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

Reduced fetal movements and COVID-19 infection: a retrospective cohort study

BACKGROUND

Fetal movements are an important indicator of fetal well-being; therefore, reduced fetal movements (RFMs) can indicate fetal compromise. RFM is associated with fetal growth restriction (FGR) and intrauterine fetal death (IUFD). Studies have implied that COVID-19 infection increases the risk of adverse fetal outcomes, such as preterm birth and IUFD. It is unclear how COVID-19 infection may aggravate these fetal outcomes among women presenting with RFM. The aims of the study were to (1) determine whether adverse fetal outcomes in women with RFM increased in 2020 compared to 2019, the year before the pandemic, and (2) evaluate whether maternal COVID-19 infection during pregnancy was a risk factor for adverse fetal outcomes in comparison to previously established risk factors among women seeking care for RFM.

METHODS

All women who sought care due to RFM and were delivered at Soder Hospital from 2019 to 2020 were included. Fetal composite outcomes were constructed and compared between women with RFM and COVID-19 and women with RFM but without COVID-19.

RESULTS

COVID-19 infection did not increase the risk of adverse fetal outcomes in women who sought care for RFM. A twofold risk for adverse fetal outcomes was found among all primiparous women vs. multiparous women with RFM (98/788 [12.4%] vs 37/644 [9.8%], AOR = 2.5, 95% CI (1.6-3.7).

CONCLUSION

The proportion of adverse composite outcomes among women with RFM during the first year of the pandemic did not increase compared to the year before. Composite outcomes were marginally higher in the COVID-19-positive group compared to the COVID-19-negative group, but it was not statistically significant.

Population-Level Study on Fetal Deaths and Preterm Births during SARS-CoV-2 Pandemic in the State of Michigan

OBJECTIVE

The aim of the study is to explore the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on preterm birth at different gestational ages and fetal death in the state of Michigan.

STUDY DESIGN

Data on live births and fetal deaths in the state of Michigan from March to November in the years 2017 through 2020 were obtained from Michigan Department of Health and Human Services (MDHHS). Preterm birth rate, fetal death rate (per 1,000 live births) overall and stratified by race and maternal comorbidities during the period of pandemic (March-November 2020) were compared with the same period (March-November) in the prepandemic years (2017-2019).

RESULTS

Of 328,879 live births and 1,470 fetal deaths during the study period, 77,983 live births and 242 fetal deaths were reported in 2020. Compared with prepandemic years, fetal death rate per 1,000 live births was significantly lower in 2020 (3.1 vs. 4.7 [2017], 5.2 [2018], 4.4 [2019], p-value <0.001). The adjusted risk for fetal death in 2020 was decreased (odds ratio [OR] = 0.64 [95% confidence interval (CI): 0.56-0.74], p <0.0001), compared with prepandemic years. Fetal death was significantly associated with African-American race, pregnancy hypertension and prepregnancy diabetes. No significant difference in the proportion of preterm births (<37 weeks' gestation) was noted between pandemic and prepandemic years (9.9 vs. 10.0%, p = 0.50). There was no significant difference in the risk of preterm birth across gestational age strata (<28, 28-316/7, 32-366/7, 37-416/7, and >42 weeks) between pandemic and prepandemic years on multinomial analysis. Significant associations with preterm birth across all years included African American race, lower level of maternal education, pregnancy-induced hypertension, chronic hypertension, prepregnancy diabetes, congenital anomalies, previous preterm birth, and prolonged rupture of membranes >12 hours.

CONCLUSION

Fetal death rate was significantly lower whereas preterm births remained unchanged during pandemic in comparison with prepandemic years in the state of Michigan.

KEY POINTS

· A decrease in fetal death rate was noted during SARS CoV-2 pandemic in the State of Michigan.. · Overall state-wide rates of preterm birth did not change in 2020, compared to previous years.. · Significant risk factors associated with preterm birth and fetal deaths did not differ between prepandemic and pandemic years..

Maternal and Newborn Outcomes of SARS-CoV-2/COVID-19 and Pregnancy: Parallels and Contrasts with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

Purpose of Review

Our review aims to compare and contrast Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome and SARS-CoV-2/COVID-19's impact on maternal and neonatal outcomes. We have made significant progress in Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome prevention and treatment over the last few decades. Drawing on empirical evidence with past public health crises can offer valuable insights into dealing with current and future pandemics. Therefore, it is imperative to conduct a comparative analysis of the resemblances and disparities existing between Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome and SARS-CoV-2/COVID-19.This research endeavor represents a pioneering and all-encompassing examination, aiming to discern and comprehend the parallels and contrasts in the respective impacts of SARS-CoV-2 and Human Immunodeficiency Virus on pregnancy.

Recent Findings

Based on the current evidence, there is no indication that pregnancy increases women's susceptibility to acquiring Human Immunodeficiency Virus or SARS-CoV-2. Nevertheless, the state of being pregnant was correlated with the worsening of diseases and their progression. Both Human Immunodeficiency Virus and SARS-CoV-2 pose increased risks of maternal mortality and several obstetric complications, including premature birth and pre-eclampsia. While the vertical transmission of Human Immunodeficiency Virus is well-established, a comprehensive understanding of the vertical transmission of SARS-CoV-2 remains elusive, emphasizing the need for further investigations. Initial data suggest low SARS-CoV-2 vertical transmission rates in the setting of proper preventative interventions and universal screening. A cesarean delivery could reduce the risk of mother-to-child transmission in Human Immunodeficiency Virus-infected women with high viral loads or poor adherence to antiretroviral therapy (ART). However, it did not offer additional protection for Human Immunodeficiency Virus-infected women who adhered to Adherence to Antiretroviral Therapy or those with COVID-19. Human Immunodeficiency Virus and SARS-CoV-2 were linked to neonatal complications such as stillbirth, low birth weight, and neonatal intensive care unit (ICU) admissions. The universal testing of both pregnant patients and neonates is an effective strategy to prevent the spread and complications of both Human Immunodeficiency Virus and SARS-CoV-2. Human Immunodeficiency Virus control largely relies on preventing vertical transmission and medications during pregnancy and postpartum, whereas safety behaviors and vaccines have proven effective in preventing SARS-CoV-2 vertical transmissions.

Summary

This review aims to compare and contrast the impact of Human Immunodeficiency Virus and SARS-CoV-2 on pregnancy outcomes, vertical transmissions, delivery modalities, neonatal outcomes, and clinical management. SARS-CoV-2 and Human Immunodeficiency Virus were associated with significant obstetric-related complications, making close clinical monitoring and preparation essential. Integration of SARS-CoV-2/COVID-19 management with reproductive health services is crucial to ensuring maternal and neonatal outcomes. Our review is not only the first to establish a groundwork for the current state of knowledge and its clinical implications on this topic, but it also sheds new insights for future research directions.Comparing Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome and SARS-CoV-2 in terms of their impact on maternal and neonatal outcomes provides valuable insights despite their differences. Leveraging Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome research can help understand SARS-CoV-2 effects on pregnancy. Both infections pose risks to pregnant individuals and their fetuses, leading to increased maternal mortality and complications. Identifying common patterns and risk factors can improve clinical management for pregnant individuals with SARS-CoV-2. While a direct observational study for this comparison may not be feasible, comparing with Human Immunodeficiency Virus offers an ethical and practical approach. However, specific studies on SARS-CoV-2 are still necessary to gather detailed data on maternal and fetal outcomes.

How Much Does SARS-CoV-2 Infection during Pregnancy Affect the Neonatal Brain, Heart, and Kidney? A Parallel between COVID-19, Vaccination, and Normal Pregnancy

During the last decades, a growing number of studies have shown that infections during pregnancy have an important impact on both pregnant women and their fetuses. Our goal was to include newborns from pregnancies with SARS-CoV-2 infection and to investigate the extension of neonatal complications using cardiac, abdominal, and cerebral ultrasonography; hearing testing; and indirect ophthalmoscopy. Likewise, neonates whose mothers were vaccinated against COVID-19 during pregnancy and those from pathology-free pregnancies were examined. A total of 458 mother-newborn dyads were included over a period of 10 months and divided into three groups: the COVID-19 group, vaccine group, and control group. Although six cardiac malformations were found in the COVID-19 group, no correlation was made compared to the vaccine and control group (p = 0.07). Grade 1 intraventricular hemorrhage and hypoxic ischemic encephalopathy were the most prevalent among neonates from mothers with SARS-CoV-2 infection (p = 0.002 and p < 0.001, respectively). The kidney anomaly found to be most frequent in this group was grade 1 unilateral hydronephrosis (p < 0.001). COVID-19 disease during the gestational period had no effect on the auditory or visual function. Our findings highlight the importance of implementing proper infection control practices for future mothers, and by continuing to investigate this topic, we can gather valuable insights that will improve neonatal health in this context.

Neonatal outcomes of maternal prenatal coronavirus infection

The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes in life and healthcare all over the world. Pregnant women and their newborns require extra attention due to the increased risk of adverse outcomes. Adverse pregnancy outcomes include intensive care unit (ICU) admission, pulmonary, cardiac, and renal impairment leading to mortality. Immaturity and variations of the neonatal immune system may be advantageous in responding to the virus. Neonates are at risk of vertical transmission and in-utero infection. Impaired intrauterine growth, prematurity, vertical transmission, and neonatal ICU admission are the most concerning issues. Data on maternal and neonatal outcomes should be interpreted cautiously due to study designs, patient characteristics, clinical variables, the effects of variants, and vaccination beyond the pandemic. Cesarean section, immediate separation of mother-infant dyads, isolation of neonates, and avoidance of breast milk were performed to reduce transmission risk at the beginning of the pandemic in the era of insufficient knowledge. Vertical transmission was found to be low with favorable short-term outcomes. Serious fetal and neonatal outcomes are not expected, according to growing evidence. Long-term effects may be associated with fetal programming. Knowledge and lessons from COVID-19 will be helpful for the next pandemic if it occurs. IMPACT: Prenatal infection with SARS-CoV-2 is associated with adverse maternal and neonatal outcomes. Our review includes the effects of COVID-19 on the fetus and neonates, transmission routes, placental effects, fetal and neonatal outcomes, and long-term effects on neonates. There is a growing body of data and evidence about the COVID-19 pandemic. Knowledge and lessons from the pandemic will be helpful for the next pandemic if it happens.

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States

BACKGROUND

Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19.

RESULTS

Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women.

CONCLUSIONS

Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes.

The pregnant traveller: An overview of general travel advice

Travel during pregnancy is common, but is associated with a number of risks and potential problems. There are many pregnancy-specific and destination-specific issues to be considered along with issues related to method of transport. Travel experiences should be made as safe as possible through evidence-based counselling via pregnancy healthcare providers prior to travel. This travelling in pregnancy article has been created to facilitate pregnancy healthcare providers in having these pre-travel discussions to optimise maternal and fetal wellbeing.

Adverse outcomes and maternal complications in pregnant women with severe-critical COVID-19: a tertiary center experience

OBJECTIVES

This study aimed to present perinatal outcomes, clinical challenges, and basic ICU management in pregnant women with severe-critical COVID-19 at our tertiary referral center.

METHODS

In this prospective cohort study, patients were divided into two groups, whether they survived or not. Clinical characteristics, obstetric and neonatal outcomes, initial laboratory test results and radiologic imaging findings, arterial blood gas parameters at ICU admission, and ICU complications and interventions were compared between groups.

RESULTS

157 of the patients survived, and 34 of the patients died. Asthma was the leading health problem among the non-survivors. Fifty-eight patients were intubated, and 24 of them were weaned off and discharged healthfully. Of the 10 patients who underwent ECMO, only 1 survived (p<0.001). Preterm labor was the most common pregnancy complication. Maternal deterioration was the most common indication for a cesarean section. Higher neutrophil-to-lymphocyte-ratio (NLR) values, the need for prone positioning, and the occurrence of an ICU complication were important parameters that influenced maternal mortality (p<0.05).

CONCLUSIONS

Overweight pregnant women and pregnant women with comorbidities, especially asthma, may have a higher risk of mortality related to COVID-19. A worsening maternal health condition can lead to increased rates of cesarean delivery and iatrogenic prematurity.

Maternal COVID-19 causing intrauterine foetal demise with microthrombotic placental insufficiency: a case report

BACKGROUND

Pregnant women have an increased risk of getting infected with SARS-CoV-2 and are more prone to severe illness. Data on foetal demise in affected pregnancies and its underlying aetiology is scarce and pathomechanisms remain largely unclear.

CASE

Herein we present the case of a pregnant woman with COVID-19 and intrauterine foetal demise. She had no previous obstetric or gynaecological history, and presented with mild symptoms at 34 + 3 weeks and no signs of foetal distress. At 35 + 6 weeks intrauterine foetal death was diagnosed. In the placental histopathology evaluation, we found inter- and perivillous fibrin depositions including viral particles in areas of degraded placental anatomy without presence of viral entry receptors and SARS-CoV-2 infection of the placenta.

CONCLUSION

This case demonstrates that maternal SARS-CoV-2 infection in the third trimester may lead to an unfavourable outcome for the foetus due to placental fibrin deposition in maternal COVID-19 disease possibly via a thrombogenic microenvironment, even when the foetus itself is not infected.

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

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

A critical review of COVID-19 course and vaccination in dermatology patients on immunomodulatory/biologic therapy: recommendations should not differ between non-pregnant and pregnant individuals

COVID-19 can have detrimental effects on immunosuppressed patients. Here, we evaluate the evidence regarding continuing immunomodulatory/biologic (IMBI) therapy in pregnant dermatology patients during the COVID-19 pandemic. Also, we discuss the risks of COVID-19 vaccination in pregnant dermatology patients on IMBI therapy. As indicated in this review, regarding continuing IMBI therapy in pregnant dermatology patients during the pandemic, there is no compelling reason for treating them differently than non-pregnant. The body of evidence indicates that mRNA COVID-19 vaccines are safe during pregnancy. Studies on rheumatology patients, a group that overlaps significantly with the dermatology group, provided essential findings. IMBI in a non-pregnant rheumatology patient was not associated with COVID-19 mortality (except for rituximab), and vaccination of the rheumatology patient during pregnancy improved the obstetric outcomes compared to the unvaccinated patient. Based on this data, it can be stated that after weighing the benefit-risk profile of the available COVID-19 vaccines, the recommendation for the pregnant dermatology patient speaks in favor of the COVID-19 vaccination. COVID-19 vaccine recommendations in pregnant dermatology patients on IMBI should not differ from those for their non-pregnant counterparts.

[COVID-19 in maternal, perinatal and neonatal mortality in four locations in Bogotá. Descriptive study.]

OBJECTIVE

The multiple effects of the COVID-19 pandemic are beginning to be seen from the alteration of vital statistics figures. This is summarized in changes in the usual causes of death and excess attributable mortality, which can finally be seen in structural changes in the populations of the countries. For this reason, this research was created with the objective of determining the impact of the COVID-19 pandemic on maternal, perinatal and neonatal mortality in four locations in Bogotá D.C. (Colombia).

METHODS

A retrospective longitudinal investigation was carried out in which 217,419 mortality data were analyzed in the towns of Kennedy, Fontibón, Bosa and Puente Aranda in the city of Bogotá - Colombia that occurred between the years 2018 to 2021, of which maternal (54), perinatal (1,370) and neonatal (483) deaths in order to identify a history of SARS-CoV-2 infection that could be related to the excess mortality associated with COVID-19. The data were collected from the open records of vital statistics of the National Statistics Department (DANE), where they were analyzed from frequency measures or central tendency and dispersion according to the types of variables. The specific mortality indicators related to maternal, perinatal and neonatal death events were calculated.

RESULTS

A decrease in perinatal and neonatal mortality was evidenced since 2020, which was associated with the progressive decrease in pregnancies in those same years; Additionally, a considerable increase in maternal deaths was observed for 2021 compared to the other years analyzed. The proportion of maternal deaths in 2020 and 2021 by 10% and 17%, respectively, were attributed to COVID-19.

CONCLUSIONS

It is observed that the trend of maternal mortality is related to the increase in mortality from COVID-19, maternal deaths associated with COVID-19 occurred specifically in the zonal planning units that registered more than 160 cases of COVID-19 for the year 2021.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection Symptoms in Pregnancy and Maternal and Neonatal Complications Due to COVID-19: A Systematic Review

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnant women is associated with severe maternal and neonatal complications including maternal and newborn death.

Aims

This review aimed to assess the SARS-CoV-2 infection symptoms during pregnancy as well as maternal and neonatal complications in Iran.

Settings and Design

A developing and low-income country and a systematic review.

Materials and Methods

International scientific databases including PubMed, Web of Science, Scopus and Google Scholar were searched in a systematic review manner. Two independent researchers were checked and identified articles from September 2019 to September 2022 based on eligibility criteria and quality appraisal. The results of review were reported in two sections including maternal and neonatal outcomes.

Statistical Analysis Used

Descriptive statistics was used for statistical analysis.

Results

Seventeen studies including 870 pregnant mothers with COVID-19 met the eligibility criteria and were reviewed. The main maternal consequences of COVID-19 were intensive care unit (ICU) admission, pre-term delivery, maternal death, pre-mature rupture of membranes, pre-eclampsia, intrauterine growth retardation and stillbirth. Neonatal ICU admission, newborn death, neonatal sepsis, low birth weight and respiratory distress syndrome, tachypnoea, asphyxia and pneumothorax were the most common outcomes of COVID-19 infection in offspring of pregnant subjects.

Conclusion

Pregnant mothers with COVID-19 infection are at higher risk of being admitted to the ICU and mechanical ventilation and consequently maternal and neonatal death. Comparing the maternal and foetal consequences in different ethnicities, regions and countries may be related to the socioeconomic status of people and should be considered with respect to different determines. Moreover, the maternal and neonatal complications due to COVID-19 infection in Iran and other developing countries seem to be higher than other countries.

Effect of COVID-19 on antenatal care: experiences of medical professionals in the Netherlands

BACKGROUND

COVID-19 has greatly affected the delivery of all health care services globally. Antenatal care is one area of care that has been impacted, despite the fact that attending antenatal check-ups is essential for pregnant women and cannot be postponed. Little is known about how exactly ANC provision has changed in the Netherlands, or how the changes have impacted midwives and gynaecologists providing those services.

METHODS

This study used a qualitative research design to investigate changes in individual and national practice following the onset of the COVID-19 pandemic. The study involved a document analysis of protocols and guidelines for ANC provision to evaluate how those changed following the onset of the COVID-19 pandemic and semi-structured interviews with ANC care providers (i.e., gynaecologists and midwives).

RESULTS

Guidance was issued by multiple organizations, during the pandemic, on how to approach the risk of infection in pregnant women, recommending several changes to ANC to protect both pregnant women and ANC providers. Both midwives and gynaecologists reported changes in their practice. With less face-to-face consultations happening, digital technologies became critical in the care of pregnant women. Shorter and fewer visits were reported, with midwifery practices adjusting their guidelines further than hospitals. Challenges, with high workloads and lack of personal protective equipment were discussed.

CONCLUSIONS

The COVID-19 pandemic has had an immense impact on the health care system. This impact has had both negative and positive effects on the provision of ANC in the Netherlands. It is important to learn from the current COVID-19 pandemic and adapt ANC, as well as health care systems as a whole, to be better prepared for future health crises and ensure continuous provision of good quality care.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Antepartum SARS-CoV-2 infection and adverse birth outcomes in South African women

Background

SARS-CoV-2 infection in pregnant women has been associated with severe illness in the women and higher rates of premature delivery. There is, however, paucity of data on the impact of the timing of SARS-CoV-2 infection and on symptomatic or asymptomatic infections on birth outcomes. Data from low-middle income settings is also lacking.

Methods

We conducted a longitudinal study from April 2020 to March 2021, in South Africa, where symptomatic or asymptomatic pregnant women were investigated for SARS-CoV-2 infection during the antepartum period. We aimed to evaluate if there was an association between antepartum SARS-CoV-2 infection on birth outcomes. SARS-CoV-2 infection was investigated by nucleic acid amplification test (NAAT), histological examination was performed in a sub-set of placentas.

Results

Overall, 793 women were tested for SARS-CoV-2 antenatally, including 275 (35%) who were symptomatic. SARS-CoV-2 infection was identified in 138 (17%) women, of whom 119 had symptoms (COVID-19 group) and 19 were asymptomatic. The 493 women who were asymptomatic and had a negative SARS-CoV-2 NAAT were used as the referent comparator group for outcomes evaluation. Women with COVID-19 compared with the referent group were 1.66-times (95% confidence interval (CI) = 1.02-2.71) more likely to have a low-birthweight newborn (30% vs 21%) and 3.25-times more likely to deliver a very low-birthweight newborn (5% vs 2%). Similar results for low-birthweight were obtained comparing women with SARS-CoV-2 confirmed infection (30%) with those who had a negative NAAT result (22%) independent of symptoms presentation. The placentas from women with antenatal SARS-CoV-2 infection had higher percentage of chorangiosis (odds ratio (OR) = 3.40, 95% CI = 1.18-.84), while maternal vascular malperfusion was more frequently identified in women who tested negative for SARS-CoV-2 (aOR = 0.28, 95% CI = 0.09-0.89).

Conclusions

Our study demonstrates that in a setting with high HIV infection prevalence and other comorbidities antenatal SARS-CoV-2 infection was associated with low-birthweight delivery.

COVID-19 vaccine acceptance and coverage among pregnant persons in the United States

Pregnant persons are at higher risk of severe COVID-19. Although vaccination is recommended, COVID-19 vaccination rates are lower among pregnant persons compared to the non-pregnant population. We aimed to evaluate acceptance of any dose of COVID-19 vaccine during pregnancy. A national online cross-sectional survey of US adults who were pregnant between December 2020 and July 2021 was used to measure COVID-19 vaccine behaviors, attitudes, and beliefs. Post-stratification weighting was used to ensure representativeness to the US population. Marginal log-binomial models were used to estimate adjusted prevalence ratios (aPR) of COVID-19 vaccine acceptance, accounting for sociodemographic factors. Of 5,660 who responded to survey advertisements, 2,213 met eligibility criteria and completed the survey; 55.4% of respondents received or planned to receive COVID-19 vaccine prior to or during pregnancy, 27.0% planned to vaccinate after pregnancy, 8.8% were unsure and 8.7% had no plans to vaccinate. Individuals were more likely to receive or plan to receive COVID-19 vaccine if they had group prenatal care (aPR 1.57; 95% CI 1.40, 1.75), were employed in a workplace with a policy recommending vaccination (aPR 1.15; 95% CI 1.06, 1.26), and believed COVID-19 vaccines are safe (aPR 2.86; 95% CI 2.49, 3.29). Pregnant persons who were recommended COVID-19 vaccination by their healthcare provider less commonly reported concerns about vaccine safety (35.5% vs 55.9%) and were more likely to accept COVID-19 vaccines (aPR 1.52; 95% CI 1.31, 1.76). COVID-19 vaccine acceptance during pregnancy is not universal and public health intervention will be needed to continue to increase vaccine coverage.

Mild COVID-19 Was Not Associated with Impaired IVF Outcomes or Early Pregnancy Loss in IVF Patients

Data collection regarding the effects of COVID-19 on reproduction is ongoing. This study examined the effect of COVID-19 on IVF cycle parameters and early pregnancy outcomes. It included two arms: the first compared non-exposed cycles to post-SARS-CoV-2 IVF cycles. Sperm parameters were also compared. The second, prospective arm compared pregnancy outcomes among IVF patients who contracted COVID-19 during early pregnancy to those who did not. None of the patients were vaccinated against SARS-CoV-2. The first arm included 60 treatment cycles of women with confirmed COVID-19, compared to 60 non-exposed cycles (either the same patient before exposure or matched non-exposed patients). The outcomes of the treatment cycles did not differ significantly between exposed and non-exposed groups, including number of oocytes, endometrial thickness, fertilization rate and number of top-quality embryos. In 11 cycles, the male partner had also recently recovered: sperm concentration was lower post-exposure: 6.27 million/mL vs. 16.5 pre-exposure (p = 0.008). In 189 patients with IVF-achieved pregnancies, pregnancy loss and hospital admissions did not differ between exposed and non-exposed groups. IVF treatment outcomes and the rate of early pregnancy loss appears to be unaffected by SARS-CoV-2 disease, despite a minor decline in sperm concentration among recent recoverees.

Clinical and epidemiological aspects of SARS-CoV-2 infection among pregnant and postpartum women in Mozambique: a prospective cohort study

Background

Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal outcomes, data on the effects of the pandemic on the obstetric population in sub-Saharan African countries are still scarce. Therefore, the study aims were to assess the prevalence and impact of COVID-19 on maternal and neonatal outcomes in the obstetric population at Central Hospital of Maputo (HCM), Mozambique.

Methods

Prospective cohort study conducted at teaching and referral maternity, HCM, from 20 October 2020 to 22 July 2021. We collected maternal and perinatal outcomes up to 6 weeks postpartum of eligible women (pregnant and postpartum women—up to the 14th day postpartum) screened for COVID-19 (individual test for symptomatic participants and pool testing for asymptomatic). The primary outcome was maternal death, Severe Acute Respiratory Syndrome (SARS) and Intensive Care Unit (ICU) admission. We estimated the COVID-19 prevalence and the unadjusted RR (95% CI) for maternal and perinatal outcomes. We used the chi-square or Fisher's exact test to compare categorical variables (two-sided p-value < 0.05 for statistical significance).

Results

We included 239 participants. The overall prevalence of COVID-19 was 9.2% (22/239) and in the symptomatic group was 32.4% (11/34). About 50% of the participants with COVID-19 were symptomatic. Moreover, the most frequent symptoms were dyspnoea (33.3%), cough (28.6%), anosmia (23.8%), and fever (19%). Not having a partner, being pregnant, and alcohol consumption were vulnerability factors for SARS-CoV-2 infection. The risk of adverse maternal and neonatal outcomes (abortion, foetal death, preterm birth, Apgar, and NICU admission) was not significantly increased with COVID-19. Moreover, we did not observe a significant difference in the primary outcomes (SARS, ICU admission and maternal death) between COVID-19 positive and COVID-19 negative groups.

Conclusion

The prevalence of COVID-19 in the obstetric population is higher than in the general population, and fifty percent of pregnant and postpartum women with COVID-19 infection are asymptomatic. Not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, being pregnant versus postpartum was associated with increased vulnerability to COVID-19. Data suggest that pregnant women with COVID-19 may have a higher frequency of  COVID-19 infection, reinforcing the need for universal testing, adequate follow-up for this population, and increasing COVID-19 therapy facilities in Mozambique. Moreover, provide counselling during Antenatal care for COVID-19 preventive measures. However, more prospective and robust studies are needed to assess these findings.

The epidemiological pattern of the COVID-19 pandemic in Africa is heterogeneous, and many African countries are still struggling to establish efficient testing policy, guarantee sufficient laboratory supply and achieve or maintain adequate testing capacity. In addition, evidence suggests that sexual and reproductive health services were the most affected by the pandemic; this scenario might have devastating effects on maternal and perinatal health. Moreover, data from non-sub-Saharan countries the SARS-CoV-2 infection among pregnant and postpartum women is associated with an increased risk of adverse maternal and neonatal health (preterm birth, preeclampsia and maternal death).

Although there is a significant increase of evidence regarding the prevalence and impact of COVID-19 on maternal and perinatal health, data on the effects of this condition on the obstetric population in low-income countries are scarce. Therefore, the study objective were to assess the prevalence and impact of COVID-19 on maternal and neonatal health at referral maternity in Maputo, Mozambique.

Our findings suggest that the prevalence of COVID-19 in the obstetric population is higher than the general population, and most pregnant and postpartum women are asymptomatic. Being pregnant, not having a partner and alcohol consumption were factors of greatest vulnerability to SARS-COV-2 infection. Moreover, the risk of COVID-19 among pregnant was seven-fold higher than in postpartum women. Pregnant women with COVID-19 may have a higher frequency of adverse gestational outcomes (foetal death and abortion). Although the risk of adverse maternal outcomes (death, Severe Acute Respiratory Syndrome and Intensive Care Unit admission) did not differ significantly between the COVID-19 and COVID-19 negative groups, universal screening for COVID-19 should be implemented to ensure adequate management of pregnant women and newborns.

The COVID-19 pandemic in Brazilian pregnant and postpartum women: results from the REBRACO prospective cohort study

Brazil presented a very high number of maternal deaths and evident delays in healthcare. We aimed at evaluating the characteristics of SARS-CoV-2 infection and associated outcomes in the obstetric population. We conducted a prospective cohort study in 15 Brazilian centers including symptomatic pregnant or postpartum women with suspected COVID-19 from Feb/2020 to Feb/2021. Women were followed from suspected infection until the end of pregnancy. We analyzed maternal characteristics and pregnancy outcomes associated with confirmed COVID-19 infection and SARS, determining unadjusted risk ratios. In total, 729 symptomatic women with suspected COVID-19 were initially included. Among those investigated for COVID-19, 51.3% (n = 289) were confirmed COVID-19 and 48% (n = 270) were negative. Initially (before May 15th), only 52.9% of the suspected cases were tested and it was the period with the highest proportion of ICU admission and maternal deaths. Non-white ethnicity (RR 1.78 [1.04–3.04]), primary schooling or less (RR 2.16 [1.21–3.87]), being overweight (RR 4.34 [1.04–19.01]) or obese (RR 6.55 [1.57–27.37]), having public prenatal care (RR 2.16 [1.01–4.68]), planned pregnancies (RR 2.09 [1.15–3.78]), onset of infection in postpartum period (RR 6.00 [1.37–26.26]), chronic hypertension (RR 2.15 [1.37–4.10]), pre-existing diabetes (RR 3.20 [1.37–7.46]), asthma (RR 2.22 [1.14–4.34]), and anaemia (RR 3.15 [1.14–8.71]) were associated with higher risk for SARS. The availability of tests and maternal outcomes varied throughout the pandemic period of the study; the beginning was the most challenging period, with worse outcomes. Socially vulnerable, postpartum and previously ill women were more likely to present SARS related to COVID-19.

sFlt-1 Is an Independent Predictor of Adverse Maternal Outcomes in Women With SARS-CoV-2 Infection and Hypertensive Disorders of Pregnancy

Background

Preeclampsia (PE) and COVID-19 share a common vascular–endothelial physiopathological pathway that may aggravate or worsen women's outcomes when both coexist. This study aims to evaluate the association of sFlt-1 levels and adverse maternal outcomes among positive SARS-CoV-2 pregnant women with and without hypertensive disorders of pregnancy (HDP).

Methods

We performed a multicenter retrospective cohort study of pregnant women with confirmed SARS-CoV-2 infection that required hospital admission. The exposed cohort comprised women with a diagnosis of an HDP. The primary outcome was a composite definition of adverse maternal outcome. The association between predictors and the main and secondary outcomes was assessed using an elastic-net regression which comprised a Lasso and Ridge regression method for automatic variable selection and penalization of non-statistically significant coefficients using a 10-fold cross-validation where the best model if automatically chosen by the lowest Akaike information criterion (AIC) and Bayesian information criteria (BIC).

Results

Among 148 pregnant women with COVID-19, the best predictive model comprised sFlt-1 MoMs [odds ratio (OR): 5.13; 95% CI: 2.19–12.05], and HDP (OR: 32.76; 95% CI: 5.24–205). sFlt-1 MoMs were independently associated with an increased probability of an adverse maternal outcome despite adjusting for HDP.

Conclusions

Our study shows that sFlt-1 is an independent predictor of adverse outcomes in women with SARS-CoV-2 despite hypertension status.

Is there a higher prevalence of mood and anxiety disorders among pregnant women during the COVID-19 pandemic? A comparative study

OBJECTIVE

This study aimed to compare data on mood and anxiety disorders of pregnant women before and during the COVID-19 pandemic.

METHODS

The study sample included 253 women evaluated on their first postpartum day during the COVID-19 pandemic. Mood and anxiety disorders were determined by the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Data from sample was compared with data from previous study that was completed and published prior to the COVID-19 pandemic.

RESULTS

The prevalence rate of mood and anxiety disorders during the COVID-19 pandemic was 7.1% and 13.0%, respectively. The most common specific disorder was generalized anxiety disorder (7.1%). Compared to period before the COVID-19 pandemic, the prevalence of mood and anxiety disorders in the current sample was not significantly different.

CONCLUSION

Results of this study suggest that pregnant women may have not be under higher risk for mood and anxiety disorders during the COVID-19 pandemic compared to before the pandemic.

Perinatal outcomes in women with severe acute respiratory syndrome coronavirus 2 infection: comparison with contemporary and matched pre-COVID-19 controls

OBJECTIVES

To compare perinatal outcomes in women with vs. without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

METHODS

Perinatal outcomes in SARS-CoV-2 positive pregnant women who delivered at our institution between October 27th 2020 and January 31st 2021 were compared to SARS-CoV-2 negative pregnancies (contemporary controls) and historical 2019 controls matched by maternal age, pre-pregnancy body mass index and parity. Testing was performed based on symptoms or close contact at any time during pregnancy and as part of universal screening at hospital admission. Multivariable log-linear regression models were used adjusting for potential confounders (p < 0.05 statistically significant).

RESULTS

One thousand three hundred seventeen women delivered at our institution during the study period. 1,124 (85%) tested negative and 193 (15%) positive for SARS-CoV-2. 189 (98%) were infected during third trimester. 19 (10%) were asymptomatic, 171 (89%) had mild to moderate coronavirus disease 2019 (COVID-19), and 3 (2%) were critically ill with one case of maternal death. There were no significant differences in preterm birth, small-for-gestational-age birth weight, congenital anomalies, operative delivery, intrapartum hypoxia, and perinatal mortality in SARS-CoV-2 positive pregnancies compared to contemporary reference group or historical controls from pre-COVID-19 period. Labor was more commonly induced in SARS-CoV-2 positive women compared to reference SARS-CoV-2 negative group (68 [35%] vs. 278 [25%], adjusted odds ratio 1.62; 95% confidence interval 1.14-2.28).

CONCLUSIONS

SARS-CoV-2 infection in pregnancy was not strongly associated with adverse perinatal outcomes. While the majority of SARS-CoV-2 positive women had no or mild/moderate symptoms, 2% were critically ill, with one case of maternal death.

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.

SARS-CoV-2 infection in pregnant women assisted in a high-risk maternity hospital in Brazil: Clinical aspects and obstetric outcomes

Background

The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the possible development of serious illness, and the possibility of severe obstetric outcomes highlight the importance of addressing SARS-CoV-2 infection in obstetric management.

Methods and findings

A cross-sectional study of pregnant women assisted in a high-risk maternity hospital in Brazil in 2020. All patients admitted for delivery or miscarriage care were tested for SARS-CoV-2 using polymerase chain reaction (PCR) and for immunoglobulin (I)gM, and/or IgG by immunochromatography. Clinical aspects and obstetric outcomes were analyzed. A total of 265 pregnant women were included in the study. There were 38 (14.4%) PCR positive cases during pregnancy, 12 (31.6%) on admission screening, and 71(27.2%) patients were IgM- and/or IgG-positive. Among the participants, 86 (32.4%) had at least one positive test during pregnancy. SARS-CoV-2 positive patients had greater contact with known positive patients (p = 0.005). The most frequently reported symptoms were runny nose, cough, loss of smell and taste, headache, and fever. There was also a 35% rate of asymptomatic infections and a 4.6% rate of severe or critical infections. Patients exposed or infected with SARS-CoV-2 had a higher incidence of preterm delivery, cesarean section, need for resuscitation in the delivery room, Apgar score <7 at 5 min, admission to the neonatal intensive care unit, and jaundice. Newborns with at least one positive test had a significantly greater need for phototherapy after delivery (p = 0.05). The results showed a high rate of positive tests among newborns (37.5%), which seems to be compatible with both neonatal and perinatal infection.

Conclusions

It is important to further investigate SARS-CoV-2 infection during pregnancy, including the clinical course and the possibility of adverse outcomes with impact on maternal and fetal health, regardless of the development of symptoms.

SARS-CoV-2 Placentitis and Intraparenchymal Thrombohematomas Among COVID-19 Infections in Pregnancy

This cases series examines SARS-CoV-2 placentitis and intraparenchymal thrombohematomas among COVID-19 infections during pregnancy.

Adverse Perinatal Outcomes in a Large US Birth Cohort During the COVID-19 Pandemic: Adverse Perinatal Outcomes During COVID-19

OBJECTIVE

To investigate whether coronavirus disease 2019 (COVID-19) is associated with adverse perinatal outcomes in a large national dataset and to examine rates of adverse outcomes during the pandemic compared to pre-pandemic period.

METHODS

This observational cohort study included 683,905 patients, between the ages of 12-50, hospitalized for childbirth and abortion between January 1, 2019 and May 31, 2021. During the pre-pandemic period, 271,444 women were hospitalized for childbirth. During the pandemic, 308,532 women were hospitalized for childbirth and 2,708 had COVID-19. Associations between COVID-19 and in-hospital adverse perinatal outcomes were examined using propensity score-adjusted logistic regression.

RESULTS

Compared to women without COVID-19, women with COVID-19 were more likely to experience both early and late preterm birth (aOR 1.38 [95% CI 1.1-1.7], aOR 1.62 [95% CI 1.3-1.7], respectively), preeclampsia (aOR 1.2 [95% CI 1.0-1.4]), disseminated intravascular coagulopathy (DIC) (aOR 1.57 [95% CI 1.1-2.2]), pulmonary edema (aOR 2.7 [95% CI 1.1- 6.3]), and need for mechanical ventilation (aOR 8.1 [95% CI 3.8-17.3]). There was no significant difference in the prevalence of stillbirth among women with (n= 16 / 2,708) and without (n= 174 / 39,562) COVID-19, p=0.257. There were no differences in adverse outcomes among women who delivered during the pandemic versus pre-pandemic period. Combined in-hospital mortality was significantly higher for women with COVID-19 (147 [95% CI 3.0 -292] vs 2.5 [95% CI 0-7.5] deaths per 100,000 women). Women diagnosed with COVID-19 within 30 days prior to hospitalization were more likely to experience early preterm birth, placental abruption, and mechanical ventilation, compared to women diagnosed with COVID-19 > 30 days prior to hospitalization for childbirth (4.0% vs. 2.4% for early preterm birth, aOR 1.7 [95% CI 1.1-2.7]; 2.2% vs. 1.2% for placental abruption, aOR 1.86 [95% CI 1.0 - 3.4]); 0.9% vs. 0.1% for mechanical ventilation, aOR 13.7 [95% CI 1.8-107.2])).

CONCLUSION

Women with COVID-19 had a higher prevalence of adverse perinatal outcomes and increased in-hospital mortality, with highest risk occurring when diagnosis was within 30 days of hospitalization, raising the possibility of a high-risk period.

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.

SARS-CoV-2 infection during pregnancy and risk of preeclampsia: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between SARS-CoV-2 infection during pregnancy and the risk for preeclampsia.

DATA SOURCES

MEDLINE, Embase, POPLINE, CINAHL, LILACS, and the World Health Organization COVID-19, Chinese, and preprint databases (all from December 1, 2019, to May 31, 2021). Google Scholar, bibliographies, and conference proceedings were also searched.

STUDY ELIGIBILITY CRITERIA

Observational studies that assessed the association between SARS-CoV-2 infection during pregnancy and preeclampsia and that reported unadjusted and/or adjusted risk estimates and 95% confidence intervals or data to calculate them.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was preeclampsia. Secondary outcomes included preeclampsia with severe features, preeclampsia without severe features, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Two reviewers independently reviewed studies for inclusion, assessed their risk of bias, and extracted data. Pooled unadjusted and adjusted odds ratios with 95% confidence intervals, and 95% prediction interval were calculated. Heterogeneity was quantified using the І2 statistic, for which І2≥30% indicated substantial heterogeneity. Subgroup and sensitivity analyses were performed to test the robustness of the overall findings.

RESULTS

A total of 28 studies comprising 790,954 pregnant women, among which 15,524 were diagnosed with SARS-CoV-2 infection, met the inclusion criteria. The meta-analysis of unadjusted odds ratios showed that the odds of developing preeclampsia were significantly higher among pregnant women with SARS-CoV-2 infection than among those without SARS-CoV-2 infection (7.0% vs 4.8%; pooled odds ratio, 1.62; 95% confidence interval, 1.45-1.82; P<.00001; І2=17%; 26 studies; 95% prediction interval of the odds ratio, 1.28-2.05). The meta-analysis of adjusted odds ratios also showed that SARS-CoV-2 infection during pregnancy was associated with a significant increase in the odds of preeclampsia (pooled odds ratio, 1.58; 95% confidence interval, 1.39-1.80; P<.0001; І2=0%; 11 studies). There was a statistically significant increase in the odds of preeclampsia with severe features (odds ratio, 1.76; 95% confidence interval, 1.18-2.63; І2=58%; 7 studies), eclampsia (odds ratio, 1.97; 95% confidence interval, 1.01-3.84; І2=0%, 3 studies), and HELLP syndrome (odds ratio, 2.10; 95% confidence interval, 1.48-2.97; 1 study) among pregnant women with SARS-CoV-2 infection when compared to those without the infection. Overall, the direction and magnitude of the effect of SARS-CoV-2 infection during pregnancy on preeclampsia was consistent across most prespecified subgroup and sensitivity analyses. Both asymptomatic and symptomatic SARS-CoV-2 infections significantly increased the odds of developing preeclampsial; however, it was higher among patients with symptomatic illness (odds ratio, 2.11; 95% confidence interval, 1.59-2.81) than among those with asymptomatic illness (odds ratio, 1.59; 95% confidence interval, 1.21-2.10).

CONCLUSION

SARS-CoV-2 during pregnancy is associated with higher odds of preeclampsia.

Pregnancy and COVID-19: prevention, vaccination, therapy, and beyond

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has alarmed the world since its first emergence. As pregnancy is characterized by significant changes in cardiovascular, respiratory, endocrine, and immunological systems, there are concerns on issues like the course of disease in pregnant women, safety of medications, route of delivery and risk of obstetric complications. The aim of this review is to summarize the current literature in the management of pregnant women during the COVID-19 pandemic. Although more than 90% of pregnant women with COVID-19 recover without serious morbidity, rapid deterioration of disease and higher rates of obstetric complications may be observed. The risk of vertical transmission has not been clearly revealed yet. Decreasing the number of prenatal visits, shortening the time allocated for the examinations, active use of telemedicine services, limiting the number of persons in healthcare settings, combining prenatal tests in the same visit, restricting visitors during the visits, providing a safe environment in healthcare facilities, strict hygiene control, and providing personal protective equipment during the visits are the main strategies to control the spread of disease according to current guidelines. Although new medication alternatives are being proposed every day for the treatment of COVID-19, our knowledge about the use of most of these drugs in pregnancy is limited. Preliminary results are promising for the administration of SARS-CoV-2 vaccines in the pregnant population. Timing of delivery should be decided based on maternal health condition, accompanying obstetric complications and gestational age. Cesarean delivery should be performed for obstetric indications. Breast feeding should be encouraged as long as necessary precautions for viral transmission are taken. In conclusion, an individualized approach should be provided by a multidisciplinary team for the management of pregnant women with COVID-19 to achieve favorable outcomes.

[Recommendations for SARS-CoV-2/COVID-19 during Pregnancy, Birth and Childbed - Update November 2021 (Long Version)]

Since the onset of the SARS-CoV-2 pandemic, the German Society of Gynecology and Obstetrics and the Society for Peri-/Neonatal Medicine have published and repeatedly updated recommendations for the management of SARS-CoV-2 positive pregnancies and neonates. As a continuation of existing recommendations, the current update addresses key issues related to the prenatal, perinatal, and postnatal care of pregnant women, women who have given birth, women who have recently given birth, women who are breastfeeding with SARS-CoV-2 and COVID-19, and their unborn or newborn infants, based on publications through September 2021. Recommendations and opinions were carefully derived from currently available scientific data and subsequently adopted by expert consensus. This guideline - here available in the long version - is intended to be an aid to clinical decision making. Interpretation and therapeutic responsibility remain with the supervising local medical team, whose decisions should be supported by these recommendations. Adjustments may be necessary due to the rapid dynamics of new evidence. The recommendations are supported by the endorsement of the professional societies: German Society for Perinatal Medicine (DGPM), German Society of Gynecology and Obstetrics (DGGG), German Society for Prenatal and Obstetric Medicine (DGPGM), German Society for Pediatric Infectiology (DGPI), Society for Neonatology and Pediatric Intensive Care Medicine (GNPI).

On the cutting edge: key findings on maternal and neonatal outcomes in women with COVID-19 in a study by the World Association of Perinatal Medicine

The World Association of Perinatal Medicine (WAPM) study on the COrona VIrus Disease 2019 (COVID-19) was an international, retrospective cohort study that included pregnant women tested positive with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection between February and April 2020. The study involved 73 centers from 22 countries. The WAPM study included 388 singletons, viable pregnancies, positive to SARS-CoV-2 at real-time reverse-transcriptase-polymerase-chain-reaction nasal and pharyngeal swab. The majority of the included women were symptomatic. The occurrence of maternal adverse events was significantly higher in symptomatic, compared with asymptomatic pregnant women. Women carrying high-risk pregnancies (either preexisting chronic medical conditions in pregnancy or obstetrical disorders occurring in pregnancy) were at a higher risk of hospital admission, presence of severe respiratory symptoms, admission to the intensive care unit, and invasive mechanical ventilation. As per maternal outcomes, the occurrence of fetal and neonatal adverse events was significantly higher in symptomatic, compared with asymptomatic pregnant women. The incidence of a composite adverse fetal outcome was significantly higher when the infection occurred in the first trimester, and in fetuses with lower birthweight.

Management of pregnant women with COVID-19: A tertiary pandemic center experience on 1416 cases

The aim of this study is to share the comprehensive experience of a tertiary pandemic center on pregnant women with COVID-19 and to compare clinical outcomes between pregnancy trimesters. The present prospective cohort study consisted of pregnant women with COVID-19 who were followed up at Ankara City Hospital between March 11, 2020 and February 20, 2021. Clinical characteristics and perinatal outcomes were compared between the pregnancy trimesters. A total of 1416 pregnant women (1400 singletons and 16 twins) with COVID-19 were evaluated. Twenty-six (1.8%) patients were admitted to the intensive care unit (ICU) and maternal mortality was observed in six (0.4%) cases. Pregnancy complications were present in 227 (16.1%) cases and preterm labor was the most common one (n = 42, 2.9%). There were 311, 433, and 672 patients in the first, second, and third trimesters of pregnancy, respectively. Rates of mild and severe/critic COVID-19 were highest in the first and second trimesters, respectively. The hospitalization rate was highest in the third trimester. Pregnancy complications, maternal mortality, and NICU admission rates were similar between the groups. The course of the disease and obstetric outcomes may be different among pregnancy trimesters. A worse course of the disease may be observed even in pregnant women without any coexisting health problems.

SARS-CoV-2 and pregnancy outcomes under universal and non-universal testing in Sweden: register-based nationwide cohort study

OBJECTIVE

To assess associations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pregnancy outcomes considering testing policy and test-positivity-to-delivery interval.

DESIGN

Nationwide cohort study.

SETTING

Sweden.

POPULATION

From the Pregnancy-Register we identified 88 593 singleton births, 11 March 2020-31 January 2021, linked to data on SARS-CoV-2-positivity from the Public Health Agency, and information on neonatal care admission from the Neonatal Quality Register. Adjusted odds ratios (aORs) were estimated stratified by testing-policy and test-positivity-to-delivery interval.

MAIN OUTCOME MEASURES

Five-minute Apgar score, neonatal care admission, stillbirth and preterm birth.

RESULTS

During pregnancy, SARS-CoV-2 test-positivity was 5.4% (794/14 665) under universal testing and 1.9% (1402/73 928) under non-universal testing. There were generally lower risks associated with SARS-CoV-2 under universal than non-universal testing. In women testing positive >10 days from delivery, generally no significant differences in risk were observed under either testing policy. Neonatal care admission was more common (15.3% versus 8.0%; aOR 2.24, 95% CI 1.62-3.11) in women testing positive ≤10 days before delivery under universal testing. There was no significant association with 5-minute Apgar score below 7 (1.0% versus 1.7%; aOR 0.64, 95% CI 0.24-1.72) or stillbirth (0.3% versus 0.4%; aOR 0.72, 95% CI 0.10-5.20). Compared with term births (2.1%), test-positivity was higher in medically indicated preterm birth (5.7%; aOR 2.70, 95% CI 1.60-4.58) but not significantly increased in spontaneous preterm birth (2.3%; aOR 1.12, 95% CI 0.62-2.02).

CONCLUSIONS

Testing policy and timing of test-positivity impact associations between SARS-CoV-2-positivity and pregnancy outcomes. Under non-universal testing, women with complications near delivery are more likely to be tested than women without complications, thereby inflating any association with adverse pregnancy outcomes compared with findings under universal testing.

TWEETABLE ABSTRACT

Testing policy and time from SARS-CoV-2 infection to delivery influence the association with pregnancy outcomes.

COVID-19 Lockdown Increased the Risk of Preterm Birth

Purpose: To estimate whether the city-specific lockdown in Shanghai induced by the COVID-19 pandemic affected preterm birth rates among uninfected pregnant women in different trimesters.

Methods: The population-based retrospective cohort study was conducted in the International Peace Maternity and Child Health Hospital (IPMCH) in Shanghai, China. Pregnant women without COVID-19 received perinatal healthcare during lockdown (from January 24, 2020 to March 24, 2020) and non-lockdown (from January 24, 2019 to March 24, 2019) period and giving birth to a live infant at IPMCH were enrolled. 1:1 propensity score matching and Inverse probability of treatment weighting were used to evaluate preterm birth (<37 weeks), very preterm birth (<34 weeks), preterm birth with premature rupture of membranes (PROM-PTB), spontaneous preterm birth with intact membranes (S-PTB), and medically induced preterm birth (MI-PTB) between two groups.

Results: 8,270 pregnant women were in the lockdown group, and 9,815 were in the non-lockdown group. Pregnant women in second trimester during lockdown had a higher risk of PTB than those during the non-lockdown period [OR: 1.43 (CI 1.01–2.02), ARD: 1.7% (CI 0.04–3.4%), p = 0.045]. Furthermore, pregnant women in third trimester during lockdown had a higher risk of PROM-PTB than those during the non-lockdown period [OR: 1.64 (CI 1.09–2.47), ARD: 0.9% (CI 0.2–1.6%), p = 0.02]; no group differences were found related to rates of VPTB, S-PTB or MI-PTB.

Conclusion: In this cohort study in China, we found that there was an increased risk in preterm birth for non-infected women in COVID-19 lockdown who were in their second trimester.

The impact of COVID-19 in pregnancy: Part I. Clinical presentations and untoward outcomes of pregnant women with COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019, COVID-19) is a pandemic disease with rapidly and widely disseminating to the world. Based on experiences about the H1N1, Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) coronavirus pandemics, pregnant women who are infected are disproportionately more likely to develop severe illness and need more hospitalizations, intensive care, and finally die of diseases compared with those nonpregnant counterparts or those pregnant women without infection. Although more than one half of pregnant women with COVID-19 are asymptomatic, and as well as their symptoms are frequently mild, this observation presents a further challenge regarding service provision, prevention, and management, in which this may result in overlooking the risk of COVID-19 during pregnancy. As predictable, despite much advance in critical care in recent decades, during the 2020 COVID-19 pandemic, pregnant women with COVID-19 are really at higher risk to progress to severe illness; require hospitalization; need intensive care, such as the use of mechanical ventilation as well as extracorporeal membrane oxygenation (ECMO), and of most important, die than their nonpregnant counterparts and pregnant women without COVID-19. The magnitude of the risk to pregnant women further extend to their newborn from COVID-19 with resultant significantly increasing perinatal and neonatal morbidity and mortality rates. The heightened risk of untoward outcomes in pregnant women emphasizes an urgent need of national or international recommendations and guidelines to optimize prevention and management strategies for COVID-19 in pregnancy. Active and passive prevention of COVID-19 is approved as effective strategies for women who attempt to be pregnant or during pregnancy. Understanding that pregnant women who are a vulnerable population is essential to improve the care in the novel and urgent COVID-19 pandemic. The current review is a part I to summarize the up-to-date information about the impact of laboratory-confirmed SARS-CoV-2 infection on pregnant women and focus on clinical presentations and untoward pregnancy outcomes of these pregnant women infected with SARS-CoV-2.

COVID-related "lockdowns" and birth rates in New York

OBJECTIVE

Recent analyses have suggested that the number of births in the United States may decrease substantially in the wake of the COVID-19 pandemic.¹ Some of this decline may be attributable to economic disruptions that are often linked to lowered birth rates.¹ However to the best of our knowledge, empirical data to validate these projections and to look more specifically at the consequences of "lockdowns," have not yet been published. The objective of our study was to compare the birth rates in New York City and Long Island hospitals during the 9 months after the lockdown, to the birth rates during the same time frames in previous years.

STUDY DESIGN

This was a multicenter, retrospective study of live births from hospitals in the New York City Maternal-Fetal Medicine Research Consortium, an ongoing collaboration at several hospitals in New York City and Long Island. This consortium captures approximately one-third of the births in New York City (eg, of the 117,013 births recorded in 2017, 42,680 [36.6%] were from this consortium). To evaluate whether the lockdown in New York City (the first in the United States) between March 2020 and June 2020 resulted in a change in the number of births after the lockdown, we calculated the total live births 9 months after the lockdown (between December 2020 and February 2021) and compared the number with the total in the same 3 months during the previous 4 years. Fourteen hospitals with a total of greater than 55,000 annualized live births were included. Time series regression was performed to test the birth trends and to determine whether any change was a part of an ongoing trend.

RESULTS

Figure 1 shows the total live births in the different time frames. There were 12,099 live births that occurred between December 2020 and February 2021. This is 2994 (19.8%) less live births than the previous year. In addition, the average number of live births in the 4 years before the study period was 15,101 births. This decrease was seen in all the hospitals included in the cohort. The hospitals located within New York City (N=10) had a larger drop in birth rate in the last 2 years (-1947, 18.9%) than in the hospitals located in Long Island (N=4) (-581, 13.4%). Figure 2 represents the total live births by individual hospitals in the different time frames. Among the entire cohort, the largest drop in birth rate in the previous years was only 4.9%. In addition, there was no significant trend in the number of births in the previous years (P=.586). Furthermore, no significant trend was identified in the hospitals located in New York City or Long Island (P=.831 and P=.178, respectively). Hospitals with large numbers of Medicaid-funded births showed the same trend as hospitals with smaller numbers of such births.

CONCLUSION

Nine months after the lockdown was implemented, we observed a nearly 20% decrease in live births than the previous year. Although these data demonstrate a decline that is even greater than previously projected by analysts,¹ there are several issues that should be considered. Firstly, the relationship between lockdowns and preterm birth is unclear, because we did not evaluate the birth outcomes, and thus, we cannot comment on preterm birth. However, most data do not suggest a major effect in the direction of more preterm births.^2-4 We are unable to comment on the outmigration of pregnant women to other hospitals, the 3 accredited free-standing birth centers in New York City, or other geographic areas. However, the estimates on the outmigration data were less than the decrease we found. Using anonymized smartphone location data of approximately 140,000 New York City residents, a company specializing in geospatial analysis found that approximately 5% of New York City residents left New York City between March and May, with the majority moving to surrounding locations in the Northeast and to South Florida.⁵ The steeper decrease in live births in hospitals located in New York City than in those located in Long Island may be related to the population density and the recommended social distancing practices. The population density is higher in New York City than in Long Island (27,000 people per square mile vs 2360 people per square mile). Thus, the lockdown may have had a reduced effect on the number of live births in areas with a lower population density. In addition, most of the New York City residents outmigrated to surrounding locations including Long Island, which may have diminished the decrease in live births. Our data clearly demonstrate that there were significant changes in the number of births in the 9 months after the nation's first lockdown. Although we cannot definitively determine the contributions of migration, family choice, or other factors to those changes, these preliminary findings should provide direction to future studies. That work should consider zip codes, parities, and other factors that might exaggerate or mitigate the trends we report here.

Coronavirus disease 2019 (COVID-19) and the risk of hypertensive disorders of pregnancy: a retrospective cohort study

Objective: To evaluate of COVID-19 disease in pregnant women and its association with hypertensive disorders of pregnancy.Design: Retrospective Cohort StudySetting: Multicenter study from a large metropolitan hospital systemMethods: Patients who tested positive for COVID-19 during their pregnancy and delivered were compared to the three subsequent deliveries of patients who tested negative (controls). We evaluated the impact of COVID-19 on the development of hypertensive disorders of pregnancy.Results: Compared with pregnancies negative for SARs-CoV-2 infection, maternal SARs-CoV-2 infection was associated with an increased risk for hypertensive disorders of pregnancy (OR 3.68, 95% CI 1.67 - 8.10).Tweetable AbstractPatients who test positive for COVID-19 during their pregnancy are at increased risk of developing a hypertensive disorder of pregnancy. Earlier SARs-CoV-2 infection results in an increased risk of developing a hypertensive disorder.

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.

Clinical and in Vitro Evidence against Placenta Infection at Term by Severe Acute Respiratory Syndrome Coronavirus 2

Despite occasional reports of vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy, the question of placental infection and its consequences for the newborn remain unanswered. Herein, we analyzed the placentas of 31 coronavirus disease 2019–positive mothers by reverse transcriptase PCR, immunohistochemistry, and in situ hybridization. Only one case of placental infection was detected, which was associated with intrauterine demise of the fetus. Differentiated primary trophoblasts were then isolated from nonpathologic human placentas at term, differentiated, and exposed to SARS-CoV-2 virions. Unlike for positive control cells Vero E6, the virus inside cytotrophoblasts and syncytiotrophoblasts or in the supernatant 4 days after infection was undetectable. As a mechanism of defense, we hypothesized that trophoblasts at term do not express angiotensin-converting enzyme 2 and transmembrane protease serine 2 (TMPRSS2), the two main host membrane receptors for SARS-CoV-2 entry. The quantification of these proteins in the placenta during pregnancy confirmed the absence of TMPRSS2 at the surface of the syncytium. Surprisingly, a transiently induced experimental expression of TMPRSS2 did not allow the entry or replication of the virus in differentiated trophoblasts. Altogether, these results underline that trophoblasts are not likely to be infected by SARS-CoV-2 at term, but raise concern about preterm infection.

Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a zoonotic coronavirus that crossed species to infect humans, causing coronavirus disease 2019 (COVID-19). Despite a potentially higher risk of pregnant women acquiring SARS-CoV-2 infection compared with the non-pregnant population (particularly in some ethnic minorities), no additional specific recommendations to avoid exposure are needed in pregnancy. The most common clinical symptoms and laboratory signs of SARS-CoV-2 infection in pregnancy are fever, cough, lymphopenia and elevated C-reactive protein levels. Pregnancy is associated with a higher risk of severe SARS-CoV-2 infection compared with the non-pregnant population, including pneumonia, admission to the intensive care unit and death, even after adjusting for potential risk factors for severe outcomes. The risk of miscarriage does not appear to be increased in women with SARS-CoV-2 infection. Evidence with regards to preterm birth and perinatal mortality is conflicting, but these risks are generally higher only in symptomatic, hospitalized women. The risk of vertical transmission, defined as the transmission of SARS-CoV-2 from the mother to the fetus or the newborn, is generally low. Fetal invasive procedures are considered to be generally safe in pregnant women with SARS-CoV-2 infection, although the evidence is still limited. In pregnant women with COVID-19, use of steroids should not be avoided if clinically indicated; the preferred regimen is a 2-day course of dexamethasone followed by an 8-day course of methylprednisolone. Non-steroidal anti-inflammatory drugs may be used if there are no contraindications. Hospitalized pregnant women with severe COVID-19 should undergo thromboprophylaxis throughout the duration of hospitalization and at least until discharge, preferably with low molecular weight heparin. Hospitalized women who have recovered from a period of serious or critical illness with COVID-19 should be offered a fetal growth scan about 14 days after recovery from their illness. In asymptomatic or mildly symptomatic women who have tested positive for SARS-CoV-2 infection at full term (i.e. ≥ 39 weeks of gestation), induction of labor might be reasonable. To date, there is no clear consensus on the optimal timing of delivery for critically ill women. In women with no or few symptoms, management of labor should follow routine evidence-based guidelines. Regardless of COVID-19 status, mothers and their infants should remain together and breastfeeding, skin-to-skin contact, kangaroo mother care and rooming-in throughout the day and night should be practiced, while applying necessary infection prevention and control measures. Many pregnant women have already undergone vaccination, mostly in the USA where the first reports show no significant difference in pregnancy outcomes in pregnant women receiving SARS-CoV-2 vaccination during pregnancy compared with the background risk. Vaccine-generated antibodies were present in the umbilical cord blood and breast milk samples of pregnant and lactating women who received the mRNA COVID-19 vaccine. Based on the available limited data on the safety of the COVID-19 vaccine in pregnancy, it seems reasonable to offer the option of vaccination to pregnant women after accurate counseling on the potential risk of a severe course of the disease and the unknown risk of fetal exposure to the vaccine. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.