Clinical Manifestations, Risk Factors, and Maternal and Perinatal Outcomes of Coronavirus Disease 2019 in Pregnancy: Living Systematic Review and Meta-analysis

Abstract

ObjectiveTo determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19). DesignLiving systematic review and meta-analysis. Data sOurcesMedline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 26 June 2020, along with preprint servers, social media, and reference lists. stuDy selectiOnCohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19. Data extractiOnAt least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios and proportions with 95% confidence intervals. All analyses will be updated regularly. results 77 studies were included. Overall, 10% (95% confidence interval 7% to14%; 28 studies, 11 432 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever (40%) and cough (39%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to report symptoms of fever (odds ratio 0.43, 95% confidence interval 0.22 to 0.85; I 2 =74%; 5 studies; 80 521 women) and myalgia (0.48, 0.45 to 0.51; I 2 =0%; 3 studies; 80 409 women) and were more likely to need admission to an intensive care unit (1.62, 1.33 to 1.96; I 2 =0%) and invasive ventilation (1.88, 1.36 to 2.60; I 2 =0%; 4 studies, 91 606 women). 73 pregnant women (0.1%, 26 studies, 11 580 women) with confirmed covid-19 died from any cause. Increased maternal age (1.78, 1.25 to 2.55; I 2 =9%; 4 studies; 1058 women), high body mass index (2.38, 1.67 to 3.39; I 2 =0%; 3 studies; 877 women), chronic hypertension (2.0, 1.14 to 3.48; I 2 =0%; 2 studies; 858 women), and pre-existing diabetes (2.51, 1.31 to 4.80; I 2 =12%; 2 studies; 858 women) were associated with severe covid-19 in pregnancy. Pre-existing maternal comorbidity was a risk factor for admission to an intensive care unit (4.21, 1.06 to 16.72; I 2 =0%; 2 studies; 320 women) and invasive ventilation (4.48, 1.40 to 14.37; I 2 =0%; 2 studies; 313 women). Spontaneous preterm birth rate was 6% (95% confidence interval 3% to 9%; I 2 =55%; 10 studies; 870 women) in women with covid-19. The odds of any preterm birth (3.01, 95% confidence interval 1.16 to 7.85; I 2 =1%; 2 studies; 339 women) was high in pregnant women with covid-19 compared with those without the disease. A quarter of all neonates born to mothers with covid-19 were admitted to the neonatal unit (25%) and were at increased risk of admission (odds ratio 3.13, 95% confidence interval 2.05 to 4.78, I 2 =not estimable; 1 st...

Counseling in maternal–fetal medicine: SARS‐CoV‐2 infection in pregnancy

“…Advanced maternal age, increased body mass index, chronic hypertension and pre-existing diabetes were associated with severe course of the disease in pregnancy and the presence of pre-existing maternal comorbidities was a risk factor for admission to the ICU and invasive ventilation. The occurrence of death for any cause in the overall population was 0.8% (339/41 664) 20 . These findings were confirmed by a recent report from the CDC in the USA that included over 23 000 pregnant women and over 386 000 non-pregnant women of reproductive age with symptomatic laboratory-confirmed SARS-CoV-2 infection, which showed a higher risk of admission to the ICU, need for invasive ventilation, need for extracorporeal membrane oxygenation (ECMO) and death in hospitalized pregnant women with COVID-19 21 .…”

“…This system classifies the quality of evidence as one of four levels: high (further research is very unlikely to change our confidence in the estimate of effect); moderate (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate); low (further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate); and very low (any estimate of effect is very uncertain) 71 . ACOG, American reported to be asymptomatic in the large majority of cases, although a few case series reported lower rates of asymptomatic pregnant women 19,20 . The frequency of the presence and type of symptoms related to SARS-CoV-2 infection in pregnancy is difficult to estimate because the large majority of published studies pool together unselected and selected cohorts of women (i.e.…”

“…Cough and fever are present in about 40% of symptomatic pregnant women affected by SARS-CoV-2 infection, while lymphopenia (33%) and elevated C-reactive protein levels (49%) are the most common laboratory findings 20 . When compared to the non-pregnant population, the likelihood of developing fever is lower in pregnancy, which partially explains the relatively high rate of asymptomatic cases reported in some series 20 .…”

“…The large majority of pregnant women acquiring SARS-CoV-2 infection do not develop critical symptoms and the course of the infection is asymptomatic in approximately three-quarters of the obstetric population undergoing universal screening 20 . However, in a recent propensity score matched analysis of 5183 pregnant and 175 905 non-pregnant women with SARS-CoV-2 infection, pregnant women had a higher risk of death (odds ratio (OR), 1.84; 95% CI, 1.26-2.69), pneumonia (OR, 1.86; 95% CI, 1.60-2.16) and ICU admission (OR, 1.86; 95% CI 1.41-2.45) compared with non-pregnant patients, after adjusting for background demographic and medical factors 7 .…”

“…The incidence of preterm birth (PTB) in pregnancies with SARS-CoV-2 infection has been reported to be higher than that in non-infected pregnancies in the majority of the studies published so far, with an incidence ranging between 15% and 20% 6,14,20 . However, the majority of the data were derived from studies including both selectively screened symptomatic patients and a smaller number of universally screened, test-positive, asymptomatic women, and most of the studies do not specify whether the reported PTB incidence includes both iatrogenic and spontaneous cases; thus, the role of SARS-CoV-2 infection in the incidence of PTB may be overestimated 4,6,20 . Indeed, reports from both European and American institutions [25][26][27] showed a decrease in the odds of PTB during the pandemic compared with a similar pre-pandemic period, particularly when focusing on early PTB.…”