key: cord-0753784-7tuxa0n3 authors: Hasnain, Muhammad; Pasha, Muhammad Fermi; Ghani, Imran; Budiarto, Rahmat title: Protection Challenges of Pregnant Women against Vertical Transmission during COVID-19 Epidemic: A Narrative Review date: 2020-07-01 journal: Am J Infect Control DOI: 10.1016/j.ajic.2020.06.206 sha: 2a9aae473388e937644348607f8a0ab0d738a08d doc_id: 753784 cord_uid: 7tuxa0n3 This paper presents a narrative review study of five popular data repositories focusing on challenges of pregnant women protection during the COVID-19 pandemic. The study concludes that the likelihood of a vertical transmission of COVID-19 infection from pregnant women to neonates was not observed. Nevertheless, it remains a serious risk for them during their earlier stage of pregnancy, thus, special attention from health professionals has been recommended. Vulnerable populations require intensive care during the outbreak of communicable diseases. Extensive measures are undertaken to ensure that the vulnerable population gets the appropriate protection and treatment. Pregnant women are a crucial part of the vulnerable population. Frontline pregnant staff working for the protection of patients with COVID-19 perform their jobs with adverse fatal effects [1] . Pregnant women thus become easily exposed to respiratory diseases that are associated with increased infection morbidity. Human coronavirus infections are known to remain mild, as opposed to the "Middle East Coronavirus" (MERS-CoV) and "Severe Acute Respiratory Syndrome" (SARS) coronavirus, which occurred in the past two decades, and were grave [2] . The latter mentioned infections resulted in the deaths of one third of the population of women infected with these infections. An outbreak of SARS-CoV-2 in the near past has been declared a pandemic and it is predicted to be at its peak in USA, Europe and many other developing countries around the end of April, or in first two weeks of May 2020. With its speedy transmission across the globe, we want to see how pregnant women are protected against the COVID-19 pandemic. During the outbreak of infectious disease, pregnant women have an adverse influence on their cardiovascular system. As a result, rapid progression occurs due to respiratory failure in gravida. Moreover, T-helper 2 system leaves pregnant women vulnerable to viral infections [13] . These challenges mandate the integrated strategies to women pregnancies, which are affected by COVID-19 disease. Pregnant women have heightened fear regarding the safety of their unborn fetus [14] . The outbreak of COVID-19 has profoundly challenged the health system and clinicians" practices, which go in maternity units. Without appropriate guidelines and practical approaches, communication with obstetricians regarding their practices has rapidly emerged, and clinicians require guidelines in the challenges time [15] . Besides, sometimes care providers are pregnant themselves, and they have added a level of concern regarding their health and their unborn babies. Therefore, the UK Royal College of Obstetricians and Gynecologists (RCOG) has recommended that a health worker with more than 28 weeks pregnancy avoid the direct contact with COVID-19 patients [16] . In this paper, we present the narrative review of published works on various themes related with challenges when it comes to the protection of pregnant women. We study deeper into how pregnant women are safe during the acute COVID-19 pandemic around the world. As of now, there is no specific country-wise real-world data of pregnant women with COVID-19 infection. However, some published works present the cases of pregnant women for specific cases in a few countries. A narrative review of emerging literature on pregnant women with COVID-19 infections and challenges to their protection is conducted on 15 April 2020. The search strategy used in this paper is based on key terms such as "pregnant women" or "protection" AND "Coronavirus 2019", or "COVID-19" with the English language. Search key terms were applied to Science Direct, PubMed, Web of Science, Ovid Medline and Springer data repositories. The search strategy of studies was completed independently by each of the authors. As a result of the searches, 550 articles were yielded. The inclusion criteria for this study consisted of the emerging literature on pregnant women with COVID-19 infection, which was published between 1 st December 2019 and 15 April 2020. The exclusion criteria of studies involved any study which discussed challenges of pregnant women without the COVID-19 infection. All those studies which were focused on pregnant women and their challenges, without any discussion on COVID-19, were excluded. Additionally, the articles which were written in languages other than English were also excluded. Since we had no facility to translate the articles in German and French languages to the English language and therefore, we excluded them. Research studies published before the dates, as mentioned earlier, were excluded. After examining the titles and abstracts, if abstracts were not available, those articles were not counted [17] . We performed screening of the articles by checking the abstracts and removed any duplicate articles. As a result of the screening of articles, 18 articles remained. Following this, we performed the full-text analysis of the remaining 18 articles, as result of which, we removed six articles that did not meet the inclusion criteria. Studies [10] [11] were impact on newborns was collected. The quality of the selected papers was evaluated by colleague author (MFP). We could not conduct the meta-analysis because of the short timeframe for this narrative review, and the fact that the number of chosen studies was only a few. This section aims to present results and discussion as follows: , [8] , [10] , [11] , [12] According to extracted information in Table 1 , studies [4] [5] [6] [7] [8] [9] [10] [11] [12] attempt to highlight the pregnant women"s protection challenges during the COVID-19 pandemic. From these studies, we have identified four features alongside their disadvantages due to lack of facilities, consequences, and preferred solutions presented in the focused studies. Moreover, we state the countries which are used for COVID-19 information regarding pregnant women protection challenges. As shown in Table 1 , most studies were undertaken in the context of data collected from mainland China. However, the study [6] includes the COVID-19 information from three countries, such as Italy, USA, and Mexico. Moreover, the study [4] is based on the data of COVID-19 infection from Singapore. In the following, we present a detailed discussion of the studies regarding the identified four features. Healthcare of women is critical during times of crisis. Pregnant women require more attention in comparison with other women. During pandemics, resources funnel away from the reproductive health system to the urgent focused targets which are pressing the world. However, it is known that pregnant women, in search of safety, rely more on the accessible health system for a successful childbirth [4] . The consequences of delayed access to a health system for them are stillbirths, preterm deliveries, maternal mortality and respiratory complications. Regardless of these consequences, Ashokka et al. [4] state that vertical transmission of COVID-19 from pregnant women with infections to a fetus remained unlikely in several cases in Singapore. However, in emergency times, the cesarean method is suggested, as mentioned in many studies. It is also suggested to avoid the complications produced by the maternal and fetal conditions related with the COVID-19 pandemic. A recent study has shown that the SARS-COV2 virus is not detected in the breast milk, amniotic fluid and cord blood in women who have been infected with SARS-COV2. It was also indicated that all neonates were free from infection. During the "severe acute respiratory syndrome coronavirus" (SARS) epidemic, the virus disease remained lower in neonates as compared to adults. This might be due to the difficulty of the vertical transmission of the virus. The same study has also revealed that COVID-19 not only adversely affects lungs, but it also weakens the functioning of kidneys and testicles. So at this stage of research on COVID-19, it cannot be ruled out that COVID-19 may have an impact on the placenta. Therefore, for the safety of pregnant women and neonates, the elective Cesarean delivery is the best option in this crisis time of the COVID-19 pandemic. However, cesarean delivery time is crucial for both physicians and medical staff, because a COVID-19 infection can quickly deteriorate the functioning of the lungs. So, pregnant women and neonates, along with the physicians and nurses, must meet safety measures in operation theatre rooms. Apart from this, biosafety measures need to be followed by medical staff when they enter or leave the operation theatre rooms [5] . These safety measures are discussed with regards to a study performed with respect to Chinese populations with the help of Wuhan University China. This study is a preliminary effort by researchers regarding the safety of women and neonates, and similar measures must be necessarily taken in other countries, which are at great risk of COVID-19 at this present time. Italy is the second highest country after USA with mortalities occurring due to the current COVID-19 pandemic. To date (12 April, 2020) a total of 19468 deaths have occurred in Italy. They still have 100269 active cases. This data has been collected from Worldometers. Italy has profoundly adapted to its health reproductive system during the crisis time. Although, COVID-19 is a real challenge to health care systems, recommendations have been proposed to provide safer healthy measures to pregnant women in Italy. They have strongly recommended the cancellation of transfers of frozen or fresh embryos. It has been remarked by them that "We fear the worst is yet to come" [6] . This statement is not only mirroring the situation prevailing in Mexico but also in many other countries of the world, where no measures have been taken to prevent the outbreak of COVID-19. No substantive measures are currently underway to break the power of the COVID-19 pandemic. The non-availability of reproductive medicine in Italy is a challenging risk. Therefore, we need to educate ourselves and suggest more measures to ensure the availability of medicine, which is one of the essential requirements of a reproductive system. Pregnant women, neonates, and adults with cardiovascular and hypertension disease are known to be more susceptible to the COVID-19 infection. Therefore, they require additional care in the intensive care units. Naicker et al. [7] in a recently published research have stated that 7184 patients with hemodialysis (HD) were treated in Renmin Hospital, Wuhan. This research further reveal that 7 patients on HD died due to cardiovascular disease and no direct link with the COVID-19 infection was found among the dead patients. However, intensive HD conditions in patients pose challenges for patients with the COVID-19 infection. Patients at this phase show a significant increase in the transmission of infections. Medical staff, family members and facility workers also become at a higher risk from these transmitted infections. The research by Liu et al. [8] has an evidence of our claim that there is no vertical transmission of coronavirus in pregnant women. In addition, it has also been revealed that preterm deliveries have occurred. It is challenging for the researchers to know whether preterm deliveries occur due to Recent works have suggested that pregnant women do not show any vertical transmission of the COVID-19 infection. We find that majority of the reviewed studies have recommended that pregnant women must be given special attention at the earlier stages of their pregnancy. The immune system of pregnant women keeps stabilizing the balance of hormones from earlier stages to the trimester stage of pregnancy. This review study also finds that the non-availability of health systems due to the COVID-19 pandemic creates more complications for pregnant women, especially those who seek treatment in intensive care units (ICUs). This narrative review was presented by the combined efforts of the above-listed authors. The first author (MH) prepared the initial draft of the article, and colleague author (MFP) proofread it and finalize the manuscript for review, (IG) as the second colleague author fixed the typos and grammatical errors, and formatted the paper according to the style of the Journal, while (RB) as the third colleague author addressed the reviewer comments and finalized the manuscript. 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