Pregnancy and Childbirth in the COVID-19 Era-The Course of Disease and Maternal-Fetal Transmission

COVID-19 and Pregnancy: An Updated Review about Evidence-Based Therapeutic Strategies

The COVID-19 pandemic posed a significant challenge for clinicians in managing pregnant women, who were at high risk of virus transmission and severe illness. While the WHO declared in May 2023 that COVID-19 is no longer a public health emergency, it emphasized that it remains a global health threat. Despite the success of vaccines, the possibility of new pandemic waves due to viral mutations should be considered. Ongoing assessment of the safety and effectiveness of pharmacological therapies is crucial in clinical practice. This narrative review summarizes the evidence-based therapeutic strategies for pregnant women with COVID-19, considering over three years of pandemic experience. The review discusses the safety and effectiveness of various drug regimens (antivirals, anticoagulants, corticosteroids, immunoglobulins, monoclonal antibodies, and therapeutic gases) and procedures (prone positioning and extracorporeal membrane oxygenation). Drugs with contraindications, inefficacy during pregnancy, or unknown adverse effects were excluded from our evaluation. The aim is to provide healthcare professionals with a comprehensive guide for managing pregnant women with COVID-19 based on lessons learned from the pandemic outbreak.

Various aspects of hearing loss in newborns: A narrative review

Hearing loss is considered the most common birth defect. The estimated prevalence of moderate and severe hearing loss in a normal newborn is 0.1%-0.3%, while the prevalence is 2%-4% in newborns admitted to the newborn intensive care unit. Neonatal hearing loss can be congenital (syndromic or non-syndromic) or acquired such as ototoxicity. In addition, the types of hearing loss can be conductive, sensorineural, or mixed. Hearing is vital for the acquisition of language and learning. Therefore, early detection and prompt treatment are of utmost importance in preventing the unwanted sequel of hearing loss. The hearing screening program is mandatory in many nations, especially for high-risk newborns. An automated auditory brainstem response test is used as a screening tool in newborns admitted to the newborn intensive care unit. Moreover, genetic testing and screening for cytomegalovirus in newborns are essential in identifying the cause of hearing loss, particularly, mild and delayed onset types of hearing loss. We aimed to update the knowledge on the various aspects of hearing loss in newborns with regard to the epidemiology, risk factors, causes, screening program, investigations, and different modalities of treatment.

Application of remote fetal heart rate monitoring via internet in late pregnancy during the COVID-19 pandemic

BACKGROUND

Internet-related technologies have rapidly developed and started to impact the traditional medical practices, which combined wireless communication technology as well as "cloud service" technology with electronic fetal heart monitoring have become a mainstream tendency.

OBJECTIVE

To investigate the clinical application value of remote fetal heart rate monitoring mode (RFHRM) on late pregnancy during the coronavirus disease (COVID-19) pandemic.

METHODS

From March 2021 to February 2022, we recruited 800 cases of pregnant women received prenatal examination at the Anhui Province Maternity and Child Healthcare Hospital. These pregnant women were randomly divided into two groups: the control group (n= 400), which was given traditional management, and the observation group (n= 400), which received remote monitoring technology on this basis. The two groups were compared with neonatal asphyxia, pregnancy outcomes, Edinburgh postnatal depression scale (EPDS), prenatal examination expenses and total time consumption.

RESULTS

There were no statistically significant differences between the groups in pregnancy outcome and neonatal outcome (P> 0.05). However, total EPDS score of 12.5% pregnant women in TPE group were higher than 12. The TPE group had significantly higher mean EPDS scores compared with the RFHRM group (7.79 ± 3.58 vs 5.10 ± 3.07; P< 0.05). The results showed a significant difference in maternity expenses (2949.83 ± 456.07 vs 2455.37 ± 506.67; P< 0.05) and total time consumption (42.81 ± 7.60 vs 20.43 ± 4.16; P< 0.05) between the groups.

CONCLUSION

Remote fetal heart rate monitoring via Internet served as an innovative, acceptable, safe and effective reduced-frequency prenatal examination model without affecting the outcome of perinatology of pregnant women with different risk factors.

Association between pregnant specific stress and depressive symptoms in the late pregnancy of Chinese women: the moderate role of family relationship and leisure hobbies

Background

Little research has been conducted on the association between pregnant specific stress and depressive symptoms, and whether family relationship and leisure hobbies moderate the association.

Methods

A cross-sectional survey of 647 pregnant women was conducted in Shenyang City, Liaoning Province of China. Pregnancy Pressure Scale (PPS), Edinburgh Postnatal Depression Scale (EPDS) and two single items were used to assess stress, perinatal depressive symptoms, family relationship and leisure hobbies, respectively. The analysis included χ2-test, Fisher's exact test, and binary logistic regression.

Results

The prevalence of perinatal depressive symptoms was 22.9% among the participants. After adjustment, four dimensions of pregnancy stress were found to increase the risk of depressive symptoms, and odds ratios (ORs) were 4.175 (95% confidence interval (CI) = 2.240, 7.779), 5.947 (95% CI = 2.624, 13.478), 3.907 (95% CI = 2.375, 6.425), and 8.534 (95% CI = 4.588, 15.873) for factors 1, 2, 3, and 4 (recognition of the role of parents, worrying about maternal and child health and safety, the changes in body shape and physical activity level, as well as child care and marriage), respectively. In addition, significant interactions were found between factor 2, factor 4 and family relationship, leisure hobbies with depressive symptoms, respectively (interaction P < 0.10).

Conclusion

Tailored stress-overcoming programs, as well as health services, are needed to relieve women's pregnancy stress and prevent them from depressive symptoms. Clinical practice should conduct family relationship-oriented interventions and women themselves can cultivate extensive leisure hobbies in the period of pregnancy preparation.

Learning deep neural networks' architectures using differential evolution. Case study: Medical imaging processing

The COVID-19 pandemic has changed the way we practice medicine. Cancer patient and obstetric care landscapes have been distorted. Delaying cancer diagnosis or maternal-fetal monitoring increased the number of preventable deaths or pregnancy complications. One solution is using Artificial Intelligence to help the medical personnel establish the diagnosis in a faster and more accurate manner. Deep learning is the state-of-the-art solution for image classification. Researchers manually design the structure of fix deep learning neural networks structures and afterwards verify their performance. The goal of this paper is to propose a potential method for learning deep network architectures automatically. As the number of networks architectures increases exponentially with the number of convolutional layers in the network, we propose a differential evolution algorithm to traverse the search space. At first, we propose a way to encode the network structure as a candidate solution of fixed-length integer array, followed by the initialization of differential evolution method. A set of random individuals is generated, followed by mutation, recombination, and selection. At each generation the individuals with the poorest loss values are eliminated and replaced with more competitive individuals. The model has been tested on three cancer datasets containing MRI scans and histopathological images and two maternal-fetal screening ultrasound images. The novel proposed method has been compared and statistically benchmarked to four state-of-the-art deep learning networks: VGG16, ResNet50, Inception V3, and DenseNet169. The experimental results showed that the model is competitive to other state-of-the-art models, obtaining accuracies between 78.73% and 99.50% depending on the dataset it had been applied on.

Maternal and Perinatal Outcomes of COVID-19-Positive Pregnant Women

Background

The risks of adverse maternal and perinatal outcomes are not very clear in coronavirus disease 2019 (COVID-19)-positive pregnant women. Therefore, this study aimed to determine the maternal and fetal outcomes in COVID-19-positive pregnancies.

Methodology

This prospective, cohort study was conducted in a tertiary care center over the period of one year. The study group comprised pregnant patients who presented with COVID-19 in the first and second waves of the pandemic. Maternal symptoms due to COVID-19 infection, comorbidities, number of admissions to the intensive care unit (ICU), and maternal mortality were noted for every patient. Perinatal outcomes were recorded in the form of intrauterine growth retardation (IUGR), mode of delivery, preterm deliveries, birth weight of newborns, neonatal intensive care unit (NICU) admissions, and neonatal mortality. Data analysis was done in the form of a variable percentage and mean ± standard deviation (SD).

Results

COVID-19-positive pregnant patients were mostly asymptomatic (48.07%). Term deliveries (37-40 weeks) were seen in 44 (89.8%) patients. The percentage of normal vaginal delivery was 74% and cesarean section was 24%. Out of 52 patients, two (3.8%) patients were admitted to the high dependency unit (HDU), one (1.9%) patient was admitted to the ICU, and 49 (94.3%) patients were in the isolation ward. Of the 49 live births, four (8.16%) newborns were admitted to the NICU. No neonatal death was recorded.

Conclusions

In this study, COVID-19-pregnant women were mostly asymptomatic. Neonates of COVID-19-infected women also mostly tested COVID-19 negative. More studies are needed with larger sample sizes to determine the effect of COVID-19 infection in pregnant women and neonates.

Clinical Characteristics and Outcomes of COVID-19 During Pregnancy-a Retrospective Cohort Study

The course of COVID-19 has been shown to be worse in pregnant women compared with their non-pregnant counterparts. The aim of this study is to share our experience treating pregnant women with COVID-19 and to establish a cohort for future studies of the long-term effects of the disease. We reviewed medical records of all SARS-CoV-2-positive pregnant women who were treated at our hospital for any reason, be it COVID-19 related or not, between April 2020 and February 2021. We extracted data regarding medical history, course of pregnancy, delivery, and neonatal outcomes. A total of 193 SARS-CoV-2-positive pregnant women were treated at our establishment during the study period, half of which were asymptomatic. Sixteen were hospitalized for COVID-19 symptoms, the most common being fatigue/malaise (58%) and cough (48%). Three women required mechanical ventilation and extracorporeal membrane oxygenation treatment. One hundred forty-four SARS-CoV-2-positive women were delivered during the study period. Of them, 24 (17%) underwent induction of labor, and four (17%) were due to symptomatic COVID-19. One hundred fifteen (80%) experienced vaginal delivery, and 29 (20%) underwent cesarean delivery. Neonatal outcomes were favorable; only 2% of 5-min Apgar scores were < 7, and all umbilical cord pH levels were > 7.1. Six infants tested positive for SARS-CoV-2; they were all asymptomatic, and none required treatment for viral infection. COVID-19 during pregnancy is a disease with potential substantial adverse maternal and neonatal outcomes. There is still much unknown regarding the long-term effects of the disease on parturients and their offspring.

The COVID-19 Pandemic and Levels of Physical Activity in the Last Trimester, Life Satisfaction and Perceived Stress in Late Pregnancy and in the Early Puerperium

Background: The aim of this study was to determine the impact of the COVID-19 pandemic on the levels of physical activity during the third trimester of pregnancy, life satisfaction and stress in women in late pregnancy and early postpartum. Methods: The study was conducted among 740 patients of maternity wards in Cracow hospitals on days 1−8 postpartum. Patients who were surveyed before the pandemic (December 2019−March 2020) were included in the prepandemic group (PPan: n = 252). The second group of women (COVID 1 group, Cov1: n = 262) was examined in the early stages of the pandemic (May−September 2020). In turn, participants who were surveyed during the population vaccination campaign (June−September 2021) were qualified to the COVID 2 group (Cov2: n = 226). The research tools used were the original questionnaire in addition to standardized questionnaires assessing physical activity in the last trimester of pregnancy (the Pregnancy Physical Activity Questionnaire); previous life satisfaction (the Satisfaction with Life Scale); and stress levels during the last month (the Perceived Stress Scale). Results: During the pandemic, women reduced the level of energy spent on total physical activity; nevertheless, statistically significant differences were found only between the PPan and Cov2 groups (p = 0.001). At the early stages of the pandemic, patients significantly reduced mobility activities (Cov1 vs. PPan: p < 0.001; Cov1 vs. Cov2: p = 0.007), while late in the pandemic they spent less energy on household activities (Cov2 vs. PPan: p = 0.002, Cov2 vs. Cov1: p = 0.002). There were no differences in the levels of stress and life satisfaction. Conclusions: The COVID-19 pandemic impacted the level of physical activity; however, it did not change levels of perceived stress and life satisfaction in women in late-stage pregnancy and in the early puerperium.

The Influence of Nutritional Supplementation for Iron Deficiency Anemia on Pregnancies Associated with SARS-CoV-2 Infection

Anemia is a very common occurrence during pregnancy, with important variations during each trimester. Anemia was also considered as a risk factor for severity and negative outcomes in patients with SARS-CoV-2 infection. As the COVID-19 pandemic poses a significant threat for pregnant women in terms of infection risk and access to care, we developed a study to determine the impact of nutritional supplementation for iron deficiency anemia in correlation with the status of SARS-CoV-2 infection. In a case-control design, we identified 446 pregnancies that matched our inclusion criteria from the hospital database. The cases and controls were stratified by SARS-CoV-2 infection history to observe the association between exposure and outcomes in both the mother and the newborn. A total of 95 pregnant women were diagnosed with COVID-19, having a significantly higher proportion of iron deficiency anemia. Low birth weight, prematurity, and lower APGAR scores were statistically more often occurring in the COVID-19 group. Birth weight showed a wide variation by nutritional supplementation during pregnancy. A daily combination of iron and folate was the optimal choice to normalize the weight at birth. The complete blood count and laboratory studies for iron deficiency showed significantly decreased levels in association with SARS-CoV-2 exposure. Puerperal infection, emergency c-section, and small for gestational age were strongly associated with anemia in patients with COVID-19. It is imperative to screen for iron and folate deficiency in pregnancies at risk for complications, and it is recommended to supplement the nutritional intake of these two to promote the normal development and growth of the newborn and avoid multiple complications during pregnancy in the COVID-19 pandemic setting.

Maternal and Perinatal Outcomes of Hospitalized COVID-19 Positive Pregnant Women

Introduction

The consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) /Coronavirus disease 2019 (COVID-19) on mothers and neonates are uncertain due to the lack of robust evidence from various available studies. Furthermore, conflicting data exist regarding the vertical transmission of coronavirus. Therefore, a hospital-based study was conducted to evaluate the effect of COVID-19 on maternal and perinatal outcomes of COVID-19 infected pregnant women.

Methodology

A hospital-based retrospective observational study was conducted between July-December 2020 in Rajarshi Dashrath Autonomous State Medical College, Ayodhya, Uttar Pradesh, a designated level-2 COVID-19 Hospital. A total of 37 confirmed COVID-19 positive pregnant women (mean age 27.5 ± 05 years) of more than 28 weeks of gestation were included in this study to evaluate the effect of COVID-19 on maternal and perinatal outcomes. Maternal symptoms related to COVID-19, comorbidities, intensive care unit (ICU) admissions, intrauterine growth retardation (IUGR), leaking per vagina, mode of delivery, preterm deliveries, and maternal deaths were recorded. Birth weight of newborns, neonatal intensive care unit (NICU) admissions, neonatal illness, neonatal deaths, and COVID-19 testing reports were recorded. 

Result

Out of 37 COVID-19 positive pregnant women, 27 (72.9%) women were asymptomatic, nine (24.4%) women were having mild disease, and one (2.7%) developed severe disease requiring ICU admission. No maternal deaths were observed. Twenty-six (70.3%) women were delivered by caesarean section, 11 (29.7%) women by normal vaginal delivery, four (10.8%) were of leaking per vagina. Among newborns, five (13.5%) were preterm, one (2.7%) newborn require NICU admission, two (5.4%) were tested COVID-19 positive on the 5th day of life but were asymptomatic, and four (10.8%) newborns developed a fever but were COVID-19 negative. One case (2.7%) was of stillbirth. No neonatal deaths were observed.

Conclusion

The present study did not reveal any direct evidence for vertical transmission of SARS-CoV-2 virus through the placenta and during vaginal delivery, but the possibility of mother-to-child infection cannot be completely ignored. SARS-CoV-2 infection during late pregnancy may have a maternal and neonatal impact. COVID-19 infections in late pregnancy might lead to an increased incidence of caesarean deliveries as observed in the present study. This study reveals that most of the COVID-19 positive pregnant women remained asymptomatic or had mild infections. Hence, efforts to limit exposure to COVID-19 of pregnant women should be strengthened for saving mother and child.

Doctor/Data Scientist/Artificial Intelligence Communication Model. Case Study

The last two years have taught us that we need to change the way we practice medicine. Due to the COVID-19 pandemic, obstetrics and gynecology setting has changed enormously. Monitoring pregnant women prevents deaths and complications. Doctors and computer data scientists must learn to communicate and work together to improve patients' health. In this paper we present a good practice example of a competitive/collaborative communication model for doctors, computer scientists and artificial intelligence systems, for signaling fetal congenital anomalies in the second trimester morphology scan.

Absence of SARS-CoV-2 RNA in Peritoneal Fluid During Surgery in Pregnant Women Who Are COVID-19 Positive

STUDY OBJECTIVE

Coronavirus disease 2019 (COVID-19) infection poses significant risks during surgical interventions. We investigated the intraperitoneal presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients who are COVID-19 positive.

DESIGN

A prospective group study.

SETTING

Department of Obstetrics and Gynecology designated for patients with COVID-19, Central Clinical Hospital of the Ministry of Interior, Warsaw.

PATIENTS

Overall, 65 pregnant women with COVID-19 infection underwent cesarian section. The diagnosis was confirmed either by positive antigen test or by positive reverse transcriptase-polymerase chain reaction assay performed within no more than 13 days before the operation.

INTERVENTIONS

On the day of the operation, a nasopharyngeal swab was taken, and peritoneal fluid was collected at the beginning of the operation. Both the nasopharyngeal swab and peritoneal fluid samples were tested for SARS-CoV-2.

MEASUREMENTS AND MAIN RESULTS

A total of 65 pregnant women with COVID-19 infection were enrolled in the study. The SARS-CoV-2 ribonucleic acid test by nasopharyngeal swab produced positive results in 34 patients. In this group as well as in 31 nonconfirmed patients, all peritoneal fluid samples tested negative for SARS-CoV-2 ribonucleic acid.

CONCLUSION

These results suggest a low risk of COVID-19 transmission from the peritoneal cavity at the time of laparoscopy or laparotomy.

Is the Course of COVID-19 Different during Pregnancy? A Retrospective Comparative Study

The COVID-19 pandemic has challenged health systems around the world. Maternal-foetal medicine, which has been particularly affected, must consider scientific data on the physiological processes occurring in the pregnant woman's body to develop relevant standards of care. Our study retrospectively compared the clinical and laboratory characteristics of 52 COVID-19 pregnant patients with 53 controls. Most of the pregnant patients required medical attention during the third trimester and therefore we propose that vaccination is needed prior to the 30th week of pregnancy. We found no differences between the 2 groups in the course of illness classification system, days of hospital stay, need for oxygen supplementation, need for mechanical ventilation, and ICU admission. Moreover, clinical manifestations and imaging findings were comparable. Pregnant patients needed a greater oxygen flow rate and required high flow oxygen therapy more frequently. Considering pregnancy-related physiological adaptations, we found that COVID-19 infection in pregnant patients is associated with higher levels of inflammatory markers, apart from serum ferritin, than in non-pregnant women, and concluded that biomarkers of cardiac and muscle injury, as well as kidney function, may not be good predictors of COVID-19 clinical course in pregnant patients at the time of admission, but more research needs to be conducted on this topic.

Impact of the Gestational Diabetes Diagnostic Criteria during the Pandemic: An Observational Study

OBJECTIVE

To analyze the effect of applying alternative diagnostic criteria for gestational diabetes mellitus (GDM) during the COVID-19 pandemic on GDM prevalence and obstetrical and perinatal outcomes, in comparison to usual diagnostic approaches.

METHODS

Data from women referred to GDM diagnosis from 1 September to 30 November 2019 were retrospectively collected (2019-group). The same data from the same period in 2020 were prospectively collected (2020-group). In both cases, a two-step diagnostic approach was used, the first step being a screening test (1 h 50 goral glucose tolerance test, OGTT). In 2019 it was followed by a 100 gr OGTT for diagnosis. In 2020, this was replaced by a blood test for the measurement of plasma glucose and HbA1c, according to alternative GDM diagnostic criteria during the COVID-19 pandemic.

RESULTS

From 237 women in the 2019 group, 40 (16.9%) were diagnosed with GDM, while from 255 women in the 2020 group, 37 (14.5%) had GDM (p = 0.470). More women in the 2020 group, in comparison to the 2019 group, were nulligravid (41.9% vs. 47.2%, p = 0.013), had a personal history of GDM (11.4% vs. 4.6%, p = 0.013) and had macrosomia in previous pregnancies (10.2% vs. 2.1%, p = 0.001). Obstetrical and perinatal outcomes were similar when comparing women with GDM to non-GDM women in the 2019 and 2020 groups and between GDM women and non-GDM women.

CONCLUSION

In a Spanish population, GDM prevalence during the COVID-19 pandemic using the alternative diagnostic criteria was similar to that found in 2019 using the usual diagnostic criteria. Despite women referred for GDM diagnosis during the pandemic having more GDM risk factors, obstetrical and perinatal outcomes were comparable to those observed before the pandemic.

Focusing Treatment on Pregnant Women With COVID Disease

Since the emergence of a novel coronavirus in China at the end of December 2019, its infection - COVID-19 - has been associated with high morbidity and mortality and has left healthcare systems wrestling with the optimal management strategy, especially for vulnerable populations, such as pregnant women. At this moment, few resources exist to guide the multi-disciplinary team through decisions regarding optimal maternal-fetal treatment and delivery timing. In this article, we present the drugs and vaccines under investigation as potential treatments and prevention for COVID-19 infection. Based on a comprehensive evaluation, we prioritized these possible treatments, and provide dose-response and dose-toxicity information on each drug. Currently, there is limited but very increasing reassuring information concerning vaccines to prevent SARS-CoV-2 during pregnancy, and in this review, we also emphasize the results (mostly positive) provided by the few small trials evaluating COVID-19 vaccines in pregnant patients.

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

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

COVID-19 positivity associated with traumatic stress response to childbirth and no visitors and infant separation in the hospital

As the novel coronavirus (COVID-19) has spread globally, a significant portion of pregnant and delivering women were infected with COVID-19. While emerging studies examined birth outcomes in COVID-19 positive women, knowledge of the psychological experience of childbirth and maternal wellness remains lacking. This matched-control survey-based study included a sample of women recruited during the first wave of the pandemic in the US who gave birth in the previous six months. Women reporting confirmed/suspected COVID-19 (n = 68) during pregnancy or childbirth were matched on background factors with women reporting COVID-19 negativity (n = 2,276). We found nearly 50% of COVID positive women endorsed acute traumatic stress symptoms at a clinical level in response to childbirth. This group was more than twice as likely to endorse acute stress and to have no visitors during maternity hospitalization than COVID negative women; they were also less likely to room-in with newborns. The COVID positive group reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Our findings suggest COVID-19 affected populations are at increased risk for traumatic childbirth and associated risk for psychiatric morbidity. Attention to delivering women's wellbeing is warranted during the pandemic.

Practical Recommendations for the Management of Patients with ITP During the COVID-19 Pandemic

The current COVID-19 pandemic requires revisiting our current approach to major blood disorders, including ITP (Immune Thrombocytopenia), stirring up the production of several disease-specific practical guidelines. This report describes an updated version of consensus-based practical guidelines on the management of ITP, adapted to the Italian health system and social context. It highlights the role of the hematologist in offering guidance for choosing differentiated approaches in relation to specific circumstances and is intended to provide them with a useful tool for sharing the decision-making process with their patients.

Probably, the greatest risk to avoid for a patient with suspected, ongoing or relapsed ITP - that is not severe enough to place him or her at risk for major bleeding - is to be infected in non-hospital and hospital healthcare settings. This risk must be carefully considered when adapting the diagnostic and therapeutic approach.

More in detail, the document first addresses the appropriate management for COVID-19 negative patients with newly diagnosed ITP or who experience a relapse of previous ITP, according to first and second lines of treatment and then the management of COVID-19 positive patients according to their severity, from paucisymptomatic to those requiring admission to Intensive Cure Units (ICU). The pros and cons of the different treatments required to correct platelet count are discussed, as are some specific situations, including chronic ITP, splenectomy, thromboembolic complication and anti COVID-19 vaccination.