key: cord-0843754-wq6wqr6f
authors: Sahin, Dilek; Tanacan, Atakan; Erol, Seyit A.; Anuk, Ali T.; Eyi, Elif G.Y.; Ozgu‐ Erdinc, A. Seval; Yucel, Aykan; Keskin, Huseyin L.; Tayman, Cüneyt; Unlu, Serpil; Kirca, Fisun; Dinc, Bedia; San, Ishak; Parpucu, Ü. Murat; Surel, Aziz A.; Moraloglu, Ozlem T.
title: A pandemic center’s experience of managing pregnant women with COVID‐19 infection in Turkey: A prospective cohort study
date: 2020-08-06
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13318
sha: 17a8c7c98b5cc9a57c033f193dd9b41511d9c86f
doc_id: 843754
cord_uid: wq6wqr6f

OBJECTIVE: To evaluate the course and effect of coronavirus disease 2019 (COVID‐19) on pregnant women followed up in a Turkish institution. METHODS: A prospective, single tertiary pandemic center cohort study was conducted on pregnant women with confirmed or suspected severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. Positive diagnosis was made on a real‐time polymerase chain reaction (RT‐PCR) assay of a nasopharyngeal and oropharyngeal specimen. Demographic features, clinical characteristics, and maternal and perinatal outcomes were evaluated. RESULTS: SARS‐CoV‐2 was suspected in 100 pregnant women. Of them, 29 had the diagnosis confirmed by RT‐PCR. Eight of the remaining 71 cases had clinical findings highly suspicious for COVID‐19. Ten (34.5%) of the confirmed cases had co‐morbidities. Cough (58.6%) and myalgia (51.7%) were the leading symptoms. COVID‐19 therapy was given to 10 (34.5%) patients. There were no admissions to the intensive care unit. Pregnancy complications were present in 7 (24.1%) patients. Half of the births (5/10) were cesarean deliveries. None of the neonates were positive for SARS‐CoV‐2. Samples of breastmilk were also negative for the virus. Three neonates were admitted to the neonatal intensive care unit. CONCLUSION: The clinical course of COVID 19 during pregnancy appears to be mild in the present study.

Coronavirus disease 2019 (COVID-19) is a global health problem threatening billions of lives all over the world. It is caused by a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and unfortunately, no effective treatment is available at the time of publication. 1, 2 Healthcare systems have been deeply affected by this pandemic and there continue to be unanswered questions in the minds of clinicians regarding the impact of COVID-19 on groups of high-risk patients. Pregnancy is a unique health condition characterized by prominent physiological changes in the bodies of women and it has been long known that infections may cause severe complications during the pregnancy period. [3] [4] [5] However, there are conflicting reports in the literature about the course and effect of COVID-19 in pregnant women. 1, 2, 6, 7 Although the prognosis in pregnant women has been generally found to be similar to non-pregnant individuals of the same age, studies have emphasized an increased risk for certain obstetric complications such as preterm delivery and fetal compromise. 1, 2, 6, 7 Additionally, there are concerns about the possibility of vertical transmission. 7 Nonetheless, knowledge is still limited on these issues and more data are urgently needed to establish more effective management protocols for pregnant women. For this reason, the experiences of tertiary referral centers are invaluable.

The aim of the present study was to evaluate the clinical course and effect of COVID-19 on pregnant women at a Turkish institution.

The present prospective cohort study was conducted on pregnant women with confirmed or suspected SARS-CoV-2 infection who were admitted to the Ministry of Health Ankara City Hospital between March 11, 2020, and June 11, 2020. All consecutive pregnancies screened for SARS-CoV-2 infection during the study period were included in the study. Written informed consent for participation in the study was obtained from all the patients and the study was conducted in accordance with the Declaration of Helsinki. 8 Pregnant women diagnosed with other respiratory tract pathogens were excluded from the study. The information of all patients, including demographic data, clinical characteristics, laboratory parameters, and outcomes, were collected prospectively. The study protocol was approved by the Turkish Ministry of Health and the institutional ethics committee (E1-20-602).

Demographic features, clinical characteristics, and obstetric outcomes of pregnant women with suspected or confirmed SARS-CoV-2 infection were retrospectively evaluated from the hospital records.

The diagnosis of SARS-CoV-2 infection was made by a positive result on a real-time polymerase chain reaction (RT-PCR) assay of a nasopharyngeal and oropharyngeal specimen. 9 Patients with significant clinical features (for example, body temperature ≥38°C, oxygen saturation ≤93% and/or respiratory rate ≥20/min, lymphocyte count ≤1000/ mm 3 , and a confirmed case in the household) and/or suspicious radiologic findings for COVID-19 (for example, ground-glass opacification, mixed consolidation, pleural thickening, interlobular septal thickening, air bronchograms) but with negative RT-PCR for SARS-CoV-2 were regarded as highly suspicious for COVID-19 in the present study.

These cases were evaluated as a separate group.

The following were recorded: maternal age, gravidity, parity, number of living children, number of previous miscarriages, pre-pregnancy body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters), route of admission to hospital, comorbid diseases, gestational age and pregnancy trimester at diagnosis of COVID-19, initial symptoms, history of close contact with a confirmed or suspected case, abnormal vital signs on admission to hospital, pregnancy-specific medications, therapy for COVID-19, use of low molecular weight heparin, presence of an additional pathogen, disease severity, rate of respiratory support, rate of admission to the intensive care unit (ICU), length of hospital stay, initial laboratory test results, radiologic imaging findings, blood group, pregnancy complications, mode of delivery, and obstetric and neonatal outcomes.

Severity of disease was assessed according to current guidelines. 10, 11 Furthermore, treatment protocols were determined in accordance with the national COVID-19 guidelines. 10 The RT-PCR test for SARS-CoV-2 was performed on nasopharyn- 

Ankara City Hospital is a new tertiary referral center in the capital of Table 1 . Ten cases (34.5%) had clinical co-morbidities: obesity was the leading condition (50%) followed by hypothyroidism (40%). Fifteen cases (51.7%) were diagnosed in the third trimester. Cough and myalgia were the leading initial symptoms (58.6% and 51.7%, respectively).

Twenty-three cases (79.3%) had close contact with a confirmed or suspected case before admission. Fever, tachypnea, and tachycardia were the most common abnormal vital signs during admission (27.6%, 24.1%, and 27.6%, respectively). Tocolytic agents were not administered to any of the positive cases and antenatal corticosteroids for fetal lung maturity were used in only 1 (3.4%) case. Therapy for COVID-19 was given in 10 (34.5%) patients and hydroxychloroquine was the most common medication (34.5%). Low molecular weight heparin was administered in 9 (31%) cases. Adenovirus was found as an additional pathogen in 1 (3.4%) case. Twenty-five cases (86.2%) had mild COVID-19. Respiratory support was needed in 4 (13.8%) cases and all of these patients received nasal oxygen therapy. None of the cases were admitted to ICU. The mean length of hospital stay was 6 days.

Initial laboratory test results of cases positive for SARS-CoV-2 with RT-PCR are shown in Table 2 . Neutrophilia (>7700/mm 3 or >70% of leukocytes) and lymphocytopenia (<1000/mm 3 or <8% of leukocytes) were found in 5 (17.2%) cases. A Rhesus positive was the most common blood group (48.3%). It has been reported that there was a higher risk for COVID-19 infection with blood group A compared with non-A blood groups. 12, 13 Obstetric and neonatal outcomes of cases positive for SARS-CoV-2 with RT-PCR are shown in Table 3 . Pregnancy complications were observed in 7 (24.1%) patients. The only fetal abnormality detected in the present study was a skeletal dysplasia. Ten patients (34.5%) delivered during the study period and half were delivered by cesarean section. Regional anesthesia was the most common method of anesthesia for cesarean delivery (80% A summary of 8 (11.2%) cases with high clinical suspicion for COVID-19 but negative RT-PCR for SARS-CoV-2 is shown in Table 4 .

Computed tomography (CT) was consistent with COVID-19 in 7

(87.5%) cases. Three patients (37.5%) were in the postnatal period.

Co-morbid diseases were observed in 3 (37.5%) cases and obstetric complications were present in 6 (75%) patients. COVID-19 therapy was administered to 7 (87.5%) patients. Two patients (25%) were still T A B L E 4 (Continued) (Continues) pregnant in this group during the study period and the rate of cesarean delivery was 50% in the remaining cases.

The findings of the present study indicate that the course of COVID-19

during pregnancy was favorable in the study population. On the other hand, relatively high rates of pregnancy complications were observed.

The Turkish Ministry of Health has been effectively fighting SARS-CoV-2 since the early days of the pandemic. Establishment of a competent scientific committee, identification of suspected cases by well-organized filiation teams, hospitalization of all cases of COVID-19, administration of medications in the early stages of the disease, and specific intensive care protocols resulted in better patient outcomes than in many other countries. 10, 15 The course of COVID-19 during pregnancy has been investigated in various studies. 2, 6, 7, [16] [17] [18] Although the course of the disease was found to be similar to non-pregnant women in most publications, severe complications such as prolonged ventilator support, need for extracorporeal membrane oxygenation, cardiovascular events, and multi-organ failure were also reported. 2, 6, 7, [16] [17] [18] Fortunately, no maternal death or serious morbidity was observed in the present study. No cases were admitted to the ICU and only nasal oxygen therapy was necessitated in a small number of patients.

It has been reported that individuals with co-morbid diseases are more susceptible to 20 Approximately one-third of confirmed cases in the present study had co-morbid diseases consistent with the literature. 19 ,20 Therefore, we can conclude that physicians should be cautious in the management of pregnancies complicated by maternal disease.

Fever, cough, myalgia, and dyspnea were the most common symptoms of COVID-19 described in the literature and this is consistent with the results of the present study. 21

The majority of the women in the present study were in the third trimester of pregnancy and approximately one-third of them delivered during the study period. The current literature indicated increased rates of cesarean section and a preference for regional anesthesia.

Furthermore, the decision for delivery due to maternal health conditions and increased rates of fetal distress were discussed in other publications. 11, 17, 22, 23 Half of the cases in the present study were delivered via cesarean section, mostly under regional anesthesia. These findings were consistent with the literature. Some publications claimed that blood group A was associated with a higher risk of acquiring COVID-19 and blood group O was associated with a lower risk of infection. 30, 31 Although it was also found that blood group A was more common in positive cases, there was no case with an AB group unlike in the previous studies.

There are increasing concerns about vertical transmission of COVID-19 and possible infection of the newborn during breastfeeding. 32 Values are given as number (percentage), mean ± standard deviation (range), or median (interquartile range, range).

Sahin ET aL.

Although it is controversial, when there was high clinical suspicion of COVID-19, the evaluation of a patient by chest CT played a key role in the management of the cases in the study cohort. Timely management of suspected cases provides optimal control of the disease and prevention of serious disease-related complications.

The strengths of the present study were the relatively high number of study parameters and the inclusion of clinically suspected cases. On the other hand, the lack of information relating to the final obstetric and neonatal outcomes of patients who had not delivered by the end of the study period was the main limitation.

In conclusion, the clinical course of COVID-19 during pregnancy appears to be mild in the present study. RT-PCR positivity as well as clinical findings should be considered in the management of COVID-19 during pregnancy. The hospitalization of all pregnant women with confirmed and suspected COVID-19 infection, the provision of an individualized approach, the appropriate use of medications, and the management of cases within the framework of a multidisciplinary team seem to be associated with favorable outcomes.

All the authors had substantial contributions to the concept and design, the execution of the work, or the analysis and interpretation of data, drafting or revising the manuscript, and have read and 

The authors have no conflicts of interest.

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