 50% reduction in KMC coverage could result in 12,570 incremental deaths and full disruption could result in 25,140 incremental deaths, representing a 2·3-4·6% increase in neonatal mortality across the 127 countries.

INTERPRETATION

The survival benefit of KMC far outweighs the small risk of death due to COVID-19. Preterm newborns are at risk, especially in LMICs where the consequences of disruptions are substantial. Policymakers and healthcare professionals need to protect services and ensure clearer messaging to keep mothers and newborns together, even if the mother is SARS-CoV-2-positive.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health & Human Development; Bill & Melinda Gates Foundation; Elma Philanthropies; Wellcome Trust; and Joint Global Health Trials scheme of Department of Health and Social Care, Department for International Development, Medical Research Council, and Wellcome Trust.

Is There an Effect of Fetal Mesenchymal Stem Cells in the Mother-Fetus Dyad in COVID-19 Pregnancies and Vertical Transmission?

Because of the polysystemic nature of coronavirus disease 2019 (COVID-19), during the present pandemic, there have been serious concerns regarding pregnancy, vertical transmission, and intrapartum risk. The majority of pregnant patients with COVID-19 infection present with mild or asymptomatic course of the disease. Some cases were hospitalized, and few needed intensive care unit admission, or mechanical ventilation. There have also been scarce case reports where neonates required mechanical ventilation post COVID-19 pregnancies. Without approved therapies other than dexamethasone, advanced mesenchymal cell therapy is one immunomodulatory therapeutic approach that is currently explored and might hold great promise. We suggest that the circulating fetal stem cells might have an immune-protective effect to mothers and contribute to the often mild and even asymptomatic post-COVID-19 pregnancies. Thus, COVID-19 pregnancies come forth as a paradigm to be further and more comprehensively approached, to understand both the mechanism and action of circulating stem cells in immunoprotection and hypoxia in microcirculation.

Maternal and Neonatal Outcomes of COVID-19 in Pregnancy: A Single-Centre Observational Study

Background: The current coronavirus disease 2019 (COVID-19) pandemic is one of the most challenging healthcare crises faced globally. Adequate information and understanding of the clinical presentation and impact of the disease on maternal and neonatal outcomes is the key to successfully manage a pregnancy with COVID-19.

Objective: The purpose of the present study was to evaluate the clinical presentation of COVID-19 in pregnancy, its course during pregnancy and its effects on maternal and neonatal outcomes.

Study design and setting: This study was a retrospective observational study conducted at Tata Main Hospital, Jamshedpur, a tertiary care hospital in Eastern India.

Population and study period: All COVID-19-positive (by reverse transcription polymerase chain reaction or rapid antigen test) pregnant women admitted to the hospital from 15^th May 2020 to 15^th November 2020. 

Results: A total of 132 COVID-19-positive pregnant women were included in the study. Eighty-six women (65.15%) were asymptomatic, 45 women (34.09%) had mild symptoms and one woman had severe disease. Major co-morbidities seen were hypertensive disorders (pre-eclampsia, gestational hypertension and chronic hypertension) in 18 (13.64%) and diabetes (gestational diabetes, diabetes mellitus type 2) in 14women (10.60%). The rate of preterm delivery was 28.69% (n=35). Caesarean section was done for 78 women (63.93%) and 44 (36.07%) delivered vaginally. Average birth weight reported was 2.59 kilograms. Forty babies (33.06%) were admitted to the neonatal intensive care unit. Two babies (1.65%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 24 hours of delivery. 

Conclusion: COVID-19 in pregnancy commonly presents as an asymptomatic or mild disease. It is associated with high rates of preterm births and neonatal admissions to the intensive care unit. Intrauterine and neonatal death rates remain low. Vertical transmission is possible; however, the incidence is low, and the majority of these neonates are asymptomatic.

COVID-19 in Neonates: A Call for Standardized Testing

The limited evidence on neonatal coronavirus disease (COVID-19) suggests that vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rare, and most neonates seem to acquire the infection postnatally through respiratory droplets and contact. Testing of neonates with perinatal or postnatal exposure to COVID-19 infection plays a vital role in the early diagnosis, management and institution of infection prevention measures thereby cutting off the chain of epidemic transmission. A recently concluded online neonatal COVID-19 conference conducted by the National Neonatology Forum (NNF) of India and a nationwide online survey pointed to substantial variation in neonatal testing strategies. We, herein, summarize the relevant literature about the incidence and outcomes of neonatal COVID-19 and call for a universal and uniform testing strategy for exposed neonates. We anticipate that the testing strategy put forth in this article will facilitate better management and safe infection prevention measures among all units offering neonatal care in the country.

Giving birth under hospital visitor restrictions: Heightened acute stress in childbirth in COVID-19 positive women

As the novel coronavirus (COVID-19) has spread globally, a significant portion of women have undergone childbirth while possibly infected with the virus and also under social isolation due to hospital visitor restrictions. Emerging studies examined birth outcomes in COVID-19 positive women, but knowledge of the psychological experience of childbirth remains lacking. This study survey concerning childbirth and mental health launched during the first wave of the pandemic in the US. Women reporting confirmed/suspected COVID-19 during childbirth were matched on various background factors with women reporting COVID-19 negative. We found higher prevalence of clinically significant acute stress in birth in COVID-19 positive women. This group was 11 times as likely to have no visitors than matched controls and reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Visitor restrictions were associated with these birth outcomes. COVID-19 positive women with no visitors were 6 times as likely to report clinical acute stress in birth than COVID-19 positive women with visitors. The findings underscore increased risk for childbirth-induced psychological morbidity in COVID-19-affected populations. As hospitals continue to revise policies concerning visitor restrictions, attention to the wellbeing of new mothers is warranted.

Giving birth under hospital visitor restrictions: Heightened acute stress in childbirth in COVID-19 positive women

As the novel coronavirus (COVID-19) has spread globally, a significant portion of women have undergone childbirth while possibly infected with the virus and also under social isolation due to hospital visitor restrictions. Emerging studies examined birth outcomes in COVID-19 positive women, but knowledge of the psychological experience of childbirth remains lacking. This study survey concerning childbirth and mental health launched during the first wave of the pandemic in the US. Women reporting confirmed/suspected COVID-19 during childbirth were matched on various background factors with women reporting COVID-19 negative. We found higher prevalence of clinically significant acute stress in birth in COVID-19 positive women. This group was 11 times as likely to have no visitors than matched controls and reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Visitor restrictions were associated with these birth outcomes. COVID-19 positive women with no visitors were 6 times as likely to report clinical acute stress in birth than COVID-19 positive women with visitors. The findings underscore increased risk for childbirth-induced psychological morbidity in COVID-19-affected populations. As hospitals continue to revise policies concerning visitor restrictions, attention to the wellbeing of new mothers is warranted.

COVID-19 in Neonates: A Call for Standardized Testing

The limited evidence on neonatal Coronavirus disease (COVID-19) suggests that vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rare, and most neonates seem to acquire the infection postnatally through respiratory droplets and contact. Testing of neonates with perinatal or postnatal exposure to COVID-19 infection plays a vital role in the early diagnosis, management and institution of infection prevention measures thereby cutting off the chain of epidemic transmission. A recently concluded online neonatal COVID-19 conference conducted by the National Neonatology Forum (NNF) of India and a nationwide online survey pointed to substantial variation in neonatal testing strategies. We, herein, summarize the relevant literature about the incidence and outcomes of neonatal COVID-19 and call for a universal and uniform testing strategy for exposed neonates. We anticipate that the testing strategy put forth in this article will facilitate better management and safe infection prevention measures among all units offering neonatal care in the country.

COVID-19 in pregnancy: the foetal perspective-a systematic review

OBJECTIVE

We aimed to conduct a systematic review of the available literature to determine the effects of confirmed cases of COVID-19 in pregnant women from the foetal perspective by estimation of mother to child transmission, perinatal outcome and possible teratogenicity.

METHODS

Data sources: eligible studies between 1 November 2019 and 10 August 2020 were retrieved from PubMed, Embase, LitCovid, Google Scholar, EBSCO MEDLINE, CENTRAL, CINAHL, MedRXiv, BioRXiv and Scopus collection databases. English language case reports, case series and cohort studies of SARS-CoV-2 confirmed pregnant women with data on perinatal outcome, congenital anomalies and mother to child transmission were analysed.

RESULTS

38 case reports, 34 cohort and case series describing 1408 neonates were included for evidence acquisition of mother to child transmission. 29 case reports and 31 case series and cohort studies describing 1318 foetuses were included for the evaluation of perinatal outcome and congenital anomalies. A pooled proportion of 3.67% neonates had positive SARS-CoV-2 viral RNA nasopharyngeal swab results and 7.1% had positive cord blood samples. 11.7% of the placenta, 6.8% of amniotic fluid, 9.6% of faecal and rectal swabs and none of the urine samples were positive. The rate of preterm labour was 26.4% (OR=1.45, 95% CI 1.03 to 2.03 with p=0.03) and caesarean delivery (CS) was 59.9% (OR=1.54, 95% CI 1.17 to 2.03 with p=0.002). The most common neonatal symptom was breathing difficulty (1.79%). Stillbirth rate was 9.9 per 1000 total births in babies born to COVID-19 mothers.

CONCLUSION

Chances of mother to child transmission of the SARS-CoV-2 virus is low. The perinatal outcome for the foetus is favourable. There is increased chances of CS but not preterm delivery. The stillbirth and neonatal death rates are low. There are no reported congenital anomalies in babies born to SARS CoV-2 positive mothers.

Signing off… As Editor in Chief

I complete my tenure as editor in chief in January 2021, and here I bring to you the last editorial of my tenure. I have enjoyed every moment of this long association with the journal. I have done my best to improve the quality of this journal in terms of readership, citations, visibility, academic recognition, promoting good quality research and publications. Many new changes were brought in during my tenure including the publishing e-book of our journal which has furthered the go green initiative of FOGSI.

COVID-19 coagulopathy in pregnancy: Critical review, preliminary recommendations, and ISTH registry-Communication from the ISTH SSC for Women's Health

BACKGROUND

Novel coronavirus (SARS-CoV-2), which causes COVID-19, has thus far affected more than 15 million individuals, resulting in more than 600 000 deaths worldwide, and the number continues to rise. In a large systematic review and meta-analysis of the literature including 2567 pregnant women, 7% required intensive care admission, with a maternal mortality ~1% and perinatal mortality below 1%. There has been a rapid increase in publications on COVID-19-associated coagulopathy, including disseminated intravascular coagulopathy and venous thromboembolism, in the non-pregnant population, but very few reports of COVID-19 coagulopathy during pregnancy; leaving us with no guidance for care of this specific population.

METHODS

This is a collaborative effort conducted by a group of experts that was reviewed, critiqued, and approved by the International Society on Thrombosis and Haemostasis Subcommittee for Women's Health Issues in Thrombosis and Hemostasis. A structured literature search was conducted, and the quality of current and emerging evidence was evaluated. Based on the published studies in the non-pregnant and pregnant population with a moderate to high risk of bias as assessed by Newcastle-Ottawa scale and acknowledging the absence of data from randomized clinical trials for management of pregnant women infected with SARS-CoV-2, a consensus in support of a guidance document for COVID-19 coagulopathy in pregnancy was identified.

RESULTS AND CONCLUSIONS

Specific hemostatic issues during pregnancy were highlighted, and preliminary recommendations to assist in the care of COVID-19-affected pregnant women with coagulopathy or thrombotic complications were developed. An international registry to gather data to support the management of COVID-19 and associated coagulopathy in pregnancy was established.

Clinical manifestations and perinatal outcomes of pregnant women with COVID-19: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the impact of COVID-19 on pregnant women. We searched for qualified studies in PubMed, Embase, and Web of Science. The clinical characteristics of pregnant women with COVID-19 and their infants were reported as means and proportions with 95% confidence interval. Eleven studies involving with 9032 pregnant women with COVID-19 and 338 infants were included in the meta-analysis. Pregnant women with COVID-19 have relatively mild symptoms. However, abnormal proportions of laboratory parameters were similar or even increased, compared to general population. Around 30% of pregnant women with COVID-19 experienced preterm delivery, whereas the mean birth weight was 2855.9 g. Fetal death and detection of SARS-CoV-2 were observed in about 2%, whereas neonatal death was found to be 0.4%. In conclusion, the current review will serve as an ideal basis for future considerations in the treatment and management of COVID-19 in pregnant women.

Elective Cesarean Section in Obstetric COVID-19 Patients under Spinal Anesthesia: A Prospective Study

BACKGROUND

Managing obstetric emergencies in COVID-19 pandemic is a real challenge as these patients need timely intervention to save the life of the mother and the baby. Hence, to avoid life-threatening challenges, all pregnant patients were electively admitted and tested for COVID-19 near term to anticipate the difficulties and prevent complications.

AIM

Our aim was to assess the impact of COVID-19 infection on maternal morbidity and mortality as well as the effect on the neonate under spinal anesthesia.

SETTINGS AND DESIGN

This was a prospective observational study.

MATERIALS AND METHODS

One hundred and fifteen COVID-19-positive pregnant patients in the age group of 20-40 years from July 2020 to December 2020 were electively taken for cesarean section under spinal anesthesia. Patients who needed emergency cesarean delivery were excluded from the study. Emergency cesarean delivery was avoided to reduce the risk of aerosol generation under general anesthesia as endotracheal intubation of COVID-19 patients poses a significant risk of viral exposure to doctors and staff. Written informed consent was obtained from all patients. Spinal anesthesia was given at L4-L5 intervertebral space. Demographic parameters, anesthetic and surgical parameters, and neonatal parameters were observed. Any inadvertent event was noted.

STATISTICAL ANALYSIS

Data were expressed as mean, median, percentage, or number.

RESULTS

All pregnancies were singleton. None of the patients was converted to general anesthesia. One hundred and ten were either mildly symptomatic or asymptomatic. Five of our patients had severe symptoms and needed intensive care unit care preoperatively and postoperatively. Seven patients developed spinal hypotension and were managed by vasopressors. No significant thrombocytopenia was noted in any of our patients. None of our patients developed symptomatic thromboembolism. Vertical transmission was not reported in any of the cases. All babies were born with weight >2500 g and good APGAR score.

CONCLUSION

Spinal anesthesia for LSCS is safe and effective for obstetric anesthesia in COVID-19 both for the parturient and the newborn.

Recommendations for prenatal, intrapartum, and postpartum care during COVID-19 pandemic in India

The pandemic of coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 19.7 million persons worldwide with 7 28 013 deaths till August 10, 2020. It has put an unprecedented workload on healthcare systems with special reference to labor rooms and obstetrics as deliveries cannot be stopped or postponed. Preparing their facilities using triage (COVID-positive patients, COVID-suspect patients, and COVID-negative patients) can help to better utilize the limited resources and help in prevention of spread of disease, and improve maternal and perinatal outcome. There is a need for proper training of healthcare providers for judicious use of personal protective equipment (PPE) for optimum outcome. Fortunately, the available literature suggests that there is no substantial increased risk of acquiring COVID-19 in pregnancy or its increased virulence in pregnancy and labor and there are no adverse effects on fetus and neonate with negligible fetal transmission rate. Nevertheless, utmost care is needed to manage such pregnancies, their prenatal care, and labor. This review aimed to highlight the main recommendations applied in Indian maternities for better management of pregnancy during the COVID-19 pandemic.

Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis

OBJECTIVE

To determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19).

DESIGN

Living systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 6 October 2020, along with preprint servers, social media, and reference lists.

STUDY SELECTION

Cohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19.

DATA EXTRACTION

At least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios and proportions with 95% confidence intervals. All analyses will be updated regularly.

RESULTS

192 studies were included. Overall, 10% (95% confidence interval 7% to 12%; 73 studies, 67 271 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever (40%) and cough (41%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to have symptoms (odds ratio 0.28, 95% confidence interval 0.13 to 0.62; I2=42.9%) or report symptoms of fever (0.49, 0.38 to 0.63; I2=40.8%), dyspnoea (0.76, 0.67 to 0.85; I2=4.4%) and myalgia (0.53, 0.36 to 0.78; I2=59.4%). The odds of admission to an intensive care unit (odds ratio 2.13, 1.53 to 2.95; I2=71.2%), invasive ventilation (2.59, 2.28 to 2.94; I2=0%) and need for extra corporeal membrane oxygenation (2.02, 1.22 to 3.34; I2=0%) were higher in pregnant and recently pregnant than non-pregnant reproductive aged women. Overall, 339 pregnant women (0.02%, 59 studies, 41 664 women) with confirmed covid-19 died from any cause. Increased maternal age (odds ratio 1.83, 1.27 to 2.63; I2=43.4%), high body mass index (2.37, 1.83 to 3.07; I2=0%), any pre-existing maternal comorbidity (1.81, 1.49 to 2.20; I2=0%), chronic hypertension (2.0, 1.14 to 3.48; I2=0%), pre-existing diabetes (2.12, 1.62 to 2.78; I2=0%), and pre-eclampsia (4.21, 1.27 to 14.0; I2=0%) were associated with severe covid-19 in pregnancy. In pregnant women with covid-19, increased maternal age, high body mass index, non-white ethnicity, any pre-existing maternal comorbidity including chronic hypertension and diabetes, and pre-eclampsia were associated with serious complications such as admission to an intensive care unit, invasive ventilation and maternal death. Compared to pregnant women without covid-19, those with the disease had increased odds of maternal death (odds ratio 2.85, 1.08 to 7.52; I2=0%), of needing admission to the intensive care unit (18.58, 7.53 to 45.82; I2=0%), and of preterm birth (1.47, 1.14 to 1.91; I2=18.6%). The odds of admission to the neonatal intensive care unit (4.89, 1.87 to 12.81, I2=96.2%) were higher in babies born to mothers with covid-19 versus those without covid-19.

CONCLUSION

Pregnant and recently pregnant women with covid-19 attending or admitted to the hospitals for any reason are less likely to manifest symptoms such as fever, dyspnoea, and myalgia, and are more likely to be admitted to the intensive care unit or needing invasive ventilation than non-pregnant women of reproductive age. Pre-existing comorbidities, non-white ethnicity, chronic hypertension, pre-existing diabetes, high maternal age, and high body mass index are risk factors for severe covid-19 in pregnancy. Pregnant women with covid-19 versus without covid-19 are more likely to deliver preterm and could have an increased risk of maternal death and of being admitted to the intensive care unit. Their babies are more likely to be admitted to the neonatal unit.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178076.

READERS' NOTE

This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 1 of the original article published on 1 September 2020 (BMJ 2020;370:m3320), and previous updates can be found as data supplements (https://www.bmj.com/content/370/bmj.m3320/related#datasupp). When citing this paper please consider adding the update number and date of access for clarity.