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 Table of Contents 
REVIEW ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 1530-1533  

Effects of COVID–19 on Pregnant women: Evidence-based review


1 Department of Obstetrics and Gynaecology, AIIMS, Bibinagar, Hyderabad, Telangana, India
2 Executive Director, AIIMS, Bibinagar, Hyderabad, Telangana, India
3 Department of Community Medicine and Family Medicine, AIIMS, Bibinagar, Hyderabad, Telangana, India
4 Department of Medicine, AIIMS, Bibinagar, Hyderabad, Telangana, India

Date of Submission29-Jul-2020
Date of Decision29-Sep-2020
Date of Acceptance07-Oct-2020
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Nabnita Patnaik
Department of Obstetrics and Gynaecology, AIIMS, Bibinagar, Hyderabad - 508 126, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1557_20

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  Abstract 

Corona virus infection (COVID-19) is increasing exponentially globally. It is also affecting pregnant women among others. Complications arising during pregnancy because of COVID-19 must be considered a health issue. The objective of the study was to analyse symptoms of pregnant women affected with COVID-19 based on the available literature. The articles were searched from Medline/PubMed, Scopus which were published till June 2020 and reviewed for the determined outcomes. The review demonstrated that common symptoms were fever, cough, nausea and myalgia. Vertical transmission of Corona virus infection was not found in any of the articles reviewed. Multicenter studies are important to better understand the pathogenesis and treatment planning for COVID-19 affected pregnant women.

Keywords: COVID-19, corona virus, pregnancy, vertical transmission, symptoms


How to cite this article:
Patnaik N, Bhatia V, Mishra KG, Sukumar M. Effects of COVID–19 on Pregnant women: Evidence-based review. J Family Med Prim Care 2021;10:1530-3

How to cite this URL:
Patnaik N, Bhatia V, Mishra KG, Sukumar M. Effects of COVID–19 on Pregnant women: Evidence-based review. J Family Med Prim Care [serial online] 2021 [cited 2021 May 18];10:1530-3. Available from: https://www.jfmpc.com/text.asp?2021/10/4/1530/314896




  Introduction Top


Corona virus (COVID-19) which surfaced in December 2019 in Wuhan territory, China, is presently a significant pandemic clearing 213 countries and tainting roughly 16 million.[1] Ever since it originally showed up, a consistent ascent in morbidity and mortality rates are being observed. As on 04th October, 2020, there have been a sum of 3,48,04,348 confirmed cases of COVID-19, including 10,30,738 deaths, reported to World Health Organization (WHO).[2] Health care systems of countries are grossly burdened to accommodate the infected to ensure comprehensive care.[3] Necessary measures are taken by nations to battle this pandemic, following the declaration of this disease to be a pandemic by WHO.[4] The virus is transmitted by respiratory droplets – coughing or sneezing and touching surfaces or objects of infected individuals – from an infected to a non-infected individual[5] and has the ability to contract 2.28 persons each day.[6] This infection likewise raises concerns about its effects among pregnant women. Pregnancy brings in physiological modifications in women, making them inclined to respiratory tract infections with subsequent complications of respiratory failure.

Literature evidence presents unfathomable 28% daily oxygen requirement in unexpedited delivery necessitating respiratory stabilisation.[7],[8] In addition, hypoxic damage was also noticed in placenta of SARS infected pregnant women, which gradually progressed from its onset to foetus delivery. This review was undertaken to accumulate the evidence of all researches done regarding implications of COVID-19 in pregnant women.


  Materials and Methods Top


Three search engines – Pubmed, Scopus, EMBASE databases – were literature searched for evidence. Those articles published in English language alone were selected. The search terms used by the authors were: “Corona virus” OR “COVID-19” OR “pregnancy” OR “Corona infection”. Publication in any year was considered. In addition to this, manual search of reference lists was also done and in cases where full articles couldn't be retrieved, authors were contacted via email. Endnote software was employed to remove duplicity in article types.

Inclusion and exclusion criteria

All kinds of articles (Meta Analysis, systematic reviews, cohort studies, case-control studies, cross sectional studies, case – series, case reports etc.) reporting on COVID-19 and pregnancy or Corona infection and pregnancy published till June 2020 were included. Unpublished conference proceedings and state of art reports were excluded due to its inaccessibility.

Data extraction

Title and abstracts were independently screened by the reviewers. Those articles obtained in full text considered to be eligible were screened. Data extraction of the review included characteristics like such as author, year of study, intervention and control group information, duration, sample size and outcome.

Quality assessment

The selected articles were reviewed for the quality according to the methodological quality of case reports and case-series of Murad et al.[9] Four domains of quality reporting included selection, ascertainment, causality and reporting made up of 8 questions for the final assessment score.

Outcome assessed: The primary outcome symptom onset, symptoms presented, prenatal issues were assessed.


  Results Top


Database searches resulted in 115 articles and 96 studies were excluded as they didn't satisfy the immediate objectives of the study. Further, 11 studies were removed as they assessed different outcomes or those were not clearly mentioned. The final assessment for review was performed on 8 articles. The characteristics of these articles are presented in [Table 1] and [Figure 1]. Evidence-based review included 5 articles, none of which had a randomised controlled design.
Figure 1: PRISMA diagram for studies inclusion

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Table 1: Data characteristics of studies reviewed

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The study of Liu et al.[10] and Li et al.[11] refuted vertical transmission of COVID-19 infection in neonate and no severe neonatal asphyxia was observed among participants. Further, all cases in the study showed epidemiological history with <2 weeks exposure to infected individuals before the onset of infection. The case of Li et al.[11] was that she was infected by her husband, who tested positive for SARS CoV-2 virus infection.

Out of the 8 studies reviewed, Zhang et al.[12] was a retrospective comparison study between 16 pregnant cases with neo-corona virus pneumonia infection with 45 cases of no neo-corona virus pneumonia. Chen et al.[13] was also a retrospective study and the remaining 6 were case studies. Zhang et al.[12] demonstrated maternal corona virus pneumonia was not passed to neonatal group.[13],[14],[15]

Results of the quality assessment of all included studies are shown in [Table 2]. All of the case series were judged to have fair to good quality, except one of poor quality. The patients appeared to represent the whole experience of the investigator, the exposure and outcome were adequately ascertained, and the length of follow-up was adequate.
Table 2: Quality assessment of studies included

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  Discussion Top


Corona virus infection (COVID-19) is an increasing pandemic with no conclusive treatment or vaccine. Pregnant women form a susceptible group for this infection owing to their physiological condition. This review was undertaken to assess systematically the symptom onset, symptoms and complications of Corona virus infection in pregnant population. Coincidentally, all studies were from China.

Fever and cough was seen in all the studies as the manifesting symptoms. Majority of the cases underwent caesarean deliveries. This intervention could be due to various factors. Primarily, Chinese local practices report a higher caesarean rate, as high as 41.5% (Ming et al).[18] Also considering the higher foetal distress grades amongst the infected population makes this intervention the preferred choice as it facilitates maternal stabilization and enhances ventilation.[18]

No vertical transmission was reported in any of the cases or studies reviewed, which was in accordance with the study of Rasmussen et al. and Schwartz et al., wherein infections were not transmitted for SARS or MERS and also suggested that transmission is not responsible for mortality or morbidity.[19],[20] Only one still birth was noted in the study of Liu et al.[10]

As for corona virus infection to be considered for termination of pregnancy, it is thought otherwise by “Expert Recommendations for New Coronavirus Infections in Pregnancy and Puerperium”.[21] It depends on disease status, gestational age and choice of delivery. But as a rule, it is thought that births must be given in a negative pressure isolation ward or in a negative pressure operating room.

This review has greater clinical implications in that medicines or treatments provided to pregnant women can result in side effects to the foetus, as no specific treatment is yet designed yet. Usage of Chloroquine and Hydroxychloroquine which is currently the favoured dug of treatment can harm the foetus and also may be transmitted to the child from feeding, supporting cautious administration of them.[22] In Indian context, the primary care level is currently great peril due to the lack of protocol for management of pregnant cases presenting with Corona. This review can lay the foundation for future researches and provide an insight into what exactly should be the course of action in order to achieve optimal care.


  Conclusion Top


This review concludes that common symptoms in pregnant women with Corona virus infection are fever, cough, nausea and myalgia. Most of the cases were in the third trimester of pregnancy. No vertical transmission was noted in COVID-19 infection and most of the deliveries were caesarean in nature. More descriptive information about this infection is necessary through further researches to help strengthen the health care services and their assets in order to combat this pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Coronavirus disease (COVID-19) pandemic [Internet]. 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019.  Back to cited text no. 1
    
2.
World Health Organization. Weekly Epidemiological Update Coronavirus Disease 2019 (COVID-19) [Internet]. 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20201005-weekly-epi-update-8.pdf. [Cited on 2020 Oct 6].  Back to cited text no. 2
    
3.
Fisher D, Heymann D. Q&A: The novel coronavirus outbreak causing COVID-19. BMC Med 2020;18:57.  Back to cited text no. 3
    
4.
Gilbert M, Pullano G, Pinotti F, Valdano E, Poletto C, Boëlle PY, et al. Preparedness and vulnerability of African countries against importations of COVID-19: A modelling study. Lancet Lond Engl 2020;395:871-7.  Back to cited text no. 4
    
5.
Chan JF-W, Yuan S, Kok K-H, To KK-W, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet 2020;395:514-23.  Back to cited text no. 5
    
6.
Zhang S, Diao M, Yu W, Pei L, Lin Z, Chen D. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: A data-driven analysis. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 2020;93:201-4.  Back to cited text no. 6
    
7.
Tomlinson MW, Caruthers TJ, Whitty JE, Gonik B. Does delivery improve maternal condition in the respiratory-compromised gravida? Obstet Gynecol 1998;91:108-11.  Back to cited text no. 7
    
8.
Daily WH, Katz AR, Tonnesen A, Allen SJ. Beneficial effect of delivery in a patient with adult respiratory distress syndrome. Anesthesiology 1990;72:383-6.  Back to cited text no. 8
    
9.
Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid-Based Med 2018;23:60-3.  Back to cited text no. 9
    
10.
Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect 2020. doi: 10.1016/j.jinf. 2020.02.028.  Back to cited text no. 10
    
11.
Li Y, Zhao R, Zheng S, Chen X, Wang J, Sheng X, et al. Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, China. Emerg Infect Dis 2020;26:1335-6.  Back to cited text no. 11
    
12.
Zhang L, Jiang Y, Wei M, Cheng BH, Zhou XC, Li J, et al. [Analysis of the pregnancy outcomes in pregnant women with COVID-19 in Hubei Province]. Zhonghua Fu Chan Ke Za Zhi 2020;55:166-71.  Back to cited text no. 12
    
13.
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records. Lancet 2020;395:809-15.  Back to cited text no. 13
    
14.
Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9:51-60.  Back to cited text no. 14
    
15.
Lee DH, Lee J, Kim E, Woo K, Park HY, An J. Emergency cesarean section performed in a patient with confirmed severe acute respiratory syndrome Coronavirus-2 -a case report. Korean J Anesthesiol 2020;73:347-51.  Back to cited text no. 15
    
16.
Liu D, Li L, Wu X, Zheng D, Wang J, Yang L, et al. Pregnancy and perinatal outcomes of women with coronavirus disease (COVID-19) pneumonia: A preliminary analysis. AJR Am J Roentgenol 2020;215:127-32.  Back to cited text no. 16
    
17.
Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, et al. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: A retrospective, single-centre, descriptive study. Lancet Infect Dis 2020;20:559-64.  Back to cited text no. 17
    
18.
Ming Y, Li M, Dai F, Huang R, Zhang J, Zhang L, et al. Dissecting the current caesarean section rate in Shanghai, China. Sci Rep 2019;9:2080.  Back to cited text no. 18
    
19.
Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol 2020;222:415-26.  Back to cited text no. 19
    
20.
Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: Lessons from SARS, MERS, and other human coronavirus infections. Viruses 2020;12:194.  Back to cited text no. 20
    
21.
Poon LC, Yang H, Lee JCS, Copel JA, Leung TY, Zhang Y, et al. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: Information for healthcare professionals. Ultrasound Obstet Gynecol 2020;55:700-8.  Back to cited text no. 21
    
22.
Levy M, Buskila D, Gladman DD, Urowitz MB, Koren G. Pregnancy outcome following first trimester exposure to chloroquine. Am J Perinatol 1991;8:174-8.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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