Objective: This is the first comprehensive review to focus on currently available evidence regarding maternal, fetal and neonatal mortality cases associated with Coronavirus Disease 2019 (COVID-19) infection, up to July 2020. Methods: We systematically searched PubMed, Scopus, Google Scholar and Web of Science databases to identify any reported cases of maternal, fetal or neonatal mortality associated with COVID-19 infection. The references of relevant studies were also hand-searched. Results: Of 2815 studies screened, 10 studies reporting 37 maternal and 12 perinatal mortality cases (7 fetal demise and 5 neonatal death) were finally eligible for inclusion to this review. All maternal deaths were seen in women with previous co-morbidities, of which the most common were obesity, diabetes, asthma and advanced maternal age. Acute respiratory distress syndrome (ARDS) and severity of pneumonia were considered as the leading causes of all maternal mortalities, except for one case who died of thromboembolism during postpartum period. Fetal and neonatal mortalities were suggested to be a result of the severity of maternal infection or the prematurity, respectively. Interestingly, there was no evidence of vertical transmission or positive COVID-19 test result among expired neonates. Conclusion: Current available evidence suggested that maternal mortality mostly happened among women with previous co-morbidities and neonatal mortality seems to be a result of prematurity rather than infection. However, further reports are needed so that the magnitude of the maternal and perinatal mortality could be determined more precisely.

Background: The coronavirus disease of 2019 (COVID-19) pandemic has become the most challenging issue for healthcare organizations and governments all over the world. The lack of evidence-based data on the management of COVID-19 infection during pregnancy causes an additional stress for obstetrics healthcare providers (HCPs). Therefore, this study was undertaken to evaluate depression, perceived social support, and quality of life among obstetrics HCPs. Materials and Methods: This cross-sectional multicenter study was conducted in eight cities in Iran. During the study period, 599 HCPs were separated into direct, no direct, and unknown contact groups according to their exposure to COVID-19-infected pregnant patients. The Patient Health Questionaire-9 (PHQ-9), Multidimensional Scale of Perceived Social Support (MSPSS), and Short Form-36 (SF-36) were used to assess depression, perceived social support, and quality of life. Results: Obstetrics and gynecology specialists had significantly higher social functioning and general health scores compared to other HCPs (residents/students or nurses/midwives). Depression was negatively correlated with most of the domains of quality of life, regardless of the COVID-19 contact status of the study participants. Social support, however, was positively correlated with some domains of quality of life, such as physical functioning, energy/fatigue, and emotional well-being, among staff members who had either direct contact or no contact with COVID-19 patients. Conclusion: During the COVID-19 outbreak, the depression score among obstetrics HCPs was negatively associated with quality of life. Social support, however, had a reinforcing effect on quality of life.

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Background: There is a growing body of evidence on low serum vitamin-D levels and the risk of uterine leiomyomas (UL). Therefore, this systematic review and meta-analysis was conducted to investigate the association between serum vitamin D levels and UL occurrence. Methods: Searches were systematically conducted of the electronic databases PubMed, Scopus, EMBASE, Web of Science (ISI), Cochrane library, Ovid, and Google Scholar to identify relevant studies from inception until February 6, 2020. Heterogeneity across the included studies was examined using Cochran's Q and I-square (I 2). Data was pooled using random effects modeling and expressed as standardized mean differences (SMDs). Results: Nine eligible studies with a total of 1730 participants (835 patients with UL and 895 controls) were included in the current meta-analysis. Pooled results with random effects modeling indicated that serum vitamin D levels were significantly lower in patients with UL than in the control group (n = 9, SMD = − 0.67; 95% CI, − 0.98, − 0.35, p < 0.001; I 2 = 89.3%, p < 0.001). Based on the findings of subgroup analyses, it was found that the SMD values across the included studies from Asia (n = 4, SMD = − 1.20; 95% CI, − 1.45, − 0.96, p < 0.001; I 2 = 30.6%, p = 0.229) were lower than those from Europe (n = 3, SMD = − 0.34; 95% CI, − 0.49, − 0.18, p < 0.001; I 2 = 0.0%, p = 0.602) and Africa (n = 2, SMD = − 0.13; 95% CI, − 0.29, 0.04, p = 0.128; I 2 = 0.0%, p = 0.417), although the difference was not significant in Africa. Publication year was also found to be a potential contributor's variable in the pooled SMD using the meta-regression method (t = − 3.00, p = 0.02). Conclusions: To the best of our knowledge, the current meta-analysis showed for the first time that serum vitamin D levels were significantly lower in women with UL in selected populations.

What are the novel findings of this work? Among fetuses with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation, those with later gestational age (GA) at the time of laser surgery, earlier GA at delivery and lower birth weight were found to be at increased risk of developing neurodevelopmental impairment (NDI) in early childhood. However, no significant association was found between Quintero stage of TTTS and risk of NDI. What are the clinical implications of this work?Clarification of the perinatal risk factors of NDI can be useful in clinical practice for parental counseling and identification of TTTS survivors at risk of developing NDI in future life.

What are the novel findings of this work? Iatrogenic chorioamniotic separation (iCAS) following fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS) is associated with earlier gestational age at intervention and at delivery, as well as increased risk of preterm prelabor rupture of membranes < 34 weeks, preterm delivery < 32 weeks and neonatal death. What are the clinical implications of this work?The findings of this systematic review and meta-analysis should help optimize counseling and management planning of patients with iCAS following FLP for TTTS.

The aim of the current study is to evaluate the efficacy and safety of acupuncture on sleep quality and overnight melatonin secretion, measured as urinary 6-sulfatoxymelatonin, in pregnant women. Patients and Methods: This randomized, parallel, single-blinded (participant), controlled trial was conducted on 72 pregnant women with insomnia. Study participants were randomly assigned to either the intervention, 10 sessions of acupuncture treatment over a 3-week period, or control group by block randomization (1:1). Patients in both groups were evaluated at baseline and post-treatment (third week) using the Pittsburgh Sleep Quality Index (PSQI) score (as the primary outcome) and urinary 6-sulfatoxymelatonin. Results: Fifty-five of 72 participants completed the study. There was no statistically significant difference regarding PSQI score and 6-sulfatoxymelatonin level between intervention and control groups at the baseline (P=0.169 and P=0.496). At the end of the study period, treatment with acupuncture significantly improved the PSQI score (P<0.001) with a large effect size of 3.7, as well as 6-sulfatoxymelatonin level (P=0.020) with a medium effect size of 0.6 as compared to the control group. No adverse effects were noted during acupuncture sessions and follow-up visits. Conclusion: Acupuncture was shown to significantly improve the sleep quality in pregnant women, possibly through increasing melatonin secretion, and could be recommended as a low-cost and low-risk alternative treatment to pharmacological therapies.

Background: Myrrh (Commiphora myrrha (Nees) Engl.) has a long history of traditional use as a herbal medicine for different purposes. In ancient traditional Persian manuscripts, it has been noted that myrrh may act as uterine stimulant and probably cause complete abortion. However, there is no evidence to verify this comment. Therefore, the current study was carried out to evaluate the efficacy and safety of Myrrh in the treatment of incomplete abortion. Materials and methods: In a randomized double-blinded placebo controlled clinical trial, 80 patients with ultrasound-documented retained products of conception (RPOC) were assigned to receive capsules containing 500 mg of Myrrh oleo-gum-resin or a placebo three times a day for 2 weeks. The existence of the retained tissue and its size were evaluated by ultrasound examination at the beginning and end of the study. Results: After 2 weeks, the mean diameter of the RPOC in the Myrrh group was significantly reduced compared with the placebo group (P < 0.001). Meanwhile, the rate of successful complete abortion was 82.9% in the intervention group and 54.3% in the placebo group (P = 0.01). The patients in both groups reported no serious drug-related adverse effects. Conclusion: This study shows that Myrrh is effective and safe in the resolution of the RPOC and may be considered as an alternative option for treatment of patients with incomplete abortion. However, further studies on active compounds isolated from myrrh and their uterine stimulant effects are needed. Trial registration: This study was retrospectively registered at Iranian Registry of Clinical Trials (www.irct.ir) IRCT code: IRCT20140317017034N7.