Pregnancy worsens the morbidity of COVID-19 and this effect becomes more prominent as pregnancy advances

COVID-19 in pregnant women: a systematic review and meta-analysis on the risk and prevalence of pregnancy loss

BACKGROUND

Pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are more likely to experience preterm birth and their neonates are more likely to be stillborn or admitted to a neonatal unit. The World Health Organization declared in May 2023 an end to the coronavirus disease 2019 (COVID-19) pandemic as a global health emergency. However, pregnant women are still becoming infected with SARS-CoV-2 and there is limited information available regarding the effect of SARS-CoV-2 infection in early pregnancy on pregnancy outcomes.

OBJECTIVE AND RATIONALE

We conducted this systematic review to determine the prevalence of early pregnancy loss in women with SARS-Cov-2 infection and compare the risk to pregnant women without SARS-CoV-2 infection.

SEARCH METHODS

Our systematic review is based on a prospectively registered protocol. The search of PregCov19 consortium was supplemented with an extra electronic search specifically on pregnancy loss in pregnant women infected with SARS-CoV-2 up to 10 March 2023 in PubMed, Google Scholar, and LitCovid. We included retrospective and prospective studies of pregnant women with SARS-CoV-2 infection, provided that they contained information on pregnancy losses in the first and/or second trimester. Primary outcome was miscarriage defined as a pregnancy loss before 20 weeks of gestation, however, studies that reported loss up to 22 or 24 weeks were also included. Additionally, we report on studies that defined the pregnancy loss to occur at the first and/or second trimester of pregnancy without specifying gestational age, and for second trimester miscarriage only when the study presented stillbirths and/or foetal losses separately from miscarriages. Data were stratified into first and second trimester. Secondary outcomes were ectopic pregnancy (any extra-uterine pregnancy), and termination of pregnancy. At least three researchers independently extracted the data and assessed study quality. We calculated odds ratios (OR) and risk differences (RDs) with corresponding 95% CI and pooled the data using random effects meta-analysis. To estimate risk prevalence, we performed meta-analysis on proportions. Heterogeneity was assessed by I2.

OUTCOMES

We included 120 studies comprising a total of 168 444 pregnant women with SARS-CoV-2 infection; of which 18 233 women were in their first or second trimester of pregnancy. Evidence level was considered to be of low to moderate certainty, mostly owing to selection bias. We did not find evidence of an association between SARS-CoV-2 infection and miscarriage (OR 1.10, 95% CI 0.81-1.48; I2 = 0.0%; RD 0.0012, 95% CI -0.0103 to 0.0127; I2 = 0%; 9 studies, 4439 women). Miscarriage occurred in 9.9% (95% CI 6.2-14.0%; I2 = 68%; 46 studies, 1797 women) of the women with SARS CoV-2 infection in their first trimester and in 1.2% (95% CI 0.3-2.4%; I2 = 34%; 33 studies; 3159 women) in the second trimester. The proportion of ectopic pregnancies in women with SARS-CoV-2 infection was 1.4% (95% CI 0.02-4.2%; I2 = 66%; 14 studies, 950 women). Termination of pregnancy occurred in 0.6% of the women (95% CI 0.01-1.6%; I2 = 79%; 39 studies; 1166 women).

WIDER IMPLICATIONS

Our study found no indication that SARS-CoV-2 infection in the first or second trimester increases the risk of miscarriages. To provide better risk estimates, well-designed studies are needed that include pregnant women with and without SARS-CoV-2 infection at conception and early pregnancy and consider the association of clinical manifestation and severity of SARS-CoV-2 infection with pregnancy loss, as well as potential confounding factors such as previous pregnancy loss. For clinical practice, pregnant women should still be advised to take precautions to avoid risk of SARS-CoV-2 exposure and receive SARS-CoV-2 vaccination.

The Effects and Outcomes of the COVID-19 Pandemic on Pregnant Women in Kuwait

OBJECTIVES

This retrospective study reports the effects of COVID-19 among hospitalized pregnant women infected with COVID-19 and compares them to a control group.

METHODS

A multi-center retrospective cohort study, in which data of pregnant women with COVID-19, admitted to five different hospitals in Kuwait, were collected. Two groups were included, the first group were women with COVID-19 who were admitted between March 22, 2020 until December 31, December 2020. The second (control) group included pregnant women without COVID-19, who were admitted between March 1, 2019 and March 21, 2020. Data were collected using a standardized data collection survey, entered using Excel Software and analyzed using Analysis of Variance (ANOVA).

RESULTS

We compared 764 patients, with confirmed COVID-19 with 765 uninfected control subjects. The majority of pregnant women were diagnosed with COVID-19 infection during the third trimester. Tachycardia was the most frequent sign at admission and dry cough and fever were the most common presenting symptoms. ICU admission and respiratory failure were significantly higher in the COVID-19 group. Cesarean section (CS) rate was higher in the COVID-19 group, with obstetric and maternal complications being the most common indications in comparison to fetal indications in the control group.

CONCLUSIONS

This study was conducted to identify the effects of COVID-19 in pregnancy. Most patients were asymptomatic. The rate of normal vaginal delivery was higher in the control group. The main indications for Cesarean section in the COVID-19 group were obstetrical and maternal complications compared to fetal complications in the control group.  .

Pathological Examination of the Placenta in COVID-19-Positive Mothers: A Short Communication

Background & Objective

It was declared that COVID-19 might be more severe in symptomatic pregnant patients. This study was conducted to examine the pathological indices of the placenta in pregnant women who were diagnosed with COVID-19.

Methods

A total of 20 COVID-19-positive mothers were enrolled in this study. Detailed placental pathology findings were compared between subjects based on the history of abortion or occurrence of preterm delivery, hypertension, and diabetes.

Results and Conclusion

Intervillositis was the most frequent abnormality of the placenta. There was also a significant association between abortion history and maternal vascular malperfusion (MVM; P=0.02). The placental abnormalities were found to be increased in women with COVID-19, regardless of maternal comorbidities. Further studies are needed to compare the placental pathology between COVID-19-positive women and healthy women.

Evaluation of the effects of COVID-19 disease and the trimester in which the disease is diagnosed on obstetric and neonatal outcomes: A retrospective cohort study

AIM

To evaluate the effects of COVID-19 disease and the trimester in which the disease is diagnosed on obstetric and neonatal outcomes.

METHODS

This retrospective cohort study was conducted with 358 patients who had or had not been diagnosed with COVID-19 during their pregnancy, had a miscarriage or had given birth.

RESULTS

COVID-19 disease during pregnancy was associated with higher maternal hypertensive disease, preterm birth, low birth weight, low first- and fifth-minute Apgar scores, and need for neonatal intensive care unit. The incidence of preterm birth, low birth weight, low first- and fifth-minute Apgar scores, and need for neonatal intensive care unit in those diagnosed with COVID-19 in the second trimester was significantly higher than those diagnosed with COVID-19 in other trimesters. The frequency of cesarean section was observed most in those diagnosed with COVID-19 in the 3rd trimester, while it was observed in those diagnosed with COVID-19 at least in the first trimester.

CONCLUSION

The presence of COVID-19 during pregnancy may be associated with an increased risk of iatrogenic preterm birth. The frequency of preterm birth in pregnant women diagnosed with COVID-19 in the second trimester is higher than in pregnant women diagnosed with COVID-19 in other trimesters. As the pregnancy trimester at the time of diagnosis progresses, the frequency of cesarean section increases. While the risk of maternal hypertensive disease increases more in pregnant women with COVID-19, the effect of the trimester in which COVID-19 was passed on the risk of maternal hypertensive disease is not observed.

COVID-19 related maternal mortality cases in associated with Delta and Omicron waves and the role of lung ultrasound

Objective

To present coronavirus disease-2019 (COVID-19) related maternal mortality in relation to Delta and Omicron waves and to investigate the role of lung ultrasound (LUS) in estimating mortality.

Materials and Methods

This retrospective cohort study was conducted in the obstetrics and gynecology clinic of a tertiary pandemic hospital between March 2020 and January 2022. The hospitalized pregnant women with COVID-19 diagnosis and maternal deaths were studied in relation with Delta and Omicron waves. The relationship between LUS scores of hospitalized patients and maternal mortality was explored.

Results

Thousand and sixty-five pregnant women were hospitalized because of COVID-19 infection. Fifty-one (4.79%) of these patients had critical sickness, 96 (9.01%) of them had severe illness, 62 (5.82%) of them were admitted to the intensive care unit and 28 (2.63%) of all hospitalized pregnant women had died. Of the 1.065 patients, 783 (73.5%) were hospitalized before the Delta wave and the maternal mortality rate was 1.28% (10/783), 243 (22.8%) were hospitalized during the Delta wave and the maternal mortality rate was 7% (17/243) [relative risk (RR)=5.478, 95% confidence interval (CI) (2.54-11.8), z=4.342, p<0.001]. During the Omicron wave 39 (3.66%) patients were hospitalized and the maternal mortality rate was 2.56% (1/39). Maternal mortality rates, according to LUS scores, were 0.37% (1/273) for LUS 0, 0.72% (2/277) for LUS 1, 2.58% (10/387) for LUS 2 and 11.72% (15/128) for LUS 3 respectively (LUS 3 vs. others; maternal mortality: RR=8.447, 95% CI (4.11-17.34), z=5.814, p<0.0001). There were no vaccinated patients in the study cohort.

Conclusion

The maternal mortality rate was relatively high, particularly during the Delta wave at our referral center. The Delta wave, delayed vaccination and vaccine hesitancy of pregnant women might have important roles in maternal mortality. Higher LUS scores should warn clinicians of an increased risk of maternal death.

The association between pregnancy and COVID-19: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to compare and determine whether there were any differences in clinical outcomes between pregnant and non-pregnant women who had been infected with COVID-19.

METHODS

A literature search was performed in 9 databases on November 20, 2021. The relative risk (RR) with 95% confidence interval (95% CI) was used to estimate the effect of pregnancy on COVID-19 outcomes. The I square value was used to assess heterogeneity, and the random or the fixed-effects model were adopted. Sensitivity and publication bias analyses were performed.

RESULTS

This study included 8 published studies with 859,278 COVID-19 female patients. The incidences of fever and cough among pregnant women with COVID-19 were 19.07% and 28.79%, respectively. Pregnancy was associated with significantly increased risks of intensive care unit (ICU) admission (RR = 2.23, 95% CI = 1.58-3.16) and ventilation (RR = 2.13, 95% CI = 1.06-4.28), but was not associated with a statistically significant increase in mortality.

CONCLUSIONS

Our results suggest that pregnant women with COVID-19 have a significantly higher probability of being hospitalized to the ICU and ventilation than non-pregnant women with COVID-19. To avoid these adverse outcomes, pregnant women should take precautions (for example, reduce going out, maintain social distance, and wear a mask) to avoid COVID-19 infection. Finally, additional research into the fetal outcomes is required to better investigate the impact of COVID-19 on pregnancy.

COVID-19 disease and vaccination in pregnant and lactating women

Background

More than 325,000 cases of coronavirus disease 2019 (COVID‐19) have been reported among pregnant women in the Americas.

Aims

This review examines the impact of COVID‐19 in pregnant women and describes available evidence on the safety, effectiveness, and immune response(s) to vaccination among pregnant and lactating women.

Content

Multiple studies indicate that pregnant women are more susceptible to adverse COVID‐19 outcomes, including hospitalization, intensive care unit admission, and invasive ventilation than non‐pregnant women with COVID‐19. Furthermore, COVID‐19 in pregnancy is associated with adverse maternal and neonatal outcomes. Adverse COVID‐19 outcomes appear to disproportionately affect pregnant women from low‐ and middle‐income countries, likely reflecting inequities in access to quality healthcare. Despite the absence of safety and efficacy data from randomized clinical trials in this subpopulation, observational studies and data from pregnancy registries thus far have demonstrated that vaccination of pregnant or lactating women against COVID‐19 is safe, effective, and results in robust immune responses including transfer of antibodies to the newborn via the placenta and breast milk, respectively.

Implications

These data support vaccination recommendations intending to help protect these vulnerable individuals against COVID‐19 and its sequelae. Randomized clinical studies will further evaluate the safety and immunogenicity of COVID‐19 vaccines in these populations. This review examines the impact of COVID‐19 in pregnant women and describes available evidence on the safety, effectiveness, and immune response(s) to vaccination among pregnant and lactating women.

Effects of SARS-CoV-2 Variants on Maternal Infection and Severity: A Single-Center Experience

Background and aims

Pregnant women are one of the vulnerable groups affected by COVID-19. With the mutation of the virus, the severity of the disease in this vulnerable group may vary in different waves of COVID-19 subtypes. The aim of this study is to define the demographic, clinical, laboratory, and mortality results of pregnant COVID-19 patients according to three time frames (March to December 2020, January to June 2021, and July to November 2021).

Materials and methods

The data of patients admitted to the ICU between March 23, 2020, and November 30, 2021, were retrospectively scanned. Pregnant patients with SARS-CoV-2 PCR test positivity or pregnant patients with COVID-19 who have a negative PCR test but symptoms of COVID-19 and radiological findings consistent with COVID-19 on thorax CT who need intensive care were included in the study. The patients were divided into three groups according to the dates when the Ministry of Health of the Republic of Turkey reported the variants of COVID-19 in Turkey. The nonvariant type was dominant in the first period (March to December 2020), alpha and beta variants were dominant in the second period (January to June 2021), and the delta variant appeared in the last period (July to November 2021). Demographic, clinical, and laboratory findings at the first admission to the ICU and mortality rates of the patients were recorded.

Results

PCR test was performed in all 109 patients, of whom 101 were PCR test positive. In other eight patients, despite the negative PCR test, thorax CT findings were typical of COVID-19 pneumonia, and other bacterial and viral agents were also excluded. The mean age of the patients was 30.53 years, the mean APACHE II score was 9.68, and the mean gestational age was 28.55 weeks. Around 72.5% of the patients were in the third trimester. Of the 101 PCR-positive patients, 20.2% were delta variants, 16.5% alpha or beta variants, and 63.3% were of unknown variants. Five of the patients were vaccinated. The most common symptom was dyspnea (94.5%), and the most common comorbidity was hypothyroidism (9.17%). Invasive mechanical ventilation (IMV) was needed in 44.95% of pregnant patients. The distribution of pregnant patients admitted to the ICU according to the periods March to December 2020, January to June 2021, and July to November 2021 was 16.5%, 21.1%, and 62.4%, respectively (p<0.001). Two groups of patients were compared: those that survived versus those that deceased. Variables predicting mortality were APACHE score, IMV requirement, length of stay in the ICU, prone positioning, Anakinra treatment, and ECMO (extracorporeal membrane oxygenator) requirement, which were significantly higher in the deceased group than in the living group (p<0.001, p<0.001, p=0.001, p<0.001, p<0.001, and p=0.001, respectively). There was no significant difference between the patients' age, gestational age, variants, treatments other than Anakinra, and the number of patients admitted to the ICU in the three periods (p=0.667, p=0.174, p=0.904, and p=0.605, respectively).In the multiple logistic regression analysis for mortality, high APACHE II score and IMV requirement were found as risk factors for mortality.

Conclusion

In the last period of delta variant predominance, pregnant COVID-19 patients were admitted to the ICU significantly more frequently than in the first two periods. Mechanical ventilation requirement and high APACHE II score were determined as risk factors for mortality.

An internally validated prediction model for critical COVID-19 infection and intensive care unit admission in symptomatic pregnant women

Background

Pregnant women are at an increased risk of mortality and morbidity owing to COVID-19. Many studies have reported on the association of COVID-19 with pregnancy-specific adverse outcomes, but prediction models utilizing large cohorts of pregnant women are still lacking for estimating the risk of maternal morbidity and other adverse events.

Objective

The main aim of this study was to develop a prediction model to quantify the risk of progression to critical COVID-19 and intensive care unit admission in pregnant women with symptomatic infection.

Study Design

This was a multicenter retrospective cohort study including 8 hospitals from 4 countries (the United Kingdom, Austria, Greece, and Turkey). The data extraction was from February 2020 until May 2021. Included were consecutive pregnant and early postpartum women (within 10 days of birth); reverse transcriptase polymerase chain reaction confirmed SARS-CoV-2 infection. The primary outcome was progression to critical illness requiring intensive care. The secondary outcomes included maternal death, preeclampsia, and stillbirth. The association between the primary outcome and 12 candidate predictors having a known association with severe COVID-19 in pregnancy was analyzed with log-binomial mixed-effects regression and reported as adjusted risk ratios. All the potential predictors were evaluated in 1 model and only the baseline factors in another. The predictive accuracy was assessed by the area under the receiver operating characteristic curves.

Results

Of the 793 pregnant women who were positive for SARS-CoV-2 and were symptomatic, 44 (5.5%) were admitted to intensive care, of whom 10 died (1.3%). The ‘mini-COvid Maternal Intensive Therapy’ model included the following demographic and clinical variables available at disease onset: maternal age (adjusted risk ratio, 1.45; 95% confidence interval, 1.07–1.95; P=.015); body mass index (adjusted risk ratio, 1.34; 95% confidence interval, 1.06–1.66; P=.010); and diagnosis in the third trimester of pregnancy (adjusted risk ratio, 3.64; 95% confidence interval, 1.78–8.46; P=.001). The optimism-adjusted area under the receiver operating characteristic curve was 0.73. The ‘full-COvid Maternal Intensive Therapy’ model included body mass index (adjusted risk ratio, 1.39; 95% confidence interval, 1.07–1.95; P=.015), lower respiratory symptoms (adjusted risk ratio, 5.11; 95% confidence interval, 1.81–21.4; P=.007), neutrophil to lymphocyte ratio (adjusted risk ratio, 1.62; 95% confidence interval, 1.36–1.89; P<.001); and serum C-reactive protein (adjusted risk ratio, 1.30; 95% confidence interval, 1.15–1.44; P<.001), with an optimism-adjusted area under the receiver operating characteristic curve of 0.85. Neither model showed signs of a poor fit. Categorization as high-risk by either model was associated with a shorter diagnosis to intensive care unit admission interval (log-rank test P<.001, both), higher maternal death (5.2% vs 0.2%; P<.001), and preeclampsia (5.7% vs 1.0%; P<.001). A spreadsheet calculator is available for risk estimation.

Conclusion

At presentation with symptomatic COVID-19, pregnant and recently postpartum women can be stratified into high- and low-risk for progression to critical disease, even where resources are limited. This can support the nature and place of care. These models also highlight the independent risk for severe disease associated with obesity and should further emphasize that even in the absence of other comorbidities, vaccination is particularly important for these women. Finally, the model also provides useful information for policy makers when prioritizing national vaccination programs to quickly protect those at the highest risk of critical and fatal COVID-19.

Vitamin D status is not associated with clinical severity of COVID-19 in pregnant women

PURPOSE

To investigate the association between vitamin D status and the clinical severity of COVID-19 in pregnant women.

METHODS

This prospective case-control study included 147 pregnant women with COVID-19 and 300 matched controls. Serum 25-hydroxyvitamin (25(OH)D) concentrations were measured on admission. Patients with mild-to-moderate disease (n = 114, 77.6%) and severe-to-critical disease (n = 33, 22.4%) were classified as symptomatic patients who did not require oxygen support and those who received oxygen support, respectively. SARS-CoV-2 positivity rates, clinical severity of COVID-19, and pulmonary involvement were compared according to vitamin D status.

RESULTS

Serum 25(OH)D concentrations were found to be 36.6 ± 26.8 and 31.3 ± 20.7 nmol/L in pregnant women infected with SARS-CoV-2 and healthy controls, respectively (p = 0.001). The clinical severity of pregnant women with COVID-19 did not differ concerning vitamin D deficiency (RR = 0.568, 95% CI [0.311-1.036]; p = 0.065), even after excluding patients on vitamin supplementation (RR = 0.625, 95% CI [0.275-1.419]; p = 0.261). Testing positive for SARS-CoV-2 was not related to vitamin D status in the overall cohort of pregnant women (RR = 0.767, 95% CI [0.570-1.030]; p = 0.078). Pulmonary involvement of COVID-19 was found to be similar between patients with vitamin D deficiency and adequate vitamin D levels (RR = 0.954; 95% CI [0.863-1.055]; p = 0.357).

CONCLUSION

The clinical severity and pulmonary involvement of COVID-19 may not be associated with vitamin D status in pregnant women. Vitamin D deficiency/adequacy rates were comparable in pregnant women infected with SARS-CoV-2 and healthy pregnant women.

Pregnant and Postpartum Women Requiring Intensive Care Treatment for COVID-19-First Data from the CRONOS-Registry

(1) Background: Data on coronavirus 2 infection during pregnancy vary. We aimed to describe maternal characteristics and clinical presentation of SARS-CoV-2 positive women requiring intensive care treatment for COVID-19 during pregnancy and postpartum period based on data of a comprehensive German surveillance system in obstetric patients. (2) Methods: Data from COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS), a prospective multicenter registry for SARS-CoV-2 positive pregnant women, was analyzed with respect to ICU treatment. All women requiring intensive care treatment for COVID-19 were included and compared regarding maternal characteristics, course of disease, as well as maternal and neonatal outcomes. (3) Results: Of 2650 cases in CRONOS, 101 women (4%) had a documented ICU stay. Median maternal age was 33 (IQR, 30–36) years. COVID-19 was diagnosed at a median gestational age of 33 (IQR, 28–35) weeks. As the most invasive form of COVID-19 treatment interventions, patients received either continuous monitoring of vital signs without further treatment requirement (n = 6), insufflation of oxygen (n = 30), non-invasive ventilation (n = 22), invasive ventilation (n = 28), or escalation to extracorporeal membrane oxygenation (n = 15). No significant clinical differences were identified between patients receiving different forms of ventilatory support for COVID-19. Prevalence of preterm delivery was significantly higher in women receiving invasive respiratory treatments. Four women died of COVID-19 and six fetuses were stillborn. (4) Conclusions: Our cohort shows that progression of COVID-19 is rare in pregnant and postpartum women treated in the ICU. Preterm birth rate is high and COVID-19 requiring respiratory support increases the risk of poor maternal and neonatal outcome.

Clinical evaluation of pregnant women with SARS-COV2 pneumonia: a real-life study from Egypt

BACKGROUND

Knowledge about the outcome of COVID-19 on pregnant women is so important. The published literature on the outcomes of pregnant women with COVID-19 is confusing. The aim of this study was to report our clinical experience about the effect of COVID-19 on pregnant women and to determine whether it was associated with increased mortality or an increase in the need for mechanical ventilation in this special category of patients.

METHODS

This was a cohort study from some isolation hospitals of the Ministry of Health and Population, in eleven governorates, Egypt. The clinical data from the first 64 pregnant women with COVID-19 whose care was managed at some of the Egyptian hospitals from 14 March to 14 June 2020 as well as 114 non-pregnant women with COVID-19 was reviewed.

RESULTS

The two groups did not show any significant difference regarding the main outcomes of the disease. Two cases in each group needed mechanical ventilation (p 0.617). Three cases (4.7%) died among the pregnant women and two (1.8%) died among the non-pregnant women (p 0.352).

CONCLUSIONS

The main clinical outcomes of COVID-19 were not different between pregnant and non-pregnant women with COVID-19. Based on our findings, pregnancy did not exacerbate the course or mortality of COVID-19 pneumonia.

Knowledge, Attitude and Practice Toward Corona virus Infection Among Pregnant Women Attending Antenatal Care at Public Hospitals in Three Wollega Zones, Ethiopia

BACKGROUND

Pregnancy is an immune-suppressed state which makes pregnant women generally more susceptible to COVID-19 infection and severe illness. Extensive precautions have been recommended to avoid exposure to the virus. Knowledge and attitude toward the disease play an integral role in readiness to accept public health measures. This study aimed to assess the knowledge, attitude and practice towards COVID-19 among pregnant women attending antenatal clinics in three Wollega zones, Ethiopia.

METHODS

Institution-based cross-sectional study was employed among 415 pregnant women attending antenatal care at public hospitals in three Wollega zones, Ethiopia from July to August 2020. The data were collected using an interviewer-administered structured questionnaire. The level of knowledge was assessed using 12 multiple choice questions; the score of above or equal to mean was considered as adequate knowledge. Binary logistic regression was performed and the adjusted odds ratio with P-value ≤0.05 at 95% CI was taken as statistically significant.

RESULTS

This study indicates that more than two-thirds (75.4%; 95% CI: 71.1-79.3%) and 43.6% of the pregnant women had adequate knowledge and good practice about the coronavirus pandemic, respectively. The pregnant women who attended secondary school and above and were urban residents were more likely to have good knowledge, AOR = 2.99 (1.7-5.0) and 1.6 (1.2-2.7), respectively. Maternal age ≤ 25 yearsand being an urban resident were the two predictors of good practice of preventive measures, AOR = 1.7 (1.2-2.6) and 2.3 (1.3-4.0), respectively.

CONCLUSIONS AND RECOMMENDATIONS

The target population demonstrated acceptable knowledge and poor practice toward COVID-19. Health-care providers should give more attention to educating pregnant women at any point of contact; legal enforcement should be implemented to improve practice of preventive measures. Special consideration should be given to those who are from rural areas, and to less-educated pregnant women.

Maternal deaths due to COVID-19 disease: The cases in a single center pandemic hospital in the south east of Turkey

Coronavirus‐19 disease is still a pandemic health problem and uncertainty in the management of severe or critically ill pregnant women confuses continually the obstetricians. The nationwide maternal mortality rate due to covid‐19 still has not been presented in any study in Turkey. The study includes four maternal mortality cases in a referral single pandemic center in our country. Case 1, a 34‐year‐old, 34 weeks of gestation with moderate disease. The cesarean section was performed due to nonreassuring nonstress tests. She died on the postpartum seventh day. Case 2, a 37‐year‐old, at 36 weeks of gestation. The symptoms consisted of dry cough, shortness of breath and labor pain, and 3 cm cervical opening. Her second cesarean section was performed and she died at postpartum ninth day. Case 3, 33 years old, 33 weeks of gestation with moderate/severe stage of the disease. A few days after the treatment, CS was performed due to her severe condition and she died at postpartum 15th day. Case 4, 39 years old, 35 weeks of gestation, she was at a severe stage of the disease. On the second day after the treatment, CS was performed due to her severe condition and she died at postpartum seventh day. The postpartum period after cesarean section should be followed cautiously under the appropriate treatment of the COVID‐19 disease. Unfortunately, the reason for this rapid deterioration which we observed in our cases is not well known and appropriate medications and algorithms should be established as soon as possible.

SARS-CoV-2 in Pregnancy: Fitting Into the Existing Viral Repertoire

The risk of viral infection during pregnancy is well-documented; however, the intervention modalities that in practice enable maternal-fetal protection are restricted by limited understanding. This becomes all the more challenging during pandemics. During many different epidemic and pandemic viral outbreaks, worse outcomes (fetal abnormalities, mortality, preterm labor, etc.) seem to affect pregnant women than what has been evident when compared to non-pregnant women. The condition of pregnancy, which is widely understood as "immunosuppressed," needs to be re-understood in terms of the way the immune system works during such a state. The immune system gets transformed to accommodate and facilitate fetal growth. The interference of such supportive conversion by viral infection and the risk of co-infection lead to adverse fetal outcomes. Hence, it is crucial to understand the risk and impact of potent viral infections likely to be encountered during pregnancy. In the present article, we review the effects imposed by previously established and recently emerging/re-emerging viral infections on maternal and fetal health. Such understanding is important in devising strategies for better preparedness and knowing the treatment options available to mitigate the relevant adverse outcomes.

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.

Corticosteroids Use in Pregnant Women with COVID-19: Recommendations from Available Evidence

Pregnant women experience immune system changes to accommodate and tolerate the growing foetus, these changes also increase their susceptibility to viral infections such as SARS-COV-2. COVID-19 in pregnancy increases the likelihood of hospital admission and intensive care compared to non-pregnant women. Early administration of low-dose corticosteroids to patients with acute respiratory distress syndrome can reduce all-cause mortality among such patients. However, during pregnancy, prolonged use of corticosteroids that readily cross the placenta like dexamethasone can negatively impact both the mother and foetus. Evidence is thus needed on the choice, timing, and duration for corticosteroids use among pregnant women with COVID-19. This article aims to provide evidence on corticosteroid use in pregnant women with COVID-19. The RECOVERY trial deduced that low-dose dexamethasone (6 milligrams) reduced mortality by up to one-third among COVID-19 patients on mechanical ventilation and one-fifth among those who received supplemental oxygen. Pregnant women in this trial received either oral prednisolone or intravenous hydrocortisone. Based on the RECOVERY trial findings, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that pregnant women with moderate-to-severe COVID-19 receive oral prednisolone or intravenous hydrocortisone. However, currently, the World Health Organisation (WHO) does not explicitly specify which corticosteroid to use among pregnant women with moderate-to-severe COVID-19. We also note that there are no published articles on corticosteroid use among pregnant women with severe COVID-19 in Africa.