Objective
This study aimed to conduct a systematic review of the clinical outcomes reported for pregnant patients with coronavirus disease 2019.
Data Sources
The PubMed, CINAHL, and Scopus databases were searched using a combination of key words such as “Coronavirus and/or pregnancy,” “COVID and/or pregnancy,” “COVID disease and/or pregnancy,” and “COVID pneumonia and/or pregnancy.” There was no restriction of language to allow collection of as many cases as possible.
Study Eligibility Criteria
All studies of pregnant women who received a coronavirus disease 2019 diagnosis using acid nucleic test, with reported data about pregnancy, and, in case of delivery, reported outcomes, were included.
Study Appraisal and Synthesis Methods
All the studies included have been evaluated according to the tool for evaluating the methodological quality of case reports and case series described by Murad et al.
Results
Six studies that involved 51 pregnant women were eligible for the systematic review. At the time of the report, 3 pregnancies were ongoing; of the remaining 48 pregnant women, 46 gave birth by cesarean delivery, and 2 gave birth vaginally; in this study, 1 stillbirth and 1 neonatal death were reported.
Conclusion
Although vertical transmission of severe acute respiratory syndrome coronavirus 2 infection has been excluded thus far and the outcome for mothers and neonates has been generally good, the high rate of preterm delivery by cesarean delivery is a reason for concern. Cesarean delivery was typically an elective surgical intervention, and it is reasonable to question whether cesarean delivery for pregnant patients with coronavirus disease 2019 was warranted. Coronavirus disease 2019 associated with respiratory insufficiency in late pregnancies certainly creates a complex clinical scenario.
Introduction
On March 12, 2020, on the basis of more than 20,000 confirmed cases and almost 1000 deaths in Europe, the World Health Organization announced the new coronavirus outbreak pandemic . At the end of December 2019, a cluster of cases of pneumonia of unknown cause was reported in Wuhan, Hubei Province, China. At the beginning of January 2020, a novel coronavirus, called 2019-nCoV, was identified as the etiologic agent by Chinese authorities. Other coronavirus infections included the common cold (HCoV-229E, NL63, OC43, and HKU1), Middle East respiratory syndrome (MERS-CoV), and severe acute respiratory syndrome (SARS-CoV). A study reviewed the epidemiologic, clinical, laboratory, and radiologic features, as well as treatment and clinical outcomes, of patients with pneumonia caused by laboratory-confirmed coronavirus disease 2019 (COVID-19).
Why was this study conducted?
Coronavirus disease 2019 (COVID-19) is a pandemic and will affect a large number of pregnant patients in the near future. Preliminary experience with pregnant patients with COVID-19 suggests that the clinical outcome of the mother and neonate is often favorable, but it is unclear how and when these patients gave birth. The aim of this study was to conduct a systematic review of the clinical outcomes reported for pregnant patients with COVID-19.
Key findings
The median gestational age was 36.5 weeks (interquartile range, 35–38), with 15 cases of preterm birth (39%); cesarean delivery was reported in 96% of the cases, but the indications were not clearly described.
What does this add to what is known?
Most pregnant patients with COVID-19 thus far have given birth preterm by cesarean delivery; in some cases, cesarean deliveries were elective. Whether cesarean delivery is warranted or not remains to be established.
The presence of COVID-19 in a pregnant patient raises concerns, as other types of coronaviruses were frequently associated with adverse outcomes. Professional organizations have rapidly published preliminary documents providing advice on diagnosis and management of pregnant patients with COVID-19. , However, the scientific literature on the subject is scanty.
Objective
The aim of this study was to collect and review the available information about the impact of COVID-19 on mothers and neonates and to focus on time and mode of delivery. In addition, we conducted a systematic review of the available literature in English and Chinese languages. ,
Materials and methods
Study design
To determine eligible articles, the following electronic databases were screened from March 14, 2020, to March 16, 2020: PubMed, Scopus, and CINAHL. To retrieve articles related with the theme of interest, the following terms were used to search the electronic databases: “coronavirus and/or pregnancy,” “COVID and/or pregnancy,” “COVID disease and/or pregnancy,” and “COVID pneumonia and/or pregnancy.”
Criteria for study selection
Reports included in this review consisted of case series, case reports, and retrospective studies. No randomized controlled trials were found. Only reports describing management of pregnancies complicated by COVID-19 were included in this systematic review. We registered this review on the International Prospective Register of Systematic Reviews. We did not provide contacts with the corresponding authors because of the time constraints and the importance to have immediate results.
Assessment of risk of bias
Two study investigators (A.N.D.G. and R.R.) independently conducted the primary literature research using the main search terms. When the studies not conforming to the preestablished eligibility and inclusion criteria were excluded, the same study investigators (A.N.D.G. and R.R.) independently reviewed the data collection forms in a second screening time. At the third review time, the remaining reports were further analyzed for compatibility. In case of any disagreement between the examiners after independent evaluation, consensus was reached by reevaluation and discussion with a more experienced author (G.S.). The remaining studies were introduced into the final review step of qualitative synthesis.
Data quality assessment
Two independent examiners (A.N.D.G. and R.R.) applied the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for the data extraction and quality assessment. The examiners (A.N.D.G. and R.R.) independently assessed the methodologies of the studies according to the tool for evaluating the methodological quality of case reports and case series described by Murad et al. The tool considers 4 domains (selection, ascertainment, causality, and reporting) and provides 8 questions to aid quality score ( Table 1 ). If all of the domains were satisfied, the study would be classified as “good quality”; if 3 of the domains were satisfied, the study would be classified as “fair quality”; and if only 2 or 1 of the domains were satisfied, the study would be classified as “poor quality.”
| Domains | Leading explanatory questions |
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| Selection |
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| Ascertainment |
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| Causality |
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| Reporting |
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Data extraction and synthesis
A total of 205 articles with publication dates from 1969 to 2020 were found through the PubMed, CINAHL, and Scopus databases. The selection process followed the PRISMA workflow. We excluded 180 articles for the following reasons: animal studies (165), abstract not available (3), contents not related to the topic of our review, or significant information not provided (12). To collect as many cases as possible, no restriction on language (Chinese and English) was applied in the selection of articles. We included only studies in which the diagnosis was based on the criteria provided by the New Coronavirus Pneumonia Prevention and Control Program (4th edition and subsequent editions) published by the National Health Commission of China. After deletion of duplicates, a total number of 12 references were selected; 6 full-text articles were excluded because data were not comparable. We subsequently reviewed the 6 articles describing clinical presentation, pathogenesis, macroscopic and histopathologic aspects, natural history, diagnosis, and treatment. Furthermore, we selected all reported cases with pregnant patients aged ≥20 years and analyzed the following aspects: clinical features, symptoms, associated diseases, fetal characteristics, time of delivery, type of delivery, and follow-up. Two study investigators (A.N.D.G. and R.R.) independently reviewed the data collection forms to verify data accuracy.
Results
A total of 6 studies were eventually selected for analysis ( Figure ; Table 2 ). From a methodological point of view, only 1 study fulfilled all of the domains, 3 studies , , were classified of fair quality, and 2 studies , were judged to be of poor quality because the selection criteria of the cases were unclear. Most articles did not report follow-up of the pregnant women after delivery, and 1 study included 3 ongoing pregnancies. We found a total of 51 cases of pregnancies with COVID-19. In 50 patients, the diagnosis of COVID-19 was confirmed by quantitative reverse transcriptase polymerase chain reaction on samples from the respiratory tract. In 1 patient, diagnosis was based on clinical symptoms and a chest computed tomography scan typical for viral interstitial pneumonia. Because of the exclusion of other diseases that could cause fever and lung infection, the local Center for Disease Control registered her as a confirmed 2019-nCoV case.
