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

Impact of SARS-CoV-2 Positivity on Delivery Outcomes for Pregnant Women between 2020 and 2021: A Single-Center Population-Based Analysis

Despite the existing body of evidence, there is still limited knowledge about the impact of SARS-CoV-2 positivity on delivery outcomes. We aimed to assess the impact of SARS-CoV-2 infection in women who gave birth at the University Hospital "Federico II" of Naples, Italy, between 2020 and 2021. We conducted a retrospective single-center population-based observational study to assess the differences in the caesarean section and preterm labor rates and the length of stay between women who tested positive for SARS-CoV-2 and those who tested negative at the time of labor. We further stratified the analyses considering the time period, dividing them into three-month intervals, and changes in SARS-CoV-2 as the most prevalent variant. The study included 5236 women with 353 positive cases. After vaccination availability, only 4% had undergone a complete vaccination cycle. The Obstetric Comorbidity Index was higher than 0 in 41% of the sample. When compared with negative women, positive ones had 80% increased odds of caesarean section, and it was confirmed by adjusting for the SARS-CoV-2 variant. No significant differences were found in preterm birth risks. The length of stay was 11% higher in positive cases but was not significant after adjusting for the SARS-CoV-2 variant. When considering only positive women in the seventh study period (July-September 2021), they had a 61% decrease in the odds of receiving a caesarean section compared to the fourth (October-December 2020). Guidelines should be implemented to improve the safety and efficiency of the delivery process, considering the transition of SARS-CoV-2 from pandemic to endemic. Furthermore, these guidelines should aim to improve the management of airborne infections in pregnant women.

Comparative clinical and placental pathologic characteristics in pregnancies with and without SARS-CoV-2 infection

OBJECTIVES

To compare the clinical and morphological characteristics of the "mother-placenta-fetus" system in high risk pregnant women of three groups: no SARS-CoV-2 infection, mild SARS-CoV-2 infection, and severe SARS-CoV-2 infection.

METHODS

A case-control study was performed for all deliveries, at 28 weeks' gestation or greater, who had standard indications for placental pathologic examination. Three groups were formed: (1) control group (no SARS-CoV-2 infection), (2) mild SARS-CoV-2 infection, (3) severe SARS-CoV-2 infection. High-risk pregnancies were registered in all cases in the study groups. The examination of the placenta and the selection of fragments of placental tissue were carried out in accordance with the consensus recommendations of the Amsterdam Placental Workshop Group. The sections were subjected to standard processing and stained with hematoxylin and eosin according to the standard protocol. All cases were reviewed by two pathologists, which did not know any information on pregnancy outcome and clinical data. Statistical analysis was performed using SPSS, p<0.05 was considered statistically significant.

RESULTS

Women with severe SARS-CoV-2 infection had an increased rate of multimorbidity including diabetes, chronic hypertension and obesity (p<0.01) compared with the other groups. Placentas at severe COVID-19 course were damaged by both chronic and acute injuries, in comparison to the mild and control groups (p<0.001). Also an important finding in severe COVID-19 was diffuse necrosis of the villous trophoblast - homogenization, diffuse circular eosinophilic masses surrounding the chorionic villi.

CONCLUSIONS

Women with multimorbidity are an "at-risk" subgroup for severe SARS-CoV-2 infection and greater likelihood of both placental damage and perinatal hypoxic-ischemic events. These results suggest that patient education, SARS-CoV-2 disease monitoring and preventive measures would be of benefit to this group.

Viral pulmonary infection in pregnancy - Including COVID-19, SARS, influenza A, and varicella

The COVID-19 pandemic has been at the forefront of medicine over the last few years. Pregnant women are often exposed to infectious agents that can be harmful not only to the mother but also to the foetus. Moreover, changes during pregnancy means that pregnant women have increased vulnerability to viral infections, especially pulmonary infections. Epidemiological studies have shown a link between maternal viral infections and miscarriage, preterm birth as well as congenital defects. With potential poor outcomes for both women and their newborns, having a good understanding of the presentation and management of these viral pulmonary infections is essential. The increased risk of adverse outcomes has been highlighted during the COVID-19, SARS and H1N1 influenza pandemics.

Global variations in the burden of SARS-CoV-2 infection and its outcomes in pregnant women by geographical region and country’s income status: a meta-analysis

Introduction

The prevalence of COVID-19 and its impact varied between countries and regions. Pregnant women are at high risk of COVID-19 complications compared with non-pregnant women. The magnitude of variations, if any, in SARS-CoV-2 infection rates and its health outcomes among pregnant women by geographical regions and country’s income level is not known.

Methods

We performed a random-effects meta-analysis as part of the ongoing PregCOV-19 living systematic review (December 2019 to April 2021). We included cohort studies on pregnant women with COVID-19 reporting maternal (mortality, intensive care admission and preterm birth) and offspring (mortality, stillbirth, neonatal intensive care admission) outcomes and grouped them by World Bank geographical region and income level. We reported results as proportions with 95% confidence intervals (CI).

Results

We included 311 studies (2 003 724 pregnant women, 57 countries). The rates of SARS-CoV-2 infection in pregnant women varied significantly by region (p<0.001) and income level (p<0.001), with the highest rates observed in Latin America and the Caribbean (19%, 95% CI 12% to 27%; 13 studies, 38 748 women) and lower-middle-income countries (13%, 95% CI 6% to 23%; 25 studies, 100 080 women). We found significant differences in maternal and offspring outcomes by region and income level. Lower-middle-income countries reported significantly higher rates of maternal mortality (0.68%, 95% CI 0.24% to 1.27%; 3 studies, 31 136 women), intensive care admission (4.53%, 95% CI 2.57% to 6.91%; 54 studies, 23 420 women) and stillbirths (1.09%, 95% CI 0.48% to 1.88%; 41 studies, 4724 women) than high-income countries. COVID-19 complications disproportionately affected South Asia, which had the highest maternal mortality rate (0.88%, 95% CI 0.16% to 1.95%; 17 studies, 2023 women); Latin America and the Caribbean had the highest stillbirth rates (1.97%, 95% CI 0.9% to 3.33%; 10 studies, 1750 women).

Conclusion

The rates of SARS-CoV-2 infection in pregnant women vary globally, and its health outcomes mirror the COVID-19 burden and global maternal and offspring inequalities.

PROSPERO registration number

CRD42020178076.

Deleterious effects of nervous system in the offspring following maternal SARS-CoV-2 infection during the COVID-19 pandemic

During the Coronavirus disease 2019 (COVID-19) pandemic, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is universally susceptible to all types of populations. In addition to the elderly and children becoming the groups of great concern, pregnant women carrying new lives need to be even more alert to SARS-CoV-2 infection. Studies have shown that pregnant women infected with SARS-CoV-2 can lead to brain damage and post-birth psychiatric disorders in offspring. It has been widely recognized that SARS-CoV-2 can affect the development of the fetal nervous system directly or indirectly. Pregnant women are recommended to mitigate the effects of COVID-19 on the fetus through vaccination, nutritional supplements, and psychological support. This review summarizes the possible mechanisms of the nervous system effects of SARS-CoV-2 infection on their offspring during the pregnancy and analyzes the available prophylactic and treatment strategies to improve the prognosis of fetal-related neuropsychiatric diseases after birth.

Investigating the association between severity of COVID-19 infection during pregnancy and neonatal outcomes

Pregnant women with COVID-19 require special attention and care, since the infection does not only affect the mother, but also her neonate and adversely affects pregnancy outcomes. The main goal of this retrospective cohort study is to investigate association between the maternal COVID-19 severity and risk of developing adverse neonatal outcomes. Patients were stratified into asymptomatic/mild and moderate to severe COVID-19. The following neonatal outcomes were assessed: gestational age at the time of delivery, birth weight, neonatal infection, neonatal intensive care unit (NICU) admission. The average age of patients was 28.5 ± 1.4 years old and majority were multigravida (74.0%, n = 148). Of total 200 pregnant women with COVID-19, 26.5% (n = 53) had moderate/severe disease and presented with higher incidence of preterm delivery and low birth weight (88.7%, n = 47; p < 0.001). In addition, more than half of the newborns delivered by mothers with severe disease were infected by SARS-COV-2 (58.5%, n = 31) and majority were admitted to the NICU (95.0%, n = 52). Based on the multivariate logistic regression analysis, pregnant women with moderate to severe COVID-19 were at much higher risk of preterm delivery, lower birth weight, neonatal infection, as well as neonatal ICU admission (p < 0.001). In addition, multigravida women were at higher risk for preterm delivery and lower birth weight (p = 0.017 and p = 0.02; respectively). Appropriate protective measures and early detection of suspected COVID-19 should be addressed for more favorable obstetric outcomes.

Performance features and mortality prediction of the 4C Score early in COVID-19 infection: a retrospective study in Saudi Arabia

The ISARIC4C consortium developed and internally validated the 4C Score for prediction of mortality only in hospitalized patients. We aimed to assess the validity of the 4C Score in mortality prediction of patients with COVID-19 who had been home isolated or hospitalized.This retrospective cross-sectional study was performed after the first wave of COVID-19. Data of all PCR-positive COVID-19 patients who had been discharged, hospitalized, or died were retrospectively analyzed. Patients were classified into four risk groups according to the 4C Mortality Score. A total of (506) patients were classified as follows: low (57.1%), intermediate (27.9%), high (13%), and very high (2%) risk groups. Clinical, radiological, and laboratory data were significantly more severe in the high and very high-risk groups compared with other groups (p<0.001 for all). Mortality rate was correctly estimated by the model with 71% sensitivity, 88.6% specificity, and area under the curve of 0.9. The mortality rate was underestimated among the very high-risk group (66.2% vs 90%). The odds of mortality were significantly greater in the presence of hypoxia (OR 2.6, 95% CI 1.5 to 4.6, p<0.001) and high respiratory rate (OR 5.3, 95% CI 1.6 to 17.9, p<0.007), C reactive protein (CRP) (OR 3.5, 95% CI 1.8 to 6.8, p<0.001), and blood urea nitrogen (BUN) (OR 1.9, 95% CI 1.3 to 3.1, p<0.002). Other components of the model had non-significant predictions. In conclusion, the 4C Mortality Score has good sensitivity and specificity in early risk stratification and mortality prediction of patient with COVID-19. Within the model, only hypoxia, tachypnea, high BUN, and CRP were the independent mortality predictors with the possibility of overlooking other important predictors.

COVID-19 in Pregnancy: Occupations With Higher Density of Population Exposure Associated With More Severe Disease

OBJECTIVE

To define the symptomatology of SARS-CoV-2 infection in pregnancy and associations between occupation, sociodemographic factors, and comorbidities with the severity of COVID-19 disease in pregnancy in all trimesters, regardless of hospitalization.

METHODS

We studied a retrospective cohort of a public health surveillance sample of persons with COVID-19 infection diagnosed during pregnancy. Data was collected March 2020 to August 2020 regarding symptoms, disease severity, comorbidities, obstetric history, and occupation.

RESULTS

One hundred sixty-three individuals were identified. Constitutional (64%) and lower respiratory symptoms (61%) were most common. Seventeen individuals (13.6%) were hospitalized, and one person (0.7%) died due to COVID-19. Risk factors for severe disease were age and an occupation that had high intensity exposure to people.

CONCLUSIONS

Occupational exposure is a risk factor for severe COVID-19 disease in pregnancy, justifying policy measures to ensure protection of this vulnerable population.

Perspectives on administration of COVID-19 vaccine to pregnant and lactating women: a challenge for low- and middle-income countries

Women who are in the pregnancy-puerperal cycle or are lactating have been deliberately excluded from participating in COVID-19 vaccine clinical trials that aimed to evaluate either the efficacy of the vaccines in inducing the formation of neutralizing antibodies or the investigational products' safety profile. The exclusion of pregnant and lactating women from such studies certainly and inequitably denies these women access to COVID-19 vaccines, since these products have become increasingly available to nonpregnant people and even to those who are pregnant and are in high-income settings. In this clinical opinion article, we discuss some aspects of the prolonged pandemic, the emergence of viral variants, the risks of severe complications of COVID-19 in pregnant women, and the disproportionate impact of the above on low- and middle-income countries. We argue that the decision to receive the COVID-19 vaccine should be a joint decision between the pregnant or lactating women and the healthcare providers, while considering the available data on vaccine efficacy, safety, the risks of SARS-CoV-2 infection in pregnant women, and the women's individual risks for infection and serious illness. The various types of vaccines that are already in use and their safety, effectiveness, and the potential risks and benefits of their administration to pregnant or lactating women are also reviewed.

Diabetes, hypertension, body mass index, smoking and COVID-19-related mortality: a systematic review and meta-analysis of observational studies

OBJECTIVES

We conducted a systematic literature review and meta-analysis of observational studies to investigate the association between diabetes, hypertension, body mass index (BMI) or smoking with the risk of death in patients with COVID-19 and to estimate the proportion of deaths attributable to these conditions.

METHODS

Relevant observational studies were identified by searches in the PubMed, Cochrane library and Embase databases through 14 November 2020. Random-effects models were used to estimate summary relative risks (SRRs) and 95% CIs. Certainty of evidence was assessed using the Cochrane methods and the Grading of Recommendations, Assessment, Development and Evaluations framework.

RESULTS

A total of 186 studies representing 210 447 deaths among 1 304 587 patients with COVID-19 were included in this analysis. The SRR for death in patients with COVID-19 was 1.54 (95% CI 1.44 to 1.64, I2=92%, n=145, low certainty) for diabetes and 1.42 (95% CI 1.30 to 1.54, I2=90%, n=127, low certainty) for hypertension compared with patients without each of these comorbidities. Regarding obesity, the SSR was 1.45 (95% CI 1.31 to 1.61, I2=91%, n=54, high certainty) for patients with BMI ≥30 kg/m2 compared with those with BMI <30 kg/m2 and 1.12 (95% CI 1.07 to 1.17, I2=68%, n=25) per 5 kg/m2 increase in BMI. There was evidence of a J-shaped non-linear dose-response relationship between BMI and mortality from COVID-19, with the nadir of the curve at a BMI of around 22-24, and a 1.5-2-fold increase in COVID-19 mortality with extreme obesity (BMI of 40-45). The SRR was 1.28 (95% CI 1.17 to 1.40, I2=74%, n=28, low certainty) for ever, 1.29 (95% CI 1.03 to 1.62, I2=84%, n=19) for current and 1.25 (95% CI 1.11 to 1.42, I2=75%, n=14) for former smokers compared with never smokers. The absolute risk of COVID-19 death was increased by 14%, 11%, 12% and 7% for diabetes, hypertension, obesity and smoking, respectively. The proportion of deaths attributable to diabetes, hypertension, obesity and smoking was 8%, 7%, 11% and 2%, respectively.

CONCLUSION

Our findings suggest that diabetes, hypertension, obesity and smoking were associated with higher COVID-19 mortality, contributing to nearly 30% of COVID-19 deaths.

TRIAL REGISTRATION NUMBER

CRD42020218115.

A Comprehensive Review of the Management of Pregnant Women with COVID-19: Useful Information for Obstetricians

Due to the physiological changes of the cardiovascular system and respiratory system in pregnancy, pregnant women are vulnerable to pathogen infection and severe pneumonia. With the increasing incidence of COVID-19 pneumonia, its influence on pregnant women and neonates has attracted more attention. In this review, we collected all relevant articles published in English from September 1, 2019 to June 10, 2021, regarding the epidemiology, clinical presentations, chemical examinations, imaging findings, the timing of delivery and delivery mode, maternal and neonatal complications, medication, and vertical transmission of COVID-19 in pregnancy. It has been reported that compared with non-pregnant females, pregnant women with COVID-19 are more likely to develop into severe type. In particular, the risk of entering the intensive care unit and endotracheal intubation was higher. Chest computed tomography and blood routine examination are useful for the diagnosis of COVID-19 in a short period of time. COVID-19 pneumonia is not an independent indication for terminating the pregnancy, and it is not contraindicated for vaginal delivery. Compared to normal pregnant females, patients with COVID-19 showed an elevated susceptibility of preterm delivery. Multidisciplinary consultation was suggested in the treatment policy of COVID-19 in pregnancy. Currently, there is no evaluation on the safety, efficacy, and immunity of the approved vaccines for mothers and infants. In human placental tissues, the COVID-19 virus has been found by different detection methods. The mechanism by which the virus enters the placental tissue is unclear, which may be related to placental inflammation. The long-term prognosis of pregnant women with COVID-19 remains unclear and requires further detailed investigation.

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.

A systematic review and meta-analysis of geographic differences in comorbidities and associated severity and mortality among individuals with COVID-19

Several comorbidities have been shown to be associated with coronavirus disease 2019 (COVID-19) related severity and mortality. However, considerable variation in the prevalence estimates of comorbidities and their effects on COVID-19 morbidity and mortality have been observed in prior studies. This systematic review and meta-analysis aimed to determine geographical, age, and gender related differences in the prevalence of comorbidities and associated severity and mortality rates among COVID-19 patients. We conducted a search using PubMed, Scopus, and EMBASE to include all COVID-19 studies published between January 1st, 2020 to July 24th, 2020 reporting comorbidities with severity or mortality. We included studies reporting the confirmed diagnosis of COVID-19 on human patients that also provided information on comorbidities or disease outcomes. We used DerSimonian and Laird random effects method for calculating estimates. Of 120 studies with 125,446 patients, the most prevalent comorbidity was hypertension (32%), obesity (25%), diabetes (18%), and cardiovascular disease (16%) while chronic kidney or other renal diseases (51%, 44%), cerebrovascular accident (43%, 44%), and cardiovascular disease (44%, 40%) patients had more COVID-19 severity and mortality respectively. Considerable variation in the prevalence of comorbidities and associated disease severity and mortality in different geographic regions was observed. The highest mortality was observed in studies with Latin American and European patients with any medical condition, mostly older adults (≥ 65 years), and predominantly male patients. Although the US studies observed the highest prevalence of comorbidities in COVID-19 patients, the severity of COVID-19 among each comorbid condition was highest in Asian studies whereas the mortality was highest in the European and Latin American countries. Risk stratification and effective control strategies for the COVID-19 should be done according to comorbidities, age, and gender differences specific to geographical location.

Management and Prevention of COVID-19 in Pregnancy and Pandemic Obstetric Care: A Review of Current Practices

Constant accumulation of data results in continuous updates of guidelines and recommendations on the proper management of pregnant women with COVID-19. This study aims to summarize the up-to-date information about the prevention and management of suspected/confirmed SARS-CoV-2 infection in obstetric patients and obstetric care during prenatal, intrapartum, and postpartum periods. We conducted a comprehensive literature search in PubMed for relevant English-written full-text reviews. We also included relevant guidelines and recommendations. In women with a low risk for infection and uncomplicated pregnancy, elective and non-urgent appointments should be postponed or completed through telehealth. Vaccination should be discussed and distance and personal hygiene preventive measures should be recommended. Routine ultrasound examinations should be adjusted in order to minimize exposure to the virus. Standardized criteria should evaluate the need for admission. Women with moderate/high-risk for infection should be isolated and tested with RT-PCR. The mode and timing of delivery should follow routine obstetric indications. In case of infection, glucocorticoids are recommended in critically ill pregnant women, after individualized evaluation. During labor and concomitant infection, the duration of the first two stages should be reduced as possible to decrease aerosolization, while minimization of hemorrhage is essential during the third stage. Close maternal monitoring and adequate oxygenation when necessary always remain a prerequisite. Discharge should be considered on the first or second day postpartum, also depending on delivery mode. Breastfeeding with protective equipment is recommended, as its benefits outweigh the risks of neonatal infection. Recommendations are currently based on limited available data. More original studies on infected pregnant women are needed to establish totally evidence-based protocols of care for these patients.