Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection during late pregnancy: a report of 18 patients from Wuhan, China

Trimester and severity of SARS-CoV-2 infection during pregnancy and risk of hypertensive disorders in pregnancy

OBJECTIVE

SARS-CoV-2 infection during pregnancy has been linked with an increased risk of hypertensive disorders of pregnancy (HDP). The aim of this study was to examine how both trimester and severity of SARS-CoV-2 infection impact HDP.

METHODS

We conducted a cohort study of SARS-CoV-2-infected individuals during pregnancy (n = 205) and examined the association between trimester and severity of infection with incidence of HDP using modified Poisson regression models to calculate risk ratios (RR) and 95% confidence intervals (CI). We stratified the analysis of trimester by severity to understand the role of timing of infection among those with similar symptomatology and also examined timing of infection as a continuous variable.

RESULTS

Compared to a reference cohort from 2018, SARS-CoV-2 infection did not largely increase the risk of HDP (RR: 1.17; CI:0.90, 1.51), but a non-statistically significant higher risk of preeclampsia was observed (RR: 1.33; CI:0.89, 1.98), in our small sample. Among the SARS-CoV-2 cohort, severity was linked with risk of HDP, with infections requiring hospitalization increasing the risk of HDP compared to asymptomatic/mild infections. Trimester of infection was not associated with risk of HDP, but a slight decline in the risk of HDP was observed with later gestational week of infection. Among patients with asymptomatic or mild symptoms, SARS-CoV-2 in the first trimester conferred a higher risk of HDP compared to the third trimester (RR: 1.70; CI:0.77, 3.77), although estimates were imprecise.

CONCLUSION

SARS-CoV-2 infection in early pregnancy may increase the risk of HDP compared to infection later in pregnancy.

A Retrospective Cohort Study on Maternal and Neonatal Clinical Characteristics and Outcomes of COVID-19: Does the Gestational Age Affect the Outcome?

Background To evaluate the maternal and neonatal clinical characteristics and outcomes of COVID-19 during pregnancy and to see whether infection with COVID-19 before or after the 20th gestational week affects these outcomes. Methods We conducted a retrospective study with data from pregnant women who were followed up and delivered at Acibadem Maslak Hospital between April 2020 and December 2021. Their demographics and clinical data were reviewed and compared. Results Among 1223 pregnant women, 42 (3.4%) were diagnosed with COVID-19 (SARS-CoV-2-positive). Approximately 52.4% of the 42 pregnant women with COVID-19 were diagnosed during or before the 20th gestational week, while 47.6% were positive after the 20th gestational week. The preterm birth rate was 11.9% and 5.9% in infected and uninfected pregnant women, respectively (p>0.05). In the infected pregnant women, the rate of preterm rupture of membranes (PROM) was 2.4%, small for gestational age (SGA) was 7.1%, cesarean delivery was 76.2%, and neonatal intensive care unit (NICU) admission was 9.5%. These rates among uninfected women were 0.9%, 9.1%, 61.7%, and 4.1%, respectively (p>0.05). Maternal ICU admission and intrapartum complications were higher in infected pregnant women (p>0.05). Postpartum hemorrhage (PPH), intrauterine growth retardation (IUGR), neonatal infection, and fetal demise were absent in SARS-CoV-2-positive pregnant women. Having a high school or lower education level significantly increased the risk of SARS-CoV-2 infection during pregnancy 10 times. Also, a one-week increase in gestational age significantly reduced the risk of SARS-CoV-2 infection during pregnancy. When SARS-CoV-2-positive pregnant women were compared according to whether or not they were positive before or after the 20th gestational week, there was no statistically significant difference between the two groups in terms of maternal outcomes, neonatal outcomes, and demographic characteristics. Conclusions COVID-19 during pregnancy did not adversely affect maternal and neonatal outcomes. Also, whether pregnant women were infected before or after the 20th gestational week did not have a negative impact on maternal and neonatal outcomes. However, infected pregnant women should be followed closely, and they should be informed in detail about the possible adverse outcomes and the importance of precautions for COVID-19.

Perinatal Cerebral Ischemic Lesion and SARS-CoV-2 Infection during Pregnancy: A Case Report and a Review of the Literature

Perinatal stroke is related to possible differences in predisposing factors and outcomes between acutely and retrospectively diagnosed cases. In most cases, there are different risk factors and infections that could play an important role. Thus far, different clinical manifestations have been reported in children presenting with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), ranging from asymptomatic status to severe disease sustained by an immune-mediated inflammatory response. SARS-CoV-2 has been associated with severe neurological diseases including seizures and encephalitis in both adults and children. However, there are still few reports regarding the possible relation between SARS-CoV-2 infection of mothers during pregnancy and the neurologic outcome of the newborns. We described the case of a newborn diagnosed with a perinatal stroke, born at 35 weeks of gestation from a mother presenting with SARS- CoV-2 infection during the last months of pregnancy. We also added a brief review of the literature with similar cases. Close monitoring and early intervention in young children born to infected mothers would be highly recommended for the potential neurodevelopmental risk.

Prevalence of Preterm Births and Complications of Prematurity: A Comparison Between First Year of COVID-19 Pandemic and the Previous Year

Background: COVID-19 pandemic imposed significant challenges on the health systems. COVID-19 management policies such as lockdown have made access to the health centers difficult. Pregnant women are a high-risk group whose pregnancy outcomes may be affected by COVID-19 pandemic. So, it is necessary to determine changes in the prevalence of preterm births and complications of prematurity during the pandemic. Objectives: This study aimed to determine the prevalence of preterm births and complications of prematurity during the first year of COVID-19 pandemic compared with the previous year. Methods: In this cross-sectional study, we included all live births born between March 2019 to March 2021 in Mahdieh hospital, Tehran, Iran. We reviewed medical records to extract the prevalence of preterm births and prematurity complications. Then, the prevalence of preterm births and prematurity complications during COVID-19 pandemic compared with the previous year. We used Chi-square test to analyze categorical variables. Results: A total of 10,830 live births were included in this study. During COVID-19 pandemic, the prevalence of moderate or late prematurity had a 4.64% reduction (P < 0.001), and the prevalence of term birth increased by 5.37% (P < 0.001) compared with the previous year. The prevalence of respiratory distress syndrome (RDS) decreased significantly during COVID-19 pandemic compared with the previous year (23.64% vs. 26.56%, P < 0.001). The prevalence of retinopathy of prematurity (ROP) significantly increased during COVID-19 pandemic compared with the previous year (3.97% vs. 2.28%, P < 0.001). Additionally, sepsis was significantly more prevalent during COVID-19 pandemic compared with the previous year (6.84% vs. 1.23%, P < 0.001). Moreover, intraventricular hemorrhage (IVH) significantly increased during COVID-19 pandemic in comparison to the previous year (1.10% vs. 0.08%, P < 0.001). Conclusions: The prevalence of preterm birth decreased during COVID-19 lockdown. Also, major complications of prematurity such as RDS, ROP, sepsis, and IVH may be affected by COVID-19 lockdown.

High rates of neonatal polycythemia and hyperbilirubinemia during the first phase of COVID-19 pandemic in Italy: a single-center experience

In our third-level Neonatal Unit in Northern Italy, we recorded a high rate of neonatal hyperbilirubinemia requiring phototherapy in March-November 2020, during the first phase of COVID-19 pandemic, compared to the previous year (198/1348, 14.2%, vs 141/1432, 9.8%, p = 0.0004). Supposing it could be the result of neonatal polycythemia, we evaluated capillary hematocrit (Hct) and the rate of hyperbilirubinemia in all newborns ≥36 weeks gestational age born in December 2020. Out of 73 neonates, 37 had Hct ≥65% (50.7%). However, as capillary blood samples may overestimate Hct by 5-15%, even downsizing all values by 15%, Hct was still ≥65% in 9/73 neonates (12.3%), much higher than 0.4-5% prevalence of polycythemia reported in healthy newborns. All those newborns were singleton and healthy, with no clinical signs of hyperviscosity and no underlying factors predisposing to polycythemia. Out of 73 newborns, 13 (17.8%) developed hyperbilirubinemia requiring phototherapy. Their mean Hct value was 66.3 ± 8.2%. Since hyperbilirubinemia is common in the offspring of women with SARS-CoV-2 infection and we recorded increased rates of neonatal hyperbilirubinemia in the first phase of COVID-19 pandemic, it could be hypothesized that even asymptomatic Sars-CoV2 infection during pregnancy might cause placental vascular malperfusion, eliciting polycythemia in the fetus as a compensatory response, that could be the link between COVID-19 in the mothers and hyperbilirubinemia in the newborns.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Perinatal outcomes of pregnant women having SARS-CoV-2 infection

OBJECTIVES

Aim of this study is to evaluate the prognosis of pregnant women having SARS-CoV-2 infection and investigate whether there was a difference in perinatal outcomes between pregnant women who had SARS-CoV-2 infection and those who did not.

MATERIALS AND METHODS

This prospective observational study was conducted with 116 singleton pregnancies. Cases enrolling in the study were divided into two groups. While those in the first group had a history of SARS-CoV-2 infection (n = 46) the second group consisted of healthy pregnant women (n = 70).

RESULTS

Emergency Cesarean section was performed on three SARS-CoV-2 infected pregnancies (30, 33 and 34 gestational weeks). Intensive care unit admission was required for all three cases after delivery and two of them died. Among the pregnancies that had an infection in the third trimester, 71.4% (n = 20) of them had delivery in 14 days after diagnosis and 17.4% (n = 8) of their newborns were followed up at newborn intensive care unit. Overall, only one newborn had a positive swab test result for SARS-CoV-2. There was no statistically significant difference between groups regarding their delivery week (37.02 ± 5.85 vs 38.5 ± 2.33). Similarly, there was no significant difference between groups, concerning mean age, parity, and birth weight (P = 0.707, P = 0.092, P = 0.334; P < 0.05). Furthermore, the difference between SARS-CoV-2 infected pregnancies that were followed up as inpatient or outpatient with respect to the delivery week and birth weight was not significant (p > 0.05). Also, APGAR 5 scores of hospitalized women (9.3 ± 1.1) were found to be lower than the outpatient group (9.8 ± 0.8) (P = 0.043; p < 0.05).

CONCLUSION

No significant difference was detected between groups in terms of the delivery week, birth weight, and APGAR scores. The inpatient group was found to have lower APGAR 5 scores.

Maternal Outcomes and Clinical Characteristics of COVID-19 in Korean Pregnant Women during the Early Period of the Pandemic

The present study aimed to compare the clinical characteristics and outcomes between pregnant women and non-pregnant women of childbearing age (20-49 years old) diagnosed with coronavirus disease 2019 (COVID-19) during the initial stage of the COVID-19 pandemic in the Republic of Korea. This nationwide observational study included the information of COVID-19 patients collected by the Korea Disease Control and Prevention Agency from January 2020 to April 2021. Among 5,647 COVID-19 patients, 2,444 (43.3%) were women of childbearing age and 19 were pregnant. None of the pregnant women died. However, 4 deaths occurred among non-pregnant women aged 20-49 years. None of the 19 pregnant women with COVID-19 were admitted to the intensive care unit: they were admitted to the general ward, and none of them required supplemental oxygen. In conclusion, none of the pregnant women with COVID-19 experienced severe infection or death, unlike non-pregnant women of childbearing age.

A meta-analysis for the risk and prevalence of preeclampsia among pregnant women with COVID-19

Preeclampsia and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection are both life-threatening disorders when they occur during pregnancy. They are similarly characterized by systemic immune activation and have a deleterious effect on maternal endothelial cells. During the coronavirus disease-2019 (COVID-19) pandemic, there were reports of preeclampsia or a preeclampsia-like syndrome occurring in pregnant women with SARS-CoV-2 infection. We performed a meta-analysis to estimate the risk and prevalence of preeclampsia and SARS-CoV-2 infection in pregnant women. A comprehensive literature search was conducted in PubMed, Web of Science, Scopus, and China National Knowledge Infrastructure to identify all relevant studies published up to February 29, 2020. All studies that reported the prevalence of preeclampsia in pregnant women with SARS-CoV-2 infection were selected. A total of 10 case-control studies and 15 case series met our inclusion criteria. Pooled data revealed no significant difference between infected pregnant women and uninfected pregnant women for the risk of preeclampsia [odds ratio (OR)=1.676, 95% confidence interval (CI) 0.679-4.139, p=0.236]. The stratified analysis revealed significant risk in the infected Asian pregnant women (OR=2.637, 95% CI 1.030-6.747, p=0.043), but not Caucasian. The prevalence of preeclampsia was 8.2% (95% CI 0.057-0.117) in infected pregnant women with COVID-19 in the overall population. Its prevalence was highest in North America (10.7%), followed by Asian (7.9%), Caucasian (6.7%), European (4.9%), and West Asian (2.6%) infected pregnant women. Our pooled data showed that the prevalence of preeclampsia in pregnant women with SARS-CoV-2 infection was 8.2%. However, there was no increased risk of occurrence of preeclampsia among pregnant women with SARS-CoV-2 infection.

Role of Maternal Infections and Inflammatory Responses on Craniofacial Development

Pregnancy is a tightly regulated immunological state. Mild environmental perturbations can affect the developing fetus significantly. Infections can elicit severe immunological cascades in the mother's body as well as the developing fetus. Maternal infections and resulting inflammatory responses can mediate epigenetic changes in the fetal genome, depending on the developmental stage. The craniofacial development begins at the early stages of embryogenesis. In this review, we will discuss the immunology of pregnancy and its responsive mechanisms on maternal infections. Further, we will also discuss the epigenetic effects of pathogens, their metabolites and resulting inflammatory responses on the fetus with a special focus on craniofacial development. Understanding the pathophysiological mechanisms of infections and dysregulated inflammatory responses during prenatal development could provide better insights into the origins of craniofacial birth defects.

Pleural abnormalities in COVID-19: a narrative review

OBJECTIVE

This narrative review aims to provide a detailed overview of pleural abnormalities in patients with coronavirus disease 19 or COVID-19.

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is a novel beta coronavirus responsible for COVID-19. Although pulmonary parenchymal and vascular changes associated with COVID-19 are well established, pleural space abnormalities have not been the primary focus of investigations.

METHODS

Narrative overview of the medical literature regarding pleural space abnormalities in COVID-19. The appropriate manuscripts were identified by searching electronic medical databases and by hand searching the bibliography of the identified papers. Pleural abnormalities on transverse and ultrasound imaging are discussed. The incidence, clinical features, pathophysiology, and fluid characteristics of pleural effusion are reviewed. Studies reporting pneumothorax and pneumomediastinum are examined to evaluate for pathogenesis and prognosis. A brief comparative analysis of pleural abnormalities among patients with COVID-19, severe acute respiratory syndrome (SARS), and Middle Eastern respiratory syndrome (MERS) has been provided.

CONCLUSIONS

Radiologic pleural abnormalities are common in COVID-19, but the incidence of pleural effusion appears to be low. Pneumothorax is rare and does not independently predispose the patient to worse outcomes. SARS-CoV-2 infects the pleural space; however, whether the pleural fluid can propagate the infection is unclear.

Association of Maternal SARS-CoV-2 Infection in Pregnancy With Neonatal Outcomes

IMPORTANCE

The outcomes of newborn infants of women testing positive for SARS-CoV-2 in pregnancy is unclear.

OBJECTIVE

To evaluate neonatal outcomes in relation to maternal SARS-CoV-2 test positivity in pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

Nationwide, prospective cohort study based on linkage of the Swedish Pregnancy Register, the Neonatal Quality Register, and the Register for Communicable Diseases. Ninety-two percent of all live births in Sweden between March 11, 2020, and January 31, 2021, were investigated for neonatal outcomes by March 8, 2021. Infants with malformations were excluded. Infants of women who tested positive for SARS-CoV-2 were matched, directly and using propensity scores, on maternal characteristics with up to 4 comparator infants.

EXPOSURES

Maternal test positivity for SARS-CoV-2 in pregnancy.

MAIN OUTCOMES AND MEASURES

In-hospital mortality; neonatal resuscitation; admission for neonatal care; respiratory, circulatory, neurologic, infectious, gastrointestinal, metabolic, and hematologic disorders and their treatments; length of hospital stay; breastfeeding; and infant test positivity for SARS-CoV-2.

RESULTS

Of 88 159 infants (49.0% girls), 2323 (1.6%) were delivered by mothers who tested positive for SARS-CoV-2. The mean gestational age of infants of SARS-CoV-2-positive mothers was 39.2 (SD, 2.2) weeks vs 39.6 (SD, 1.8) weeks for comparator infants, and the proportions of preterm infants (gestational age <37 weeks) were 205/2323 (8.8%) among infants of SARS-CoV-2-positive mothers and 4719/85 836 (5.5%) among comparator infants. After matching on maternal characteristics, maternal SARS-CoV-2 test positivity was significantly associated with admission for neonatal care (11.7% vs 8.4%; odds ratio [OR], 1.47; 95% CI, 1.26-1.70) and with neonatal morbidities such as respiratory distress syndrome (1.2% vs 0.5%; OR, 2.40; 95% CI, 1.50-3.84), any neonatal respiratory disorder (2.8% vs 2.0%; OR, 1.42; 95% CI, 1.07-1.90), and hyperbilirubinemia (3.6% vs 2.5%; OR, 1.47; 95% CI, 1.13-1.90). Mortality (0.30% vs 0.12%; OR, 2.55; 95% CI, 0.99-6.57), breastfeeding rates at discharge (94.4% vs 95.1%; OR, 0.84; 95% CI, 0.67-1.05), and length of stay in neonatal care (median, 6 days in both groups; difference, 0 days; 95% CI, -2 to 7 days) did not differ significantly between the groups. Twenty-one infants (0.90%) of SARS-CoV-2-positive mothers tested positive for SARS-CoV-2 in the neonatal period; 12 did not have neonatal morbidity, 9 had diagnoses with unclear relation to SARS-CoV-2, and none had congenital pneumonia.

CONCLUSIONS AND RELEVANCE

In a nationwide cohort of infants in Sweden, maternal SARS-CoV-2 infection in pregnancy was significantly associated with small increases in some neonatal morbidities. Given the small numbers of events for many of the outcomes and the large number of statistical comparisons, the findings should be interpreted as exploratory.

Our anesthesia experiences in COVID-19 positive patients delivering by cesarean section: A retrospective single-center cohort study

Aim

Pregnancy increases susceptibility to respiratory complications of viral diseases. This study aims to evaluate our anesthesia practices in pregnant women with COVID‐19 undergoing cesarean section.

Methods

A total of 61 patients who underwent cesarean section and had positive Polymerase chain reaction (PCR) testing for COVID‐19 with nasopharyngeal swabs were included in the study. Patient demographics and information about anesthesia were analyzed retrospectively from the patient medical files.

Results

A total of 61 parturients undergoing cesarean section that had positive SARS‐CoV‐2 PCR tests were assessed. General anesthesia was applied to only three patients (4.9%), while spinal anesthesia was administered to the remaining 58 patients (95.1%). The incidence of hypotension was 25.9% in the spinal anesthesia group. Forty‐one (67.2%) parturients were asymptomatic. While the rate of pneumonia in symptomatic patients was 45% (9/20), the pneumonia incidence among all SARS‐CoV‐2 PCR (+) parturients was 14% (9/61). Three (4.9%) COVID‐19 patients required intensive care in the perioperative period. The overall mortality rate was 1.6% (1/61) among parturients with COVID‐19 undergoing cesarean section, while it was 11.1% (1/9) in patients with pneumonia.

Conclusion

It was observed that COVID‐19 is associated with mortality in pregnant women undergoing cesarean section. Spinal anesthesia was safely and effectively administered in COVID‐19 parturients, especially in patients with pneumonia.

SARS-CoV-2-Morphology, Transmission and Diagnosis during Pandemic, Review with Element of Meta-Analysis

The outbreak of Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2). Thus far, the virus has killed over 2,782,112 people and infected over 126,842,694 in the world (state 27 March 2021), resulting in a pandemic for humans. Based on the present data, SARS-CoV-2 transmission from animals to humans cannot be excluded. If mutations allowing breaking of the species barrier and enhancing transmissibility occurred, next changes in the SARS-CoV-2 genome, leading to easier spreading and greater pathogenicity, could happen. The environment and saliva might play an important role in virus transmission. Therefore, there is a need for strict regimes in terms of personal hygiene, including hand washing and surface disinfection. The presence of viral RNA is not an equivalent of active viral infection. The positive result of the RT-PCR method may represent either viral residues or infectious virus particles. RNA-based tests should not be used in patients after the decline of disease symptoms to confirm convalescence. It has been proposed to use the test based on viral, sub-genomic mRNA, or serological methods to find the immune response to infection. Vertical transmission of SARS-CoV-2 is still a little-known issue. In our review, we have prepared a meta-analysis of the transmission of SARS-CoV-2 from mother to child depending on the type of delivery. Our study indicated that the transmission of the virus from mother to child is rare, and the infection rate is not higher in the case of natural childbirth, breastfeeding, or contact with the mother. We hope that this review and meta-analysis will help to systemize knowledge about SARS-CoV-2 with an emphasis on diagnostic implications and transmission routes, in particular, mother-to-child transmission.

Laboratory Effects of COVID-19 Infection in Pregnant Women and Their Newborns: A Systematic Review and Meta-Analysis

Amidst the COVID-19 pandemic, there is a need for further research on its manifestation in pregnant women, since they are particularly prone to respiratory pathogens, like severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), due to physiological changes during pregnancy. Its effects on infants born to mothers with COVID-19 are also not well-studied, and more evidence is needed on vertical transmission of the disease from mother to infant and on the transmission of IgG/IgM antibodies between mother and infant. We aim to systematically review and evaluate the effects of COVID-19 among SARS-CoV-2-positive pregnant women in late pregnancy and neonates with SARS-CoV-2-positive pregnant mothers using blood assays to find indicators of maternal and neonatal complications. We searched for original published articles in Google Scholar, Medline (PubMed), and Embase databases to identify articles in the English language from December 2019 to July 20, 2020. Duplicate entries were searched by their titles, authors, date of publication, and Digital Object Identifier. The selected studies were included based on patient pregnancy on admission, pregnant mothers with laboratory-confirmed COVID-19 virus, maternal/neonatal complications, and blood test results. We excluded duplicate studies, articles where full text was not available, other languages than English, opinions, and perspectives. The meta-analysis using the Generalized Linear Mixed model was conducted using the "meta" and "metaprop" packages in R code. Of the 1,642 studies assessed for eligibility, 29 studies (375 mothers and neonates) were included. Preterm birth rate was 34.2%, and cesarean section rate was 82.7%. Maternal laboratory findings found elevated neutrophils (71.4%; 95% CI: 38.5-90.9), elevated CRP (67.7%; 95%: 50.6-81.1), and low hemoglobin (57.3%; 95% CI: 26.0-87.8). We found platelet count, lactate dehydrogenase, and procalcitonin to be less strongly correlated with preterm birth than between high neutrophil counts (P = 0.0007), low hemoglobin (P = 0.0188), and risk of preterm birth. There is little evidence for vertical transmission. Elevated procalcitonin levels (23.2%; 95% CI: 8.4-49.8) are observed in infants born to mothers with COVID-19, which could indicate risk for neonatal sepsis. These infants may gain passive immunity to COVID-19 through antibody transfer via placenta. These results can guide current obstetrical care during the current SARS-CoV-2 pandemic.

Immunity and coagulation and fibrinolytic processes may reduce the risk of severe illness in pregnant women with coronavirus disease 2019

BACKGROUND

There are specific physiological features regarding the immunity and coagulation among pregnant women, which may play important roles in the development of coronavirus disease 2019.

OBJECTIVE

This study aimed to determine the key factors associated with the deterioration of patients with coronavirus disease 2019 and the differentiating clinical characteristics of pregnant women with coronavirus disease 2019 to interfere with the progression of coronavirus disease 2019.

STUDY DESIGN

A retrospective study of 539 Chinese Han adult patients with coronavirus disease 2019 was conducted, of which 36 cases were pregnant women. In addition, 36 pregnant women without coronavirus disease 2019 were recruited as the control. The characteristics of severe and critical illnesses, which were differentiated from mild and moderate illnesses in patients with coronavirus disease 2019, were analyzed using a machine learning algorithm. In addition, major differences between pregnant women with coronavirus disease 2019 and age-matched nonpregnant women with severe or critical coronavirus disease 2019, paired with pregnant women without coronavirus disease 2019, were explored to identify specific physiological features of pregnant women with coronavirus disease 2019.

RESULTS

For the total patient population, the lymphocyte, CD3⁺, CD4⁺, CD8⁺, CD19⁺, and CD16⁺CD56⁺ cell counts were significantly lower, and white blood cell count, neutrophil count, and neutrophil-to-lymphocyte ratio were higher in those with severe or critical illness than those with mild or moderate illness (P<.001). The plasma levels of interleukin-6, interleukin-10, and interleukin-6-to-interleukin-10 ratio were significantly increased in patients with critical illness compared with patients with mild, moderate, and severe illnesses (P<.001). The above immunologic coclusters achieved an area under the receiver operating characteristic curve of 0.801 (95% confidence interval, 0.764-0.838), and its combined model with the coagulation and fibrinolysis indices (prothrombin time, D-dimer) achieved an area under the receiver operating characteristic curve of 0.815 (95% confidence interval, 0.779-0.851) using the random forest regression model to predict severe or critical illness. For pregnant women with coronavirus disease 2019, none had preexisting diseases. Compared with nonpregnant women with mild or moderate coronavirus disease 2019, pregnant women with coronavirus disease 2019 displayed increased white blood cell count, neutrophil count, neutrophil-to-lymphocyte ratio, and levels of D-dimer and fibrinogen, along with decreased lymphocyte and interleukin-4 levels (P<.05). Although they presented similar changes of immunologic markers of lymphocyte; white blood cell count; neutrophil-to-lymphocyte ratio; CD3⁺, CD4⁺, CD8⁺, and CD16⁺CD56⁺ cell counts; and interleukin-6-to-interleukin-10 ratio, compared with nonpregnant women with severe or critical coronavirus disease 2019, none of the pregnant women with coronavirus disease 2019 deteriorated into severe or critical illness. There was no significant difference in white blood cell count, lymphocyte count, neutrophil count, neutrophil-to-lymphocyte ratio, immunologic markers, or coagulation and fibrinolysis markers between pregnant women with coronavirus disease 2019 and pregnant women without coronavirus disease 2019. As for the discrepancy of pathophysiological features between pregnant women with coronavirus disease 2019 and nonpregnant women with severe or critical coronavirus disease 2019, the immunologic markers achieved an area under the receiver operating characteristic curve of 0.875 (95% confidence interval, 0.773-0.977), and its combined model with coagulation and fibrinolysis indices achieved an area under the receiver operating characteristic curve of 0.931 (95% confidence interval, 0.850-1.000).

CONCLUSION

Immune dysregulation was identified as a crucial feature of patients with coronavirus disease 2019, which developed severe or critical illness, and pregnant women with coronavirus disease 2019 presented with similar immune responses but rarer incidences of severe or critical illness. Immune dysregulation is related to the risks of deterioration into severe or critical illness. The specific coagulation and fibrinolysis systems of pregnancy may reduce the risk of pregnant women with coronavirus disease 2019 without preexisting disease from developing severe illness.

Current trends and geographical differences in therapeutic profile and outcomes of COVID-19 among pregnant women - a systematic review and meta-analysis

BACKGROUND

Coronavirus disease (COVID-19) has been associated with adverse pregnancy outcomes. Due to the lack of effective treatments for COVID-19, it becomes imperative to assess the geographical differences and trends in the current clinical care and outcomes of COVID-19 in pregnant women.

METHODS

A PubMed search was performed to screen articles reporting therapeutics and outcomes of confirmed COVID-19 in pregnant women prior to August 27, 2020. We performed searches, quality assessments of eligible studies, extracted and reported data according to PRISMA guidelines. Meta-analyses and cumulative meta-analyses of proportions were performed for estimating each outcome and their pattern over time respectively.

RESULTS

One thousand two hundred thirty nine pregnant women with COVID-19 from 66 studies were analyzed. In case series analysis reflecting average-risk patients, the proportion of oxygen support, antibiotics, antivirals, and plasma therapy administration except for hydroxychloroquine was substantially higher in Asian studies (55, 78, 80, 6, and 0%) compared to the US (7, 1, 12, 0, and 7%) or European (33, 12, 14, 1, and 26%) studies, respectively. The highest preterm birth and the average length of hospital stay (35%, 11.9 days) were estimated in Asian studies compared to the US studies (13%, 9.4 days) and European studies (29%, 7.3 days), respectively. Even in case reports reflecting severe cases, the use of antivirals and antibiotics was higher in Asian studies compared to the US, Latin American, and European studies. A significant decline in the use of most therapeutics along with adverse outcomes of COVID-19 in pregnant women was observed.

CONCLUSIONS

Geographical differences in therapeutic practice of COVID-19 were observed with differential rates of maternal and clinical outcomes. Minimizing the use of some therapeutics particularly antibiotics, antivirals, oxygen therapy, immunosuppressants, and hydroxychloroquine by risk stratification and careful consideration may further improve maternal and clinical outcomes.

Contracting COVID-19 in the first and second trimester of pregnancy: what we know - a concise qualitative systematic review

INTRODUCTION

Recent medical literature has drawn attention to the possible influence of COVID-19 on the course of pregnancies. As the coherence of results seems to vary, especially in relation to first and second trimester pregnancies, a concise qualitative systematic review can shed light on the most recent data.

MATERIAL AND METHODS

A structured systematic search was performed to collect all COVID-19 pregnancy-related articles published between January 1 and September 16, 2020. Two independent reviewers evaluated studies using the STROBE statement in combination with the CERQual quality assessment of findings.

RESULTS

In total 1387 articles were screened and finally 22 studies were evaluated (179 1st/2nd trimesters of pregnant women with COVID-19). The majority of reported mothers who contracted COVID-19 during 1st/2nd trimesters are yet to complete their pregnancy.

CONCLUSIONS

Evidently a limited amount of data is available. Usually, mothers and newborns are discharged from the hospital without any serious complications. Further observations are imperative.

A Comprehensive Analysis of Maternal and Newborn Disease and Related Control for COVID-19

The maternal-fetal/newborn unit is established at risk for COVID-19 infection. This narrative review summarizes the contemporary and cumulative publications which detail maternal infection, antenatal and newborn infections, and maternal/fetal/newborn management and prevention. There is a wide spectrum of maternal disease, but the potential for severe disease albeit in a minority is confirmed. COVID-19 carries risk for preterm delivery. Pregnant females can suffer multisystem disease, and co-morbidities play a significant role in risk. Congenital infection has been supported by several anecdotal reports, but strong confirmatory data are few. No typical congenital dysmorphisms are evident. Nevertheless, placental vascular compromise must be considered a risk for the fetus during advanced maternal infections. Clinical manifestations of newborn infection have been mild to moderate and relatively uncommon. Proven antiviral therapy is of yet lacking. The mode of delivery is a medical decision that must include patient risk assessment and patient directives. Both presymptomatic and asymptomatic mothers and offspring can complicate infection control management with the potential for spread to others in several regards. In the interim, infections of the maternal-fetal-newborn unit must be taken seriously both for the disease so caused and the potential for further dissemination of disease.

Effect of COVID-19 on Mortality of Pregnant and Postpartum Women: A Systematic Review and Meta-Analysis

BACKGROUND

Based on what is known at this time, pregnant women are at an increased risk of severe illness from COVID-19 compared to nonpregnant women. Additionally, pregnant women with COVID-19 might have an increased risk of adverse pregnancy outcomes. To investigate the effects of coronavirus disease 2019 (COVID-19) on mortality of pregnant and postpartum women, we performed a systematic review of available published literature on pregnancies affected by COVID-19.

METHODS

Web of Science, SCOPUS, and MEDLINE- databases were searched for original studies concerning the effect of COVID-19 on mortality of pregnant and postpartum women published by July 10, 2020. Meta-analyses of proportions were used to combine data and report pooled proportions.

RESULTS

117 studies with a total of 11758 pregnant women were included. The age ranged between 15 and 48 years. Most subjects were infected with SARS-CoV-2 in the third trimester. Disease severity was not reported in 1125 subjects. Maternal mortality was 1.3%. In 100% of fatal cases with adequate data, fever alone or with cough was one of the presenting symptoms. Also, dyspnea (58.3%) and myalgia (50%) were the most common symptoms. Sore throat (8.3%) and gastrointestinal symptoms (anorexia, nausea) (8.3%) were rare. The rate of comorbidities was 20% among COVID-19 deaths. The majority of COVID-19-infected women who died had cesarean section (58.3%), 25% had a vaginal delivery, and 16.7% of patients were not full term.

CONCLUSION

COVID-19 infection in pregnant women was associated with higher rates (and pooled proportions) of cesarean section and mortality. Because new data are continuously being generated and published, the findings of this study can be complete and updated with new researches. The results of this study can guide and improve prenatal counseling of COVID-19-infected pregnant women.

The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review

BACKGROUND

COVID-19-related pleural effusions are frequently described during the ongoing pandemic.

OBJECTIVES

We described the incidence, characteristics, and outcomes of COVID-19-related pleural effusions based on the current evidence available in the literature.

METHODS

We searched MEDLINE, Pubmed, and Google Scholar databases using keywords of "coronavirus disease 2019 (COVID-19)," "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)," "pleural effusion," "pleural fluid," and "pleura" from January 1st, 2020 to January 31st, 2021.

RESULTS

The incidence of pleural effusions was low at 7.3% among the 47 observational studies. Pleural effusions were commonly observed in critically ill patients and had Multisystem Inflammatory Syndrome (MIS). COVID-19-related pleural effusions were identified 5-7 days and 11 days, after hospital admission and onset of COVD-19 symptoms. The characteristic findings of pleural fluid were exudative, lymphocytic or neutrophilic-predominant pleural fluid with markedly elevated lactate dehydrogenase (LDH) levels and pleural fluid to serum LDH ratio.

CONCLUSION

A well-designed study is required to assess the significance of COVID-19-related pleural effusions during this current pandemic.

Association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes: a cohort study

OBJECTIVES

The secondary impacts of the COVID-19 pandemic on adverse maternal and neonatal outcomes remain unclear. In this study, we aimed to evaluate the association between the COVID-19 pandemic and the risk for adverse pregnancy outcomes.

DESIGN

We conduced retrospective analyses on two cohorts comprising 7699 pregnant women in Beijing, China, and compared pregnancy outcomes between the pre-COVID-2019 cohort (women who delivered from 20 May 2019 to 30 November 2019) and the COVID-2019 cohort (women who delivered from 20 January 2020 to 31 July 2020). The secondary impacts of the COVID-2019 pandemic on pregnancy outcomes were assessed by using multivariate log-binomial regression models, and we used interrupted time-series (ITS) regression analysis to further control the effects of time-trends.

SETTING

One tertiary-level centre in Beijing, China PARTICIPANTS: 7699 pregnant women.

RESULTS

Compared with women in the pre-COVID-19 pandemic group, pregnant women during the COVID-2019 pandemic were more likely to be of advanced age, exhibit insufficient or excessive gestational weight gain and show a family history of chronic disease (all p<0.05). After controlling for other confounding factors, the risk of premature rupture of membranes and foetal distress was increased by 11% (95% CI, 1.04 to 1.18; p<0.01) and 14% (95% CI, 1.01 to 1.29; p<0.05), respectively, during the COVID-2019 pandemic. The association still remained in the ITS analysis after additionally controlling for time-trends (all p<0.01). We uncovered no other associations between the COVID-19 pandemic and other pregnancy outcomes (p>0.05).

CONCLUSIONS

During the COVID-19 pandemic, more women manifested either insufficient or excessive gestational weight gain; and the risk of premature rupture of membranes and foetal distress was also higher during the pandemic.

Clinical manifestation and maternal complications and neonatal outcomes in pregnant women with COVID-19: a comprehensive evidence synthesis and meta-analysis

OBJECTIVES

There is little known about pregnancy-related complications and comorbidity in this group of women. Therefore, this systematic review and meta-analysis were performed to find out whether COVID-19 may cause different manifestations and outcomes in the antepartum and postpartum period or not.

MATERIAL AND METHODS

We searched databases, including Medline (PubMed), Embase, Scopus, Web of sciences, Cochrane library, Ovid, and CINHAL to retrieve all articles reporting the prevalence of maternal and neonatal complications, in addition to clinical manifestations, in pregnant women with COVID-19 that published with English language January to November 2020.

RESULTS

Seventy-four studies with total 5560 pregnant women included in this systematic review. The results show that the pooled prevalence of neonatal mortality, lower birth weight, stillbirth, premature birth, and intrauterine fetal distress in women with COVID-19 was 4% (95% Cl: 1 - 9%), 21% (95% Cl: 11 - 31%), 2% (95% Cl: 1 - 6%), 28% (95% Cl: 13 - 43%), and 14% (95% Cl: 4 - 25%); respectively. Moreover, the pooled prevalence of fever, cough, diarrhea, and dyspnea were 56% (95% Cl: 32 - 81%), 29% (95% Cl: 21 - 38%), 9% (95% Cl: 2 - 16%), and 3% (95% Cl: 1 - 6%) in pregnant women with COVID-19. Two studies reported that pregnant women with severe COVID pneumonia have higher levels of d-dimer. Also, COVID pneumonia is more common in pregnant women than non-pregnant.

CONCLUSION

According to this meta-analysis, pregnant women with COVID-19 with or without pneumonia, are at a higher risk of preeclampsia, preterm birth, miscarriage and cesarean delivery. Furthermore, the risk of LBW and intrauterine fetal distress seems to be increased in neonates. In addition, our evaluations are investigative of higher risk of COVID-19 in the third trimester in pregnant women comparing to the first and second trimester. It can be due to higher BMI in the third trimester causing to increase the likelihood of disease deterioration, which can trigger a cascade of side effects starting with coagulation, pneumonia, hypoxemia affecting the placenta leading to ICU admission, fetal distress, premature birth and higher rates of C-section.

COVID-19 and pregnancy: are they friends or enemies?

OBJECTIVES

Novel coronavirus disease (COVID-19) is rapidly spreading all over the world. Although in many cases the infection causes very weak symptoms, it can be severe in patient with diverse chronical diseases and immunological compromising patients. Pregnancy is a unique condition in which mother and fetus peacefully collaborate. Diverse endocrine-immune mechanisms, mostly under progesterone control work together to protect the fetus from maternal immunocompetent cell activation driven rejection. The physiological shift to Th2 dominant environment, while favourable for fetus, it makes mothers susceptible to infective pathogens, making pregnancy during COVID-19 pandemic challenging.

MATERIALS AND METHODS

Studies involving COVID-19 in pregnancy and those analysing changes of immune system induced by COVID-19 were searched in databases such as PubMed, Scopus, Google Scholar and ScienceDirect. Databases were searched using a keyword COVID-19/coronavirus, that was combined with following terms: immune system, pregnancy, oestrogen, or progesterone. Search included studies published up to 01.07.2020. Almost 1,500 articles were found, but only 18 met criteria.

RESULTS

Most frequent symptoms of COVID-19 in mothers infected in the late pregnancy were fever and cough accompanied with lymphopenia and elevated C-reactive protein. Mothers reported to have severe disease had comorbidities and were obese. Low rate of neonatal complications of maternal Sars-Coc-2 infection without neonatal mortality was observed.

CONCLUSIONS

Currently available data didn't show significant relationship between COVID-19 severity and pregnancy and there is no strong evidence that mother's infection can lead to adverse pregnancy outcome, but further studies are needed to determinate the possible effects of COVID-19 gained during earlier pregnancy.

COVID-19: can we treat the mother without harming her baby?

Medical care is predicated on 'do no harm', yet the urgency to find drugs and vaccines to treat or prevent COVID-19 has led to an extraordinary effort to develop and test new therapies. Whilst this is an essential cornerstone of a united global response to the COVID-19 pandemic, the absolute requirements for meticulous efficacy and safety data remain. This is especially pertinent to the needs of pregnant women; a group traditionally poorly represented in drug trials, yet a group at heightened risk of unintended adverse materno-fetal consequences due to the unique physiology of pregnancy and the life course implications of fetal or neonatal drug exposure. However, due to the complexities of drug trial participation when pregnant (be they vaccines or therapeutics for acute disease), many clinical drug trials will exclude them. Clinicians must determine the best course of drug treatment with a dearth of evidence from either clinical or preclinical studies, where at least in the short term they may be more focused on the outcome of the mother than of her offspring.

The Profile of the Obstetric Patients with SARS-CoV-2 Infection According to Country of Origin of the Publication: A Systematic Review of the Literature

SARS-CoV-2 is the novel member of coronavirus responsible for the worldwide pandemic COVID-19, affecting all types of people. In this context, established research identified pregnant women as a susceptible group of SARS-CoV-2 infection, although there is still limited data regarding the real impact of COVID-19 in this group. With that purpose, we conducted a systematic review describing the maternal-fetal results of pregnant women infected by SARS-CoV-2, in aim to analyze the profile of the obstetric patients according to the country of origin of the publication. A total of 38 articles were included in this systematic review with 2670 patients from 7 countries, with 20 works published from China (52.6%). We reported significative differences according to the median maternal age, with Spain as the country with the highest age (34.6 years); The percentage of tabaquism; proportion of symptomatic patients in the triage; type of radiological exam (China and France conduct CT scans on all their patients in comparison to the use of chest X-Ray in the rest of the countries studied); percentages of C-sections (83.9% in China; 35.9% Spain, p < 0.001); maternal mortality rate, proportion of patients who need treatments, the use of antivirals, antibiotics, and anticoagulants as well as measurements of the newborns. Perinatal results are favorable in the majority of countries, with very low rates of vertical transmission in the majority of works. The studies collected in this review showed moderate to high index of quality. The different works describe the affectation during the first wave of the pandemic, where the pregnant woman with SARS-CoV-2 infection is generally symptomatic during the third trimester of gestation along with other factors associated with worse prognosis of the disease, such as higher age, body mass index, and further comorbidities developed during pregnancy. In the obstetric patient, proportion of C-sections are elevated together with prematurity, increasing maternal perinatal morbimortality. Differences found between countries could be based on the proper profile of the patient in each region, the period of the pandemic directly affecting how it was managed, and the variations regarding in situ medical attention.

The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review

Introduction

The Covid-19 pandemic affects maternal health both directly and indirectly, and direct and indirect effects are intertwined. To provide a comprehensive overview on this broad topic in a rapid format behooving an emergent pandemic we conducted a scoping review.

Methods

A scoping review was conducted to compile evidence on direct and indirect impacts of the pandemic on maternal health and provide an overview of the most significant outcomes thus far. Working papers and news articles were considered appropriate evidence along with peer-reviewed publications in order to capture rapidly evolving updates. Literature in English published from January 1st to September 11 2020 was included if it pertained to the direct or indirect effects of the COVID-19 pandemic on the physical, mental, economic, or social health and wellbeing of pregnant people. Narrative descriptions were written about subject areas for which the authors found the most evidence.

Results

The search yielded 396 publications, of which 95 were included. Pregnant individuals were found to be at a heightened risk of more severe symptoms than people who are not pregnant. Intrauterine, vertical, and breastmilk transmission were unlikely. Labor, delivery, and breastfeeding guidelines for COVID-19 positive patients varied. Severe increases in maternal mental health issues, such as clinically relevant anxiety and depression, were reported. Domestic violence appeared to spike. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies implemented with little evidence. Women were more likely to lose their income due to the pandemic than men, and working mothers struggled with increased childcare demands.

Conclusion

Pregnant women and mothers were not found to be at higher risk for COVID-19 infection than people who are not pregnant, however pregnant people with symptomatic COVID-19 may experience more adverse outcomes compared to non-pregnant people and seem to face disproportionate adverse socio-economic consequences. High income and low- and middle-income countries alike faced significant struggles. Further resources should be directed towards quality epidemiological studies.

Plain English summary

The Covid-19 pandemic impacts reproductive and perinatal health both directly through infection itself but also indirectly as a consequence of changes in health care, social policy, or social and economic circumstances. The direct and indirect consequences of COVID-19 on maternal health are intertwined. To provide a comprehensive overview on this broad topic we conducted a scoping review. Pregnant women who have symptomatic COVID-19 may experience more severe outcomes than people who are not pregnant. Intrauterine and breastmilk transmission, and the passage of the virus from mother to baby during delivery are unlikely. The guidelines for labor, delivery, and breastfeeding for COVID-19 positive patients vary, and this variability could create uncertainty and unnecessary harm. Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies are implemented with little evidence in high and low/middle income countries. The social and economic impact of COVID-19 on maternal health is marked. A high frequency of maternal mental health problems, such as clinically relevant anxiety and depression, during the epidemic are reported in many countries. This likely reflects an increase in problems, but studies demonstrating a true change are lacking. Domestic violence appeared to spike. Women were more vulnerable to losing their income due to the pandemic than men, and working mothers struggled with increased childcare demands. We make several recommendations: more resources should be directed to epidemiological studies, health and social services for pregnant women and mothers should not be diminished, and more focus on maternal mental health during the epidemic is needed.

Impact of COVID-19 on maternal and neonatal outcomes: a systematic review and meta-analysis

BACKGROUND

Previous outbreaks of severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) and Middle East respiratory syndrome coronavirus (MERS-CoV) have been associated with unfavourable pregnancy outcomes. SARS-CoV-2 belongs to the human coronavirus family, and since this infection shows a pandemic trend it will involve many pregnant women.

AIMS

This systematic review and meta-analysis aimed to assess the impact of coronavirus disease 19 (COVID-19) on maternal and neonatal outcomes.

SOURCES

PubMed, EMBASE, MedRxiv, Scholar, Scopus, and Web of Science databases were searched up to 8th May 2020. Articles focusing on pregnancy and perinatal outcomes of COVID-19 were eligible. Participants were pregnant women with COVID-19.

CONTENT

The meta-analysis was conducted following the PRISMA and MOOSE reporting guidelines. Bias risk was assessed using the Joanna Briggs Institute (JBI) manual. The protocol was registered with PROSPERO (CRD42042020184752). Twenty-four articles, including 1100 pregnancies, were selected. The pooled prevalence of pneumonia was 89% (95%CI 70-100), while the prevalence of women admitted to the intensive care unit was 8% (95%CI 1-20). Three stillbirths and five maternal deaths were reported. A pooled prevalence of 85% (95%CI 72-94) was observed for caesarean deliveries. There were three neonatal deaths. The prevalence of COVID-19-related admission to the neonatal intensive care unit was 2% (95%CI 0-6). Nineteen out of 444 neonates were positive for SARS-CoV-2 RNA at birth. Elevated levels of IgM and IgG Serum antibodies were reported in one case, but negative swab.

IMPLICATIONS

Although adverse outcomes such as ICU admission or patient death can occur, the clinical course of COVID-19 in most women is not severe, and the infection does not significantly influence the pregnancy. A high caesarean delivery rate is reported, but there is no clinical evidence supporting this mode of delivery. Indeed, in most cases the disease does not threaten the mother, and vertical transmission has not been clearly demonstrated. Therefore, COVID-19 should not be considered as an indication for elective caesarean section.

COVID-19 in 28-Week Triplets Caused by Intrauterine Transmission of SARS-CoV-2-Case Report

Since the beginning of the COVID-19 pandemic, in-utero transmission of SARS-CoV-2 remains a rarity and only very few cases have been proven across the world. Here we depict the clinical, laboratory and radiologic findings of preterm triplets born at 28 6/7 weeks to a mother who contracted COVID-19 just 1 week before delivery. The triplets showed SARS-CoV-2 positivity right after birth, developed significant leukopenia and early-onset pulmonary interstitial emphysema. The most severely affected triplet I required 10 days of high-frequency oscillatory ventilation due to failure of conventional invasive ventilation, and circulatory support for 4 days. Despite a severe clinical course in two triplets (triplet I and II), clinical management without experimental, targeted antiviral drugs was successful. At discharge home, the triplets showed no signs of neurologic or pulmonary sequelae. Placental immunohistology with SARS-CoV-2 N-protein localized strongly to syncytiotrophoblast cells and, to a lesser extent, to fetal Hofbauer cells, proving intrauterine virus transmission. We discuss the role of maternal viremia as a potential risk factor for vertical transmission. To the best of our knowledge, our report presents the earliest unequivocally confirmed prenatal virus transmission in long-term surviving children, i.e., at the beginning of the third trimester.

Perinatal COVID-19 outcomes: evaluating the strength of current evidence

Purpose of the Study: Viral respiratory diseases, like those caused by novel strains of influenza and Coronaviridae, have historically disproportionately affected pregnant women and conferred increased risk of adverse perinatal outcomes. Initial reports published from Wuhan, China identified only limited symptoms in pregnant women and no cases of mortality, but more recent reports from other regions of the world have reported contrasting information. The purpose of the study was to evaluate initially published cases of SARS-CoV-2 infection in pregnant women in China and compare them to subsequently published studies from the remainder of the world. Materials and Methods: This review curates 199 maternal published cases of SARS-CoV-2 infection and COVID-19 initially reported in the literature from China and contrasts them to more recent literature reporting clinical findings and outcomes of 729 selected cases from the rest of the world, including the United States. Results: Overall, initial case reports and series from China reported no cases of maternal mortality, which contrasts with subsequent reports from other regions of the world demonstrating significant morbidity and mortality can and does occur in pregnant women infected with SARS-CoV-2. Conclusion: While initial reports suggest limited risks of infection in pregnancy with SARS-CoV-2, subsequent findings have demonstrated pregnant women are at risk for severe morbidity and mortality. Case studies and series that are imperative in the early stages of a pandemic to provide data on a novel pathogen cannot be used to provide generalizable information predicting group risks.

The COVID-19 pandemic through eyes of a NYC fertility center: a unique learning experience with often unexpected results

Affecting basic tenets of human existence such as health, economic as well as personal security and, of course, reproduction, the COVID-19 pandemic transcended medical specialties and professional disciplines. Yet, six months into the pandemic, there still exists no consensus on how to combat the virus in absence of a vaccine. Facing unprecedented circumstances, and in absence of real evidence on how to proceed, our organization early in the pandemic decided to act independently from often seemingly irrational guidance and, instead, to carefully follow a quickly evolving COVID-19 literature. Here described is the, likely, unique journey of a fertility center that maintained services during peaks of COVID-19 and political unrest that followed. Closely following publicly available data, we recognized relatively early that New York City and other East Coast regions, which during the initial COVID-19 wave between March and May represented the hardest-hit areas in the country, during the second wave, beginning in June and still in progress, remained almost completely unaffected. In contrast, south western regions, almost completely unaffected by the initial wave, were severely affected in the second wave. These two distinctively different infectious phenotypes suggested two likely explanations: The country was witnessing infections with two different SARS-CoV-2 viruses and NYC (along with the East Coast) acquired during the first wave much better immunity to the virus than south western regions. Both hypotheses since have been confirmed: East and West Coasts, indeed, were initially infected by two distinctively different lineages of the virus, with the East Coast lineage being 10-times more infectious. In addition, immunologists discovered an up to this point unknown long-term anti-viral innate (cellular) immune response which offers additional and much broader anti-viral immunity than the classical adaptive immunity via immobilizing antibodies that has been known for decades. Consequently, we predict that in the U.S., even in absence of an available vaccine, COVID-19, by September-October, will be at similarly low levels as are currently seen in NYC and other East Coast regions (generally < 1% test-positivity). We, furthermore, predict that, if current mitigation measures are maintained and no newly aggressive mutation of the virus enters the country, a significant fall-wave of COVID-19, in combination with the usual fall wave of influenza, appears unlikely. To continue serving patients uninterrupted throughout the pandemic, turned for all of our center's staff into a highly rewarding experience, garnered respect and appreciation from patients, and turned into an absolutely unique learning experience.

Pregnancy and Neonatal Outcomes in SARS-CoV-2 Infection: A Systematic Review

With the emergence of SARS-CoV-2 and its rapid spread, concerns regarding its effects on pregnancy outcomes have been growing. We reviewed 245 pregnancies complicated by maternal SARS-CoV-2 infection across 48 studies listed on PubMed and MedRxiv. The most common clinical presentations were fever (55.9%), cough (36.3%), fatigue (11.4%), and dyspnea (12.7%). Only 4.1% of patients developed respiratory distress. Of all patients, 89.0% delivered via cesarean section (n = 201), with a 33.3% rate of gestational complications, a 35.3% rate of preterm delivery, and a concerning 2.5% rate of stillbirth delivery or neonatal death. Among those tested, 6.45% of newborns were reported positive for SARS-CoV-2 infection. Relative to known viral infections, the prognosis for pregnant women with SARS-CoV-2 is good, even in the absence of specific antiviral treatment. However, neonates and acute patients, especially those with gestational or preexisting comorbidities, must be actively managed to prevent the severe outcomes being increasingly reported in the literature.

COVID-19: Neurological Considerations in Neonates and Children

The ongoing worldwide pandemic of the novel human coronavirus SARS-CoV-2 and the ensuing disease, COVID-19, has presented enormous and unprecedented challenges for all medical specialists. However, to date, children, especially neonates, have been relatively spared from the devastating consequences of this infection. Neurologic involvement is being increasingly recognized among adults with COVID-19, who can develop sensory deficits in smell and taste, delirium, encephalopathy, headaches, strokes, and peripheral nervous system disorders. Among neonates and children, COVID-19-associated neurological manifestations have been relatively rare, yet reports involving neurologic dysfunction in this age range are increasing. As discussed in this review, pediatric neurologists and other pediatric specialists should be alert to potential neurological involvement by this virus, which might have neuroinvasive capability and carry long-term neuropsychiatric and medical consequences.