Universal testing of patients and their support persons for severe acute respiratory syndrome coronavirus 2 when presenting for admission to labor and delivery at Mount Sinai Health System

Universal Testing Policy for COVID-19 in Pregnancy: A Systematic Review

Background

The coronavirus disease (COVID-19) has spread at an accelerated rate. WHO reported that in the general population, the majority are either asymptomatic or mildly infected. In view of the high risk of SARS-CoV-2 transmission from a pregnant woman to her newborn, healthcare workers and other patients, it is a raised concern whether universal testing should be implemented in this targeted population. The current guidelines have not recommended a universal testing policy. In certain European countries, however, the policy was implemented by some hospitals in regions with high prevalence of COVID-19 infection.

Aim(s)

To assess the justification for universal screening of pregnant women for COVID-19 prior to admission in labor through systematic review of antenatal prevalence of asymptomatic infection, hence risk of inadvertent spread of infection.

Materials and Methods

Three databases confined to PubMed, Ovid and Science Direct were used to search for articles from November 2019 onwards published in the English language. The search was conducted using the keywords “COVID-19” or “coronavirus” or “SARS-CoV-2” and “pregnancy” or “pregnant” or “obstetric” or “labor” and “universal” or “testing” or “prevalence”. The review was registered with PROSPERO.

Results

The search result retrieved 34 studies, with the majority consisting of retrospective cohort studies, while other studies such as prospective cohort study, research letters and a case series were also identified. A total of 19,958 pregnant women were universally tested until the date of report. Overall, the prevalence of universal testing among pregnant women presenting to labor and delivery units are higher in Western regions. From the total number of pregnant women 5.3% tested positive and among these, the majority (75.5%) did not manifest any symptoms at the time of testing.

Conclusion

In areas with high prevalence of COVID-19 infection, the implementation of a universal testing policy among pregnant women presenting to labor and admission units may be cost effective in helping to curb disease transmission.

Systematic Trial Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020184248, PROSPERO: CRD42020184248.

The Epidemiology of COVID-19 in Pregnancy

As of November, 2021 there have been more than 250 million coronavirus disease-2019 (COVID-19) cases worldwide and more than 5 million deaths. Obstetric patients have been a population of interest given that they may be at risk of more severe infection and adverse pregnancy outcomes. The purpose of this review is to assess current epidemiology and outcomes research related to COVID-19 for the obstetric population. This review covers the epidemiology of COVID-19, symptomatology, transmission, and current knowledge gaps related to outcomes for the obstetric population.

Evaluating the Immediate Response of Country-Wide Health Systems to the Covid-19 Pandemic: Applying the Gray Incidence Analysis Model

The purpose of the study is to evaluate county-wide health systems using the data set of the first wave of the COVID-19 pandemic. The overall design of study comprises a literature review, secondary data, and a mathematical analysis. It is a cross-sectional quantitative study following a deductive approach. It uses the data of the first wave of the COVID-19 pandemic taken from the website of Worldometer as of April 8, 2020. The study uses a gray incidence analysis model (commonly known as Gray Relational Analysis, i.e., GRA) as its research methodology. On the basis of the results of GRA, a classification has been made under a predetermined scheme of ensigns: much better, better, somewhat better, fair, poor, somewhat worse, and worse health systems. There are a total 211 countries that have been divided into the seven aforementioned categories. Findings of the study show that Southern Africa Development Community (SADC) countries fall predominantly under the much better ensign, whereas Organization for Economic Co-operation and Development (OECD), Schengen Area (SA), and/or European Union (EU) countries fall under the worse ensign. Pakistan falls under the ensign of poor. It is an original attempt to evaluate the response of health systems based on real data using a scientific methodology. The study provides valuable information about the health systems of the countries for forming an informed opinion about the health systems herein. The study provides useful new information for stakeholders and a new framework for future research.

Management of maternal COVID-19: considerations for anesthesiologists

PURPOSE OF REVIEW

To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19.

RECENT FINDINGS

Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates.

SUMMARY

Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.

Coronavirus Disease 2019 in Pregnancy and Outcomes Among Pregnant Women and Neonates: A Literature Review

Limited data are available about the outcomes of coronavirus disease 2019 (COVID-19) during pregnancy and risk of vertical transmission in exposed neonates. We reviewed studies published February 1, 2020, through August 15, 2020, on outcomes in pregnant women with COVID-19 and neonates with perinatal exposure. Among pregnant women with COVID-19, 181 (11%) required intensive care unit admission and 123 (8%) required mechanical ventilation. There were 22 maternal deaths. Most infections occurred in the third trimester. Among women who delivered, 28% had a preterm birth, and 57% had a Caesarean section. Sixty-one (4%) of 1222 neonates with reported testing had at least 1 positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test. The most common symptom among neonates was respiratory distress (n = 126; 21%). There were 14 neonatal deaths, one of which occurred in a neonate with positive testing. Further study of COVID-19 in pregnant women and neonates, including standardized reporting of outcomes, testing and treatment protocols, is essential to optimize maternal and neonatal care.

Samba II PCR testing for COVID-19 in pregnant women: a retrospective cohort study and literature review

BACKGROUND

Asymptomatic carriage of COVID-19 in pregnant women has been reported and could lead to outbreaks in maternity units. We sought to ascertain the impact of rapid isothernal nucleic acid based testing for COVID-19 in an unselected cohort of pregnant women attending our maternity unit. We also assessed the correlation between community prevalence and asymptomatic carriage.

METHODS

Data for the retrospective cohort study were collected from a large UK tertiary maternity unit over a 4-week period using computerised hospital records. Literature searches were performed across multiple repositories. COVID-19 prevalence was extracted from online repositories.

RESULTS

Nasopharyngeal and oropharyngeal swabs were obtained from 457/465 (98%) women during the study period. The median turnaround time for results was 5.3 h (interquartile range (IQR) 2.6-8.9 h), with 92% of the results returned within 24 h. In our cohort, only one woman tested positive, giving a screen positive rate of 0.22% (1/457; 95% CI: 0.04-1.23%). One woman who tested negative developed a fever postnatally following discharge but was lost to follow-up. From our literature review, we did not find any correlation between asymptomatic carriage in pregnant women and the reported regional prevalence of COVID-19.

CONCLUSIONS

Testing using the SAMBA-II machine was acceptable to the vast majority of pregnant women requiring admission and had a low turnaround time. Asymptomatic carriage is low, but not correlated to community prevalence rates. Screening pregnant women on admission will remain an important component in order to minimise nosocomial infection.

The Psychological Experience of Obstetric Patients and Health Care Workers after Implementation of Universal SARS-CoV-2 Testing

OBJECTIVE

This study was aimed to describe the hospitalization and early postpartum psychological experience for asymptomatic obstetric patients tested for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) as part of a universal testing program and report the impact of this program on labor and delivery health care workers' job satisfaction and workplace anxiety.

STUDY DESIGN

This is a cohort study of asymptomatic pregnant women who underwent SARS-CoV-2 testing between April 13, 2020 and April 26, 2020. Semistructured interviews were conducted via telephone at 1 and 2 weeks posthospitalization to assess maternal mental health. Depression screening was conducted using the patient health questionnaire-2 (PHQ-2). An online survey of labor and delivery health care workers assessed job satisfaction and job-related anxiety before and during the novel coronavirus disease 2019 (COVID-19) pandemic, as well as employees' subjective experience with universal testing. Patient and employee responses were analyzed for recurring themes.

RESULTS

A total of 318 asymptomatic women underwent SARS-CoV-2 testing during this 2-week period. Six of the eight women (75%) who tested positive reported negative in-hospital experiences secondary to perceived lack of provider and partner support and neonatal separation after birth. Among the 310 women who tested negative, 34.4% of multiparous women reported increased postpartum anxiety compared with their prior deliveries due to concerns about infectious exposure in the hospital and lack of social support. Only 27.6% of women, tested negative, found their test result to be reassuring. Job satisfaction and job-related anxiety among health care workers were negatively affected. Universal testing was viewed favorably by the majority of health care workers despite concerns about delays or alterations in patient care and maternal and neonatal separation.

CONCLUSION

Universal testing for SARS-CoV-2 in obstetric units has mixed effects on maternal mental health but is viewed favorably by labor and delivery employees. Ongoing evaluation of new testing protocols is paramount to balance staff and patient safety with quality and equality of care.

KEY POINTS

· Women with SARS-CoV-2 had a negative hospital experience.. · A negative SARS-CoV-2 test was not reassuring for patients.. · COVID-19 negatively impacts healthcare workers' well-being..

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.

Outcomes of universal SARS-CoV-2 testing program in pregnant women admitted to hospital and the adjuvant role of lung ultrasound in screening: a prospective cohort study

BACKGROUND

The emerging evidence for the asymptomatic carriers of SARS-CoV-2 infection emphasized the critical need for universal screening of pregnant women.

OBJECTIVES

This study aimed to present the prevalence of overall and asymptomatic SARS-CoV-2 infection rates in pregnant women admitted to the hospital, and assess the diagnostic accuracy of maternal symptoms and lung ultrasound (LUS) findings in detecting the infection.

PATIENTS AND METHODS

This prospective cohort study was conducted at a single tertiary center in Istanbul, Turkey, for a month period starting from 27 April 2020. Women with a confirmed pregnancy regardless of the gestational week admitted to the obstetric unit with any indication were consecutively underwent LUS and PCR testing for SARS-CoV-2.

RESULTS

A total of 296 patients were included for the final analysis. The universal screening strategy diagnosed 23 pregnant women (7.77%) with SARS-CoV-2 infection. The rate of symptomatic and asymptomatic patients diagnosed with SARS-CoV-2 was found as 3.72% (n = 11) and 4.05% (n = 12), respectively. Four of nine women who underwent a second testing for SARS-CoV-2 upon abnormal LUS findings were found positive eventually (17.4%, n = 4/23). The asymptomatic pregnant women with LUS score of 1 and those with normal LUS findings were considered as likely to be normal. Symptomatic patients with LUS score of 1 and those with score of 2 or 3 were considered as abnormal. On a secondary diagnostic performance analysis, the positive predictive value and the sensitivity were found as 44% and 47.8% for the triage based on maternal symptoms and, 82.3% and 60.9% for the triage based on LUS, respectively.

CONCLUSION

A one-month trial period of universal testing for SARS-CoV-2 infection with RT-PCR in pregnant women who admitted to the hospital showed an overall and asymptomatic infection diagnose rate of 7.77% and 4%, respectively. Using lung ultrasound was found more predictive in detecting the infection than the use of symptomatology solely.