key: cord-321315-bzmokdzk authors: Tanacan, Atakan; Erol, Seyit Ahmet; Turgay, Batuhan; Anuk, Ali Taner; Secen, Elcin Islek; Yegin, Gulin Feykan; Ozyer, Sebnem; Kirca, Fisun; Dinc, Bedia; Unlu, Serpil; Yapar Eyi, Elif Gul; Keskin, Huseyin Levent; Sahin, Dilek; Surel, Aziz Ahmet; Tekin, Ozlem Moraloglu title: The Rate of SARS-CoV-2 Positivity in Asymptomatic Pregnant Women Admitted to Hospital for Delivery: Experience of A Pandemic Center in Turkey date: 2020-07-30 journal: Eur J Obstet Gynecol Reprod Biol DOI: 10.1016/j.ejogrb.2020.07.051 sha: doc_id: 321315 cord_uid: bzmokdzk OBJECTIVE: To investigate the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity in asymptomatic pregnant women admitted to hospital for delivery in a Turkish pandemic center. STUDY DESIGN: This prospective cohort study was conducted in Ankara City Hospital between April, 15, 2020 and June, 5, 2020. A total of 206 asymptomatic pregnant women (103 low-risk pregnant women without any defined risk factor and 103 high-risk pregnant women) were screened for SARS-CoV-2 positivity upon admission to hospital for delivery. Detection of SARS-CoV2 in nasopharyngeal samples was performed by Real Time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) method targeting RdRp (RNA dependent RNA polymerase) gene. Two groups were compared in terms of demographic features, clinical characteristics and SARS-CoV-2 positivity. RESULTS: Three of the 206 pregnant women participating in the study had positive RT-PCR tests (1.4%) and all positive cases were in the high-risk pregnancy group. Although, one case in the high-risk pregnancy group had developed symptoms highly suspicious for COVID-19, two repeated RT-PCR tests were negative. SARS-CoV-2 RT-PCR positivity rate was significantly higher in the high-risk pregnancy group (2.9% vs 0%, p = 0.04). CONCLUSION: Healthcare professionals should be cautious in the labor and delivery of high-risk pregnant women during the pandemic period and universal testing for COVID-19 may be considered in selected populations. Coronavirus disease 2019 (COVID-19) has radically influenced the world in a short period of time. Beyond the mortality and morbidity it caused, it left deep marks on social life and lifestyle (1) . As no efficent treatment nor vaccine is available at present, the most important management option is the prevention of disease transmission. For this reason governments have taken precautions like lockdown, social distancing, compulsory use of personal protective equipments and comprehensive regulations in healthcare policies (2) . Moreover, health authorities all over the world have prepared guidelines and management protocols to control the disease (3) . On the other hand, no consensus has been reached on the optimal COVID-19 screening policy, procedure specific precautions for healthcare workers and treatment modalities for infected patients. Obstetricians and midwifes are especially at high risk for COVID-19 transmission due to the nature of their specialities. Management of delivery necessitates close contact with pregnant women and exposure to various potential infectious particles. For this reason, delivery of COVID-19 positive patients should be performed in special isolated negative pressure rooms by appropriately equipped healthcare professionals (3) (4) (5) (6) . Furthermore, infected patients may be asymptomatic on admission to the hospital and they may easily transmit disease during delivery (4) (5) (6) . Up to 13.5% of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity rate was reported in asymtomatic pregnant women (7, 8) . For this reason, obstetricians should be extremely cautious during the pandemic period. Turkish Ministry of Health has pursued an effective and rational policy since the beginning of the pandemic. The pandemic process was successfully managed in line with the J o u r n a l P r e -p r o o f recommendations of the established scientific committee and the spread of the disease was brought under control in a short period of time (9) . However, no information is available on the rate of SARS-CoV-2 positivity for asymptomatic pregnant women in Turkey. Furthermore, to the best of our knowledge, none of the studies in the current literature has investigated the positivity rate in asymptomatic high-risk pregnancies. Thus, we believe studies on this issue are valuable to establish more comprehensive management protocols for pregnant women in our country. Additionally, the results of these studies will make a significant contribution to the current literature. The aim of this study is to investigate the rate of SARS-CoV-2 positivity in asymptomatic pregnant women admitted to hospital for delivery in a Turkish pandemic center. This prospective cohort study was conducted in Ankara City Hospital between April, 15, 2020 and June, 5, 2020. A total of 206 asymptomatic pregnant women (103 low-risk pregnant women without any defined risk factor and 103 high-risk pregnant women) were screened for SARS-CoV-2 positivity upon admission to hospital for delivery. Informed consent was obtained from all participants and study protocol was approved by institutional ethics committee (E1-20-586). Maternal age, gravidity, parity, number of previous miscarriages, body mass index (BMI) (kg/m2), gestational age at birth, birth weight, 1st-5th minute Apgar scores, route of delivery (spontaneous vaginal deliver yor cesarean section) and SARS-CoV-2 positivity rates were compared between the healthy and high-risk pregnant women. Thereafter, clinical characteristics of patients with SARS-CoV-2 were evaluated in detail. Statistical analyses were performed using the Statistical Package for the Social Sciences Mann-Whitney U test was conducted to compare the median values and the chi-square test was used to compare categorical variables among the groups. A two-tailed P value < 0.05 was regarded as statistically significant. and all positive cases were in the high-risk pregnancy group. Although, one case in the highrisk pregnancy group had developed symptoms highly suspicious for COVID-19, two repeated RT-PCR tests were negative. The distribution of risk factors among the high-risk pregnancy group was shown in Table 1 . Preterm delivery, hypertensive disorders of pregnancy, diabetes mellitus and fetal growth restriction were the leading defined risk factors in the high-risk pregnancy group. Comparision of high-risk and low-risk pregnancy groups in terms of demographic features and clinical characteristics was shown in Table 2 . Significantly lower BMI, gestational age at birth, birth weight, 1 st -5 th Apgar score values and significantly higher cesarean section rates were found in the high-risk pregnancy group (p values were 0.02 for BMI and <0.001 for the J o u r n a l P r e -p r o o f remaining). Moreover, SARS-CoV-2 RT-PCR positivity rate was significantly higher in the highrisk pregnancy group (2.9% vs 0%, p=0.04). Defined risk factors in the 3 SARS-CoV-2 RT-PCR cases were maternal Chiari malformation, preterm delivery and preeclampsia, respectively. First case was a 24 year old primigravid woman with Chiari malformation. Her BMI was 38.36 kg/m 2 and a 4010 g boy was delivered by cesarean section under general anesthesia at 38 weeks of gestation. Computerized tomography (CT) revealed bilateral ground-glass specific opacities in her lungs. However, her clinic was mild and no medication was necessitated. Two repeated RT-PCR tests with 24 hours apart were negative and she was discharged from hospital in 2 days. Second case was a 24 year old multiparous woman with a history of preterm delivery. She was admitted to hospital with preterm premature rupture of the membranes and preterm labor. Due to the history of previous cesarean operations and persistance of contractions, a 1630 g boy was delivered by cesarean section under regional anesthesia at 31 weeks of gestation. Her clinic was mild and there was no finding in her CT. She was discharged from hospital after 2 days without any medication. Third case was a 19 year old primiparous women with asthma. She lost one of her twins in the first trimester and followed up at perinatology clinic during her pregnancy. Her BMI was 35.75 kg/m 2 . A 3410 g girl was delivered by cesarean section at 37 th weeks of gestation due to mild preeclampsia under regional anesthesia. Again, her clinic was mild, no finding was present in CT and no medication was administered. She was discharged from hospital after two consecutive negative RT-PCR tests. All cases with SARS-CoV-2 positivity were followed up regularly during the antenatal period at the perinatology clinic of our institution. The case with suspicious clinic but negative RT-PCR test was a 31 year old primigravid woman with fetal growth restriction and maternal thrombocytopenia. She was referred to our clinic from another hospital and she had a history for irregular antenatal follow up. She was diagnosed as Immune thrombocytopenic purpura (ITP). Preterm labor occurred during her hospitalization and a 1800 g boy was delivered by cesarean section under general anesthesia after necessary transfusions. She became symptomatic after delivery. A fever of 37.7 °C was measured and she felt difficulty in breathing. Chest CT revealed bilateral groundglass opacities and septal thickening. According to the recommendations of the infectious diseases, hydroxychloroquine (2X400 mg p.o at first day and 2X200 mg/day p.o for 5 days) and azithromycin (500 mg p.o at first day and 250 mg/day p.o for 5 days) were administered immediately. However, two repeated RT-PCR tests were negative and the diagnosis of COVID-19 was excluded. The neonates of the mentioned 4 cases were tested for SARS-CoV-2 and all of them were found to be negative. Furthermore, all of the healthcare staff who took part in the labor and delivery of these 4 patients were evaluated by special filiation teams for COVID-19. Fortunately, none of them were found to be positivie for SARS-CoV-2. Healthcare professionals have been fighting with devotion in the frontline since the beginning of the COVID-19 pandemic. For this reason, they are at great risk for disease transmission. This risk may reach much higher levels especially in branches like obstetrics (3) (4) (5) (6) . In order to protect physicians, nurses and midwifes from infection during delivery, many organisations all over the world have prepared guidelines, flowcharts and management protocols (3) (4) (5) (6) . Appropritate screening for patients at risk for COVID-19, strict use of personal protective equipment and delivery of suspected / positive cases in isolated negative J o u r n a l P r e -p r o o f pressure rooms seem to be the key points in prevention (3) (4) (5) (6) . However, there are rising concerns of the physicians about the management of asymptomatic patients without any defined risk factors for COVID-19 transmission. It has been known that asymptomatic patients with SARS-CoV-2 positivity can easily transmit disease to other people (7, 8) . Thus, researchers are trying to answer two questions: '' Should we approach each patient as COVID-19 positive or should we screen every pregnant patient admitted to the hospital?''. The strenghts of this study were prospective design, large number of cases and comparison of high-risk pregnancy group with low-risk pregnancy group. However, lack of long term follow up was the limitation. In conclusion, healthcare professionals should be cautious in the labor and delivery of highrisk pregnant women during the pandemic period and universal testing for COVID-19 may be considered in selected populations. No funding was used for this study. The authors state that they have no conflict of interest in this study. J o u r n a l P r e -p r o o f Environmental perspective of COVID-19. The Science of the total environment Modeling the effects of intervention strategies on COVID-19 transmission dynamics SARS-CoV-2 in Pregnancy: A Comprehensive Summary of Current Guidelines General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic Care of the Pregnant Woman with COVID-19 in Labor and Delivery: Anesthesia, Emergency cesarean delivery, Differential diagnosis in the acutely ill parturient, Care of the newborn, and Protection of the healthcare personnel Coronavirus in pregnancy and delivery: rapid review. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology Universal screening for SARS-CoV-2 in women admitted for delivery The Relationship between Status at Presentation and Outcomes among Pregnant Women with COVID-19 Turkish Ministry of Health, General Directorate of Public Health, COVİD-19 (SARS-CoV-2 infection) Guideline, Scientific Committee Report A systematic scoping review of COVID-19 during pregnancy and childbirth. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics Effects of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcomes: a systematic review Coronavirus disease 2019 in pregnant women: a report based on 116 cases COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of SARS-CoV-2 in pregnancy: symptomatic pregnant women are only the tip of the iceberg Clinical infectious diseases : an official publication of the Infectious Diseases Society of America Covid-19 during pregnancy: a case series from an universally tested population from the north of Portugal None.