Objective To 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). Design Living systematic review and meta-analysis. Data sources Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 6 October 2020, along with preprint servers, social media, and reference lists. Study selection Cohort 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 extraction At 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 192 studies were included. Overall, 10% (95% confidence interval 7% to 12%; 73 studies, 67 271 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 (41%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to have symptoms (odds ratio 0.28, 95% confidence interval 0.13 to 0.62; I2=42.9%) or report symptoms of fever (0.49, 0.38 to 0.63; I2=40.8%), dyspnoea (0.76, 0.67 to 0.85; I2=4.4%) and myalgia (0.53, 0.36 to 0.78; I2=59.4%). The odds of admission to an intensive care unit (odds ratio 2.13, 1.53 to 2.95; I2=71.2%), invasive ventilation (2.59, 2.28 to 2.94; I2=0%) and need for extra corporeal membrane oxygenation (2.02, 1.22 to 3.34; I2=0%) were higher in pregnant and recently pregnant than non-pregnant reproductive aged women. Overall, 339 pregnant women (0.02%, 59 studies, 41 664 women) with confirmed covid-19 died from any cause. Increased maternal age (odds ratio 1.83, 1.27 to 2.63; I2=43.4%), high body mass index (2.37, 1.83 to 3.07; I2=0%), any pre-existing maternal comorbidity (1.81, 1.49 to 2.20; I2=0%), chronic hypertension (2.0, 1.14 to 3.48; I2=0%), pre-existing diabetes (2.12, 1.62 to 2.78; I2=0%), and pre-eclampsia (4.21, 1.27 to 14.0; I2=0%) were associated with severe covid-19 in pregnancy. In pregnant women with covid-19, increased maternal age, high body mass index, non-white ethnicity, any pre-existing maternal comorbidity including chronic hypertension and diabetes, and pre-eclampsia were associated with serious complications such as admission to an intensive care unit, invasive ventilation and maternal death. Compared to pregnant women without covid-19, those with the disease had increased odds of maternal death (odds ratio 2.85, 1.08 to 7.52; I2=0%), of needing admission to the intensive care unit (18.58, 7.53 to 45.82; I2=0%), and of preterm birth (1.47, 1.14 to 1.91; I2=18.6%). The odds of admission to the neonatal intensive care unit (4.89, 1.87 to 12.81, I2=96.2%) were higher in babies born to mothers with covid-19 versus those without covid-19. Conclusion Pregnant and recently pregnant women with covid-19 attending or admitted to the hospitals for any reason are less likely to manifest symptoms such as fever, dyspnoea, and myalgia, and are more likely to be admitted to the intensive care unit or needing invasive ventilation than non-pregnant women of reproductive age. Pre-existing comorbidities, non-white ethnicity, chronic hypertension, pre-existing diabetes, high maternal age, and high body mass index are risk factors for severe covid-19 in pregnancy. Pregnant women with covid-19 versus without covid-19 are more likely to deliver preterm and could have an increased risk of maternal death and of being admitted to the intensive care unit. Their babies are more likely to be admitted to the neonatal unit. Systematic review registration PROSPERO CRD42020178076. Readers’ note This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 1 of the original article published on 1 September 2020 (BMJ 2020;370:m3320), and previous updates can be found as data supplements (https://www.bmj.com/content/370/bmj.m3320/related#datasupp). When citing this paper please consider adding the update number and date of access for clarity.

https://www.bmj.com/content/bmj/370/bmj.m3320.full.pdf

Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis.

BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) on maternal and newborn health is unclear. We aimed to evaluate the association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and adverse pregnancy outcomes. METHODS: We conducted a systematic review and meta-analysis of observational studies with comparison data on SARS-CoV-2 infection and severity of COVID-19 during pregnancy. We searched for eligible studies in MEDLINE, Embase, ClinicalTrials.gov, medRxiv and Cochrane databases up to Jan. 29, 2021, using Medical Subject Headings terms and keywords for "severe acute respiratory syndrome coronavirus 2 OR SARS-CoV-2 OR coronavirus disease 2019 OR COVID-19" AND "pregnancy." We evaluated the methodologic quality of all included studies using the Newcastle-Ottawa Scale. Our primary outcomes were preeclampsia and preterm birth. Secondary outcomes included stillbirth, gestational diabetes and other pregnancy outcomes. We calculated summary odds ratios (ORs) or weighted mean differences with 95% confidence intervals (CI) using random-effects meta-analysis. RESULTS: We included 42 studies involving 438 548 people who were pregnant. Compared with no SARS-CoV-2 infection in pregnancy, COVID-19 was associated with preeclampsia (OR 1.33, 95% CI 1.03 to 1.73), preterm birth (OR 1.82, 95% CI 1.38 to 2.39) and stillbirth (OR 2.11, 95% CI 1.14 to 3.90). Compared with mild COVID-19, severe COVID-19 was strongly associated with preeclampsia (OR 4.16, 95% CI 1.55 to 11.15), preterm birth (OR 4.29, 95% CI 2.41 to 7.63), gestational diabetes (OR 1.99, 95% CI 1.09 to 3.64) and low birth weight (OR 1.89, 95% CI 1.14 to 3.12). INTERPRETATION: COVID-19 may be associated with increased risks of preeclampsia, preterm birth and other adverse pregnancy outcomes.

/pdf/the-impact-of-covid-19-on-pregnancy-outcomes-a-systematic-421w2f8qje.pdf

The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis.

Diagnosis of UTI: results of an evidence based approach to guideline development carried out for the National Institute for Health and Clinical Excellence (NICE)

Summary Background Previous studies on the pneumonia outbreak caused by the 2019 novel coronavirus disease (COVID-19) were based on information from the general population. Limited data are available for pregnant women with COVID-19 pneumonia. This study aimed to evaluate the clinical characteristics of COVID-19 in pregnancy and the intrauterine vertical transmission potential of COVID-19 infection. Methods Clinical records, laboratory results, and chest CT scans were retrospectively reviewed for nine pregnant women with laboratory-confirmed COVID-19 pneumonia (ie, with maternal throat swab samples that were positive for severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) who were admitted to Zhongnan Hospital of Wuhan University, Wuhan, China, from Jan 20 to Jan 31, 2020. Evidence of intrauterine vertical transmission was assessed by testing for the presence of SARS-CoV-2 in amniotic fluid, cord blood, and neonatal throat swab samples. Breastmilk samples were also collected and tested from patients after the first lactation. Findings All nine patients had a caesarean section in their third trimester. Seven patients presented with a fever. Other symptoms, including cough (in four of nine patients), myalgia (in three), sore throat (in two), and malaise (in two), were also observed. Fetal distress was monitored in two cases. Five of nine patients had lymphopenia ( Interpretation The clinical characteristics of COVID-19 pneumonia in pregnant women were similar to those reported for non-pregnant adult patients who developed COVID-19 pneumonia. Findings from this small group of cases suggest that there is currently no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy. Funding Hubei Science and Technology Plan, Wuhan University Medical Development Plan.

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

Obstetric guidelines have rapidly evolved to incorporate new data and research on the novel coronavirus disease (COVID-19), with data on perinatal mental health building over the last year. Our aim in the present manuscript is to provide a systematic review of mental health outcomes in pregnant and postpartum women during the COVID-19 pandemic in the context of neonatal and obstetric guidelines addressing symptoms and complications of COVID-19 during pregnancy, mother-to-neonate transmission, Cesarean-section delivery, neonatal prematurity, maternal/neonate mortalities, maternal-neonatal separation, and breastfeeding. We summarize data from 81 mental health studies of pregnant and postpartum women and underscore protective and risk factors identified for perinatal mental health outcomes amidst the COVID-19 pandemic. Data reviewed here suggest increased psychological symptoms, especially depressive and anxiety symptoms, in pregnant and postpartum women during COVID-19. Our systematic review integrates the most current obstetric and neonate guidelines, along with perinatal mental health outcomes associated with COVID-19, highlighting the best available data for the care of women and their neonates amidst the current COVID-19 pandemic.

/pdf/one-year-into-the-pandemic-a-systematic-review-of-perinatal-3v8t4x02jw.pdf

One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19

Incidence of jaundice in pregnancy, including underlying chronic liver diseases, is 3–5%. However, the maternal mortality rate in some conditions can be as high as 18% in acute fatty liver of pregnancy and 22% in hepatitis E in pregnancy. This is an observational study of the demographics, obstetrical profile, aetiology, maternal morbidity, mortality and neonatal outcomes in pregnancies complicated with jaundice. This is an observational study conducted in Department of Obstetrics and Gynaecology of a tertiary care hospital, situated amidst the biggest urban slum in Mumbai spanning over 1 year from January 2016 to December 2016. All registered, unregistered and transferred patients with abnormal liver function tests excluding patients with chronic liver diseases were included in this study. Most of the cases of jaundice in pregnancy were seen in primigravida (51%) and age group of 20–30 years (58%). Fifty-three percentage of cases were referred or transferred from periphery hospitals. Hepatitis E was the most common cause (42%) of jaundice in pregnancy. Complications like disseminated intravenous coagulopathy, postpartum haemorrhage, hepatic encephalopathy and hepatoportal hypertension were seen in 65% of cases. Maternal mortality rate and perinatal mortality rate were as high as 40 and 37%, respectively, in our study. Incidence of jaundice in pregnancy, mainly due to viral hepatitis, is very high in lower socio-economic, densely populated urban slums. Special efforts should be made to counsel and educate the mothers about initial symptoms and preventive measures for viral hepatitis. Patients along with the relatives should be informed about the severe features of pre-eclampsia to combat these preventable causes of maternal mortality.

An Observational Study to Evaluate the Maternal and Foetal Outcomes in Pregnancies Complicated with Jaundice.

COVID-19 is an infectious disease caused by a recently discovered coronavirus (SARS-CoV-2). Most of the people infected with the coronavirus will experience mild to moderate respiratory illness and recover without requiring any special treatment. Elderly people and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, any chronic illness and malignancies are more likely to develop serious illness and related complications. Implantation of fertilized ovum at site other than normal uterine cavity is known as an ectopic pregnancy. Ectopic Pregnancy is a life threatening emergency associated with significant mortality. Routinely diagnosis shall start not only with clinical suspicion but also needs to be confirmed with supportive evidences from radiological findings which help in deciding further line of management. Female of reproductive age group who are presenting with complaints of lower abdominal pain or vaginal bleeding with missed period will rise strong suspicion of an ectopic pregnancy. Early diagnosis and prompt management helps in reduction of not only the mortality but also morbidity of condition can be reduced. In current study we have studied impact COVID-19 pandemic on clinical outcome and management of ectopic pregnancy. ABSTRACT

/pdf/study-of-impact-of-covid-19-infection-on-ectopic-pregnancy-4shq28oi3e.pdf

Study of impact of COVID-19 infection on ectopic pregnancy in a tertiary care center

Abnormal uterine bleeding (AUB) is a significant debilitating clinical condition and affects 14-25% of women of reproductive age and up to 50% of perimenopausal women. It may have a significant impact on women’s personal, social, physical and quality of life with significant financial burden to the country’s economy. Acute AUB is defined as bleeding in a nonpregnant woman of reproductive age of sufficient quantity to require immediate intervention to prevent further loss. Chronic AUB is defined as bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for most of the previous 6 months.

/pdf/a-study-of-causes-investigation-and-management-of-structural-333qkkkjbn.pdf

A study of causes, investigation and management of structural causes of abnormal uterine bleeding in reproductive age group

Background: This is an observational analytical study carried out in the department of obstetrics and gynecology, in a tertiary care center to determine the factors influencing fetal and maternal outcome, prognosis and complications in booked and unbooked eclamptic cases. Methods: The present study is a prospective study of perinatal and maternal outcome in 50 cases of eclampsia, above 32 weeks of gestation, from 1 st May 2013 to 30 th April 2014. Patients with medical complications like anemia, preexisting hypertension, diabetes, vascular or renal disease, multiple gestation, polyhydraminos, etc. are excluded from the study. Detailed history, physical examinations were carried out and appropriate management instituted as per individual patient need. Follow-up of mothers up to 6weeks postpartum and neonates in the early neonatal period was done.                 Results: Incidence of eclampsia is 0.64%, incidence of maternal mortality is 0.4% and perinatal mortality is 24%. 36% of patients developed complications. Maternal mortality was significantly high in patients with 6 or more episodes of convulsions. The most common cause of perinatal mortality is prematurity. Antepartum eclampsia with gestational age less than 36 weeks, BP >160/100, preterm births, low birth weight babies, low apgar scores influenced adverse perinatal outcome. Conclusions: Eclampsia still remains a major problem in developing countries. It is one of the important causes of maternal and perinatal morbidity and mortality due to lack of proper ANC, low socio-economic status and lack of education.

/pdf/a-prospective-study-of-the-study-of-maternal-and-perinatal-385dhxj1ll.pdf

A prospective study of the study of maternal and perinatal outcome in cases of eclampsia

Puerperal sepsis is among the leading and preventable causes of maternal morbidity and mortality worldwide and especially in developing countries. We report an interesting case of home delivery complicated with puerperal sepsis, who required obstetric hysterectomy. Inspite of being a resident of an urban metropolitan city patient had no access to antepartum, intrapartum or even postpartum care. She presented on day eleven postpartum to our institute by which time, her condition had progressed to frank pyoperitoneum and severe anaemia. Urgent, aggressive intervention in the form of evacuation of intra-abdominal pus, obstetric hysterectomy with oophorectomy saved her life.

Home delivery complicated with puerperal sepsis in urban India

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