key: cord-0987138-ksog5oj0 authors: Rodrigues, C.; Baia, I.; Domingues, R.; Barros, H. title: Pregnancy and breastfeeding during COVID-19 pandemic: A systematic review of published pregnancy cases date: 2020-04-29 journal: nan DOI: 10.1101/2020.04.25.20079509 sha: 3c6064a5527ae67861090d6d2c6b074cb37382b2 doc_id: 987138 cord_uid: ksog5oj0 Background: The COVID-19 pandemic is an emerging concern regarding the potential adverse effects during pregnancy. This study reviews knowledge on the impact of COVID-19 on pregnancy and describes the outcome of published cases of pregnant women diagnosed with COVID-19, as well as the characteristics of COVID-19 positive women who delivered in Portugal by 31 of March 2020. Methods: Searches were conducted in PubMed up to 8 April 2020, using PRISMA standards, to identify original published studies describing pregnant women at any gestational age diagnosed COVID-19. There were no date or language restrictions on the search. All identified studies were included irrespective of assumptions on study quality. Portuguese cases were ascertained by contact with all Portuguese maternities and based on the information provided by their health professionals. Results: We identified 30 original studies reporting 212 cases of pregnant women with COVID-19 (30 discharged while pregnant), 200 from China and 12 from other countries. The 182 published deliveries resulted in one stillbirth and 185 live births. Four women with severe COVID-19 required admission to an intensive care unit but no cases of maternal death were reported. There was one neonatal death. Preterm births occurred in 28.7% of cases, but it is unclear whether this was iatrogenic. All cases with amniotic fluid, placenta, and/or cord blood analyzed for the SARS-CoV-2 virus were negative. Four newborns were positive for SARS-CoV-2 and three newborns had high levels of IgM antibodies. None of the first eight infants born in Portugal tested positive. Breast milk samples from 13 mothers and described in seven studies showed no evidence of SARS-CoV-2. Conclusion: The evidence related to the effect of COVID-19 on pregnant women is still limited. Pregnant women and newborns should be considered particularly vulnerable populations regarding COVID-19 prevention and management strategies. with the potential risk of SARS-COV-2 vertical transmission (from mother to fetus) or 106 associated malformations, and contagion during delivery and breastfeeding; likewise, it 107 is important to determine the potential adverse effects of COVID-19 in pregnant women. 5-108 8 However, in general, the available information remains scarce. 109 This study reviews published cases of pregnant women diagnosed with COVID-19 and CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. intrauterine and/or neonatal samples collected for detection of SARS-CoV-2 (such as 139 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020 April 29, . . https://doi.org/10.1101 April 29, /2020 doi: medRxiv preprint 8 amniotic fluid, cord blood, placenta, breast milk, nasopharyngeal and anal swabs) and 140 their results (negative/positive). All identified original studies reporting cases of pregnant women at any gestational age 142 diagnosed with COVID-19 were included irrespective of study quality. Cases reported in 143 more than one study, and for which it was possible to identify duplicates, were described 144 only once, presenting the more detailed data. We identified duplicates based on author 145 names and hospital location, publication date, participant admission date, maternal and 146 neonatal characteristics and outcomes. Doubts on possible duplicates and/or differences in the data extraction were discussed 148 and resolved by consensus, involving a third researcher (CR) whenever necessary. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. All cases in which amniotic fluid, placenta, and/or cord blood were analyzed for SARS-174 CoV-2 virus were negative. 5, 11, 13, 15, 18-26 175 Most studies detected the SARS-CoV-2 RNA by real-time reverse transcription- There is yet another case of a newborn with a positive RT-PCR for SARS COV-2 in one 186 throat swab collected at 36 hours after birth. 21, 24 However, it was not possible to confirm 187 whether it was a real case of intrauterine transmission since the umbilical cord and 188 placenta blood samples were negative for SARS-CoV-2 and the possibility of postnatal 189 contact could not be discarded. 21, 24 No other study reported positive results for the CoV-2 virus in nasopharyngeal exudates from newborns of mothers diagnosed with 191 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10. 1101 /2020 None of the first eight infants born in Portugal tested positive 192 for the SARS-CoV-2 virus (Table 2) . In a series of six cases that had blood collected after delivery evaluated, two of the CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . Cesarean section was the most common type of delivery: 88.0% of 158 cases with 216 available information. This was also observed in Portuguese cases in which 6 (75%) were 217 born by cesarean. Most studies did not specify the indication for the cesarean section. There is no evidence that the risk of infection with COVID-19 in pregnant women is 237 greater than in the general population. 7, 37 However, the incidence of infection in pregnant 238 women is unknown, as screening tests were not generally used, except in the presence of 239 symptoms. In a New York's hospital that implemented universal SARS-CoV-2 testing in 240 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020 CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020 the pregnancy itself. 7, 55, 56 It is therefore extremely important that pregnant women adopt The limited scientific knowledge currently available makes it difficult to develop specific 304 breastfeeding recommendations. There is not enough scientific evidence to unequivocally 305 state that there is no possibility that mothers with COVID-19 can transmit the virus 306 through breast milk. 55 Therefore, recommendations should be based on the available data 307 5, 15, 16, [20] [21] [22] 28 and the analogy with past circumstances and predictable costs and benefits. Breastfeeding is recognized as the best form of child feeding due to the countless benefits 309 for both the mother and the newborn, including the protection against gastrointestinal and 310 respiratory infections. 60 Thus, considering the benefits of breastfeeding and the fact that CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10. 1101 /2020 States, 55 women with suspected or confirmed infection with COVID-19 can initiate or 315 continue breastfeeding as long as clinical conditions permit. The CDC indicates that the 316 decision to initiate or continue breastfeeding must be determined by the mother with 317 COVID-19, together with family members and health professionals. 55 Limitations of this systematic review should be acknowledged. Considerable 319 heterogeneity was observed across the studies, which did not allow us to conduct a meta-320 analysis. On the other hand, we cannot guarantee that we were able to identify all the in intensive care were uncommon. Although the complications appear to be similar to 338 those of non-pregnant women, services must be prepared to attend to complications, 339 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020 16 especially in pregnant women with comorbidities. Therefore, pregnant women and 340 newborns should be considered particularly vulnerable populations regarding COVID-19 341 prevention and management strategies. Information, counseling and adequate monitoring 342 are essential to prevent major adverse effects of SARS-CoV-2 infection during 343 pregnancy. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020 Age, years (min-max) SARS-CoV-2 infection confirmed by oral swabs 4/185 (2.2) 367 Carina Rodrigues and Henrique Barros: Conceptualization, Original draft preparation. 368 Inês Baía and Rosa Domingues: Methodology, Data curation, and 369 Editing. All authors read and approved the final manuscript. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted April 29, 2020. Am J Roentgenol 2020:1-6. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. From an Infected Mother to Her Newborn. Jama 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. Lancet Infect Dis 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . https://doi.org/10. 1101/2020.04.25.20079509 doi: medRxiv preprint 551 552 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted April 29, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)The copyright holder for this preprint this version posted April 29, 2020 . . https://doi.org/10.1101 /2020