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

Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned

Pregnant individuals with viral illness may experience significant morbidity and have higher rates of pregnancy and neonatal complications. With the growing number of viral infections and new viral pandemics, it is important to examine the effects of infection during pregnancy on both the gestational parent and the offspring. Febrile illness and inflammation during pregnancy are correlated with risk for autism, attention deficit/hyperactivity disorder, and developmental delay in the offspring in human and animal models. Historical viral epidemics had limited follow-up of the offspring of affected pregnancies. Infants exposed to seasonal influenza and the 2009 H1N1 influenza virus experienced increased risks of congenital malformations and neuropsychiatric conditions. Zika virus exposure in utero can lead to a spectrum of abnormalities, ranging from severe microcephaly to neurodevelopmental delays which may appear later in childhood and in the absence of Zika-related birth defects. Vertical infection with severe acute respiratory syndrome coronavirus-2 has occurred rarely, but there appears to be a risk for developmental delays in the infants with antenatal exposure. Determining how illness from infection during pregnancy and specific viral pathogens can affect pregnancy and neurodevelopmental outcomes of offspring can better prepare the community to care for these children as they grow. IMPACT: Viral infections have impacted pregnant people and their offspring throughout history. Antenatal exposure to maternal fever and inflammation may increase risk of developmental and neurobehavioral disorders in infants and children. The recent SARS-CoV-2 pandemic stresses the importance of longitudinal studies to follow pregnancies and offspring neurodevelopment.

Impact of SARS-COV-2 Infection on Maternal, Obstetric and Neonatal Outcomes in a Cohort of Vaccinated Women: A Pilot Study

We aimed to investigate the impact of COVID-19 infection on maternal characteristics and obstetric and neonatal outcomes in a cohort of women in labor previously vaccinated who tested positive for SARS-CoV-2 infection, compared to aged-matched healthy controls. A retrospective case-control study was conducted among 66 women in labor. Clinical data were obtained from medical records. The attendance rates at childbirth and parenting classes, as well as the implementation of a birth plan, were significantly lower in the COVID-19 infection group (6.1% vs. 48.5%, <0.001; 6.1% vs. 33.3%, p = .005, respectively). Women with COVID-19 had a higher prevalence of prolonged postpartum hospital stay (33.3% vs. 9.1%, p = .016), and significantly higher prevalence of spontaneous preterm birth (27.3% vs. 1.09%, p = .006). Breastfeeding within the first 24 hr was also lower in women with COVID-19 (72.7% vs. 97.0%, p = .006). Maternal characteristics and neonatal outcomes are influenced by COVID-19 infection in vaccinated women. Complications include spontaneous preterm birth, prolonged postpartum hospital stay, and lack of breastfeeding within the first 24 hr. Childbirth education, parenting classes and implementing a birth plan may be associated with a decreased risk of COVID-19 infection.

The Impact of COVID-19 during Pregnancy on Maternal Hemodynamic Function, Angiogenic Markers and Neonatal Outcome

Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in pregnancy are associated with the development of preeclampsia and fetal growth restriction (FGR). Recently, preeclampsia was linked to impaired maternal hemodynamic function. This retrospective study evaluated singleton pregnancies with COVID-19 during pregnancy and healthy pregnant controls matched for gestational age from November 2020 to March 2022. Non-invasive assessment of maternal hemodynamics by continuous wave Doppler ultrasound measurements (USCOM-1A® Monitor) and oscillometric arterial stiffness (Arteriograph) was performed. Overall, 69 pregnant women were included-23 women after COVID-19 during pregnancy and 46 healthy controls. While two women (8.7%) were admitted to the hospital due to COVID-19-related symptoms, none required intensive care unit admission or non-invasive/invasive ventilation. There were no statistically significant differences in the majority of hemodynamic parameters between the two cohorts. The prevalence of FGR was significantly higher in the COVID-19 during pregnancy group (9.5% vs. healthy controls: 0.0%; p = 0.036), especially in nulliparous women. No difference in angiogenic markers and neonatal outcomes were observed between pregnant women after COVID-19 and healthy controls. In conclusion, no significant differences in hemodynamic parameters or neonatal outcome were observed in women with COVID-19 during pregnancy. However, an increased prevalence of FGR could be described.

Maternal and neonatal outcomes associated with illness severity of maternal COVID-19

BACKGROUND

Several reports demonstrated that perinatal SARS-CoV-2 has significant impact on maternal and neonatal health outcomes. However, the relationship between severity of maternal illness with outcomes remains less clear.

METHODS

This is a single-center retrospective cohort study of mother/infant dyads with positive maternal test for SARS-CoV-2 between 14 days prior and 3 days after delivery from 3/30/2020 to 12/28/2021.

RESULTS

Among 538 mothers, those with moderate/severe/critical illness were more likely to undergo induction, receive oxygen, mechanical ventilation or ECMO. Mortality was significantly higher among the mothers with severe illness than asymptomatic and those with mild illness (6% vs 0% and 0%, respectively, P < 0.05). Neonates born to mothers with moderate/severe/critical illness were more likely to be preterm with lower birth weight, and to be admitted to the NICU (P < 0.05) but not to be small for gestational age. Mild maternal illness was only associated with NICU admission for isolation precaution and decreased rate of breastfeeding.

CONCLUSIONS

Maternal illness severity was significantly associated with prematurity and several adverse maternal and neonatal outcomes.

Outcomes of SARS-CoV-2 infection in early pregnancy-A systematic review and meta-analysis

INTRODUCTION

Available data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pregnancy outcomes mostly refer to women contracting the infection during advanced pregnancy or close to delivery. There is limited information on the association between SARS-CoV-2 infection in early pregnancy and outcomes thereof.

MATERIAL AND METHODS

We aimed to systematically review the maternal, fetal and neonatal outcomes following SARS-CoV-2 infection in early pregnancy, defined as <20 weeks of gestation (PROSPERO Registration 2020 CRD42020177673). Searches were carried out in PubMed, Medline, EMBASE, and Scopus databases from January 2020 until April 2023 and the WHO database of publications on coronavirus disease 2019 (COVID-19) from December 2019 to April 2023. Cohort and case-control studies on COVID-19 occurring in early pregnancy that reported data on maternal, fetal, and neonatal outcomes were included. Case reports and studies reporting only exposure to SARS-CoV-2 or not stratifying outcomes based on gestational age were excluded. Data were extracted in duplicate. Meta-analyses were conducted when appropriate, using R meta (R version 4.0.5).

RESULTS

A total of 18 studies, 12 retrospective and six prospective, were included in this review, reporting on 10 147 SARS-CoV-2-positive women infected in early pregnancy, 9533 neonates, and 180 882 SARS-CoV-2 negative women. The studies had low to moderate risk of bias according to the Newcastle-Ottawa quality assessment Scale. The studies showed significant clinical and methodological heterogeneity. A meta-analysis could be performed only on the outcome miscarriage rate, with a pooled random effect odds ratio of 1.44 (95% confidence interval 0.96-2.18), showing no statistical difference in miscarriage in SARS-CoV-2-infected women. Individual studies reported increased incidences of stillbirth, low birthweight and preterm birth among neonates born to mothers affected by COVID-19 in early pregnancy; however, these results were not consistent among all studies.

CONCLUSIONS

In this comprehensive systematic review of available evidence, we identified no statistically significant adverse association between SARS-CoV-2 infection in early pregnancy (before 20 weeks of gestation) and fetal, neonatal, or maternal outcomes. However, a 44% increase in miscarriage rate is concerning and further studies of larger sample size are needed to confirm or refute our findings.

Impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in low-and middle-income countries: a systematic review of the literature

Background

The COVID-19 pandemic has had a multifaceted impact on maternal and child services and adversely influenced pregnancy outcomes. This systematic review aims to determine the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in low- and middle-income countries.

Methods

The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A primary search of electronic databases was performed using a combination of search terms related to the following areas of interest: "impact' AND 'COVID-19' AND 'maternal and child health services' AND 'low- and middle-income countries. A narrative synthesis approach was used to analyse and integrate the results.

Results

Overall, 45 unique studies conducted across 28 low- and middle-income countries met the inclusion criteria for the review. The findings suggest the number of family planning visits, antenatal and postnatal care visits, consultations for sick children, paediatric emergency visits and child immunisation levels decreased compared to the pre-pandemic levels in the majority of included studies. An analytical framework including four main categories was developed based on the concepts that emerged from included studies: the anxiety of not knowing (1), overwhelmed healthcare systems (2), challenges perceived by healthcare professionals (3) and difficulties perceived by service users (4).

Conclusion

The COVID-19 pandemic disrupted family planning services, antenatal and postnatal care coverage, and emergency and routine child services. Generalised conclusions are tentative due to the heterogeneity and inconsistent quality of the included studies. Future research is recommended to define the pandemic's impact on women and children worldwide and prepare healthcare systems for future resurgences of COVID-19 and potential challenges beyond.

Systematic review registration

PROSPERO (CRD42021285178).

Lack of association between COVID-19 vaccines and miscarriage onset using a case-crossover design

Pregnant women might have an increased risk of SARS-COV-2 infection. Although evidence towards the efficacy and safety of COVID-19 is growing still there is room for improvement on the knowledge towards pregnancy adverse events, such as miscarriage. We explored the association of COVID-19 vaccine with the risk of miscarriages using the Real-World. We identified a cohort of vaccinated pregnancies using the BIFAP database which contains systematically recorded data on care patients in Spain (N = 4054). We then restricted it to those women who had a miscarriage using a validated algorithm (N = 607). Among them, we performed a case-crossover design to evaluate the effect of intermittent exposures on the risk of miscarriage. Adjusted Odds Ratio with their confidence intervals were calculated using two analytical approaches: conditional logistic regression and Generalized Linear Mixed-Effects Models. A total of 225 (37.1%) were aged 35-39 years. The most common comorbidities were asthma, migraine, gastritis, and hypothyroidism. A total of 14.7% received only one dose of COVID-19 and 85.3% two doses, respectively. A total of 36.8% of women with one dose and 27.6% with two doses received the vaccine 7 days prior to the miscarriage. Corresponding adjusted estimates for the risk of miscarriage using the conditional logistic regression where as follows: 1.65 (95% CI 0.85-3.23) when using as the sum of 3 control moments among women with one dose, 1.02 (95% CI 0.72-1.46) among women with two doses and 1.03 (95% CI 0.72, 1.46) using the whole study population. Very similar results were obtained when conducting the Generalized Linear Mixed-Effects Models. There was no overall increased risk of miscarriage onset associated with COVID-19 vaccine although contradictory results were found according to the number of doses. Further studies are required with larger sample sizes to assess this association.

The ethics of clinical research in the era of COVID-19

There is an urgent need for increased understanding of COVID-19 and strategies for its prevention, treatment, and mitigation. All participants in the research enterprise, including institutional review boards, have an ethical duty to protect participants and ensure that the benefits gained from such research do not conflict with the core principles that guided researchers prior to the pandemic. In this review, we discuss the ethical issues surrounding initiation and conduct of clinical trials, focusing on novel COVID-19 therapeutic, vaccine, or biospecimen research, using the principles of autonomy, beneficence, and justice. We discuss strategies to manage the practical challenges associated with the conduct of clinical trials, with an emphasis on maintaining the rights and welfare of research participants.

Pregnancy and SARS-COV2 Infection

Pachisia AV, Govil D. Pregnancy and SARS-COV2 Infection. Indian J Crit Care Med 2024;28(3):196-197.

COVID testing hesitancy among pregnant patients: Lessons learned from the COVID-19 pandemic about the unique needs and challenges of medically complex populations

Background Pregnant patients were a significant population to consider during the pandemic, given the impact of SARS-CoV-2 infection on obstetric outcomes. While COVID testing was a central pillar of infection control, it became apparent that a subset of the population declined to test. At the same time, data emerged about pregnant persons also declining to test. Yet, it was unknown why pregnant patients declined tests and if those reasons were similar or different from those of the general population. We conducted this study to explore pregnant patients' attitudes, access, and utilization of COVID-19 testing to support healthcare for infection prevention management for this unique and medically complex population. Methods We conducted a qualitative study of patients who were currently or recently pregnant during the early stages of the pandemic and received outpatient prenatal care at one of the participating study sites. An interview guide was used to conduct in-depth telephone interviews. Coding was performed using NVivo, and analysis was conducted using Grounded Theory. Results The average age of the participants (N = 37) was 32 (SD 4.21) years. Most were < 35 years of age (57%) and self-described as White (68%). Qualitative analysis identified themes related to barriers to COVID-19 testing access and use during pregnancy, including concerns about test accuracy, exposure to COVID-19 in testing facilities, isolation and separation during labor and delivery, and diminished healthcare quality and patient experience. Conclusions The implementation of widespread and universal COVID testing policies did not address the unique needs and challenges of pregnant patients as a medically complex population. It is important to understand the reasons and implications for pregnant patients who declined COVID testing during the current pandemic to inform strategies to prevent infection spread in future public health emergencies.

Evaluation of pregnancy outcomes in mothers with COVID-19 infection: a systematic review and meta-analysis

Pregnant women are one of the endangered groups who need special attention in the COVID-19 epidemic. We conducted a systematic review and summarised the studies that reported adverse pregnancy outcomes in pregnant women with COVID-19 infection. A literature search was performed in PubMed and Scopus up to 1 September 2022, for retrieving original articles published in the English language assessing the association between COVID-19 infection and adverse pregnancy outcomes. Finally, in this review study, of 1790 articles obtained in the initial search, 141 eligible studies including 1,843,278 pregnant women were reviewed. We also performed a meta-analysis of a total of 74 cohort and case-control studies. In this meta-analysis, both fixed and random effect models were used. Publication bias was also assessed by Egger's test and the trim and fill method was conducted in case of a significant result, to adjust the bias. The result of the meta-analysis showed that the pooled prevalence of preterm delivery, maternal mortality, NICU admission and neonatal death in the group with COVID-19 infection was significantly more than those without COVID-19 infection (p<.01). A meta-regression was conducted using the income level of countries. COVID-19 infection during pregnancy may cause adverse pregnancy outcomes including of preterm delivery, maternal mortality, NICU admission and neonatal death. Pregnancy loss and SARS-CoV2 positive neonates in Lower middle income are higher than in High income. Vertical transmission from mother to foetus may occur, but its immediate and long-term effects on the newborn are unclear.

Impact of SARS-CoV-2 infection in pregnant women and their babies: clinical and epidemiological features

OBJECTIVE

Assess the risk associated with COVID-19 in pregnant women on maternal and neonatal outcomes in Catalonia (Spain) in 2020, before the beginning of COVID-19 vaccination campaign.

METHOD

Cross-sectional descriptive study with all pregnant women (41,560) and their live newborns (42,097) (1st March to 31st December 2020). Women were classified: positive and negative COVID-19 diagnosis during pregnancy. The outcomes analysed were complications during pregnancy, gestational age, admission of newborns to neonatal intensive care unit (NICU) and birth weight. Associations among positive COVID-19 and maternal and infant variables were measured with logistic regression models. Results were expressed as odds ratios and 95% confidence intervals. Models were adjusted for nationality, maternal age, socioeconomic status, type of pregnancy and type of centre where the delivery occurred (public or private management hospital).

RESULTS

A total of 696 women (1.7%) were diagnosed with COVID-19 during pregnancy. Women with COVID-19 were 4.37 times more likely to have complications during pregnancy (4.37; 3.52-5.40). A total of 713 newborns (1.7%) were from mothers with COVID-19. A positive diagnosis of COVID-19 increased the risk of preterm birth (1.41; 1.03-1.89), admission to NICU (1.40; 1.06-1.82) and low birth weight (1.35; 0.99-1.80) in babies.

CONCLUSIONS

Pregnant women with COVID-19 had higher risk of developing complications during pregnancy and their newborns were more likely to be admitted to NICU and had prematurity.

Evaluation of Histopathologic Alterations in First-trimester COVID-19-positive Pregnancies Ending in Abortion

This study aims to evaluate histopathologic alterations and the presence of chronic histiocytic intervillositis in first-trimester coronavirus-2019 (COVID-19)-positive pregnancies ending in abortion, compared with those at a similar gestational week and undergoing curettage before the pandemic. This retrospective case-control study consisted of 9 patients who were infected with COVID-19 and undergoing curettage for abortion between April 2020 and January 2021. The control group consisted of 34 patients with a similar gestational age who underwent curettage for abortion before August 2019. Demographic and clinical data were recorded. A histopathologic examination of the placental specimens was performed. The CD68 immunostaining was performed to detect intravillous and intervillous histiocytes. At the time of diagnosis of COVID 19, 7 patients (77.8%) of COVID-19-positive women had symptoms with the most common symptoms of fatigue (66.7%) and cough (55.6%). Histopathologic examination revealed that the rate of intravillous and intervillous calcification, intervillous fibrinoid deposition, hydropic villi and acute lymphocytic villitis, and fetal and maternal thrombi was significantly higher in the COVID-19-positive patients than the control group ( P =0.049, 0.002, 0.049, 0.014, 0.008, 0.001, and 0.014, respectively). There was a significant difference in the CD68 staining of the intravillous and intervillous histiocytes between the groups ( P =0.001). This study showed a significant increase in the intervillous fibrinoid deposition, thrombi formation in the maternal and fetal vascular structures, acute lymphocytic villitis, and an increase of CD68 + stained histiocytes in the intravillous and intervillous spaces in women infected with COVID-19 during the first trimester of pregnancy.

Perinatal Outcomes at Birth in Women Infected and Non-Infected with SARS-CoV-2: A Retrospective Study

BACKGROUND

Coronavirus disease 2019 (COVID-19) was declared as a pandemic and public health emergency on 11 March 2020 by the World Health Organization. Different clinical trials on the efficacy of mRNA vaccination have excluded pregnant women, leading to a lack of empirical evidence on the efficacy of the vaccine in this population. The aim of the study was to examine the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at birth and adverse perinatal outcomes in infected and non-infected women from a university hospital in Spain.

METHODS

The data were obtained from electronic health records from 1 March 2020 to 28 February 2022. A bivariate descriptive analysis was performed, comparing women with and without confirmed SARS-CoV-2 infection during pregnancy using the chi-square test. A multivariate logistic regression was complementarily conducted to determine whether SARS-CoV-2 infection increases the risk of adverse obstetric and perinatal outcomes.

RESULTS

A total of 2676 women were divided into two groups: non-infected with SARS-CoV-2 (n = 2624) and infected with SARS-CoV-2 (n = 52). Infected women were primarily multiparous (p < 0.03) and had received an incomplete vaccination regimen (p < 0.001). A greater incidence of premature rupture of membranes (p < 0.04) was observed among the non-infected women. Pertaining to perinatal outcomes, there was a notable rise in NICU admissions (p < 0.014), coupled with an extended duration of stay (p < 0.04), for neonates born to infected mothers in comparison to their non-infected counterparts.

CONCLUSION

Although SARS-CoV-2 infection may pose significant risks to pregnant women and their infants, adverse obstetrical/puerperal outcomes do not significantly differ between women infected and non-infected to SARS-CoV-2 in our study. NICU admissions were higher for neonates born to infected mothers. Additionally, coronavirus disease 2019 vaccination during pregnancy is not associated with severe adverse perinatal outcomes.

Impact of Action Taken in Response to Stillbirth Audit: A Success Story

Objectives

Study the impact of intra-facility interventions on the modifiable factors causing stillbirths (SB), using point-of-care quality improvement (POCQI) methodology.

Material and Methods

Stillbirth data during the 9 months pre-intervention period were reviewed to identify the common preventable causes. Two interventions, namely, ultrasound at 34-36 weeks gestation and intrapartum monitoring on a common customized labor chart for all health-care providers, were done. Post-intervention data were collected to observe the impact of the interventions.

Results

The stillbirth rate reduced from 212/5940 deliveries (35.7/1000) in the pre-intervention period to 165/5993 deliveries (27.7/1000) in the post-intervention period (p = 0.011). The intra-facility failure to identify FGR significantly reduced in the post-intervention group (p = 0.033), leading to 63% (RR 0.37) reduction in its risk. Using a common customized labor chart led to a significant decline in the inadequate monitoring as a provider-related cause of stillbirth (p < 0.001) leading to its 42% decline as contributor to modifiable cause of SB (RR 0.48).

Conclusion

Reviewing the perinatal death surveillance response (PDSR) data, identifying gaps in care, and using improvement methodology for instituting corrective measures play an important role in reducing intramural stillbirths.

Adverse Events in Pregnant Patients Treated with Coronavirus Disease 2019 Therapeutics

BACKGROUND

Pregnant patients are at high risk of maternal and fetal complications from Coronavirus Disease 2019 (COVID-19) infections. The COVID-19 pandemic prompted a surge in the development and repurposing of therapies for the SARS-CoV-2 virus. Evidence is sparse on the efficacy and safety of these therapies in pregnant patients. Our objective was to describe adverse events (AEs) to COVID-19 therapeutics in pregnant patients.

METHODS

This was a case series of AEs reported to the FDA ACMT COVID-19 ToxIC (FACT) Pharmacovigilance Project between November 23, 2020, and June 28, 2022. FACT is an ongoing toxicosurveillance project at 17 sites to proactively identify and report AEs associated with COVID-19 therapeutics. Abstracted information includes demographics, case narratives, exposure details, clinical information, pregnancy details, treatments, and outcomes.

RESULTS

Forty-six COVID-19-positive pregnant patients who developed AEs following COVID-19 therapeutics were reported to the FACT Pharmacovigilance Project over 19 months. The most reported medications were remdesivir in 22 patients (47.8%) and casirivimab/imdevimab in 8 patients (17.4%). Four patients (8.7%) had life-threatening clinical manifestation, and 16 patients (34.8%) required intervention to prevent permanent damage. The most common maternal and fetal events were elevated serum alanine aminotransferase (26.1%) and non-reassuring fetal heart patterns (20.0%), respectively.

CONCLUSIONS

This case series reports AEs of elevated serum alanine aminotransferase, maternal bradycardia, maternal hypothermia, non-reassuring fetal heart patterns, and emergent or unplanned cesarean sections following administration of several COVID-19 therapeutics. This study was not designed to definitely identify causation, and further study is needed to evaluate the causal role of these therapeutics in AEs affecting pregnant COVID-19 patients.

Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania

OBJECTIVES

The COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.

DESIGN

Prospective observational mixed-methods study, combining monthly routine data (March 2019-February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.

SETTING

Six referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.

PARTICIPANTS

22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.

RESULTS

Percentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%-40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.

CONCLUSIONS

Maternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women's and care providers' needs, this can contribute to ensuring continuation of essential care provision during emergency.

The Effects and Outcomes of the COVID-19 Pandemic on Pregnant Women in Kuwait

OBJECTIVES

This retrospective study reports the effects of COVID-19 among hospitalized pregnant women infected with COVID-19 and compares them to a control group.

METHODS

A multi-center retrospective cohort study, in which data of pregnant women with COVID-19, admitted to five different hospitals in Kuwait, were collected. Two groups were included, the first group were women with COVID-19 who were admitted between March 22, 2020 until December 31, December 2020. The second (control) group included pregnant women without COVID-19, who were admitted between March 1, 2019 and March 21, 2020. Data were collected using a standardized data collection survey, entered using Excel Software and analyzed using Analysis of Variance (ANOVA).

RESULTS

We compared 764 patients, with confirmed COVID-19 with 765 uninfected control subjects. The majority of pregnant women were diagnosed with COVID-19 infection during the third trimester. Tachycardia was the most frequent sign at admission and dry cough and fever were the most common presenting symptoms. ICU admission and respiratory failure were significantly higher in the COVID-19 group. Cesarean section (CS) rate was higher in the COVID-19 group, with obstetric and maternal complications being the most common indications in comparison to fetal indications in the control group.

CONCLUSIONS

This study was conducted to identify the effects of COVID-19 in pregnancy. Most patients were asymptomatic. The rate of normal vaginal delivery was higher in the control group. The main indications for Cesarean section in the COVID-19 group were obstetrical and maternal complications compared to fetal complications in the control group.  .

Neonatal Outcome of Mothers With COVID-19 in King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

OBJECTIVES

This study was conducted to assess the neonatal outcome of mothers with COVID-19 in King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

METHODS

This was a hospital record-based, retrospective cohort study. The case group included neonates born to mothers who were positive for the COVID-19 virus during pregnancy, whereas the control group included neonates born to mothers who were not infected with the COVID-19 virus during pregnancy. The data were collected from the records and were analyzed using the Statistical Package for the Social Sciences software (IBM Corp., Armonk, NY, USA).

RESULTS

This study covered the hospital records of 342 women (114 cases and 228 control). The rates of cesarean sections and small for gestational age were significantly higher among the cases compared to the controls (71.1% versus 43.4%, p < 0.001 and 24.6% versus 11.8%, p = 0.003; respectively). The mean birth weight was significantly lower among the cases group (3.0 ± 0.6 versus 3.3 ± 0.6 kg, p = 0.022). Only the case group reported the occurrence of neonatal COVID-19 infection (7.9%, p < 0.001). The study reported only a single case of intrauterine fetal death and one stillbirth in the cases group, but no neonatal deaths (p > 0.05).

CONCLUSIONS

Maternal COVID-19 may be associated with undesirable neonatal outcomes. There is a possibility of vertical transmission of COVID-19 from the mother to the neonate, but this cannot be confirmed.

Morphological placental findings in women infected with SARS-CoV-2 according to trimester of pregnancy and severity of disease

INTRODUCTION

Placental morphology findings in SARS-CoV-2 infection are considered nonspecific, although the role of trimester and severity of infection are underreported. Therefore, we aimed to investigate abnormal placental morphology, according to these two criteria.

METHODS

This is an ancillary analysis of a prospective cohort study of pregnant women with suspected SARS-CoV-2 infection, managed in one maternity, from March 2020 to October 2021. Charting of clinical/obstetric history, trimester and severity of COVID-19 infection, and maternal/perinatal outcomes were done. Placental morphological findings were classified into maternal and fetal circulatory injury and acute/chronic inflammation. We further compared findings with women with suspected disease which tested negative for COVID-19. Diseases' trimester of infection and clinical severity guided the analysis of confirmed COVID-19 cases.

RESULTS

Ninety-one placental discs from 85 women were eligible as a COVID-19 group, and 42 discs from 41 women in negative COVID-19 group. SARS-CoV-2 infection occurred in 68.2% during third trimester, and 6.6% during first; 16.5% were asymptomatic, 61.5% non-severe and 22.0% severe symptomatic (two maternal deaths). Preterm birth occurred in 33.0% (one fetal death). Global maternal vascular malperfusion (MVM) were significant in COVID-19 group whether compared with negative COVID-19 tests group; however, fetal vascular malperfusion lesions and low-grade chronic villitis were not. Three placentas had COVID-19 placentitis. Decidual arteriopathy was associated with infection in first/mid trimester, and chorangiosis in asymptomatic infections.

DISCUSSION

Placental abnormalities after an infection by COVID-19 were more frequent after first/mid-trimester infections. Extensive placental lesions are rare, although they may be more common upon underlying medical conditions.

Factors that influenced utilization of antenatal and immunization services in two local government areas in The Gambia during COVID-19: An interview-based qualitative study

INTRODUCTION

Evidence is being consolidated that shows that the utilization of antenatal and immunization services has declined in low-income countries (LICs) during the COVID-19 pandemic. Very little is known about the effects of the pandemic on antenatal and immunization service utilization in The Gambia. We set out to explore the COVID-19-related factors affecting the utilization of antenatal and immunization services in two Local Government Areas (LGAs) in The Gambia.

METHODS

A qualitative methodology was used to explore patients' and providers' experiences of antenatal and immunization services during the pandemic in two LGAs in The Gambia. Thirty-one study participants were recruited from four health facilities, applying a theory-driven sampling framework, including health workers as well as female patients. Qualitative evidence was collected through theory-driven semi-structured interviews, and was recorded, translated into English, transcribed, and analysed thematically, applying a social-ecological framework.

RESULTS

In our interviews, we identified themes at five different levels: individual, interpersonal, community, institutional and policy factors. Individual factors revolved around patients' fear of being infected in the facilities, and of being quarantined, and their anxiety about passing on infections to family members. Interpersonal factors involved the reluctance of partners and family members, as well as perceived negligence and disrespect by health workers. Community factors included misinformation within the community and mistrust of vaccines. Institutional factors included the shortage of health workers, closures of health facilities, and the lack of personal protective equipment (PPEs) and essential medicines. Finally, policy factors revolved around the consequences of COVID-19 prevention measures, particularly the shortage of transport options and mandatory wearing of face masks.

CONCLUSIONS

Our findings suggest that patients' fears of contagion, perceptions of poor treatment in the health system, and a general anxiety around the imposing of prevention measures, undermined the uptake of services. In future emergencies, the government in The Gambia, and governments in other LICs, will need to consider the unintended consequences of epidemic control measures on the uptake of antenatal and immunization services.

Effects of Covid-19 Vaccination during Pregnancy on the Obstetric and Neonatal Outcomes in a Tertiary Health Care Center

BACKGROUND

Pregnancy is an immuno-compromised state, and pregnant women with COVID-19 are at an increased risk for adverse pregnancy outcomes. Thus, the Center for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization (ACIP) have advocated for COVID-19 vaccination in pregnant women. COVAXIN and COVISHIELD were the vaccines being used in India in the first phase of vaccination, but limited data exist on pregnancy outcomes regarding SARS-CoV-2 vaccines and pregnancy and lactation.

MATERIAL AND METHODS

A retrospective study was conducted which included only women who delivered after 24 weeks gestation. Women with an unknown vaccination status or with past or active COVID-19 infection were excluded. Demographic characteristics, maternal and obstetric outcomes, and fetal and neonatal outcomes were compared between the unvaccinated and vaccinated groups. Statistical analysis was done with Chi-square testing and the Fisher exact test using SPSS-26 software.

RESULTS

Deliveries before a gestation of 37 weeks were significantly higher in the unvaccinated group compared to the vaccinated group. Rates of vaginal deliveries and preterm deliveries were found to be higher in the unvaccinated population. Women who had taken COVAXIN had a higher rate of adverse events compared to those who had taken COVISHIELD.

CONCLUSION

There were no significant differences in adverse obstetric outcomes attributed to vaccine administration between the vaccinated and unvaccinated pregnant women. The beneficial effects of the vaccines in protecting against COVID-19 infection, particularly in pregnancy, outweigh the minor adverse events associated with vaccine administration.

The Effect of an Educational Intervention Based on Protection Motivation Theory on Pregnant Women's Knowledge and Self-Protection Regarding COVID-19. An Intervention Study

Background

COVID-19 infection endangers pregnant women and newborns. Infection prevention measures are available and easy to apply, but the problem is the application continuity. Empowering pregnant women to increase their intention for self-protection is very important. This study explores the effect of educational intervention based on the Protection Motivation Theory (PMT) on pregnant women's knowledge and self-protection regarding COVID-19.

Materials and Methods

A randomized, controlled trial was conducted at the Obstetrics and Gynecology outpatient clinic at El Shatby Hospital, Alexandria governorate/Egypt, from November 2020 to May 2021. The study included a convenient sample of 163 pregnant women using the randomization block technique. A self-reported questionnaire was used for data collection. For the intervention group, the PMT-based education included need assessment, planning, implementation, and evaluation. Two months later, a reevaluation was done.

Results

ANCOVA showed a significant improvement in the intervention group's knowledge (F1 = 8.56, p < 0.001) when taking the pretest as a reference. The effect size shows that 25.8% of the intervention group's knowledge improvement and 58.80% of the difference between the two groups were due to intervention. ANCOVA showed a significant improvement in the intervention group's PMT constructs when taking the pretest or group as a reference (p <0.001). The effect size shows that 56.10% of the intervention group's total PMT constructs improvement and 89.60% of the differences between the two groups were due to the intervention.

Conclusions

PMT-based intervention is effective in improving pregnant women's knowledge and self-protection intention regarding COVID-19. PMT is recommended to tailor educational intervention for pregnant women.

Pregnant women's knowledge about and beliefs toward COVID-19 vaccine: a cross-sectional study

Purpose

The aim of this study was to determine the scope of knowledge, attitudes, and behaviors of pregnant women about the coronavirus disease 2019 (COVID-19) vaccine.

Materials and Methods

A total of 886 pregnant women were recruited for the study. A cross-sectional questionnaire was conducted on these selected participants. Data about past infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS-CoV-2 infection of closely related people, and deaths due to COVID-19 among their relatives were questioned.

Results

The rate of vaccination was higher (64.1%) in pregnant women with higher education levels. Informing about the vaccine, especially by health professionals, showed that the rates of vaccination (25%) increased (p<0.001). In addition, a significant increase was observed in vaccination rates with increasing age and financial income (p<0.001).

Conclusion

The main limitation of our study is that the vaccine, which was approved for "emergency use", was just started to be administered to pregnant women during the study. Our findings show that our target audience, low-income, low-education, younger pregnant women should be given more attention than those who apply to the doctor for routine follow-up.

Impact of variants of SARS-CoV-2 on obstetrical and neonatal outcomes

BACKGROUND

SARS-CoV-2 can lead to several types of complications during pregnancy. Variant surges are associated with different severities of disease. Few studies have compared the clinical consequences of specific variants on obstetrical and neonatal outcomes. Our goal was to evaluate and compare disease severity in pregnant women and obstetrical or neonatal complications between variants of SARS-CoV-2 that have circulated in France over a two-year period (2020-2022).

METHOD

This retrospective cohort study included all pregnant women with a confirmed SARS-CoV-2 infection (positive naso-pharyngeal RT-PCR test) from March 12, 2020 to January 31, 2022, in three tertiary maternal referral obstetric units in the Paris metropolitan area, France. We collected clinical and laboratory data for mothers and newborns from patients' medical records. Variant identification was either available following sequencing or extrapolated from epidemiological data.

RESULTS

There were 234/501 (47%) Wild Type (WT), 127/501 (25%) Alpha, 98/501 (20%) Delta, and 42/501 (8%) Omicron. No significative difference was found regarding two composite adverse outcomes. There were significantly more hospitalizations for severe pneumopathy in Delta variant than WT, Alpha and Omicron respectively (63% vs 26%, 35% and 6%, p<0.001), more frequent oxygen administration (23% vs 12%, 10% and 5%, p = 0,001) and more symptomatic patients at the time of testing with Delta and WT (75% and 71%) versus Alpha and Omicron variants (55% and 66% respectively, p<0.01). Stillbirth tended to be associated with variants (p = 0.06): WT 1/231 (<1%) vs 4/126 (3%), 3/94 (3%), and 1/35 (3%) in Alpha, Delta and Omicron cases respectively. No other difference was found.

CONCLUSION

Although the Delta variant was associated with more severe disease in pregnant women, we found no difference regarding neonatal and obstetrical outcomes. Neonatal and obstetrical specific severity may be due to mechanisms other than maternal ventilatory and general infection.

Neonatal outcomes and indirect consequences following maternal SARS-CoV-2 infection in pregnancy: a systematic review

OBJECTIVES

To identify the association between maternal SARS-CoV-2 infection in pregnancy and individual neonatal morbidities and outcomes, particularly longer-term outcomes such as neurodevelopment.

DESIGN

Systematic review of outcomes of neonates born to pregnant women diagnosed with a SARS-CoV-2 infection at any stage during pregnancy, including asymptomatic women.

DATA SOURCES

MEDLINE, Embase, Global Health, WHOLIS and LILACS databases, last searched on 28 July 2021.

ELIGIBILITY CRITERIA

Case-control and cohort studies published after 1 January 2020, including preprint articles were included. Study outcomes included neonatal mortality and morbidity, preterm birth, caesarean delivery, small for gestational age, admission to neonatal intensive care unit, level of respiratory support required, diagnosis of culture-positive sepsis, evidence of brain injury, necrotising enterocolitis, visual or hearing impairment, neurodevelopmental outcomes and feeding method. These were selected according to a core outcome set.

DATA EXTRACTION AND SYNTHESIS

Data were extracted into Microsoft Excel by two researchers, with statistical analysis completed using IBM SPSS (Version 27). Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

The search returned 3234 papers, from which 204 were included with a total of 45 646 infants born to mothers with SARS-CoV-2 infection during pregnancy across 36 countries. We found limited evidence of an increased risk of some neonatal morbidities, including respiratory disease. There was minimal evidence from low-income settings (1 study) and for neonatal outcomes following first trimester infection (17 studies). Neonatal mortality was very rare. Preterm birth, neonatal unit admission and small for gestational age status were more common in infants born following maternal SARS-CoV-2 infection in pregnancy in most larger studies.

CONCLUSIONS

There are limited data on neonatal morbidity and mortality following maternal SARS-CoV-2 infection, particularly from low-income countries and following early pregnancy infections. Large, representative studies addressing these outcomes are needed to understand the consequences for babies born to women with SARS-CoV-2.

PROSPERO REGISTRATION NUMBER

CRD42021249818.

Risks and Preventions for Pregnant Women and Their Preterm Infants in a World with COVID-19: A Narrative Review

(1) Background and Aim: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is linked to increasing cases of coronavirus disease 2019 (COVID-19) around the world. COVID-19 infections have an important impact on pregnancy, preterm birth (PTB) and delivery. Although several complications have been reported in infected pregnant women, the effect of infection on PTB is controversial. The purpose of this study was to summarize the existing literature on the effects and complications of COVID-19 on the health of pregnant women and preterm babies and its impact on the incidence of PTB. We also discuss the effect of current COVID-19 vaccines during pregnancy. (2) Methods: We carried out a systematic search of MEDLINE, Embase, and PubMed for studies on preterm births associated with COVID-19. (3) Results and Conclusions: We discovered contradictory results regarding the prevalence of PTB during the pandemic compared to earlier years. While most studies indicated an increase in PTBs with COVID-19, some indicated a decline in the preterm delivery rate during this time. During pregnancy, COVID-19 infection can increase the incidence of cesarean section, stillbirth, ICU admission, preeclampsia/eclampsia, and mortality rates. In the treatment of pregnant women with severe COVID-19, methylprednisolone was favored over prednisolone, and a brief course of dexamethasone is advised for pregnant women with anticipated PTB to accelerate the development of the fetal lung. Generally, vaccination for COVID-19 in pregnant and lactating women stimulates anti-SARS-CoV2 immune responses, and it does not result in any noteworthy negative reactions or outcomes for the mother or baby.

SARS-CoV-2 in Pregnancy, Birth and Puerperium. Guideline of the DGGG und DGPM (S2k-Level, AWMF Registry Number 015/092, March 2022)

Objective This S2k guideline of the German Society for Gynecology and Obstetrics (DGGG) and the German Society of Perinatal Medicine (DGPM) contains consensus-based recommendations for the care and treatment of pregnant women, parturient women, women who have recently given birth, and breastfeeding women with SARS-CoV-2 infection and their newborn infants. The aim of the guideline is to provide recommendations for action in the time of the COVID-19 pandemic for professionals caring for the above-listed groups of people.

Methods The PICO format was used to develop specific questions. A systematic targeted search of the literature was carried out using PubMed, and previously formulated statements and recommendations issued by the DGGG and the DGPM were used to summarize the evidence. This guideline also drew on research data from the CRONOS registry. As the data basis was insufficient for a purely evidence-based guideline, the guideline was compiled using an S2k-level consensus-based process. After summarizing and presenting the available data, the guideline authors drafted recommendations in response to the formulated PICO questions, which were then discussed and voted on.

Recommendations Recommendations on hygiene measures, prevention measures and care during pregnancy, delivery, the puerperium and while breastfeeding were prepared. They also included aspects relating to the monitoring of mother and child during and after infection with COVID-19, indications for thrombosis prophylaxis, caring for women with COVID-19 while they are giving birth, the presence of birth companions, postnatal care, and testing and monitoring the neonate during rooming-in or on the pediatric ward.

The Histopathological "Placentitis Triad" Is Specific for SARS-CoV-2 Infection, and Its Acute Presentation Can Be Associated with Poor Fetal Outcome

(1) Background: Placental histological lesions reported in relation with SARS-CoV-2 infection are various, with potential consequences such as fetal growth retardation, prematurity or stillbirth/neonatal death. We report here on a placental pathological association which could be specific for SARS-CoV-2 infection and associated with poor fetal outcome; (2) Methods: We collected all the placental pathological examinations performed in Brest University Hospital (France) since the beginning of COVID-19 pandemic with a known maternal SARS-CoV-2 infection and a poor pregnancy outcome. In these cases, we described the pathological lesions and we searched for these lesions in a large series of placentas collected and examined in the same institution before the SARS-CoV-2 pandemic; (3) Results: Three cases with severe fetal outcome (tardive abortion, prematurity, neonatal death), from the first to the third trimesters of pregnancy, were included. The three cases showed features of massive and acute "placentitis triad" consisting in massive perivillous fibrin deposition, sub-acute intervillositis and trophoblastic necrosis. This association was not encountered in any of 8857 placentas analyzed during the period between 2002 and 2012 in our institution; (4) Conclusions: The "placentitis triad" appears to be specific for SARS-CoV-2 infection and, in case of massive and acute presentation, could result in poor fetal outcome.

Clinical risk factors of adverse outcomes among women with COVID-19 in the pregnancy and postpartum period: a sequential, prospective meta-analysis

OBJECTIVE

This sequential, prospective meta-analysis sought to identify risk factors among pregnant and postpartum women with COVID-19 for adverse outcomes related to disease severity, maternal morbidities, neonatal mortality and morbidity, and adverse birth outcomes.

DATA SOURCES

We prospectively invited study investigators to join the sequential, prospective meta-analysis via professional research networks beginning in March 2020.

STUDY ELIGIBILITY CRITERIA

Eligible studies included those recruiting at least 25 consecutive cases of COVID-19 in pregnancy within a defined catchment area.

METHODS

We included individual patient data from 21 participating studies. Data quality was assessed, and harmonized variables for risk factors and outcomes were constructed. Duplicate cases were removed. Pooled estimates for the absolute and relative risk of adverse outcomes comparing those with and without each risk factor were generated using a 2-stage meta-analysis.

RESULTS

We collected data from 33 countries and territories, including 21,977 cases of SARS-CoV-2 infection in pregnancy or postpartum. We found that women with comorbidities (preexisting diabetes mellitus, hypertension, cardiovascular disease) vs those without were at higher risk for COVID-19 severity and adverse pregnancy outcomes (fetal death, preterm birth, low birthweight). Participants with COVID-19 and HIV were 1.74 times (95% confidence interval, 1.12-2.71) more likely to be admitted to the intensive care unit. Pregnant women who were underweight before pregnancy were at higher risk of intensive care unit admission (relative risk, 5.53; 95% confidence interval, 2.27-13.44), ventilation (relative risk, 9.36; 95% confidence interval, 3.87-22.63), and pregnancy-related death (relative risk, 14.10; 95% confidence interval, 2.83-70.36). Prepregnancy obesity was also a risk factor for severe COVID-19 outcomes including intensive care unit admission (relative risk, 1.81; 95% confidence interval, 1.26-2.60), ventilation (relative risk, 2.05; 95% confidence interval, 1.20-3.51), any critical care (relative risk, 1.89; 95% confidence interval, 1.28-2.77), and pneumonia (relative risk, 1.66; 95% confidence interval, 1.18-2.33). Anemic pregnant women with COVID-19 also had increased risk of intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.25-2.11) and death (relative risk, 2.36; 95% confidence interval, 1.15-4.81).

CONCLUSION

We found that pregnant women with comorbidities including diabetes mellitus, hypertension, and cardiovascular disease were at increased risk for severe COVID-19-related outcomes, maternal morbidities, and adverse birth outcomes. We also identified several less commonly known risk factors, including HIV infection, prepregnancy underweight, and anemia. Although pregnant women are already considered a high-risk population, special priority for prevention and treatment should be given to pregnant women with these additional risk factors.

Pregnancy during the pandemic: The psychological impact of COVID-19 on pregnant women in Greece

INTRODUCTION

The COVID-19 outbreak has affected the overall health of people worldwide. Historically, pandemics pose a challenge to psychological resilience, causing heightened stress levels. This study aimed to investigate the impact of the COVID-19 pandemic on the psychological state of pregnant women in Greece.

METHODS

A survey study was conducted on a sample of 149 pregnant women in late 2020, including the 'fear of COVID-19' scale, a self-report instrument that assess fear of COVID-19 among the general population and the State-Trait Anxiety Inventory (STAI) scale which measures state and trait anxiety.

RESULTS

Pregnant women with a mental health history tended to score higher on the 'fear of COVID-19' scale (mean ± SD: 19.48 ± 4.35) compared to pregnant women who had never had mental health problems before (17.12 ± 5.27). Moreover, pregnant women with anxiety as part of their personality tended to also score higher on the 'fear of COVID-19' scale. In all, 48.3% of pregnant women reported that their psychological state had been severely affected by the COVID-19 outbreak.

CONCLUSIONS

Pregnant women were highly affected by the COVID-19 pandemic. A significantly increased 'fear of COVID-19' scale score was associated with self-reported pre-existence mental health conditions. Pregnant women with higher levels of 'trait anxiety' tended to report higher scores on the 'fear of COVID-19' scale.

Assessment of the Prevalence and Incidence of COVID-19 in Saudi Arabia

The global pandemic of coronavirus disease 2019 (COVID 19) is reported to have started in Wuhan City, Hebei Province, China. It has spread rapidly all over the world, including Saudi Arabia, having a severe health emergency. This new virus was named as the 2019 novel coronavirus (2019-nCoV), and now severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on previous practice and phylogenetic and taxonomic investigations. SARS-CoV-2 belongs to the family of Coronaviridae, Betacoronavirus, Sarbecovirus subgenus, genome β. Throughout the COVID 19 pandemic, several strains of SARS-CoV-2 have been recognized around the world. The SARS-CoV-2 variants have caused significant morbidity and mortality worldwide and in Saudi Arabia as well. The rate at which COVID-19 spread across borders and affected countries has highlighted the significance of health care systems to nations and global operations. This review focuses on the origin, epidemiology, pathophysiology, transmission, and the impact of this disease, while highlighting the knowledge about SARS-CoV-2 variants.

Thromboprophylaxis in Pregnant Women with COVID-19: An Unsolved Issue

SARS-CoV-2 infection in pregnant women is of growing interest due to controversy over the use of antiplatelet and/or anticoagulant drugs during pregnancy and postpartum. Pregnant women are susceptible to develop severe forms of viral infections due to pregnancy-related immune alterations, changes in lung functions, and hypercoagulability. The association of pregnancy with SARS-CoV-2 infection can cause an increased incidence of thrombotic complications, especially in the case of patients with some genetic variants that favor inflammation and thrombosis. Compared to the general population, pregnant women may be at increased risk of thrombotic complications related to COVID-19. The lack of extensive clinical trials on thromboprophylaxis and extrapolating data from non-pregnant patients lead to major discrepancies in treating pregnant women with COVID-19. Currently, a multidisciplinary team should determine the dose and duration of prophylactic anticoagulant therapy for these patients, depending on the disease severity, the course of pregnancy, and the estimated due date. This narrative review aims to evaluate the protective effect of thromboprophylaxis in pregnant women with COVID-19. It is unknown at this time whether antiplatelet or anticoagulant therapy initiated at the beginning of pregnancy for various diseases (preeclampsia, intrauterine growth restriction, thrombophilia) offers a degree of protection. The optimal scheme for thromboprophylaxis in pregnant women with COVID-19 must be carefully established through an individualized decision concerning gestational age and the severity of the infection.

Aumento de mortalidad materna y de prematuridad durante pandemia de COVID-19 en Chile

Introducción

En Chile los casos reportados de COVID-19 a nivel nacional al tercer año de pandemia (3 de noviembre del 2022) son de 4.769.638 y 61.725 fallecidos (1,3%), con el 93% de la población con esquema completo de vacunación (17.686.528).

Objetivo

El objetivo de este estudio es una comunicación breve sobre el impacto de la pandemia de SARS-CoV-2 en la mortalidad materna, perinatal y prematuridad en Chile.

Método

Se utilizó la base de datos nacional del Departamento de Informática del Ministerio de Salud de Chile (DEIS), y la información reportada desde sitio web oficial de OMS. Se incluyeron todos los nacidos, muertes generales y fetales desde enero 1990 a septiembre del 2022. Se realiza una comparación entre los indicadores básicos maternos y perinatales de los últimos 30 años y los de los años de la pandemia.

Resultados

Desde marzo 2020 a septiembre 2022, fallecieron más de 61.000 personas en Chile con diagnóstico asociado al COVID-19, el 17% de la mortalidad general para el período (364.000 fallecidos). Se observó una aceleración en la tendencia histórica hacia la disminución de la razón nacimientos/defunciones generales de 1,9 pre-pandemia a 1,4 al tercer año de pandemia. La razón de mortalidad materna en el año 2020 fue de 28,1 × 100.000 nacidos vivos y aumentó en comparación al año 2019 pre-pandemia (19,1) o a la línea simple de tendencia histórica proyectada para el 2020 (18) en un 56%. La prematuridad bajo 37 semanas de gestación, se incrementó de 8,5% (2019) a 9,5% para los años 2021 y 2022. La mortalidad neonatal de los primeros 28 días se mantuvo estable en 9 × 1.000 nacidos vivos durante los 3 años de pandemia y la mortalidad fetal (>21 semanas) tuvo un leve incremento a 4,7 × 1.000 nacidos vivos (año 2020) en relación a 3,4 del año 2019.

Conclusiones

En Chile ocurrió un aumento de aproximadamente un 56% de la mortalidad materna el primer año de pandemia de SARS-CoV-2, el segundo año se observa un aumento significativo de la prematuridad tardía y un leve incremento de la mortalidad fetal. Estos hallazgos han sido reportados en las revisiones y últimas actualizaciones del año 2022.

COVID-19 and pregnancy: clinical outcomes; mechanisms, and vaccine efficacy

As the COVID-19 pandemic continues into its third year, emerging data indicates increased risks associated with SARS-CoV-2 infection during pregnancy, including pre-eclampsia, intrauterine growth restriction, preterm birth, stillbirth, and risk of developmental defects in neonates. Here, we review clinical reports to date that address different COVID-19 pregnancy complications. We also document placental pathologies induced by SARS-CoV-2 infection, entry mechanisms in placental cells, and immune responses at the maternal-fetal interface. Since new variants of SARS-CoV-2 are emerging with characteristics of higher transmissibility and more effective immune escape strategies, we also briefly highlight the genomic and proteomic features of SARS-CoV-2 investigated to date. Vector and mRNA-based COVID-19 vaccines continue to be rolled out globally. However, because pregnant individuals were not included in the vaccine clinical trials, some pregnant individuals have safety concerns and are hesitant to take these vaccines. We describe the recent studies that have addressed the effectiveness and safety of the current vaccines during pregnancy. This review also sheds light on important areas that need to be carefully or more fully considered with respect to understanding SARS-CoV-2 disease mechanisms of concern during pregnancy.

SARS-CoV-2 Seroconversion and Pregnancy Outcomes in a Population of Pregnant Women Recruited in Milan, Italy, between April 2020 and October 2020

The possible link between SARS-CoV-2 infection and adverse pregnancy outcomes has so far demonstrated heterogeneous results in terms of maternal, fetal, and neonatal complications. We aim to investigate the correlation between SARS-CoV-2 seroconversion and/or neutralization titer and pregnancy outcomes. We analyzed a population of 528 pregnant women followed up from the first trimester of gestation until delivery. For each woman, we collected a first blood sample between 11 and 13 weeks of gestation and a second sample in the perinatal period (between peripartum and puerperium) to assess the presence of SARS-CoV-2 antibodies and/or microneutralization titer (MN titer). Data on pregnancy outcomes (gestational age at delivery, preterm birth before 34 weeks, hypertensive disorders, gestational diabetes, and abnormal fetal growth) were collected. We observed that serologic status per se is not associated with major pregnancy complications. On the contrary, the MN titer was associated with increased odds of gestational diabetes. Although we mainly reported asymptomatic SARS-CoV-2 infections and the absence of severe maternal and neonatal adverse outcomes, SARS-CoV-2 infection might challenge the maternal immune system and explain the moderate increase in adverse outcome odds.

Clinical-epidemiological characteristics and maternal-foetal outcomes in pregnant women hospitalised with COVID-19 in Venezuela: a retrospective study

BACKGROUND

In low- and middle-income countries, pregnant women and newborns are more vulnerable to adverse outcomes from coronavirus disease 2019 (COVID-19). However, in Venezuela, there are no integrated data in a national surveillance system to identify the clinical-epidemiological characteristics and maternal-foetal outcomes of pregnant women hospitalised with COVID-19.

METHODS

A retrospective study was conducted among Venezuelan pregnant women hospitalised with COVID-19 seen at the "Ruiz y Páez" University Hospital Complex and the San Cristobal Central Hospital between June 2020 and September 2021. Information was obtained from physical and digitised clinical records using a purpose-designed proforma to collect epidemiological, clinical, paraclinical, treatment, obstetric and perinatal complications, and maternal-foetal outcomes data.

RESULTS

A total of 80 pregnant women with confirmed severe acute respiratory syndrome coronavirus 2 infection were seen within the study period, 59 (73.8%) survived and 21 (26.2%) died. The median (interquartile range) age was 29 (23-33) years, the majority being in the third trimester of pregnancy (81.2%; n = 65). Interestingly, four (5%) pregnant women were co-infected with malaria by Plasmodium vivax and three (3.8%) with syphilis. The most frequent symptoms were fever (75%; n = 60), dry cough (68.8%; n = 55), dyspnoea (55%; n = 44), and headache (53.8%; n = 43). The most frequent maternal complications were anaemia (51.5%; n = 66) and hypertensive disorders of pregnancy (17.5%; n = 14). The most frequent perinatal complications were preterm delivery (39.2%; n = 20/51) and oligohydramnios (31.3%; n = 25). A total of 29 (36.3%) adverse foetal outcomes were documented, 21 stillbirth and eight abortions.

CONCLUSION

This is the first study to describe the clinical-epidemiological behaviour of COVID-19 in hospitalised Venezuelan pregnant women. Anaemia, hypertensive disorders of pregnancy, oligohydramnios, and low birth weight were the most frequent maternal-foetal complications in this population of pregnant women.

Comparison of Maternal-Fetal Outcomes among Unvaccinated and Vaccinated Pregnant Women with COVID-19

Background: This study sought to elucidate whether COVID-19 vaccination, during gestation or before conception, entails a decreased incidence of severe COVID-19 disease during pregnancy. Methods: This retrospective cohort study included all pregnant women that were followed up at a tertiary University Hospital with SARS-CoV-2 infection diagnosed between 1 March 2020 and 30 July 2022. The primary outcome of the study was to compare maternal and perinatal outcomes in unvaccinated and vaccinated pregnant patients with SARS-CoV-2 infection. Results: A total of 487 pregnant women with SARS-CoV-2 infection were included. SARS-CoV-2 infection during the third trimester of pregnancy was associated with an 89% lower probability of positive cord-blood SARS-CoV-2 IgG antibodies (OR 0.112; 95% CI 0.039-0.316), compared with infection during the first or the second trimester. Vaccinated pregnant women (201 (41.27%)) with COVID-19 had an 80% lower risk for developing pneumonia and requiring hospital admission due to COVID-19 than unvaccinated patients (aOR 0.209; 95% CI 0.044-0.985). Noticeably, pregnant patients with SARS-CoV-2 infection with at least two doses of the COVID-19 vaccine did not develop severe COVID-19. Conclusion: Vaccinated women with SARS-CoV-2 infection during pregnancy are associated with decreased hospital admission due to COVID-19 as well as reduced progression to severe COVID-19.

PERINATAL ASPECTS OF SARS-CoV-2 INFECTION DURING PREGNANCY: A POTENTIAL CAUSE FOR CONCERN

Ever since the beginning of COVID-19 pandemic, uncertainty regarding clinical presentation and differences among various subpopulations exist. With more than 209,870,000 confirmed cases and more than 4,400,000 deaths worldwide, we are facing the new era of health crisis which will undoubtedly impair global health, economic and social circumstances. In the past year, numerous genetic mutations which code SARS-CoV-2 proteins led to the occurrence of new viral strains, with higher transmission rates. Apart from the implementation of vaccination, the effect of SARS-CoV-2 on pregnancy outcome and maternal fetal transmission remains an important concern. Although neonates diagnosed with COVID-19 were mostly asymptomatic or presented with mild disease, the effect on early pregnancy is yet to be evident. While positive finding of SARS-CoV-2 RNA in some samples such as amniotic fluid, placental tissue, cord blood and breast milk exists, additional research should confirm its association with transplacental transmission.

SARS-CoV-2 in Pregnancy-A Retrospective Analysis of Selected Maternal and Fetal Laboratory Parameters

Pregnant women and their neonates belong to the group of individuals with elevated risk for COVID-19 infection. Data on the course of the disease and how it affects the pregnancy and neonatal wellbeing remain conflicting. The aim of the study was to evaluate the effect of SARS CoV-2 infection on the mode of delivery, neonatal condition and selected maternal and fetal laboratory parameters. This was a single-center retrospective case-control study. This dataset was generated using electronic medical records collected by medical personnel. Two groups of patients, hospitalized between April, 2020 and February, 2021, were included in the study: study group (304)-pregnant women with SARS-CoV-2 and control group (N = 329)-healthy pregnant women or parturients. Mothers with a severe course of COVID-19 had higher activated partial thromboplastin-APTT (p = 0.02), C-Reactive Protein-CRP (p = 0.00) and procalcitonin (p = 0.032) levels as compared to pregnant women with mild or moderate course of the disease. Neonates born to SARS-CoV-2-infected mothers presented with worse condition at 1 and 5 minutes of life (p = 0.000 and 0.00, respectively) and lower Arterial Blood Gas-ABG pH scores (p = 0.016). Elective cesarean section is the most common mode of delivery for SARS-CoV2-infected mothers. Emergency cesarean sections are performed at earlier gestational age as compared to vaginal delivery and elective cesarean section. Lower Apgar scores were observed in neonates born to SARS-CoV-2-infected mothers who required oxygen therapy and whose procalcitonin levels were elevated. There is a relationship between more severe course of COVID-19 and APTT, as well as CRP and procalcitonin levels.

COVID-19 Pregnancies with Heart Disease: Challenges of Delivery

This case series of four cases of pregnancy with rheumatic heart disease with COVD-19 disease reports on the management of delivery and complications of heart disease with COVID-19, high-lighting the presentation, severity, delivery concerns, and clinical management with the maternal and fetal outcomes. Of the four full-term deliveries, one delivered normally, one instrumental delivery and two by cesarean section. All four required oxygen support post-delivery, 2/4 (50%) were transferred for intensive care unit (ICU) care, 1/4 (25%) required mechanical ventilation, 1/4 (25%) had postpartum hemorrhage, 1/4 (25%) had COVID related sepsis and received convalescent plasma therapy, and 2/4 (50%) received antiviral remdesivir. The most severe disease (COVID sepsis and ICU stay) was seen in patient of heart disease with COVID with preclampsia. All neonates tested SARS-CoV-2 negative, with one early neonatal death. All four mothers were discharged in stable condition of COVID and heart status. COVID-19 in cardiac disease pregnancies has increased rates of complications, oxygen, and ICU requirements than other pregnancies with COVID, requiring multidisciplinary team for intensive monitoring of intrapartum and postpartum period.

[COVID-19 in Pregnancy - a Risk for the Unborn Child?]

Geburtskliniken werden zunehmend mit an Covid-19 erkrankten Schwangeren konfrontiert. Dies stellt Geburtshelfer vor große Herausforderungen, da einige Fragestellungen noch nicht ausreichend wissenschaftlich erforscht sind. Über Covid-19 während der Schwangerschaft und seine Auswirkungen auf das ungeborene und neugeborene Kind ist nicht viel bekannt.

Maternal and neonatal immune response to SARS-CoV-2, IgG transplacental transfer and cytokine profile

SARS-CoV-2 infected pregnant women are at increased risk of severe COVID-19 than non-pregnant women and have a higher risk of adverse pregnancy outcomes like intrauterine/fetal distress and preterm birth. However, little is known about the impact of SARS-CoV-2 infection on maternal and neonatal immunological profiles. In this study, we investigated the inflammatory and humoral responses to SARS-CoV-2 in maternal and cord blood paired samples. Thirty-six pregnant women were recruited at delivery at Hospital Sant Joan de Déu, Barcelona, Spain, between April-August 2020, before having COVID-19 available vaccines. Maternal and pregnancy variables, as well as perinatal outcomes, were recorded in questionnaires. Nasopharyngeal swabs and maternal and cord blood samples were collected for SARS-CoV-2 detection by rRT-PCR and serology, respectively. We measured IgM, IgG and IgA levels to 6 SARS-CoV-2 antigens (spike [S], S1, S2, receptor-binding domain [RBD], nucleocapsid [N] full-length and C-terminus), IgG to N from 4 human coronaviruses (OC43, HKU1, 229E and NL63), and the concentrations of 30 cytokines, chemokines and growth factors by Luminex. Mothers were classified as infected or non-infected based on the rRT-PCR and serology results. Sixty-four % of pregnant women were infected with SARS-CoV-2 (positive by rRT-PCR during the third trimester and/or serology just after delivery). None of the newborns tested positive for rRT-PCR. SARS-CoV-2 infected mothers had increased levels of virus-specific antibodies and several cytokines. Those with symptoms had higher cytokine levels. IFN-α was increased in cord blood from infected mothers, and in cord blood of symptomatic mothers, EGF, FGF, IL-17 and IL-15 were increased, whereas RANTES was decreased. Maternal IgG and cytokine levels showed positive correlations with their counterparts in cord blood. rRT-PCR positive mothers showed lower transfer of SARS-CoV-2-specific IgGs, with a stronger effect when infection was closer to delivery. SARS-CoV-2 infected mothers carrying a male fetus had higher antibody levels and higher EGF, IL-15 and IL-7 concentrations. Our results show that SARS-CoV-2 infection during the third trimester of pregnancy induces a robust antibody and cytokine response at delivery and causes a significant reduction of the SARS-CoV-2-specific IgGs transplacental transfer, with a stronger negative effect when the infection is closer to delivery.

Written Briefing and Oral Counseling Increase the Willingness to Receive the SARS-CoV-2 Vaccination among Women in Puerperium: A Qualitative Prospective Cohort Study

(1) Background: Vaccination rates for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) are low in Austria. International obstetric societies recommend the SARS-CoV-2 mRNA vaccination for women in puerperium. (2) Methods: A prospective two-stage cohort study was conducted at the Medical University of Vienna between October 2022 and December 2022. Firstly, women in puerperium were assigned to the evaluation group (step 1), and secondly, another cohort of unvaccinated women were randomly assigned to study group A (written briefing) or B (written and oral briefing) (step 2). We evaluated the vaccination status among women in the evaluation group and the willingness to receive the vaccination in all three cohorts. (3) Results: We included 217 women in puerperium (evaluation: n = 69, A: n = 68; B: n = 80). In the evaluation group, 66.7% (n = 46/69) of the women were unvaccinated. A total of 45.7% (21/46) of the unvaccinated women categorically declined the SARS-CoV-2 vaccination. A total of 26.5% (n = 18/68) of women in study group A, and 43.8% (n = 35/80) of women in study group B expressed their willingness to receive the vaccination (p = 0.029). There were no differences in willingness to receive the vaccination between different age strata of women in study groups A and B. (D) Conclusion: Our qualitative data demonstrate a benefit from oral counseling in addition to written briefing in order to increase the willingness to receive the vaccination among women in puerperium.

Clinical manifestations of COVID-19: An overview of 102 systematic reviews with evidence mapping

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, but there is so far no comprehensive analysis of all known symptoms of the disease. Our study aimed to present a comprehensive picture of the clinical symptoms of COVID-19 using an evidence map.

METHODS

We systematically searched MEDLINE via PubMed, Web of Science, Embase, and Cochrane library from their inception to March 16, 2021. We included systematic reviews reporting the clinical manifestations of COVID-19 patients. We followed the PRISMA guidelines, and the study selection, data extraction, and quality assessment were done by two individuals independently. We assessed the methodological quality of the studies using AMSTAR. We visually presented the clinical symptoms of COVID-19 and their prevalence.

RESULTS

A total of 102 systematic reviews were included, of which, 68 studies (66.7%) were of high quality, 19 studies (18.6%) of medium quality, and 15 studies (14.7%) of low quality. We identified a total of 74 symptoms including 17 symptoms of the respiratory system, 21 symptoms of the neurological system, 10 symptoms of the gastrointestinal system, 16 cutaneous symptoms, and 10 ocular symptoms. The most common symptoms were fever (67 studies, ranging 16.3%-91.0%, pooled prevalence: 64.6%, 95%CI, 61.3%-67.9%), cough (68 studies, ranging 30.0%-72.2%, pooled prevalence: 53.6%, 95%CI, 52.1%-55.1%), muscle soreness (56 studies, ranging 3.0%-44.0%, pooled prevalence: 18.7%, 95%CI, 16.3%-21.3%), and fatigue (52 studies, ranging 3.3%-58.5%, pooled prevalence: 29.4%, 95%CI, 27.5%-31.3%). The prevalence estimates for COVID-19 symptoms were generally lower in neonates, children and adolescents, and pregnant women than in the general populations.

CONCLUSION

At least 74 different clinical manifestations are associated with COVID-19. Fever, cough, muscle soreness, and fatigue are the most common, but attention should also be paid to the rare symptoms that can help in the early diagnosis of the disease.

SARS-CoV-2 Is Persistent in Placenta and Causes Macroscopic, Histopathological, and Ultrastructural Changes

SARS-CoV-2 is a virus that belongs to the Betacoronavirus genus of the Coronaviridae family. Other coronaviruses, such as SARS-CoV and MERS-CoV, were associated with complications in pregnant women. Therefore, this study aimed to report the clinical history of five pregnant women infected with SARS-CoV-2 (four symptomatic and one asymptomatic who gave birth to a stillborn child) during the COVID-19 pandemic. They gave birth between August 2020 to January 2021, a period in which there was still no vaccination for COVID-19 in Brazil. In addition, their placental alterations were later investigated, focusing on macroscopic, histopathological, and ultrastructural aspects compared to a prepandemic sample. Three of five placentas presented SARS-CoV-2 RNA detected by RT-PCRq at least two to twenty weeks after primary pregnancy infection symptoms, and SARS-CoV-2 spike protein was detected in all placentas by immunoperoxidase assay. The macroscopic evaluation of the placentas presented congested vascular trunks, massive deposition of fibrin, areas of infarctions, and calcifications. Histopathological analysis showed fibrin deposition, inflammatory infiltrate, necrosis, and blood vessel thrombosis. Ultrastructural aspects of the infected placentas showed a similar pattern of alterations between the samples, with predominant characteristics of apoptosis and detection of virus-like particles. These findings contribute to a better understanding of the consequences of SARS-CoV-2 infection in placental tissue, vertical transmission.

Fetoplacental transmission and placental response to SARS-CoV-2: Evidence from the literature

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a dreadful novel coronavirus with global health concerns among pregnant women. To date, the vertical transmission of SARS-CoV-2 during pregnancy remains controversial. We briefly report recent findings of placental response to SARS-CoV-2 infection and updates on vertical transmission. We systematically searched PubMed and Google Scholar databases according to PRISMA guidelines for studies reporting the effects of SARS-CoV-2 infection on the placenta and possibility of vertical transmission. We identified 45 studies reporting 1,280 human placentas that were analyzed by molecular pathology methods and 11,112 placenta-derived cells from a publicly available database that was analyzed using bioinformatics tools. The main finding of this study is that the SARS-CoV-2 canonical entry receptors (ACE2 and TMPRSS2) are abundantly expressed on the placenta during the first trimester, and this expression diminishes across gestational age. Out of 45 eligible studies identified, 24 (53.34%) showed no evidence of vertical transmission, 15 (33.33%) supported the hypothesis of very rare, low possibility of vertical transmission and 6 (13.33%) were indecisive and had no comment on vertical transmission. Furthermore, 433 placentas from 12 studies were also identified for placental pathology investigation. There was evidence of at least one form of maternal vascular malperfusion (MVM), 57/433 (13.1%), fetal vascular malperfusion (FVM), 81/433 (18.7%) and placental inflammation with excessive infiltration of CD3+ CD8+ lymphocytes, CD68+ macrophages and CD20+ lymphocytes in most of the eligible studies. Decidual vasculopathy (3.2%), infarction (3.2%), chronic histiocytic intervillositis (6.0%), thrombi vasculopathy (5.1%) were also observed in most of the MVM and FVM reported cases. The results indicated that SARS-CoV-2 induces placenta inflammation, and placenta susceptibility to SARS-CoV-2 decreases across the pregnancy window. Thus, SARS-CoV-2 infection in early pregnancy may adversely affect the developing fetus.

The İmpact of Elevated Liver Enzymes and İntrahepatic Cholestasis of Pregnancy on the Course of COVID-19 in Pregnant Women

This study aims to investigate the perinatal outcomes in COVID-19 pregnant women with intrahepatic cholestasis of pregnancy (ICP) and elevated liver enzymes. Present study was carried out on pregnant women with COVID-19 between March 11, 2020, and August 11, 2021. Patients with liver enzyme levels higher than twice the upper limit of the reference range for aspartate aminotransferase(AST) and/or alanine aminotransferase (ALT) were included. Patients with unexplained pruritus and elevated fasting biliary acid (FBA) levels were considered ICP. The remaining cases were used as the control group. There were a total of 1751 patients in the study period. Among them, 126 had elevated liver enzymes. Nineteen of these cases had also ICP. AST and ALT values were statistically higher in the ICP group. Demographic features, clinical characteristics, and perinatal outcomes were similar between the groups. The rate of ICP in pregnant women with COVID-19 was similar to the literature in this study. Although the preterm delivery rates for both groups were higher than in the current literature, the preterm delivery rates in the study and control groups were similar. Elevated liver enzymes can be observed in pregnant women with COVID-19 with higher rates of preterm delivery compared to the previous literature. However, the diagnosis of ICP in addition to elevated liver enzymes seems to have no significant impact on the perinatal outcomes. Future studies conducted on larger populations are necessary to confirm these results.