A Review on Mode of Delivery during COVID-19 between December 2019 and April 2020

Pre-Pandemic Versus Early COVID-19 Perinatal Outcomes at a Military Hospital

PURPOSE

The purpose of this study was to examine the impact of the first year of COVID-19 pandemic on maternal and neonatal outcomes at a large military treatment facility in Southern California.

STUDY DESIGN AND METHODS

A retrospective review of maternal and neonatal medical records was conducted between January 1, 2019, and December 31, 2020. Outcomes measured included stillbirth rate, neonatal intensive care unit admission, neonatal death, cesarean birth, and postpartum hemorrhage.

RESULTS

A total of 4,425 records were analyzed. Rates of stillbirth between the years did not vary. The neonatal death rate decreased more than 50% in 2020 (p = .149). Cesarean births rose by 2.7% in 2020 (p = .046). Rates of postpartum hemorrhage did not vary between years.

CLINICAL IMPLICATIONS

The impact of COVID-19 on maternal and neonatal outcomes at a military treatment facility in the first year of the COVID-19 pandemic provides guidance for optimizing perinatal health care. Vertical transmission of COVID-19 is low and routine testing of asymptomatic neonates of positive mothers may not be necessary. COVID-19 infections should not be an indication for cesarean birth and are not associated with neonatal deaths or NICU admission.

Mode of delivery and birth outcomes before and during COVID-19 -A population-based study in Ontario, Canada

There is lack of clarity on whether pregnancies during COVID-19 resulted in poorer mode of delivery and birth outcomes in Ontario, Canada. We aimed to compare mode of delivery (C-section), birth (low birthweight, preterm birth, NICU admission), and health services use (HSU, hospitalizations, ED visits, physician visits) outcomes in pregnant Ontario women before and during COVID-19 (pandemic periods). We further stratified for pre-existing chronic diseases (asthma, eczema, allergic rhinitis, diabetes, hypertension). Deliveries before (Jun 2018-Feb 2020) and during (Jul 2020-Mar 2022) pandemic were from health administrative data. We used multivariable logistic regression analyses to estimate adjusted odds ratios (aOR) of delivery and birth outcomes, and negative binomial regression for adjusted rate ratios (aRR) of HSU. We compared outcomes between pre-pandemic and pandemic periods. Possible interactions between study periods and covariates were also examined. 323,359 deliveries were included (50% during pandemic). One in 5 (18.3%) women who delivered during the pandemic had not received any COVID-19 vaccine, while one in 20 women (5.2%) lab-tested positive for COVID-19. The odds of C-section delivery during the pandemic was 9% higher (aOR = 1.09, 95% CI: 1.08-1.11) than pre-pandemic. The odds of preterm birth and NICU admission were 15% (aOR = 0.85, 95% CI: 0.82-0.87) and 10% lower (aOR = 0.90, 95% CI: 0.88-0.92), respectively, during COVID-19. There was a 17% reduction in ED visits but a 16% increase in physician visits during the pandemic (aRR = 0.83, 95% CI: 0.81-0.84 and aRR = 1.16, 95% CI: 1.16-1.17, respectively). These aORs and aRRs were significantly higher in women with pre-existing chronic conditions. During the pandemic, healthcare utilization, especially ED visits (aRR = 0.83), in pregnant women was lower compared to before. Ensuring ongoing prenatal care during the pandemic may reduce risks of adverse mode of delivery and the need for acute care during pregnancy.

Type of delivery and perinatal outcomes in pregnant women diagnosed with COVID-19: A systematic review and meta-analysis

BACKGROUND

There is paucity in the literature that provides a comprehensive and evidence-based conclusion regarding this topic.

OBJECTIVE

To compare perinatal outcomes of vaginal and caesarean section delivery in women diagnosed with COVID-19 by meta-analysis of literature.

SEARCH STRATEGY

The search was conducted on MEDLINE, EMBASE, LILACS, CINAHL, Scopus, Web of Science and Cochrane Database of Systematic Reviews by 25th May 2022.

SELECTION CRITERIA

The inclusion criteria involved pregnant women diagnosed with COVID-19 who underwent caesarean section and those who had vaginal deliveries.

DATA COLLECTION AND ANALYSIS

The included studies were meta-analyzed for various outcomes including: Gestational age, maternal intensive care unit admission, maternal death, prematurity, newborn birth weight, newborn intensive care unit admission, Apgar scores, newborn death, and newborn vertical transmission of COVID-19. The meta-analysis was conducted using Comprehensive Meta-Analysis (CMA) software, version 3.3.070.

MAIN RESULTS

The meta-analyses included 2,566 deliveries (866 caesarean sections and 1,700 vaginal deliveries) and identified that caesarean section was significantly associated with increased prematurity (OR 2.5 [1.7; 3.6], p < 0.001), lower birth weight (-118 g [-170; -66], p < 0.001), and a higher need for maternal (OR 9.54 [5.22; 17.43], p < 0.01) and neonatal intensive care unit intervention (OR 3.67 [2.71; 4.96], p < 0.01) compared to vaginal delivery.

CONCLUSION

COVID-19 infection alone should not be an indication for caesarean section as there is insufficient evidence that caesarean section reduces mortality, improves birth conditions, or prevents vertical transmission. Additionally, caesarean section is associated with poorer perinatal outcomes compared to vaginal delivery.

The impact of covid-19 pandemic on pregnancy outcome

BACKGROUND

The acute respiratory disease caused by the coronavirus (COVID-19) has spread rapidly worldwide yet has not been eliminated. The infection is especially deadly in vulnerable populations. The current studies indicate that pregnant women are at greater risk of getting seriously ill. Even though fetuses protect against disease, the additional finding showed that the COVID-19 pandemic could increase fetal and maternal morbidities. In a situation where COVID-19 and new strains of the virus are still not controlled, scientists predicted that the world might experience another pandemic. Consequently, more research about the effects of COVID-19 infection on pregnancy outcomes is needed. This study aimed to compare the pregnancy outcomes of Iranian pregnant women in the first year of the pandemic with the previous year.

METHODS

This prospective cross-sectional study was performed to compare the pregnancy outcome during the COVID-19 pandemic among Iranian pregnant women who gave birth during the pandemic and one year before the pandemic (2019-2020 and 2020-2021). The sample size was 2,371,332 births registered at hospitals and birth centers platforms. The studied variables include stillbirth, congenital anomaly, birth weight, preeclampsia, gestational diabetes, cesarean section, ICU admission, mean of the gestational age at birth, preterm births, NICU admission, neonatal mortality and the percentage of deliveries with at least one complication such as blood transfusion and postpartum ICU admission. Analyzing data was done by using SPSS version 25 software.

RESULTS

We found statistical differences between pregnancy and birth outcomes during the COVID-19 pandemic compared to one year before. The risk of preeclampsia, gestational diabetes, cesarean section, preterm birth and NICU admission were clinically significant. Also, there was a significant decrease in mean gestational age.

CONCLUSION

The COVID-19 pandemic has affected the pregnancy outcome by increasing morbidities and complications during pregnancy, birth, and postpartum. In addition, extensive quarantine outbreaks disrupted the healthcare system and hindered access to prenatal services. It is necessary to develop preventive and therapeutic care protocols for similar pandemic conditions.

Impact of the COVID-19 Pandemic on Births, Vaginal Deliveries, Cesarian Sections, and Maternal Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study

Purpose

The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in healthcare. The primary objective of the study was to assess the impact of the COVID-19 pandemic on birth, vaginal delivery, and cesarian section (c-section) rates. The secondary objective was to compare the maternal mortality before and after the pandemic.

Patients and Methods

Time-series cohort study including data of all women admitted for childbirth (vaginal delivery or c-section) at the maternities in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. Causal impact analysis was used to evaluate the impact of COVID-19 on birth, vaginal delivery, and c-section using the CausalImpact R package, and a propensity score matching was used to evaluate the effect on maternal mortality rate using the Easy R (EZR) software.

Results

There were 150,617 births, and considering total births, the effect of the COVID-19 pandemic was not statistically significant (absolute effect per week: 5.5, 95% CI: -24.0-33.4). However, there was an increase in c-sections after COVID-19 (absolute effect per week: 18.1; 95% CI: 11.9-23.9). After propensity score matching, the COVID-19 period was associated with increased maternal mortality (OR: 3.22, 95% CI: 1.53-6.81). The e-value of the adjusted OR for the association between the post-COVID-19 period and maternal mortality was 5.89, with a 95% CI: 2.43, suggesting that unmeasured confounders were unlikely to explain the entirety of the effect.

Conclusion

Our study revealed a rise in c-sections and maternal mortality during the COVID-19 pandemic, possibly due to disruptions in maternal care. These findings highlight that implementing effective strategies to protect maternal health in times of crisis and improve outcomes for mothers and newborns is crucial.

Setting up a specialized maternity unit in a tertiary hospital: An oasis for pregnant women with COVID-19 during the pandemic

OBJECTIVE

The COVID-19 pandemic has had an enormous impact on society and the medical environment in Taiwan in 2022. As pregnant women with COVID-19 are at higher risk for multiple complications, Taiwan needs a COVID-19 specialized maternity unit to improve the quality of maternal and neonatal care.

MATERIALS AND METHODS

We share our experience with specialized maternity unit for pregnant women with COVID-19 at the National Cheng Kung University Hospital, where we can have careful evaluation, safe birth, and comprehensive postpartum care.

RESULTS

Our COVID-19 specialized maternity unit enrolled 253 pregnant women with COVID-19, 90 (35.6%) pregnant women were admitted to the specialized maternity unit, and 71 (28.1%) pregnant women gave birth during hospitalization in two months. All pregnant women recovery well and real-time polymerase chain reaction tests on all infants were negative for COVID-19.

CONCLUSION

A specialized maternity unit can provide pregnant women with a safe birth environment, immediate maternity care, and high medical quality. It can also help health workers in non-specialized maternity units deal with COVID-19-related psychological stress. Therefore, setting up one specialized maternity unit in the city during the pandemic should be guardedly considered.

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.

Managing Labour in Women with COVID-19

Since first reported in December 2019 in Wuhan, China, COVID-19 caused by Severe Acute Respiratory Syndrome (SARS) Corona virus2 (SARS CoV-2) quickly spread to become a pandemic that has caused significant morbidity and mortality. The rapidity of the spread of the virus and the high mortality at the outset threatened to overwhelm health systems worldwide, and, indeed, this significantly impacted maternal health, especially since there was minimal experience to draw from. Experience with Covid 19 has grown exponentially as the unique needs of pregnant and labouring women with COVID-19 infection have become more evident. Managing COVID-19 parturients requires a multidisciplinary team consisting of anaesthesiologists, obstetricians, neonatologists, nursing staff, critical care staff, infectious disease and infection control experts. There should be a clear policy on triaging patients depending on the severity of their condition and the stage of labour. Those at high risk of respiratory failure should be managed in a tertiary referral centre with facilities for intensive care and assisted respiration. Staff and patients in delivery suites and operating rooms should be protected by enforcing infection protection principles such as offering dedicated rooms and theatres to SARS CoV-2 positive patients and using personal protective equipment. All hospital staff must be trained in infection control measures which should be updated regularly. Breastfeeding and care of the new-born must be part of the healthcare package offered to COVID-19 parturient mothers.

An increase in cesarean section rate during the first wave of COVID-19 pandemic in Iran

BACKGROUND

The COVID-19 pandemic and its impact on healthcare services is likely to affect birth outcomes including the delivery mode. However, recent evidence has been conflicting in this regard. The study aimed to assess changes to C-section rate during the COVID-19 pandemic in Iran.

METHODS

This is a retrospective analysis of electronic medical records of women delivered in the maternity department of hospitals in all provinces of Iran before the COVID-19 pandemic (February-August 30, 2019) and during the pandemic (February-August 30, 2020). Data were collected through the Iranian Maternal and Neonatal Network (IMAN), a country-wide electronic health record database management system for maternal and neonatal information. A total of 1,208,671 medical records were analyzed using the SPSS software version 22. The differences in C-section rates according to the studied variables were tested using the χ2 test. A logistic regression analysis was conducted to determine the factors associated with C-section.

RESULTS

A significant rise was observed in the rates of C-section during the pandemic compared to the pre-pandemic (52.9% vs 50.8%; p = .001). The rates for preeclampsia (3.0% vs 1.3%), gestational diabetes (6.1% vs 3.0%), preterm birth (11.6% vs 6.9%), IUGR (1.2% vs 0.4%), LBW (11.2% vs 7.8%), and low Apgar score at first minute (4.2% vs 3.2%) were higher in women who delivered by C-section compared to those with normal delivery (P = .001).

CONCLUSIONS

The overall C-section rate during the first wave of COVID-19 pandemic was significantly higher than the pre-pandemic period. C-section was associated with adverse maternal and neonatal outcomes. Thus, preventing the overuse of C-section especially during pandemic becomes an urgent need for maternal and neonatal health in Iran.

Symptomatic COVID-19 in Pregnancy: Hospital Cohort Data between May 2020 and April 2021, Risk Factors and Medicolegal Implications

Pregnancy does not appear to increase susceptibility to SARS-CoV-2 infection, but some physiological changes, such as the reduction of residual functional volumes, elevation of the diaphragm, and impaired cellular immunity, may increase the risk of severe disease and result in a higher risk of complications. The article’s primary objective is to evaluate the factors associated with symptomatic COVID-19 disease in pregnancy. The secondary objective is to describe maternal and neonatal outcomes and cases of vertical transmission of the infection. All pregnant women hospitalized with SARS-CoV2 infection were included in a prospective study in the UOC of Obstetrics and Gynecology, AOOR Villa Sofia—Cervello, Palermo, between May 2020 and April 2021. The patients who requested the termination of the pregnancy according to Law 194/78 were excluded. We included 165 pregnancies with a total number of 134 deliveries. Overall, 88.5% of the patients were asymptomatic at the time of admission and 11.5% were symptomatic. Of them, 1.8% of the patients required hospital admission in the intensive care unit. Symptoms occurrences were positively associated with the increase in maternal BMI (OR 1.17; p = 0.002), the prematurity (OR 4.71; p = 0.022), and at a lower birth weight (OR 0.99; p = 0.007). One infant tested positive for SARS-CoV2 nasopharyngeal swab; 11.4% of newborns had IgG anti SARS-CoV2 at birth; IgM was positive in 2.4% of newborns. There was no difference statistically significant difference in the vertical transmission of the infection among the group of symptomatic pregnant women and that of asymptomatic pregnant women.

Maternal and Fetal Outcome in Pregnant Women With Critical COVID-19 Treated With Tocilizumab in a Tertiary Care Hospital in Dubai

INTRODUCTION

Pregnancy, complicated by coronavirus disease 2019 (COVID-19), results in higher hospitalization and mortality rate. Pathogenesis of COVID-19 is similar to any other systemic inflammatory condition but results in a cytokine storm of higher magnitude causing severe acute respiratory distress syndrome and multiorgan failure. Tocilizumab, a humanized monoclonal antibody, targets soluble and membrane-bound IL-6 receptors and is used in the treatment of juvenile idiopathic arthritis, rheumatoid arthritis, and cytokine release syndrome. However, studies exploring its role in pregnancy are minimal. Hence, this study was done to study the effect of tocilizumab on maternal and fetal outcomes in critical COVID-19 pregnant women.

METHODOLOGY

A retrospective study was conducted on 28 pregnant women with critical COVID-19 who received tocilizumab. Clinical status, chest x-ray, biochemical parameters, and fetal well-being were monitored and documented. The discharged patients were followed up through telemedicine.

RESULT

On treatment with tocilizumab, improvement was seen in the number of zones and patterns of chest x-ray, along with 80% reduction in the c-reactive protein (CRP) levels. Based on the WHO clinical progression scale, 20 patients improved by the end of first week, and by the end of first month, 26 patients became asymptomatic. Two patients died during the course of the disease. No fetal adverse effects were noted.

CONCLUSION

Based on the encouraging response and as tocilizumab did not impart any adverse effects on the pregnancy, tocilizumab may be administered as an adjuvant to critical COVID-19 pregnant women in their second and third trimesters.

Clinical Characteristics, Transmission Rate and Outcome of Neonates Born to COVID-19-Positive Mothers: A Prospective Case Series From a Resource-Limited Setting

BACKGROUND

Coronavirus disease (COVID-19) infection during pregnancy could damage the placenta, but data on neonates born to COVID-19-positive mothers is scarce. In this case series, we aim to describe clinical characteristics, transmission rate and outcomes at 3 months of age among neonates born to mothers with COVID-19 diagnosed near the time of delivery.

METHODS

Prospective, multicenter case series from Suriname. We collected clinical data of neonates born to mothers with COVID-19 infection between June and August 2021. COVID-19 swabs were taken within 5 days and 2 weeks after birth. Follow-up took place at 3 months.

RESULTS

We enrolled 18 neonates. However, 18/18 (100%) mothers were infected in the third trimester and 10/18 (55.6%) had severe COVID-19 infection requiring ICU admission and 2/10 (20%) died. In total 16/18 (77.8%) neonates were born after cesarean section and 13/18 (72.2%) were born preterm (median 35 weeks, Interquartile range 32 + 4-38 + 0). Neonatal intensive care unit admission was needed in 7/18 (38.9%) neonates. Respiratory symptoms occurred in 12/18 (66.7%), 5/18 (27.8%) were suspected of early-onset sepsis and 1/18(5.6%) of late-onset sepsis. One preterm neonate developed necrotizing enterocolitis. A nasopharyngeal swab was positive in 1/18 (5.5%) neonates within 5 days of life and in 0/11 (0%) neonates after 2 weeks. Follow-up showed mild neurodevelopmental delay in 2/14 (14.3%) patients.

CONCLUSION

We describe a high proportion of severely ill mothers due to COVID-19 infection with subsequent cesarean delivery and prematurity. Accounting for gestational age at birth, the neonatal clinical course and findings at follow-up appeared similar to neonates born to COVID-19-negative mothers. Maternal vaccination is recommended to prevent neonatal risks associated with prematurity and cesarean delivery.

Parent organizations' experiences of the pandemic response in maternity care in thirteen European countries

We surveyed changes to maternity care services in the first 17 months of the COVID-19 pandemic in 13 different European countries, from the perspective of national maternity service (parent) organizations advocating for a human rights approach to maternity services. A qualitative study was conducted in November 2020. An open-question survey was sent to national maternity service (parent) organizations and members of COST Action 18211 in Europe, asking about COVID-19 measures in maternity services (antenatally, intrapartum, postnatally, and overall satisfaction). From the open answers, 16 core issues were extracted. Between February and August 2021, semi-structured interviews with the national representatives of 14 parent member organizations in Europe were conducted, collecting details on overall national situations and changes due to COVID-19 measures. The reported experiences of parent organizations from 13 European countries show wide variations in epidemiological containment measures during the first 17 months of the COVID-19 pandemic. Practices differed between facilities, resulting in emotional disquiet and confusion for parent-patients. Most countries maintained antenatal and postnatal care but restricted psychosocial support (antenatal and birth companions, visitors). Organizations from nine countries reported that women had to wear masks during labor, and all but two countries saw separations of mothers and babies. Most parent organizations described a need for more reliable information for new parents. During the pandemic, non-evidence-based practices were (re-) established in many settings, depriving women and families of many factors which evidence has shown to be essential for a positive birthing experience. Based on the findings, we consider the challenges in maternity services and propose a strategy for future crises.

Did the first wave of the COVID-19 pandemic impact the cesarean delivery rate? A retrospective cohort study at a primary care center in Switzerland

OBJECTIVES

During the first 3 months of the coronavirus disease 2019 (COVID-19) pandemic, our hospital's quality management team determined a decline in the rate of cesarean deliveries (CD). Thus, in this study we examined both the factors associated with this decrease as well as neonatal outcomes.

METHODS

This was a retrospective observational cohort study comparing deliveries (n=597) between March and May 2020 (first nationwide "lockdown" in Switzerland) with those during the same period in 2018 and 2019 (n=1,063). A multivariable logistic regression analysis was used to examine the association between CD and the pandemic, adjusting for relevant risk factors for CD.

RESULTS

The overall rate of CD during the pandemic period was lower (30.0%), than during the pre-pandemic period (38.7%, unadjusted odds ratio 0.68, 95% confidence interval [95%CI]: 0.55 to 0.84, p=0.0004) a result that was supported by the adjusted odds ratio (0.73, 95%CI: 0.54 to 0.99, p=0.04).

CONCLUSIONS

The results of this study confirmed a significant reduction in the rate of CD in early 2020, during the first lockdown period due to COVID-19, but without major differences in maternal and infant health indicators or in obstetric risk factors than before the pandemic. These results may have been due to a difference in the composition of the obstetric team as well as the behavior of the obstetrics team and in the patients during the pandemic, given the burden it placed on healthcare systems. However, this hypothesis remains to be tested in further research.

Individual and country-level variables associated with the medicalization of birth: Multilevel analyses of IMAgiNE EURO data from 15 countries in the WHO European region

OBJECTIVE

To investigate potential associations between individual and country-level factors and medicalization of birth in 15 European countries during the COVID-19 pandemic.

METHODS

Online anonymous survey of women who gave birth in 2020-2021. Multivariable multilevel logistic regression models estimating associations between indicators of medicalization (cesarean, instrumental vaginal birth [IVB], episiotomy, fundal pressure) and proxy variables related to care culture and contextual factors at the individual and country level.

RESULTS

Among 27 173 women, 24.4% (n = 6650) had a cesarean and 8.8% (n = 2380) an IVB. Among women with IVB, 41.9% (n = 998) reported receiving fundal pressure. Among women with spontaneous vaginal births, 22.3% (n = 4048) had an episiotomy. Less respectful care, as perceived by the women, was associated with higher levels of medicalization. For example, women who reported having a cesarean, IVB, or episiotomy reported not feeling treated with dignity more frequently than women who did not have those interventions (odds ratio [OR] 1.37; OR 1.61; OR 1.51, respectively; all: P < 0.001). Country-level variables contributed to explaining some of the variance between countries.

CONCLUSION

We recommend a greater emphasis in health policies on promotion of respectful and patient-centered care approaches to birth to enhance women's experiences of care, and the development of a European-level indicator to monitor medicalization of reproductive care.

Trends in Caesarean Section Rate According to Robson Group Classification among Pregnant Women with SARS-CoV-2 Infection: A Single-Center Large Cohort Study in Italy

BACKGROUND

Since there is no available data on temporal trends of caesarean section (CS) rates in pregnant women with COVID-19 through the pandemic, we aimed to analyze the trends in caesarean section rate in a large cohort of pregnant women with COVID-19, according to the Robson Ten Group Classification System of deliveries.

METHODS

We prospectively enrolled pregnant women with a diagnosis of COVID-19 who delivered in our center between March 2020 and November 2021. Deliveries were classified, according to the Robson group classification, and according to three time periods: (1) deliveries from March 2020 to December 2020; (2) deliveries from January 2021 to April 2021; (3) deliveries from May 2021 to November 2021. We compared pregnancy characteristics and incidence of caesarean section, according to the Robson category in the total population, and according to the three time periods.

RESULTS

We included 457 patients matching the inclusion criteria in our analysis. We found that overall CS rate significantly decreased over time from period 1 to period 3 (152/222, 68.5% vs. 81/134, 60.4% vs. 58/101, 57.4%, χ2 = 4.261, p = 0.039). CS rate significantly decreased over time in Robson category 1 (48/80, 60% vs. 27/47,57.4% vs. 8/24, 33.3%, χ2 = 4.097, p = 0.043) and Robson category 3 (13/42, 31% vs. 6/33, 18.2% vs. 2/22, 9.1%, χ2 = 4.335, p = 0.037). We also found that the incidence of induction of labor significantly increased over time (8/222, 3.6% vs. 12/134, 9% vs. 11/101, 10.9%, χ2 = 7.245, p = 0.027).

CONCLUSION

Our data provide an overview of the temporal changes in the management and obstetric outcome of COVID-19 pregnant women through the pandemic, confirming that standards of obstetrical assistance for pregnancies complicated by SARS-CoV-2 infection improved over time.

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.

COVID-19 and Pregnancy: Citation Network Analysis and Evidence Synthesis

BACKGROUND

COVID-19 spread quickly around the world shortly after the first outbreaks of the new coronavirus disease at the end of December 2019, affecting all populations, including pregnant women.

OBJECTIVE

The aim of this study was to analyze the relationship between different publications on COVID-19 in pregnancy and their authors through citation networks, as well as to identify the research areas and to determine the publication that has been the most highly cited.

METHODS

The search for publications was carried out through the Web of Science database using terms such as "pregnancy," "SARS-CoV-2," "pregnant," and "COVID-19" for the period between January and December 2020. Citation Network Explorer software was used for publication analysis and VOSviewer software was used to construct the figures. This approach enabled an in-depth network analysis to visualize the connections between the related elements and explain their network structure.

RESULTS

A total of 1330 publications and 5531 citation networks were identified in the search, with July being the month with the largest number of publications, and the United States, China, and England as the countries with the greatest number of publications. The most cited publication was "Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records" by Chen and colleagues, which was published in March 2020. Six groups identified as being close in the citation network reflect multidisciplinary research, including clinical characteristics and outcomes in pregnancy, vertical transmission, delivery mode, and psychological impacts of the pandemic on pregnant women.

CONCLUSIONS

Thousands of articles on COVID-19 have been published in several journals since the disease first emerged. Identifying relevant publications and obtaining a global view of the main papers published on COVID-19 and pregnancy can lead to a better understanding of the topic. With the accumulation of scientific knowledge, we now know that the clinical features of COVID-19 during pregnancy are generally similar to those of infected nonpregnant women. There is a small increase in frequency of preterm birth and cesarean birth, related to severe maternal illness. Vaccination for all pregnant women is recommended. Several agents are being evaluated for the treatment of COVID-19, but with minimal or no information on safety in pregnancy. These results could form the basis for further research. Future bibliometric and scientometric studies on COVID-19 should provide updated information to analyze other relevant indicators in this field.

Validity of Apgar Score as an Indicator of Neonatal SARS-CoV-2 Infection: A Scoping Review

The coronavirus disease 2019 (COVID-19) pandemic has had profound impacts on healthcare systems worldwide, particularly regarding the care of pregnant women and their neonates. The use of the Apgar score—a discrete numerical index used to evaluate neonatal condition immediately following delivery that has been used ubiquitously as a clinical indicator of neonatal condition and widely reported in the literature for decades—has continued during the pandemic. Although health systems adopted protocols that addressed pregnant women and their neonates during the pandemic, limited research has assessed the validity of Apgar scores for determining neonatal conditions in the context of COVID-19. Therefore, this scoping review was conducted on the first 2 years of the pandemic and included mothers with reverse transcription-polymerase chain reaction confirmed COVID-19 and their resulting positive or negative neonates. In total, 1,966 articles were assessed for eligibility, yielding 246 articles describing 663 neonates. Neonates who tested negative had median Apgar scores of 9 and 9 at 1 and 5 mins, respectively, while test-positive neonates had median Apgar scores of 8 and 9 at the same time points. The proportions of test-negative neonates with Apgar scores below 7 were 29 (4%) and 11 (2%) at 1 and 5 mins, which was not statistically significant (p = 0.327, χ² = 0.961). These proportions were even lower for positive neonates: 22 (3%) and 11 (2%) at 1 and 5 mins, respectively, which was not statistically significant (p = 1, χ² = 0). The low proportion of Apgar scores below 7 suggests that low Apgar scores are likely to be associated with severe maternal COVID-19 symptoms during delivery rather than neonatal COVID-19. Therefore, this study indicated that Apgar scores are poor indicators of neonatal COVID-19 status.

Effects of the COVID-19 pandemic on perinatal outcomes: a retrospective cohort study from Turkey

Background

Lockdowns, pregnant women’s fear from hospitalization in addition to uncertainties about appropriate birthing practices at the beginning of the pandemic may have affected the health outcomes of mother-infant couples. We aimed to explore whether pregnancy outcomes including the rates of cesarean delivery (CS), preterm, and low birth weight (LBW) births have changed during the pandemic period compared with the pre-pandemic period.

Methods

We applied a population-based retrospective cohort, before-after approach in 2020 vs. similar calendar months in 2019 for five periods [Jan-Feb (pre-pandemic); March–May (1st wave and lockdown); June–August; September–October; November–December (2nd wave and lockdown)]. The data was modelled through multiple logistic regressions using key outcomes; CS, preterm, and LBW births as the dependent variables, and adjustments were made for independent variables in SPSS software. We evaluated the modification of years by periods by adding interaction term (yearXperiod) to the model.

Results

The rate of CS in hospital births increased from 57.7% in 2019 to 60.2% in 2020. CS rates were significantly increased during the 3rd and 4th periods. The overall preterm rate was 11%. When singleton pregnancies were considered, adjusted multivariable analyses showed a decrease in preterm proportions during all time periods with respect to the pre-pandemic period. The percentage of LBW was 7.7% during the pandemic period and was found to be significantly reduced compared to the pre-pandemic period. There was a significant reduction in LBW rates in all periods except the second lockdown period.

Conclusions

Our findings suggested significant reductions in preterm and LBW births possibly due to the indirect effects of the pandemic. Moreover, strategies need to be considered to address the increased CS rates and shifting of maternity service utilization to private facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04349-5.

Impact of SARS-CoV-2 on pregnancy and neonatal outcomes: An open prospective study of pregnant women in Brazil

OBJECTIVES

To determine the incidence and risk of adverse obstetric and neonatal outcomes according to SARS-CoV-2 infection severity in pregnant women.

METHOD

Open prospective study of pregnant women tested for SARS-CoV-2 by serological and molecular assays during pregnancy or delivery in two hospitals in Sao Paulo, Brazil from April 12, 2020, to February 28, 2021. Five groups were considered for analysis: C0, negative COVID-19 results and no COVID-19 symptoms; C1, positive COVID-19 results, and no symptoms; C2, positive COVID-19 results with mild symptoms; C3, positive COVID-19 results with moderate symptoms; and C4, positive COVID-19 results with severe symptoms. The association between obstetric and neonatal outcomes and COVID-19 severity was determined using multivariate analysis.

RESULTS

734 eligible pregnant women were enrolled as follows: C0 (n = 357), C1 (n = 127), C2 (n = 174), C3 (n = 37), and C4 (n = 39). The following pregnancy and neonatal outcomes were associated with severe COVID-19: oligohydramnios (adjusted Odds Ratio [aOR] = 6.18; 95% CI 1.87‒20.39), fetal distress (aOR = 4.01; 95% Confidence Interval [CI] 1.84‒8.75), preterm birth (aOR = 5.51; 95% CI 1.47‒20.61), longer hospital stay (aOR = 1.66; 95% CI 1.36‒2.02), and admission to the neonatal intensive care unit (aOR = 19.36; 95% CI, 5.86‒63.99). All maternal (n = 6, 15.4%, p < 0.001) and neonatal (n = 5, 12.5%, p < 0.001) deaths and most fetal deaths (n = 4, 9.8%, p < 0.001) occurred in C4 group. Moderate COVID-19 was associated with oligohydramnios (aOR = 6.23; 95% CI 1.93‒20.13) and preterm birth (aOR = 3.60; 95% CI 1.45‒9.27). Mild COVID-19 was associated with oligohydramnios (aOR = 3.77; 95% CI 1.56‒9.07).

CONCLUSION

Adverse pregnancy and neonatal outcomes were associated with maternal symptomatic COVID-19 status, and risk increased with disease severity.

A prospective cohort study of confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy evaluating SARS-CoV-2 antibodies in maternal and umbilical cord blood and SARS-CoV-2 in vaginal swabs

Introduction

Evidence about the consequences of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in pregnancy is rapidly increasing; however, data on antibody response and risk of transmission during pregnancy and delivery are still limited. The aim of this study was to evaluate if SARS‐CoV‐2 is detectable in vaginal swabs and whether antibodies against SARS‐CoV‐2 are present in maternal and umbilical cord blood of pregnant women with confirmed SARS‐CoV‐2.

Material and methods

A single‐unit prospective cohort study in Denmark including pregnant women with SARS‐CoV‐2 infection confirmed by a pharyngeal swab between August 20, 2020, and March 1, 2021, who gave birth during the same period. All patients admitted to the maternity ward and antepartum clinic were screened for SARS‐CoV‐2 infection. A maternal blood sample and vaginal swabs were collected at inclusion. If included antepartum, these samples were repeated intrapartum when an umbilical cord blood sample was also collected. Swabs were analyzed for SARS‐CoV‐2 and blood samples were analyzed for SARS‐CoV‐2 total antibodies. Placental and neonatal swabs as well as placental histopathological examinations were performed on clinical indications.

Results

We included 28 women, of whom four had serious maternal or fetal outcomes including one case of neonatal death. Within the first 8 days after confirmed SARS‐CoV‐2 infection, SARS‐CoV‐2 was detectable in two vaginal swabs (2/28) and SARS‐CoV‐2 antibodies were detected in 1 of 13 women. From 16 days after confirmed infection, antibodies were observed in 19 of 21 of women. Antibodies in cord blood were not detected during the first 16 days after confirmed infection (n = 7). However, from 26 days, antibodies were present in 16 of 17 cord blood samples of seropositive mothers. Placental examination in two cases of severe fetal outcomes preceded by reduced fetal movements revealed SARS‐CoV‐2 in swabs and severe histopathological abnormalities.

Conclusions

SARS‐CoV‐2 was detected in only 2 of 28 vaginal swabs within 8 days after confirmed infection in pregnant women. Our data suggest that maternal seroconversion occurs between days 8 and 16, whereas antibodies in cord blood of seropositive mothers were present in the majority from 26 days after confirmed infection. Additional data are needed regarding timing of seroconversion for the mother and appearance of antibodies in cord blood.

Perioperative melatonin in COVID-19 patients: benefits beyond sedation and analgesia

Cytokine storm in coronavirus disease 2019 (COVID-19) patients leads to acute lung injury, acute respiratory distress syndrome, multiorgan dysfunction, shock, and thrombosis thus contributing to significant morbidity and mortality. Several agents like steroids, ascorbic acid, vitamins (C, D, E), glutathione, N-acetylcysteine have been used and several studies are underway to identify its efficacy in addressing undesirable effects due to COVID-19 illness. Among several experimental modalities based on expert opinion and anecdotal data, melatonin is one molecule that appears promising. Owing to its anti-inflammatory, anti-oxidant, and immunomodulatory properties, melatonin can be an important agent used as a component of multimodal analgesia in COVID-19 patients, suspected patients, and patients with exposure to positive patients undergoing emergency or urgent surgeries. Further research is required to know the optimal time of initiation, dose, and duration of melatonin as an adjunct.

Perinatal Transmission and Outcome of Neonates Born to SARS-CoV-2-Positive Mothers: The Experience of 2 Highly Endemic Italian Regions

INTRODUCTION

COVID-19 is the disease caused by the novel coronavirus SARS-CoV-2, responsible of the pandemic declared in March 2020 and still ongoing. COVID-19 affects all ages but presents less complications and fatalities in children. Neonatal infections have rarely been reported worldwide, and vertical transmission is uncertain.

METHODS

We conducted a prospective cohort study of all infants born to SARS-CoV-2-positive mothers admitted to 2 hospitals in South (Bari) and North (Varese) of Italy from April to December 2020. A molecular nasopharyngeal swab for SARS-CoV-2 using a reverse transcriptase polymerase chain reaction was made at birth for all enrolled newborns to evaluate vertical transmission of infection. We also evaluated postnatal transmission with a second nasopharyngeal swab made at 1 month of life and described maternal and neonatal clinical findings and short-term outcomes.

RESULTS

176/179 (97%) newborns were SARS-CoV-2 negative at birth and 151/156 (97%) infants were still negative at 1 month of life. All newborns were asymptomatic. Seventy percent of newborns were breastfed during hospitalization. At 1 month of life, 76% of infants were breastfed.

CONCLUSION

According to our results, vertical and perinatal infection is very rare. Breastfeeding does not increase the risk of COVID-19 and should be encouraged.

Maternal and fetal outcomes of the pregnant woman with COVID-19: The first case report in Taiwan

OBJECTIVE

A real-Taiwan experience to deal with near-term pregnant woman infected by severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 (coronavirus disease 2019, COVID-19) is extremely limited. We described the first case in Taiwan.

CASE REPORT

A 30-year-old woman, primigravida had a laboratory-confirmed COVID-19 infection at 36 gestational weeks (GW). She was asymptomatic. Ten days later, she was hospitalized and receive a selective cesarean section with a term baby weighted 3142 gm (Apgar score 8 and 9 at 1st and 5th minute, respectively) at 38 GW. No evidence of in utero and direct transmission was found and newborn was free of COVID-19.

CONCLUSION

It is still uncertain whether timing or mode of delivery is appropriate in SARS-CoV-2 infected pregnant woman in near term, but we suggested that a selective delivery time at 38 GW or later, regardless of which mode of delivery is finally decided, can be considered.

COVID-19 in Pregnancy-Perinatal Outcomes and Vertical Transmission Preventative Strategies, When Considering More Transmissible SARS-CoV-2 Variants

The COVID-19 pandemic affected the physical and mental health of people around the world and left unprepared health care systems struggling to mount an adequate response. Understanding the impact of COVID-19 on pregnancy in terms of perinatal and fetal outcomes is essential to propose strategies for mminimising viral transmission. Overall, 91 pregnant women in labour, or with indication for induction of labour, with COVID-19 were admitted to hospital. On the day of admission, each pregnant woman underwent a nasopharyngeal swab to validate SARS-CoV-2 infection. Whenever delivery was by caesarean section, an amniotic fluid sample was collected after uterus incision. Neonates were tested twice: first by nasopharyngeal swab at birth and secondly either at 24 h after (when babies were isolated) or at discharge (when rooming-in). All samples underwent rRT-PCR testing for SARS-CoV-2. The SARS-CoV-2 RNA tests by nasopharyngeal swab of the pregnant women produced positive results in 47 patients. This cohort gave birth to 48 infants who were double tested by nasopharyngeal swab and included in the prospective observational study. Moreover, in this same cohort, 39 amniotic fluid samples were taken during caesarean section. All samples underwent rRT-PCR testing for SARS-CoV-2 and came back negative. The study results suggest a low risk of vertical transmission of COVID-19 and favourable perinatal outcomes due to adequate preventative strategies. This approach may prove to be more beneficial in the new SARS-CoV-2 variants era.

Current Resources for Evidence-Based Practice, July 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of how fetal monitoring may lead to overuse of birth-related interventions, commentaries on reviews focused on bedsharing, and women's lifetime estrogen exposure and risk of cardiovascular mortality.

Infants infected with SARS-CoV-2 and newborns born to mother diagnosed with COVID-19: clinical experience

Background

Almost every day, new information about the COVID-19 pandemic continues to emerge. COVID-19 presents a mild clinical picture in children. However, how it goes in newborns and pregnant is still entirely unclear.

Aims

To present the clinical course of SARS-CoV-2 positive newborns and outcomes of babies born to mothers diagnosed with COVID-19.

Methods

The present cohort-study examined two groups. The first group includes fourteen newborns born to mothers diagnosed with COVID-19. The second group evaluates twelve newborns infected with SARS-CoV-2.

Results

Fourteen infants born to mothers diagnosed with COVID-19 were not infected with SARS-CoV-2. They had no symptoms and pathological laboratory findings. Additionally, forty-one newborns suspected of COVID-19 were evaluated, and 12 of them were detected to be infected with SARS-CoV-2. The most common symptoms were feeding intolerance (vomiting or refusing to feed, 58%), cough (50%), elevated fever (42%), and respiratory distress (42%).

Conclusion

We did not come across any signs of vertical SARS-CoV-2 transmission. COVID-19 diagnosed newborns entirely healed with conservative treatment.

COVID-19 and the neonatal microbiome: will the pandemic cost infants their microbes?

Mortality and morbidity from SARS-CoV2 (COVID-19) infections in children remains low, including an exceedingly low rate of horizontal and vertical transmission. However, unforeseen complications to childhood health have emerged secondary to the pandemic. Few studies to date have examined unintended complications of the pandemic in newborns and infants. In this Commentary, we discuss the impact that COVID-19 may have on inheritance of the newborn microbiome and its assembly throughout the first years of life. In the early stages of the pandemic when vertical transmission of COVID-19 was poorly understood, several studies reported increased rates of C-sections in COVID-19 positive women. Initial recommendations discouraged COVID-19 positive mothers from breastfeeding and participating in skin-to-skin care, advising them to isolate during their window of infectivity. These shifts in perinatal care can adversely impact microbial colonization during the first 1000 days of life. While obstetrical and neonatal management have evolved to reflect our current knowledge of perinatal transmission, we are observing other changes in early life exposures of infants, including increased attention to hygiene, fewer social interactions, and decreased global travel, all of which are major drivers of early-life gut colonization. Composition of the gut microbiota in adults directly impacts severity of infection, suggesting a role of microbial communities in modulating immune responses to COVID-19. Conversely, the role of the intestinal microbiome in susceptibility and severity of COVID-19 in newborns and children remains unknown. The onset of adulthood diseases is related to the establishment of a healthy gut microbiome during childhood. As we continue to define COVID-19 biology, further research is necessary to understand how acquisition of the neonatal microbiome is affected by the pandemic. Furthermore, infection control measures must be balanced with strategies that promote microbial diversity to impart optimal health outcomes and potentially modulate susceptibility of children to COVID-19.

COVID-19 Disease During Pregnancy and Peripartum Period: A Cardiovascular Review

Pregnancy with various physiological effects on cardiovascular system, makes mothers with borderline cardiovascular reserve at significant risk for adverse events during labor and early postpartum period. Cardiac imaging modalities, have shown that Coronavrus Disease 2019 disease is associated with subclinical myocardial injury in significant numbers of infected people, even in mild or asymptomatic disease and previous healthy ones. Herein, we have discussed the cardiovascular aspects of prepartum pregnant women with Coronavrus Disease 2019, especially patients with moderate to severe illness. Also, we have proposed how to handle the hemodynamic load during labor and the first 48 hours postpartum in the hypoxemic overloaded parturients with possible subclinical myocardial injury.

COVID-19 with severe acute respiratory distress in a pregnant woman leading to preterm caesarean section: A case report

We report the case of a 25-year-old pregnant woman, parity one, at 34 + 2 weeks of gestation, with a body mass index of 41 kg/m2 but no other comorbidities. There was a family history of COVID-19 among her one-year-old son, husband, brother, father and mother. She was admitted with chest pain and a nasopharyngeal swap positive for COVID-19. Due to the severity of the infection, a multidisciplinary team of anaesthesiologists, intensivists, obstetricians, neonatologists, and infectious disease specialists recommended delivery by caesarean section at 35 + 0 weeks of gestation, with combined spinal and epidural anaesthesia. Three days after delivery, the patient developed severe acute respiratory distress syndrome (ARDS) and was intubated for 25 days. The neonate was observed in the neonatal intensive care unit and no vertical transmission occurred. This case highlights the importance of the timing of delivery, the need for extended postpartum observation and a beneficial effect of inhaled nitric oxide after delivery for women with COVID-19.

The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study

This article extends the findings of a rapid response article researched in April 2020 to illustrate how providers' practices and attitudes toward COVID-19 had shifted in response to better evidence, increased experience, and improved guidance on how SARS-CoV-2 and COVID-19 impacted maternity care in the United States. This article is based on a review of current labor and delivery guidelines in relation to SARS-CoV-2 and COVID-19, and on an email survey of 28 community-based and hospital-based maternity care providers in the United State, who discuss their experiences and clients' needs in response to a rapidly shifting landscape of maternity care during the COVID-19 pandemic. One-third of our respondents are obstetricians, while the other two-thirds include midwives, doulas, and labor and delivery nurses. We present these providers' frustrations and coping mechanisms in shifting their practices in relation to COVID-19. The primary lessons learned relate to improved testing and accessing PPE for providers and clients; the need for better integration between community- and hospital-based providers; and changes in restrictive protocols concerning labor support persons, rooming-in with newborns, immediate skin-to-skin contact, and breastfeeding. We conclude by suggesting that the COVID-19 pandemic offers a transformational moment to shift maternity care in the United States toward a more integrated and sustainable model that might improve provider and maternal experiences as well as maternal and newborn outcomes.