Clinical Presentation and Outcomes of Pregnant Women With Coronavirus Disease 2019: A Systematic Review and Meta-analysis
Reem Matar, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota, USA Search for other works by this author on: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota, USA Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Loyola University Medical Center , Chicago, Illinois, USA Correspondence: L. Alrahmani, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (layan.md@gmail.com). Search for other works by this author on: Department of Medicine, Royal College of Surgeons in Ireland , Dublin, Ireland Search for other works by this author on: Division of Pulmonary and Critical Care, Department of Internal Medicine, Henry Ford , Detroit, Michigan, USA Search for other works by this author on: Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota, USA Search for other works by this author on: Department of Neurological Surgery, Northwestern University , Chicago, Illinois, USA Search for other works by this author on: Department of Microbiology, Beaumont Hospital , Dublin, Ireland Department of Clinical Microbiology, Royal College of Surgeons in Ireland , Dublin, Ireland Search for other works by this author on: Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, Minnesota, USA Search for other works by this author on:
Editorial decision:
13 June 2020
Corrected and typeset:
11 July 2020
Abstract
Background
Descriptions of coronavirus disease 2019 (COVID-19) have focused on the nonpregnant adult population. This study aims to describe the clinical characteristics and perinatal outcomes of COVID-19 in pregnancy.
Methods
We searched databases from December 2019 to 30 April 2020. Eligible studies reported clinical characteristics, radiological findings, and/or laboratory testing of pregnant women during infection. Data were pooled across studies using a random-effects model.
Results
Twenty-four studies (136 women) were included. The most common symptoms were fever (62.9%) and cough (36.8%). Laboratory findings included elevated C-reactive protein (57%) and lymphocytopenia (50%). Ground-glass opacity was the most common radiological finding (81.7%). Preterm birth rate was 37.7% and cesarean delivery rate was 76%. There was 1 maternal death. There were 2 fetal COVID-19 cases.
Conclusions
The clinical picture in pregnant women with COVID-19 did not differ from the nonpregnant population; however, the rate of preterm birth and cesarean delivery are considerably higher than international averages.
In December 2019, a virus of unknown origin was detected in Wuhan, China, and causing a cluster of pneumonia cases [1]. Shortly thereafter, the virus was classified as part of the novel enveloped RNA betacoronavirus family [2] and named the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); its associated disease is called coronavirus disease 2019 (COVID-19). The World Health Organization has recently declared COVID-19 as a pandemic [3]. As of 22 June 2020, >8 million confirmed cases had been documented globally with >400 000 deaths [4].
Many studies have reported the clinical characteristics, laboratory findings, and radiological imaging associated with COVID-19 in both the nonpregnant adult and pediatric populations. Clinical characteristics are quite similar in adults and children; the most common symptoms include fever and cough, usually dry [5–9]. Laboratory findings also appear to be similar, with lymphopenia and elevated C-reactive protein being the most common findings [5–9]. In addition, more than half of adults and children demonstrate ground-glass opacity on computed tomography (CT) of the chest [5–9].
Pregnancy poses a unique situation where the management of an affected patient is influenced by 2 patients: the mother and her fetus. Additionally, the normal pregnancy adaptations of the immune system pregnancy may theoretically cause clinical dilemmas and remains poorly understood. There is an urgent need for certain questions to be addressed: Do pregnant patients have similar clinical presentations, and are they more likely to experience adverse maternofetal or obstetrical outcomes? Understanding the clinical course of COVID-19 in the pregnant population is imperative for health providers to be able to care for the mother and her unborn fetus in a standardized way. This study aims to describe the clinical characteristics, laboratory abnormalities, radiological findings, and outcomes of pregnancy during COVID-19 to aid practitioners in managing these unique patients. To our knowledge, this is the largest systematic review and meta-analysis of its kind in pregnancy.
METHODS
Search Strategy and Data Sources
A comprehensive search of several databases from 1 December 2019 to 30 April 2020 was conducted and limited to English-language publications. The databases included Ovid Medline and Epub Ahead of Print, In-Process and Other Non-Indexed Citations; Ovid Embase; Ovid Cochrane Central Register of Controlled Trials; and Scopus. The search strategy was conducted by a medical reference librarian. Controlled vocabulary supplemented with keywords was used to search for SARS-CoV-2 infection and pregnancy. The search strategy and terms used are available in Supplementary Item 1.
Eligibility Criteria and Quality Assessment
Eligible studies had to meet all of the following inclusion criteria: (1) participants must be women who were pregnant; (2) reverse-transcription polymerase chain reaction (RT-PCR)–confirmed COVID-19 infection through throat or nasal swabs; and (3) report of neonatal outcomes. The quality of each study was independently evaluated by 2 authors (R. M. and N. M.) using the methodological quality and synthesis of case series and case reports described by Murad et al [10]. This article followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Statistical Analysis
Means of continuous variables and rates of binary variables were pooled using the random-effects model, and the generic inverse variance method of DerSimonian and Laird [11]. Proportions underwent logit transformation prior to meta-analysis. The heterogeneity of effect size estimates across the studies was quantified using the Q statistic and the I 2 index (P < .10 was considered significant). A value of I 2 of 0–25% indicates minimal heterogeneity, 26%–50% moderate heterogeneity, and 51%–100% substantial heterogeneity [12]. Data analysis was performed using Open Meta analyst software (CEBM, Brown University, Providence, Rhode Island).
RESULTS
Study Selection and Characteristics
The initial search yielded 1082 potentially relevant articles from which 24 unique studies involving 136 pregnant women met eligibility criteria [13–36]. Details of the study selection process are depicted in Supplementary Item 2. The baseline characteristics of the included studies are described in Table 1. The maternal age ranged from 25 to 34 years, and the gestational age at admission ranged from 30 to 40 weeks.
Table 1.
Baseline Characteristics of Included Studies
| Author, Year | Country | Study Design | No. of Subjects | Mean Age, y | Mean Gestational Age on Admission, wk |
|---|---|---|---|---|---|
| Chen et al, 2020 [13] | China | RC | 9 | 29.89 | 37.11 |
| Chen et al, 2020 [14] | China | RC | 17 | 29.1 | NA |
| Liu et al, 2020 [15] | China | RC | 10 | 29.69 | 33.85 |
| Wang et al, 2020 [16] | China | Case report | 1 | 34 | 40 |
| Wang et al, 2020 [17] | China | Case report | 1 | 28 | 30 |
| Zhu et al, 2020 [18] | China | RC | 9 | 30.89 | NA |
| Liu et al, 2020 [19] | China | Case series | 3 | 32.67 | NA |
| Iqbal et al, 2020 [20] | United States | Case report | 1 | 34 | 39 |
| Chen et al, 2020 [21] | China | RC | 5 | 28.8 | NA |
| Chen et al, 2020 [22] | China | Case series | 4 | 29 | NA |
| Dong et al, 2020 [23] | China | Case report | 1 | 29 | 34 |
| Fan et al, 2020 [24] | China | Case series | 2 | 31.5 | 36.5 |
| Karami et al, 2020a [25] | Iran | Case report | 1 | 27 | 30 |
| Khan et al, 2020 [26] | China | Case series | 3 | 29.33 | 37 |
| Lee et al, 2020 [27] | Republic of Korea | Case report | 1 | 28 | 36 |
| Li et al, 2020 [28] | China | Case-control study | 16 | 30.9 | 35.5 |
| Liu et al, 2020 [29] | China | RC | 11 | 32 | 37 |
| Yu et al, 2020 [30] | China | RC | 7 | 32.14 | 39 |
| Peng et al, 2020 [31] | China | Case report | 1 | 25 | NA |
| Wu et al, 2020 [32] | China | RC | 23 | 29 | 33 |
| Xiong et al, 2020 [33] | China | Case report | 1 | 25 | 33 |
| Yang et al, 2020 [34] | China | PC | 7 | NA | NA |
| Zambrano et al, 2020 [35] | Honduras | Case report | 1 | 41 | 31 |
| Li et al, 2020 [36] | China | Case report | 1 | 30 | 35 |
| Author, Year | Country | Study Design | No. of Subjects | Mean Age, y | Mean Gestational Age on Admission, wk |
|---|---|---|---|---|---|
| Chen et al, 2020 [13] | China | RC | 9 | 29.89 | 37.11 |
| Chen et al, 2020 [14] | China | RC | 17 | 29.1 | NA |
| Liu et al, 2020 [15] | China | RC | 10 | 29.69 | 33.85 |
| Wang et al, 2020 [16] | China | Case report | 1 | 34 | 40 |
| Wang et al, 2020 [17] | China | Case report | 1 | 28 | 30 |
| Zhu et al, 2020 [18] | China | RC | 9 | 30.89 | NA |
| Liu et al, 2020 [19] | China | Case series | 3 | 32.67 | NA |
| Iqbal et al, 2020 [20] | United States | Case report | 1 | 34 | 39 |
| Chen et al, 2020 [21] | China | RC | 5 | 28.8 | NA |
| Chen et al, 2020 [22] | China | Case series | 4 | 29 | NA |
| Dong et al, 2020 [23] | China | Case report | 1 | 29 | 34 |
| Fan et al, 2020 [24] | China | Case series | 2 | 31.5 | 36.5 |
| Karami et al, 2020a [25] | Iran | Case report | 1 | 27 | 30 |
| Khan et al, 2020 [26] | China | Case series | 3 | 29.33 | 37 |
| Lee et al, 2020 [27] | Republic of Korea | Case report | 1 | 28 | 36 |
| Li et al, 2020 [28] | China | Case-control study | 16 | 30.9 | 35.5 |
| Liu et al, 2020 [29] | China | RC | 11 | 32 | 37 |
| Yu et al, 2020 [30] | China | RC | 7 | 32.14 | 39 |
| Peng et al, 2020 [31] | China | Case report | 1 | 25 | NA |
| Wu et al, 2020 [32] | China | RC | 23 | 29 | 33 |
| Xiong et al, 2020 [33] | China | Case report | 1 | 25 | 33 |
| Yang et al, 2020 [34] | China | PC | 7 | NA | NA |
| Zambrano et al, 2020 [35] | Honduras | Case report | 1 | 41 | 31 |
| Li et al, 2020 [36] | China | Case report | 1 | 30 | 35 |
Abbreviations: NA, not available; PC, prospective cohort study; RC, retrospective cohort study.
aStudy retracted.
Table 1.
Baseline Characteristics of Included Studies
| Author, Year | Country | Study Design | No. of Subjects | Mean Age, y | Mean Gestational Age on Admission, wk |
|---|---|---|---|---|---|
| Chen et al, 2020 [13] | China | RC | 9 | 29.89 | 37.11 |
| Chen et al, 2020 [14] | China | RC | 17 | 29.1 | NA |
| Liu et al, 2020 [15] | China | RC | 10 | 29.69 | 33.85 |
| Wang et al, 2020 [16] | China | Case report | 1 | 34 | 40 |
| Wang et al, 2020 [17] | China | Case report | 1 | 28 | 30 |
| Zhu et al, 2020 [18] | China | RC | 9 | 30.89 | NA |
| Liu et al, 2020 [19] | China | Case series | 3 | 32.67 | NA |
| Iqbal et al, 2020 [20] | United States | Case report | 1 | 34 | 39 |
| Chen et al, 2020 [21] | China | RC | 5 | 28.8 | NA |
| Chen et al, 2020 [22] | China | Case series | 4 | 29 | NA |
| Dong et al, 2020 [23] | China | Case report | 1 | 29 | 34 |
| Fan et al, 2020 [24] | China | Case series | 2 | 31.5 | 36.5 |
| Karami et al, 2020a [25] | Iran | Case report | 1 | 27 | 30 |
| Khan et al, 2020 [26] | China | Case series | 3 | 29.33 | 37 |
| Lee et al, 2020 [27] | Republic of Korea | Case report | 1 | 28 | 36 |
| Li et al, 2020 [28] | China | Case-control study | 16 | 30.9 | 35.5 |
| Liu et al, 2020 [29] | China | RC | 11 | 32 | 37 |
| Yu et al, 2020 [30] | China | RC | 7 | 32.14 | 39 |
| Peng et al, 2020 [31] | China | Case report | 1 | 25 | NA |
| Wu et al, 2020 [32] | China | RC | 23 | 29 | 33 |
| Xiong et al, 2020 [33] | China | Case report | 1 | 25 | 33 |
| Yang et al, 2020 [34] | China | PC | 7 | NA | NA |
| Zambrano et al, 2020 [35] | Honduras | Case report | 1 | 41 | 31 |
| Li et al, 2020 [36] | China | Case report | 1 | 30 | 35 |
| Author, Year | Country | Study Design | No. of Subjects | Mean Age, y | Mean Gestational Age on Admission, wk |
|---|---|---|---|---|---|
| Chen et al, 2020 [13] | China | RC | 9 | 29.89 | 37.11 |
| Chen et al, 2020 [14] | China | RC | 17 | 29.1 | NA |
| Liu et al, 2020 [15] | China | RC | 10 | 29.69 | 33.85 |
| Wang et al, 2020 [16] | China | Case report | 1 | 34 | 40 |
| Wang et al, 2020 [17] | China | Case report | 1 | 28 | 30 |
| Zhu et al, 2020 [18] | China | RC | 9 | 30.89 | NA |
| Liu et al, 2020 [19] | China | Case series | 3 | 32.67 | NA |
| Iqbal et al, 2020 [20] | United States | Case report | 1 | 34 | 39 |
| Chen et al, 2020 [21] | China | RC | 5 | 28.8 | NA |
| Chen et al, 2020 [22] | China | Case series | 4 | 29 | NA |
| Dong et al, 2020 [23] | China | Case report | 1 | 29 | 34 |
| Fan et al, 2020 [24] | China | Case series | 2 | 31.5 | 36.5 |
| Karami et al, 2020a [25] | Iran | Case report | 1 | 27 | 30 |
| Khan et al, 2020 [26] | China | Case series | 3 | 29.33 | 37 |
| Lee et al, 2020 [27] | Republic of Korea | Case report | 1 | 28 | 36 |
| Li et al, 2020 [28] | China | Case-control study | 16 | 30.9 | 35.5 |
| Liu et al, 2020 [29] | China | RC | 11 | 32 | 37 |
| Yu et al, 2020 [30] | China | RC | 7 | 32.14 | 39 |
| Peng et al, 2020 [31] | China | Case report | 1 | 25 | NA |
| Wu et al, 2020 [32] | China | RC | 23 | 29 | 33 |
| Xiong et al, 2020 [33] | China | Case report | 1 | 25 | 33 |
| Yang et al, 2020 [34] | China | PC | 7 | NA | NA |
| Zambrano et al, 2020 [35] | Honduras | Case report | 1 | 41 | 31 |
| Li et al, 2020 [36] | China | Case report | 1 | 30 | 35 |
Abbreviations: NA, not available; PC, prospective cohort study; RC, retrospective cohort study.
aStudy retracted.
Risk of Bias
Results of the quality assessment of all included studies are shown in Table 2. All of the case series were judged to have good 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.
Methodological Quality Assessment Tool Results
| Author, Year | Question 1 | Question 2 | Question 3 | Question 4 | Question 5 |
|---|---|---|---|---|---|
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Wang et al, 2020 | Yes | Yes | Yes | No | No |
| Wang et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Zhu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Iqbal et al, 2020 | Yes | Yes | Yes | Yes | No |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Dong et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Fan et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Karami et al, 2020a | Yes | Yes | Yes | Yes | Yes |
| Khan et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Lee et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Li et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | No | No |
| Yu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Peng et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Wu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Xiong et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Yang et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Zambrano et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Li et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Author, Year | Question 1 | Question 2 | Question 3 | Question 4 | Question 5 |
|---|---|---|---|---|---|
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Wang et al, 2020 | Yes | Yes | Yes | No | No |
| Wang et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Zhu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Iqbal et al, 2020 | Yes | Yes | Yes | Yes | No |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Dong et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Fan et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Karami et al, 2020a | Yes | Yes | Yes | Yes | Yes |
| Khan et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Lee et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Li et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | No | No |
| Yu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Peng et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Wu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Xiong et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Yang et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Zambrano et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Li et al, 2020 | Yes | Yes | Yes | Yes | Yes |
Question 1: Does the patient(s) represent(s) the whole experience of the investigator (center)?
Question 2: Was the exposure adequately ascertained?
Question 3: Was the outcome adequately ascertained?
Question 4: Was follow-up long enough for outcomes to occur?
Question 5: Is the case(s) described with sufficient detail to allow other investigators to replicate the research or to allow practitioners make inferences related to their own practice?
aStudy retracted.
Table 2.
Methodological Quality Assessment Tool Results
| Author, Year | Question 1 | Question 2 | Question 3 | Question 4 | Question 5 |
|---|---|---|---|---|---|
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Chen et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Liu et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Wang et al, 2020 | Yes | Yes | Yes | No | No |
| Wang et al, 2020 | Yes | Yes | Yes | Yes | Yes |
| Zhu et al, 2020 |
Subscribe to:
Post Comments (Atom)
Christmas Tree Png : Download Christmas Fir-Tree Png Image HQ PNG Image ... / In the large christmas tree png gallery, all of the files can be used for commercial purpose.Christmas Tree Png : Download Christmas Fir-Tree Png Image HQ PNG Image ... / In the large christmas tree png gallery, all of the files can ... 
|
No comments:
Post a Comment