Racial-ethnic disparities and pregnancy outcomes in SARS-CoV-2 infection in a universally-tested cohort in Houston, Texas

Disparities in perinatal COVID-19 infection and vaccination

The COVID-19 pandemic exposed and exacerbated persistent health inequities in perinatal populations, resulting in disparities of maternal and fetal complications. In this narrative review, we present an adapted conceptual framework of perinatal social determinants of health in the setting of the COVID-19 pandemic and use this framework to contextualize the literature regarding disparities in COVID-19 vaccination and infection. We synthesize how elements of the structural context, individual socioeconomic position, and concrete intermediary determinants influence each other and perinatal COVID-19 vaccination and infection, arguing that systemic inequities at each level contribute to observed disparities in perinatal health outcomes. From there, we identify gaps in the literature, propose mechanisms for observed disparities, and conclude with a discussion of strategies to mitigate them.

Social Drivers of COVID-19 Disease Severity in Pregnant Patients

OBJECTIVE

While coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had global impact in all populations, certain groups of patients have experienced disproportionate rates of morbidity and mortality. The purpose of this study was to assess the relationship between COVID-19 disease severity, demographic variables, race and ethnicity, and social determinants of health among pregnant patients in a diverse urban population.

STUDY DESIGN

A retrospective analysis was performed of all pregnant patients diagnosed with COVID-19 at two urban tertiary care centers in Houston, TX between March and August 2020. Maternal demographic, COVID-19 illness criteria, and delivery characteristics were collected. The Centers for Disease Control and Prevention Social Vulnerability Index (SVI) and COVID-19 Community Vulnerability Index (CCVI) were obtained based on a patients' census tract of residence. Analyses compared persons with asymptomatic, mild, or severe-critical disease at diagnosis.

RESULTS

A total of 317 persons tested positive for COVID-19 during this time period. Asymptomatic persons were more likely to be diagnosed at later gestational ages, but there were no other differences in baseline maternal characteristics. Persons with more severe disease had greater social vulnerability specifically for housing and transportation than those with mild disease (mean SVI [standard error]: 0.72 [0.06] vs. 0.58 [0.2], p = 0.03). Total SVI, total CCVI, and other themed SVI and CCVI indices were not significantly different between groups.

CONCLUSION

In this cohort of pregnant persons infected with SARS-CoV-2, an association was shown between disease severity and increased vulnerability in living conditions and transportation. Drivers of the pandemic and COVID-19 outcomes are complex and multifactorial, and likely change over time. However, continued efforts to accurately identify and measure social determinants of health in medicine will likely help identify geographic areas and patient populations that are at risk of higher disease burden. This could facilitate preventative and mitigation measures in these areas in future disaster or pandemic situations.

KEY POINTS

· SVI and CCVI estimate social determinants of health.. · COVID-19 is associated with housing and transportation vulnerability.. · Social determinants contribute to disease burden in pregnancy..

Solutions From Mexican-Descent Perinatal Women To Pandemic-Related Food, Mental Health, And Health And Safety Stressors

Latina women in the US were disproportionately affected by the COVID-19 pandemic because of structural racism, including discrimination, reduced care access, and elevated risk for illness and death. Although several US policies were implemented to offset the economic toll of the pandemic, few addressed complex stressors, particularly those among Mexican-descent mothers. This qualitative study with thirty-eight perinatal women and mothers of young children who were of Mexican descent sought to identify pandemic-related stressors and solicit recommendations for addressing them during future large-scale crises. Identified stressors included food access issues, mental health needs, and health and safety concerns. The women's recommendations revealed feasible and actionable strategies, including increased access to behavioral and health care services and accessible information about food-related resources. The findings highlight the critical need for responsive policies and programs to ensure the well-being of Mexican-descent perinatal women and mothers of young children during large-scale crises.

Delivery outcomes in a cohort of pregnant patients with COVID-19 with and without viral pneumonia

BACKGROUND

Among pregnant people, COVID-19 can lead to adverse outcomes, but the specific pregnancy outcomes that are affected by the disease are unclear. In addition, the effect of the severity of COVID-19 on pregnancy outcomes has not been clearly identified.

OBJECTIVE

This study aimed to evaluate the associations between COVID-19 with and without viral pneumonia and cesarean delivery, preterm delivery, preeclampsia, and stillbirth.

STUDY DESIGN

We conducted a retrospective cohort study (April 2020-May 2021) of deliveries between 20 and 42 weeks of gestation from US hospitals in the Premier Healthcare Database. The primary outcomes were cesarean delivery, preterm delivery, preeclampsia, and stillbirth. We used a viral pneumonia diagnosis (International Classification of Diseases -Tenth-Clinical Modification codes J12.8 and J12.9) to categorize patients by severity of COVID-19. Pregnancies were categorized into 3 groups: NOCOVID (no COVID-19), COVID (COVID-19 without viral pneumonia), and PNA (COVID-19 with viral pneumonia). Groups were balanced for risk factors by propensity-score matching.

RESULTS

A total of 814,649 deliveries from 853 US hospitals were included (NOCOVID: n=799,132; COVID: n=14,744; PNA: n=773). After propensity-score matching, the risks of cesarean delivery and preeclampsia were similar in the COVID group compared with the NOCOVID group (matched risk ratio, 0.97; 95% confidence interval, 0.94-1.00; and matched risk ratio, 1.02; 95% confidence interval, 0.96-1.07; respectively). The risks of preterm delivery and stillbirth were greater in the COVID group than in the NOCOVID group (matched risk ratio, 1.11; 95% confidence interval, 1.05-1.19; and matched risk ratio, 1.30; 95% confidence interval, 1.01-1.66; respectively). The risks of cesarean delivery, preeclampsia, and preterm delivery were higher in the PNA group than in the COVID group (matched risk ratio, 1.76; 95% confidence interval, 1.53-2.03; matched risk ratio, 1.37; 95% confidence interval, 1.08-1.74; and matched risk ratio, 3.33; 95% confidence interval, 2.56-4.33; respectively). The risk of stillbirth was similar in the PNA and COVID group (matched risk ratio, 1.17; 95% confidence interval, 0.40-3.44).

CONCLUSION

Within a large national cohort of hospitalized pregnant people, we found that the risk of some adverse delivery outcomes was elevated in people with COVID-19 with and without viral pneumonia, with much higher risks in the group with viral pneumonia.

Can prenatal ultrasound predict adverse neonatal outcomes in SARS-CoV-2-affected pregnancies?

BACKGROUND

On the basis of available data, at least 1 ultrasound assessment of pregnancies recovering from SARS-CoV-2 infection is recommended. However, reports on prenatal imaging findings and potential associations with neonatal outcomes following SARS-CoV-2 infection in pregnancy have been inconclusive.

OBJECTIVE

This study aimed to describe the sonographic characteristics of pregnancies after confirmed SARS-CoV-2 infection and assess the association of prenatal ultrasound findings with adverse neonatal outcomes.

STUDY DESIGN

This was an observational prospective cohort study of pregnancies diagnosed with SARS-CoV-2 by reverse transcription polymerase chain reaction between March 2020 and May 2021. Prenatal ultrasound evaluation was performed at least once after diagnosis of infection, with the following parameters measured: standard fetal biometric measurements, umbilical and middle cerebral artery Dopplers, placental thickness, amniotic fluid volume, and anatomic survey for infection-associated findings. The primary outcome was the composite adverse neonatal outcome, defined as ≥1 of the following: preterm birth, neonatal intensive care unit admission, small for gestational age, respiratory distress, intrauterine fetal demise, neonatal demise, or other neonatal complications. Secondary outcomes were sonographic findings stratified by trimester of infection and severity of SARS-CoV-2 infection. Prenatal ultrasound findings were compared with neonatal outcomes, severity of infection, and trimester of infection.

RESULTS

A total of 103 SARS-CoV-2-affected mother-infant pairs with prenatal ultrasound evaluation were identified; 3 cases were excluded because of known major fetal anomalies. Of the 100 included cases, neonatal outcomes were available in 92 pregnancies (97 infants); of these, 28 (29%) had the composite adverse neonatal outcome, and 23 (23%) had at least 1 abnormal prenatal ultrasound finding. The most common abnormalities seen on ultrasound were placentomegaly (11/23; 47.8%) and fetal growth restriction (8/23; 34.8%). The latter was associated with a higher rate of the composite adverse neonatal outcome (25% vs 1.5%; adjusted odds ratio, 22.67; 95% confidence interval, 2.63-194.91; P<.001), even when small for gestational age was removed from this composite outcome. The Cochran Mantel-Haenszel test controlling for possible fetal growth restriction confounders continued to show this association (relative risk, 3.7; 95% confidence interval, 2.6-5.9; P<.001). Median estimated fetal weight and birthweight were lower in patients with the composite adverse neonatal outcome (P<.001). Infection in the third trimester was associated with lower median percentile of estimated fetal weight (P=.019). An association between placentomegaly and third-trimester SARS-CoV-2 infection was noted (P=.045).

CONCLUSION

In our study of SARS-CoV-2-affected maternal-infant pairs, rates of fetal growth restriction were comparable to those found in the general population. However, composite adverse neonatal outcome rates were high. Pregnancies with fetal growth restriction after SARS-CoV-2 infection were associated with an increased risk for the adverse neonatal outcome and may require close surveillance.

A pilot study: Validation of dried blood spots (DBS) to assess SARS-CoV2 IgG antibody immunoassays in underserved minority population

Underserved, low-income, rural and certain migrant populations have greater risks and higher incidences of Coronavirus disease 2019 (COVID-19) than more privileged populations. Current in-person testing methods have limitations, namely exposure risk, a requirement of accessible transportation to healthcare facilities, and economic barriers. Dried blood spots (DBS) samples are widely used for diagnostics in many infectious diseases including Rabies, HIV, Ebola viruses and newborn screening. Our goal was to determine the accuracy and reliability of measuring COVID-19 IgG in DBS compared to paired plasma samples in a population with known infection status and then apply this method to screen an underserved minority population with high risk for COVID-9 infection (unvaccinated, pregnant, low income, Hispanic women). To optimize the assay, we tested 22 nonpregnant women, 12 with positive prior PCR testing for SARS-CoV2 infection and 10 with negative PCR results. After the assay was optimized, we tested the assay in a vulnerable population with a high risk for infection, who were 52 Hispanic pregnant women without prior PCR testing or vaccination. DBS assay results in both groups showed an agreement of 100% with paired plasma samples. The availability of a DBS assay could enable people who may not have access or transportation to healthcare facilities to use DBS as a COVID-19 testing vehicle.

Maternal COVID-19 infection and associated factors: A cross-sectional study

BACKGROUND

Since the declaration of COVID-19 as a global pandemic, several studies have been conducted to examine associated factors. However, few studies have focused on pregnant women infected with COVID-19 in sub-Saharan Africa. Therefore, this study investigated the prevalence and factors associated with COVID-19 infection among pregnant women at the Levy Mwanawasa University Teaching Hospital and Women and Newborn Hospital of the University Teaching Hospitals in Lusaka, Zambia.

METHODS

A cross-sectional study was conducted between March and July 2021. Women were recruited as they presented for antenatal care. Data was collected using a structured questionnaire to capture variables of interest (socio-demographic, clinical and obstetric). COVID-19 diagnosis was made using a nasopharyngeal swab by PCR test. Multivariable logistic regression was used to control for confounding and calculate the odds ratios for each explanatory variable and respective 95% confidence intervals.

RESULTS

The study enrolled 352 participants with a mean (standard deviation [SD]) age of 30.1 years (5.6). One hundred thirty of 352 (36.9%; 95% CI: 31.9 to 42.2) participants had a confirmed positive SARS-CoV-2 test result. At univariable analysis, factors associated with COVID-19 were increased gestational age, education status and maternal HIV serostatus. Women with a secondary level of education were less likely to have COVID-19 infection than those with a primary level of education (AOR = 0.23, 95% CI: 0.09-0.63). On the other hand, a one-week increase in gestational age was associated with higher odds of COVID-19 infection (AOR = 1.03, 95% CI: 1.01-1.06).

CONCLUSION

The results showed that the prevalence of COVID-19 infection among pregnant women was 36.9% and was associated with increased gestational age and a lower level of education. To mitigate adverse maternal outcomes, there is a need to screen for COVID-19 strictly and broadly monitor prenatal women presenting for healthcare.

Evaluation of Safety Concerns for COVID-19 Immunization of Pregnant Women: a Systematic Review of Emerging Evidence

Objectives: There is an urgent need to review the status of COVID-19 vaccine immunization in pregnant women globally, so that adverse outcomes may be prevented. In this study, we performed a systematic review to evaluate the probable outcomes of COVID-19 vaccination in pregnant women. Materials and methods:An electronic search over three months (June 15-August 15, 2021) was conducted. Original studies evaluating safety concerns in pregnant women for COVID-19 vaccination were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were used for data collection and reporting of findings. Results:COVID-19 vaccination in pregnant women was not associated with increased adverse effects or complications to the mother as well as the developing fetus or new-born compared to non-vaccinated pregnant women. Vaccinated pregnant women showed a robust immune response against COVID-19 infection. Conclusion:COVID-19 vaccination during pregnancy causes no significant health risks for the mother or the developing fetus or new-born.

Maternal and Neonatal Outcomes in Pregnant Women With Coronavirus Disease 2019 in Korea

BACKGROUND

This study aimed to describe the maternal, obstetrical, and neonatal outcomes in pregnant women with coronavirus disease 2019 (COVID-19) and identify the predictors associated with the severity of COVID-19.

METHODS

This multicenter observational study included consecutive pregnant women admitted because of COVID-19 confirmed using reverse transcriptase-polymerase chain reaction (RT-PCR) test at 15 hospitals in the Republic of Korea between January 2020 and December 2021.

RESULTS

A total of 257 women with COVID-19 and 62 newborns were included in this study. Most of the patients developed this disease during the third trimester. Nine patients (7.4%) developed pregnancy-related complications. All pregnant women received inpatient treatment, of whom 9 (3.5%) required intensive care, but none of them died. The gestational age at COVID-19 diagnosis (odds ratio [OR], 1.096, 95% confidence interval [CI], 1.04-1.15) and parity (OR, 1.703, 95% CI, 1.13-2.57) were identified as significant risk factors of severe diseases. Among women who delivered, 78.5% underwent cesarean section. Preterm birth (38.5%), premature rupture of membranes (7.7%), and miscarriage (4.6%) occurred, but there was no stillbirth or neonatal death. The RT-PCR test of newborns' amniotic fluid and umbilical cord blood samples was negative for severe acute respiratory syndrome coronavirus 2.

CONCLUSION

At the time of COVID-19 diagnosis, gestational age and parity of pregnant women were the risk factors of disease severity. Vertical transmission of COVID-19 was not observed, and maternal severity did not significantly affect the neonatal prognosis.

Cardiovascular Complications of COVID-19 among Pregnant Women and Their Fetuses: A Systematic Review

Background: COVID-19 is a viral infectious disease leading to a spectrum of clinical complications, especially cardiovascular. Evidence shows that this infection can potentially accompany a worse outcome in pregnant women. Cardiovascular complications in mothers and their fetuses are reported by previous studies. Objective: In this systematic review, we aim to investigate the cardiovascular complications of COVID-19 during pregnancy in the mothers and fetus, according to the published literature. Method: We systematically searched the online databases of PubMed, Scopus, Web of Science, and Google Scholar, using relevant keywords up to April 2022. We included all observational studies reporting cardiovascular complications among COVID-19-affected pregnant women and their fetuses. Results: We included 74 studies containing 47582 pregnant COVID-19 cases. Pre-eclampsia, hypertensive disorders, cardiomyopathy, heart failure, myocardial infarction, thrombosis formation, alterations in maternal–fetal Doppler patterns, and maternal and fetal arrhythmia were reported as cardiovascular complications. The highest incidences of pre-eclampsia/eclampsia among COVID-19 pregnant cases, reported by studies, were 69% and 62%, and the lowest were 0.5% and 3%. The highest and lowest incidences of fetal bradycardia were 20% and 3%, and regarding fetal tachycardia, 5.4% and 1%, respectively. Conclusion: SARS-CoV-2 infection during pregnancy can potentially be associated with cardiovascular complications in the mother, particularly pre-eclampsia and heart failure. Moreover, SARS-CoV-2 infection during pregnancy can potentially cause cardiovascular complications in the fetus, particularly arrhythmia.

Effect of the COVID-19 pandemic on racial disparities in neuraxial labor analgesia at a Texas level IV maternal care center

We hypothesized that racial disparities in labor epidural analgesia at our hospital that existed prior to the COVID-19 pandemic would be exacerbated during the COVID-19 pandemic. We examined patients who delivered vaginally at our hospital for the last 6 months of 2019 and the last 6 months of 2020. We performed joint testing of coefficient P values, and the interaction term between race and year of delivery was not significant (0.364). A multivariate logistic regression model found that Hispanic patients (odds ratio 0.555 [0.408, 0.756], P < 0.001) and Black or African American patients (odds ratio 0.613 [0.408, 0.921], P = 0.018) were less likely to receive labor epidural analgesia compared to White or Caucasian patients. Odds ratios of receiving labor epidural analgesia were higher with increasing gestational age (1.116 [1.067, 1.168], P < 0.001) and lower with increasing parity (0.789 [0.719, 0.867], P < 0.001). The year of birth that corresponded to before or during the COVID-19 pandemic did not predict whether a patient received labor epidural analgesia (1.247 [0.941, 1.652], P = 0.124). Because the interaction between race and year of birth was not statistically significant, we conclude that the COVID-19 pandemic did not exacerbate racial disparities in labor epidural analgesia at our hospital.

The association between maternal characteristics and SARS-CoV-2 in pregnancy: a population-based registry study in Sweden and Norway

The objectives of the current study were to identify risk factors for SARS-CoV-2 positivity, and to address how different testing strategies, choice of comparison group, and population background characteristics may influence observed associations. National registries data for 107,627 pregnant women in Sweden and 81,195 in Norway, were used to identify risk factors for SARS-CoV-2, separately for women under non-universal testing (testing by indication) and universal testing (testing of all pregnant women in contact with a delivery ward). We also investigated underlying characteristics associated with testing for SARS-CoV-2. Overall, 2.1% of pregnant women in Sweden and 1.1% in Norway were test-positive during the pandemic’s first 18 months. We show that the choice of test strategy for SARS-CoV-2 provided different associations with risk factors for the disease; for instance, women who were overweight, obese or had gestational diabetes had increased odds of being test-positive under non-universal testing, but not under universal testing. Nevertheless, a consistent pattern of association between being born in the Middle East and Africa and test-positivity was found independent of test strategy and in both countries. These women were also less likely to get tested. Our results are useful to consider for surveillance and clinical recommendations for pregnant women during the current and future pandemics.

Pregnancy and the Risk of In-Hospital Coronavirus Disease 2019 (COVID-19) Mortality

OBJECTIVE

To evaluate whether pregnancy is an independent risk factor for in-hospital mortality among patients of reproductive age hospitalized with coronavirus disease 2019 (COVID-19) viral pneumonia.

METHODS

We conducted a retrospective cohort study (April 2020-May 2021) of 23,574 female inpatients aged 15-45 years with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code for COVID-19 discharged from 749 U.S. hospitals in the Premier Healthcare Database. We used a viral pneumonia diagnosis to select for patients with symptomatic COVID-19. The associations between pregnancy and in-hospital mortality, intensive care unit (ICU) admission, and mechanical ventilation were analyzed using propensity score-matched conditional logistic regression. Models were matched for age, marital status, race and ethnicity, Elixhauser comorbidity score, payer, hospital number of beds, season of discharge, hospital region, obesity, hypertension, diabetes mellitus, chronic pulmonary disease, deficiency anemias, depression, hypothyroidism, and liver disease.

RESULTS

In-hospital mortality occurred in 1.1% of pregnant patients and 3.5% of nonpregnant patients hospitalized with COVID-19 and viral pneumonia (propensity score-matched odds ratio [OR] 0.39, 95% CI 0.25-0.63). The frequency of ICU admission for pregnant and nonpregnant patients was 22.0% and 17.7%, respectively (OR 1.34, 95% CI 1.15-1.55). Mechanical ventilation was used in 8.7% of both pregnant and nonpregnant patients (OR 1.05, 95% CI 0.86-1.29). Among patients who were admitted to an ICU, mortality was lower for pregnant compared with nonpregnant patients (OR 0.33, 95% CI 0.20-0.57), though mechanical ventilation rates were similar (35.7% vs 38.3%, OR 0.90, 95% CI 0.70-1.16). Among patients with mechanical ventilation, pregnant patients had a reduced risk of in-hospital mortality compared with nonpregnant patients (0.26, 95% CI 0.15-0.46).

CONCLUSION

Despite a higher frequency of ICU admission, in-hospital mortality was lower among pregnant patients compared with nonpregnant patients with COVID-19 viral pneumonia, and these findings persisted after propensity score matching.

Obstetric and perinatal outcomes of pregnancies with COVID 19: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed at comparing obstetric and perinatal outcomes in laboratory-tested pregnant women for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection before delivering.

METHOD

We performed a comprehensive systematic review of electronic databases for studies reporting pregnant women with and without SARS-CoV-2 infection, as determined by polymerase chain reaction (PCR) before delivery, during the pandemic period published up to June 25, 2021. Results are reported as mean difference (MD) or odds ratio (OR) and their 95% confidence interval (CI).

RESULTS

Seventeen observational studies with low to moderate risk of bias, reported on 2,769 pregnant women with a positive SARS-CoV-2 PCR test and 13,807 with a negative test. Pregnant women with a positive PCR test delivered at an earlier gestational age (MD -0.19; 95% CI -0.36 to -0.02 weeks), smoked less (OR 0.75; 95% CI 0.61-0.94) and were associated with higher odds for preeclampsia (OR 1.30; 95% CI 1.09-1.54), NICU admissions (OR 2.37; 95% CI 1.18-4.76), stillbirths (OR 2.70; 95% CI, 1.38-5.29), and perinatal mortality (OR 3.23; 95% CI 1.23-8.52). There were no significant differences between positive and negative tested women in terms of nulliparity, multiple pregnancies, gestational diabetes, route of delivery, labor induction, preterm birth, infant birth weight, 5 min Apgar scores < 7, small-for-gestational-age infants and fetal malformations. Eleven studies included neonatal PCR SARS-CoV-2 testing which was performed on 129 infants, of which 20 were positive.

CONCLUSION

Positive SARS-CoV-2 tested pregnant women had higher odds for preeclampsia/hypertensive disorders of pregnancy, NICU admissions, stillbirths and perinatal mortality.

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.

Health Care Disparities in the COVID-19 Pandemic in the United States: A Focus on Obstetrics

The influence of social determinants of health on disease dynamics and outcomes has become increasingly clear, making them a prime target of investigation and mitigation efforts. The obstetric population is uniquely positioned to provide insight into the health inequities exacerbated by the coronavirus disease 2019 pandemic given their susceptibility to infectious disease morbidity and frequent interactions with the health care system, which provide opportunities for ascertainment of disease incidence and severity. This review summarizes the data on disparities identified in the US obstetric population during the coronavirus disease 2019 pandemic as they relate to race and ethnicity, built environment, insurance status, language, and immigration status.

Strategies to Estimate Prevalence of SARS-CoV-2 Antibodies in a Texas Vulnerable Population: Results From Phase I of the Texas Coronavirus Antibody Response Survey

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and immunity remains uncertain in populations. The state of Texas ranks 2nd in infection with over 2.71 million cases and has seen a disproportionate rate of death across the state. The Texas CARES project was funded by the state of Texas to estimate the prevalence of SARS-CoV-2 antibody status in children and adults. Identifying strategies to understand natural as well as vaccine induced antibody response to COVID-19 is critical.

Materials and Methods: The Texas CARES (Texas Coronavirus Antibody Response Survey) is an ongoing prospective population-based convenience sample from the Texas general population that commenced in October 2020. Volunteer participants are recruited across the state to participate in a 3-time point data collection Texas CARES to assess antibody response over time. We use the Roche Elecsys® Anti-SARS-CoV-2 Immunoassay to determine SARS-CoV-2 antibody status.

Results: The crude antibody positivity prevalence in Phase I was 26.1% (80/307). The fully adjusted seroprevalence of the sample was 31.5%. Specifically, 41.1% of males and 21.9% of females were seropositive. For age categories, 33.5% of those 18–34; 24.4% of those 35–44; 33.2% of those 45–54; and 32.8% of those 55+ were seropositive. In this sample, 42.2% (89/211) of those negative for the antibody test reported having had a COVID-19 test.

Conclusions: In this survey we enrolled and analyzed data for 307 participants, demonstrating a high survey and antibody test completion rate, and ability to implement a questionnaire and SARS-CoV-2 antibody testing within clinical settings. We were also able to determine our capability to estimate the cross-sectional seroprevalence within Texas's federally qualified community centers (FQHCs). The crude positivity prevalence for SARS-CoV-2 antibodies in this sample was 26.1% indicating potentially high exposure to COVID-19 for clinic employees and patients. Data will also allow us to understand sex, age and chronic illness variation in seroprevalence by natural and vaccine induced. These methods are being used to guide the completion of a large longitudinal survey in the state of Texas with implications for practice and population health.

COVID-19 and pregnancy: A comparison of case reports, case series and registry studies

BACKGROUND

Selection, outcome and publication biases are well described in case reports and case series but may be less of a problem early in the appearance of a new disease when all cases might appear to be worth publishing.

OBJECTIVE

To use a prospectively collected database of primary sources to compare the reporting of COVID-19 in pregnancy in case reports, case series and in registries over the first 8 months of the pandemic.

STUDY DESIGN

MEDLINE, Embase and Maternity and Infant Care databases were searched from 22 March to 5 November 2020, to create a curated list of primary sources. Duplicate reports were excluded. Case reports, case series and registry studies of pregnant women with confirmed COVID-19, where neonatal outcomes were reported, were selected and data extracted on neonatal infection status, neonatal death, neonatal intensive care unit admission, preterm birth, stillbirth, maternal critical care unit admission and maternal death.

RESULTS

149 studies comprising 41,658 mothers and 8,854 neonates were included. All complications were more common in case reports, and in retrospective series compared with presumably prospective registry studies. Extensive overlap is likely in registry studies, with cases from seven countries reported by multiple registries. The UK Obstetric Surveillance System was the only registry to explicitly report identification and removal of duplicate cases, although five other registries reported collection of patient identifiable data which would facilitate identification of duplicates.

CONCLUSIONS

Since it is likely that registries provide the least biased estimates, the higher rates seen in the other two study designs are probably due to selection or publication bias. However even some registry studies include self- or doctor-reported cases, so might be biased, and we could not completely exclude overlap of cases in some registries.

Disparities in COVID-19 Outcomes by Race, Ethnicity, and Socioeconomic Status: A Systematic-Review and Meta-analysis

IMPORTANCE

COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear.

OBJECTIVE

To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants.

DATA SOURCES

A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021.

STUDY SELECTION

Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The main measures were RRs, ORs, and combined prevalence values.

RESULTS

A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P < .001). The area deprivation index was positively correlated with mortality rates in Asian American and Hispanic individuals (P < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals (P < .001) and African American individuals (P < .001).

CONCLUSIONS AND RELEVANCE

In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.

COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California

BACKGROUND

Research on COVID-19 during pregnancy has mainly focused on women hospitalized for COVID-19 or other reasons during their pregnancy. Little is known about COVID-19 in the general population of pregnant women.

OBJECTIVE

To describe the prevalence of COVID-19, symptoms, consequent healthcare use, and possible sources of COVID-19 exposure among a population-based sample of pregnant women residing in Northern California.

METHODS

We analyzed data from 19,458 members of Kaiser Permanente Northern California who were pregnant between January 2020 and April 2021 and responded to an online survey about COVID-19 testing, diagnosis, symptoms, and their experiences during the COVID-19 pandemic. Medical diagnosis of COVID-19 during pregnancy was defined separately by self-report and by documentation in electronic health records (EHR). We examined relationships of COVID-19 with sociodemographic factors, underlying comorbidities, and survey measures of COVID-19-like symptoms, consequent healthcare utilization, and possible COVID-19 exposures.

RESULTS

Among 19,458 respondents, the crude prevalence of COVID-19 was 2.5% (n = 494) according to self-report and 1.4% (n = 276) according to EHR. After adjustment, the prevalence of self-reported COVID-19 was higher among women aged <25 years compared with women aged ≥35 years (prevalence ratio [PR], 1.75, 95% CI: 1.23, 2.49) and among Hispanic women compared with White women (PR, 1.91, 95% CI: 1.53, 2.37). Prevalence of self-reported COVID-19 was higher among women affected by personal or partner job loss during the pandemic (PR, 1.23, 95% CI: 1.02, 1.47) and among women living in areas of high vs. low neighborhood deprivation (PR, 1.74, 95% CI: 1.33, 2.27). We did not observe differences in self-reported COVID-19 between women with and without underlying comorbidities. Results were similar for EHR-documented COVID-19. Loss of smell or taste was a unique and common symptom reported among women with COVID-19 (42.3% in self-reported; 54.0% in EHR-documented). Among women with symptomatic COVID-19, approximately 2% were hospitalized, 71% had a telehealth visit, and 75% quarantined at home. Over a third of women with COVID-19 reported no known exposure to someone with COVID-19.

CONCLUSIONS

Observed COVID-19 prevalence differences by sociodemographic and socioeconomic factors underscore social and health inequities among reproductive-aged women. Women with COVID-19 reported unique symptoms and low frequency of hospitalization. Many were not aware of an exposure to someone with COVID-19.

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

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

Ultrasound and Doppler findings in pregnant women with SARS-CoV-2 infection

OBJECTIVES

To describe and compare ultrasound and Doppler findings in pregnant women who were positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with findings in those who were SARS-CoV-2-negative, evaluated during the pandemic period.

METHODS

In this retrospective case-control study, we analyzed data from 106 pregnant women who tested positive for SARS-CoV-2 at the time of, or within 1 week of, an ultrasound scan between 1 May and 31 August 2020. Scans were either performed for routine fetal evaluation or indicated due to a positive SARS-CoV-2 test. Forty-nine women were symptomatic and 57 were asymptomatic. For comparison, we analyzed data from 103 pregnant women matched for maternal age, parity, body mass index and gestational age at the time of the ultrasound scan. These control women did not report symptoms of SARS-CoV-2 infection at the time of the ultrasound scan or at the time of admission for delivery and had a negative SARS-CoV-2 test at admission for delivery. Fetal biometry, fetal anatomy, amniotic fluid volume and Doppler parameters, including umbilical and fetal middle cerebral artery pulsatility indices, cerebroplacental ratio and biophysical profile (BPP), were evaluated as indicated. Biometric and Doppler values were converted to Z-scores for comparison. Our primary outcome, an adverse prenatal composite outcome (APCO) included any one or more of: small-for-gestational-age (SGA) fetus, oligohydramnios, abnormal BPP, abnormal Doppler velocimetry and fetal death. Comorbidities, delivery information and neonatal outcome were compared between the two groups.

RESULTS

Eighty-seven (82.1%) women who were positive for SARS-CoV-2 had a body mass index > 25 kg/m2 . SARS-CoV-2-positive women had a higher prevalence of diabetes (26/106 (24.5%) vs 13/103 (12.6%); P = 0.03), but not of pre-eclampsia (21/106 (19.8%) vs 11/103 (10.7%); P = 0.08), compared with controls. The prevalence of APCO was not significantly different between SARS-CoV-2-positive women (19/106 (17.9%)) and controls (9/103 (8.7%)) (P = 0.06). There were no differences between SARS-CoV-2-positive women and controls in the prevalence of SGA fetuses (12/106 (11.3%) vs 6/103 (5.8%); P = 0.17), fetuses with abnormal Doppler evaluation (8/106 (7.5%) vs 2/103 (1.9%); P = 0.08) and fetuses with abnormal BPP (4/106 (3.8%) vs 0/103 (0%); P = 0.14). There were two fetal deaths in women who were positive for SARS-CoV-2 and these women had a higher rate of preterm delivery ≤ 35 weeks of gestation (22/106 (20.8%) vs 9/103 (8.7%); odds ratio, 2.73 (95% CI, 1.19-6.3); P = 0.01) compared with controls.

CONCLUSIONS

There were no significant differences in abnormal fetal ultrasound and Doppler findings observed between pregnant women who were positive for SARS-CoV-2 and controls. However, preterm delivery ≤ 35 weeks was more frequent among SARS-CoV-2-positive women. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

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

Contexte:

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

MÉTHODES:

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

RÉSULTATS:

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

INTERPRÉTATION:

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

The coronavirus disease 2019 vaccine in pregnancy: risks, benefits, and recommendations

The coronavirus disease 2019 has caused over 2 million deaths worldwide, with over 412,000 deaths reported in Unites States. To date, at least 57,786 pregnant women in the United States have been infected, and 71 pregnant women have died. Although pregnant women are at higher risk of severe coronavirus disease 2019-related illness, clinical trials for the available vaccines excluded pregnant and lactating women. The safety and efficacy of the vaccines for pregnant women, the fetus, and the newborn remain unknown. A review of maternal and neonatal coronavirus disease 2019 morbidity and mortality data along with perinatal vaccine safety considerations are presented to assist providers with shared decision-making regarding vaccine administration for this group, including the healthcare worker who is pregnant, lactating, or considering pregnancy. The coronavirus disease 2019 vaccine should be offered to pregnant women after discussing the lack of safety data, with preferential administration for those at highest risk of severe infection, until safety and efficacy of these novel vaccines are validated.

SARS-CoV-2 Vaccination During Pregnancy: A Complex Decision

As the first severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines passed UK and US regulatory milestones in late 2020 and early 2021, multiple professional societies offered recommendations to assist pregnant and breastfeeding people as they choose whether to undergo vaccination. Despite such guidance, the lack of data describing vaccine safety, immunogenicity, and efficacy in pregnant and breastfeeding people has made this decision challenging for many. However, even considering the paucity of data, the known risks of coronavirus disease 2019 during pregnancy likely outweigh the not yet fully elucidated risks of SARS-CoV-2 vaccines, which have reassuring safety and efficacy profiles among nonpregnant people.

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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

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

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

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

SARS-CoV-2 testing and clinical outcomes in a Texas tertiary care center labor and delivery unit

Our hospital adopted universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing for labor and delivery patients in April 2020. The primary aim of this study was to determine the number of subjects from April 1, 2020, to July 31, 2020, who had laboratory-confirmed SARS-CoV-2 infection, and the secondary aims were to report demographic and clinical data for subjects with and without SARS-CoV-2 infection and the time from SARS-CoV-2 test collection to result for tests administered in the hospital. A total of 898 subjects had either vaginal or cesarean deliveries with a gestational age of >20 weeks during the study period. Of this group, 746 subjects underwent SARS-CoV-2 testing, and 16 had a positive test result. Four of the 16 subjects with laboratory-confirmed SARS-CoV-2 infection had documented symptoms at the time of admission. The difference in cohort size was too large to make a meaningful statistical comparison in demographic and clinical data between those with positive vs negative SARS-CoV-2 test results. The median time from SARS-CoV-2 test collection to result decreased from 239 minutes in April 2020 to 119 minutes in July 2020. Universal SARS-CoV-2 testing revealed a 2.1% positivity rate during our study period.

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.