MedPage Today 02.09.2020
Pregnant patients with COVID-19 were more likely to require intensive care, yet less likely to show symptoms, according to a “living systematic review.”
Compared to non-pregnant women, pregnant women with COVID-19 were 60% more likely to require admission to the intensive care unit (OR 1.62, 95% CI 1.33-1.96) and had nearly double the risk of invasive ventilation (OR 1.88, 95% CI 1.36-2.60), according to John Allotey, PhD, of the University of Birmingham in England, and colleagues.
COVID-19 patients who were pregnant were also less likely to report symptoms of fever (OR 0.43, 95% CI 0.22-0.85) and myalgia (OR 0.48, 95% CI 0.45-0.51), researchers wrote in The BMJ.
Pregnant patients with both confirmed and suspected COVID-19 also had a higher risk of delivering preterm, and infants born to these mothers were more likely to be admitted to the neonatal intensive care unit.
Allotey and colleagues stated that “healthcare professionals should be aware that pregnant and recently pregnant women with COVID-19 might manifest fewer symptoms than the general population,” adding that those with pre-existing conditions, obesity or older maternal age were at the greatest risk.
“Clinicians will need to balance the need for regular multidisciplinary antenatal care to manage women with pre-existing comorbidities against unnecessary exposure to the virus, through virtual clinic appointments when possible,” the authors added.
Asked for her perspective, Kjersti Aagaard, MD, PhD, a maternal-fetal medicine specialist and professor at the Baylor College of Medicine in Houston, said that a living systematic review — meaning it will be updated regularly — is necessary to make clinical decisions about caring for this at-risk population based on the latest evidence.
However, Aagaard, who was not involved in this research, suggested a cautious interpretation of the findings that estimate risk, specifically the finding that pregnant women are less likely to show symptoms.
“The reason why that data would appear that way is because one of the early surveillance cohorts that most of us engaged with were pregnant women,” Aagaard told MedPage Today.
“Stating that pregnant women are more likely than non-pregnant women to present without symptoms may largely be a byproduct of the fact that there’s a very large denominator,” because most hospitals implemented widespread surveillance testing upon admission to labor and delivery, she said.
Aagaard also urged caution when interpreting data around mortality rates.
Pregnant women have endured worse outcomes than the general population in past respiratory viral outbreaks, she noted, and are considered an at-risk population for COVID-19.
Allotey’s group examined the existing literature with updates planned monthly. For the initial iteration, they searched publications from December 2019 to June 2020 in the Medline, Embase, Cochrane database, the World Health Organization, China National Knowledge Infrastructure, and Wanfang databases, as well as preprint servers and blogs. Studies with duplicated data were excluded.
After identifying more than 20,000 candidate studies, Allotey’s group chose 77 for the final analysis, the majority of which were comparative. Of the included studies, 34% were from the U.S. and 31% were from China.
Overall, about 10% of pregnant or recently pregnant women admitted to the hospital were diagnosed with COVID-19. Among symptomatic cases, the most common manifestations were fever (40%) and cough (39%).
Older maternal age, higher BMI, chronic hypertension, and pre-existing diabetes were all identified as risk factors for severe COVID-19 illness.
In those with COVID-19, rates of spontaneous and overall preterm birth were 6% and 17%, respectively. About a quarter of all neonates born to mothers with COVID-19 were admitted to the neonatal intensive care unit.
Of more than 11,000 pregnant women with COVID-19 in 26 studies, 73 died.
Allotey and colleagues recognized several limitations of their research. Firstly, the studies included in this review used various testing methods to identify women with COVID-19, consisted of women with both suspected and confirmed infection, and primarily reported on those who required a hospital visit, all which limit generalizability. In addition, criteria for cesarean section, admission to the neonatal unit, and causes of preterm birth were not recorded, such that the effects of medical treatment verus COVID-19 illness itself could not be distinguished.
Aagaard emphasized the importance of a comprehensive evaluation of data regarding pregnant people with COVID-19, considering their increased risk. However, she added that a push to enroll more pregnant women in clinical trials is needed around SARS-CoV-2 infection and COVID-19.
“They are disproportionately affected and they are underrepresented,” Aagaard said. “We’ve got to change that. It is a disservice to the women we pledge to care for.