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Abstract

Initial reports at the onset of the COVID‐19 pandemic indicated that the obstetric population did not appear to be at higher risk of developing severe symptoms of COVID‐19 than the general population.[1] However, following recent publications showing that pregnancy and the postpartum period might indeed pose additional risks for both women and babies, these preliminary observations urgently require review.[2] Explanations for heightened risk may include relative immunodeficiency associated with maternal physiological adaptations, as well as organic response to virus infections.
Int J Gynecol Obstet 2020; 1–3 wileyonlinelibrary.com/journal/ijgo  
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 1
© 2020 Internaonal Federaon of
Gynecology and Obstetrics
Received:26June2020 
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  Accepted:3July2020
DOI: 10.1002/ijgo.13300
BRIEF COMMUNICATION
Obstetrics
The tragedy of COVID‐19 in Brazil: 124 maternal deaths and
counng
Maira L. S. Takemoto1| Mariane de O. Menezes1,* | Carla B. Andreucci2|
Marcos Nakamura‐Pereira3| Melania M.R. Amorim4| Leila Katz4|
Roxana Knobel5
1MedicalSchoolofBotucatu,UniversidadeEstadualPaulistaJúliodeMesquitaFilho(UNESP),Botucatu,SP,Brazil
2DepartmentofMedicine,UniversidadeFederaldeSãoCarlos(UFSCAR),SãoCarlos,SP,Brazil
3FundaçãoOswaldoCruz(FIOCRUZ),InstutoNacionaldeSaúdedaMulher,daCriançaedoAdolescenteFernandesFigueira,RiodeJaneiro,RJ,Brazil
4InstutodeMedicinaIntegralProf.FernandoFigueira(IMIP),ProgramadePós‐graduaçãoemSaúdeMaternoInfanl,Recife,PE,Brazil
5DepartmentofGynecologyandObstetrics,UniversidadeFederaldeSantaCatarina(UFSC),Florianópolis,SC,Brazil
*Correspondence
MarianedeO.Menezes,MedicalSchoolofBotucatu,UniversidadeEstadualPaulistaJúliodeMesquitaFilho(UNESP),Address:Av.Prof.Montenegro,s/n–
Botucatu,SP,18618‐687,Brazil.
Email:mariane.menezes@unesp.br
KEYWORDS: COVID‐19;Healthservicesaccessibility;Healthstatusindicators;Maternaldeath;Maternalmortality;SARS‐CoV‐2
1 | INTRODUCTION
InialreportsattheonsetoftheCOVID‐19pandemicindicatedthat
theobstetricpopulaondidnotappearto beathigherrisk ofdevel‐
oping severesymptoms of COVID‐19 than the general populaon.1
However,followingrecent publicaons showing thatpregnancyand
the postpartum period might indeed pose addional risks for both
women and babies, these preliminary observaonsurgently require
review.2Explanaonsforheightened riskmayinclude relaveimmu‐
nodeciency associated with maternal physiologicaladaptaons, as
wellasorganicresponsetovirusinfecons.
Thepresentstudyaimstodescribeoutcomesforpregnantandpost
partumwomenwithCOVID‐19diseasefromtherstdocumentedcase
inBrazil on February26, 2020unlJune 18,2020using the Brazilian
Ministry of Health’s Acute Respiratory Distress Syndrome (ARDS)
Surveillance System.According to Brazilian ethics regulatory require
ments, literature search and secondary analysis of publicly available
anonymized data do not require ethical approval by an Instuonal
Review Board.
ARDScausedbyCOVID‐19wasdiagnosedin978pregnantand
postpartumwomeninBrazilduringthestudyperiod.Brazilcurrently
has no universal tesng policy forthe obstetric populaon. Since
onlywomenpresenngwithseveresymptomsaretested,it iscer
tain that the numberof COVID‐19 infecons in this populaon is
underreported.Thepresentstudyfound124deathsofpregnantor
postpartumwomen(Table1),agurewhichis3.4meshigherthan
the total number of COVID‐19‐related maternal deaths reported
throughouttherestoftheworldattheme ofwring.3–7 The cur
rent mortality rate is 12.7% in the Brazilian obstetricpopulaon,
whichis alsohigherthan ratesreported sofarin theliterature.3,4,7
Notably, the mortality rate was higher for cases idened in the
postpartumperiodthanduringpregnancy,likelyreecngtheonset
mingofCOVID‐19symptoms.
Brazil’s elevated COVID‐19 mortality rate in pregnantwomen
and women in the postpartum period might have several expla
naons. In Brazil,obstetric care is beset by chronic problems that
can aect maternal and perinatal outcomes, such as poor quality
antenatal care, insucient resources to manage emergency and
cricalcare,racialdispariesinaccessmaternityservices,obstetric
violence,andthe pandemic poses addional barriers for access to
healthcare.Addionally,therateofcesareanseconsisamongthe
highestin the world andquesonsremain regardingtheincreased
risk of postoperave morbidity and mortality for paents with
COVID‐19undergoingsurgery.8
Our findings identified diabetes, cardiovascular disease, and
obesity as significant conditions associatedwith mortality in the
obstetricpopulation,similartothegeneralpopulation(Table1).Of
the 978 positive cases, 207 (21.2%) were admitted to ICU (134
recoveredcases and 73 fatal cases) It is noteworthy that 22.6%
ofthe women who died were not admitted to the ICU,and only
2 
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   TakemoTo eT aL.
TABLE 1 CharacteriscsofBrazilianCOVID‐19obstetriccasesaccordingtotheoutcome(recoveryordeath)(n=978).
Recovery Death p‐valueb
n % n %
Total 854 87.3 124 12.7
Age—mean(SD) 29.5(6.9) 31.5(7.5)
Timinginrelaontobirth(atnocaondate)
Pregnancy 680 90.2 74 9.8 <0.001
Postpartum 174 77.7 50 22.3
Race
White 212 90.2 23 9.8 0.116
Non‐white 440 86.1 71 13.9
Missing/Unknown 202 87.1 30 12.9
Region
North 116 84.7 21 15.3 0.032
Northeast 245 83.9 47 16.1
Midwest 32 97.0 1 3.0
Southeast 426 88.6 55 11.4
South 35 100.0 0 0.0
Prevalenceofselectedcomorbidies
Cardiovasculardisease
Yes 41 6.7 13 16.3 0.002
No 573 93.3 67 83.7
Missing/Unknown(%)a  28.1 35.5
Diabetes(gestaonalorprevious)
Yes 67 20.8 22 33.8 0.023
No 255 79.2 43 66.2
Missing/Unknown(%)a62.3 47.6
Obesity
Yes 31 10.3 13 21.3 0.016
No 270 89.7 48 78.7
Missing/Unknown(%)a  64.8 50.8
Asthma
Yes 18 5.9 59.3 0.360
No 285 94.1 49 90.7
Missing/Unknown(%)a64.5 56.5
Frequencyofsupporvecare
ICUadmission
Yes 134 17.5 73 72.3 <0.001
No 630 82.5 28 27.7
Missing/Unknown(%)a10.5 18.5
Respiratorysupport
Invasive 32 4.4 66 64.0 <0.001
Non‐invasive 197 27.1 22 21.4
None 497 68.5 15 14.6
Missing/Unknowna15.0 16.9
aMissing/unknownpercentagesreferstothenumberofcaseswithmissingvaluesorcodedasunknownamongthetotalnumberofcasesineachrow(854
cureand124deathcases).
bChi‐squaretest.
    
|
 3
TakemoTo eT aL.
64.0%hadinvasiveventilation.Noventilatorysupportwasoffered
to 14.6% of all fatal cases, while the remaining 21,4% received
non‐invasive ventilation only. Failure to adequately report these
variables in the surveillance system cannot be ruled out due to
its retrospective nature.The data seem to reflect that obstetric
patientsmayfacebarrierstoaccessventilatorsandintensivecare.
ThisisnotanovelissuewithintheBrazilianhealthcaresystemand
itisaggravatedbytheCOVID‐19pandemic;shortageofhealthcare
providersand lack ofintensive care resources arewell‐described
chronic challenges in Brazilian maternity services.9 A similar
observation was described in Mexico: of seven reported mater
nal deaths, only twowere admitted to an ICU and one received
mechanicalventilation.5Sofar,thenumberofmaternaldeathsdue
to COVID‐19 represents almost 10% of overall annual maternal
deathsinBrazil.Contingency actions focusedonmaternalhealth
areurgentlyneededto improvebothantenatalcare andaccessto
intensivecareforpregnantandpostpartumwomen.
AUTHOR CONTRIBUTIONS
MLST,MOM,CBA,MNP,MMRA,LK,andRKequallycontributedto
studyconceponanddesign,datacollecon,analysis,andinterpreta‐
on.MLST,MOM,RK,andCBAwrotetherstdraofthepaper.All
authorsreviewedandapprovedthenalmanuscript.
ACKNOWLEDGMENTS
Theauthorswould like to thank all membersoftheBrazilian Group
forStudiesofCOVID‐19andPregnancyfortheireortsinsupporng
thiswork.
CONFLICTS OF INTEREST
Theauthorshavenoconictsofinterest.
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... Among patients with information, those infected during pregnancy, the median time between hospital admission and delivery was two days (IQR, 0-5). The median time between the onset of symptoms and delivery in the entire sample was seven days (IQR, [2][3][4][5][6][7][8][9][10][11][12], and between the onset of symptoms and death was 14 days (IQR, [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] (Figure 2). Death in 99¢7% (344/345) of cases occurred during the puerperium, with a median of seven days (IQR, 1-15) between delivery and death. ...
... The reported diabetes rate (gestational or previous) in Brazil was almost three times the rate we found (12%). 22 While Mexico and Iran were the closest to our figure with 11¢3% and 14¢3%, respectively, India reported the lowest rate, with 5¢9%. 21,23,24 The asthma rate in our study (6¢7%) was close to what was reported in Brazil (9¢3%) but significantly higher than what was reported in the Mexican study (2¢6%). ...
... 21,23,24 The asthma rate in our study (6¢7%) was close to what was reported in Brazil (9¢3%) but significantly higher than what was reported in the Mexican study (2¢6%). 22,23 Finally, chronic hypertension was 2¢9% in the Indian study. While the Mexican study reported 7¢7% similarly to our finding (8¢4%). ...
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Full-text available
Background This study aimed to describe the clinical characteristics of maternal deaths associated with COVID-19 registered in a collaborative Latin-American multi-country database. Methods This was an observational study implemented from March 1st 2020 to November 29th 2021 in eight Latin American countries. Information was based on the Perinatal Information System from the Latin American Center for Perinatology, Women and Reproductive Health. We summarized categorical variables as frequencies and percentages and continuous variables into median with interquartile ranges. Findings We identified a total of 447 deaths. The median maternal age was 31 years. 86·4% of women were infected antepartum, with most of the cases (60·3%) detected in the third trimester of pregnancy. The most frequent symptoms at first consultation and admission were dyspnea (73·0%), fever (69·0%), and cough (59·0%). Organ dysfunction was reported in 90·4% of women during admission. A total of 64·8% women were admitted to critical care for a median length of eight days. In most cases, the death occurred during the puerperium, with a median of seven days between delivery and death. Preterm delivery was the most common perinatal complication (76·9%) and 59·9% were low birth weight. Interpretation This study describes the characteristics of maternal deaths in a comprehensive multi-country database in Latin America during the COVID-19 pandemic. Barriers faced by Latin American pregnant women to access intensive care services when required were also revealed. Decision-makers should strengthen severity awareness, and referral strategies to avoid potential delays. Funding Latin American Center for Perinatology, Women and Reproductive Health.
... Это связано с изменениями в иммунной системе во время беременности, активацией системы комплемента и провоспалительных цитокинов, таких как IL-6 и TNF-α, состоянием физиологической гиперкоагуляции [5,6]. Беременные в 6 раз чаще нуждались в госпитализации, в т. ч. в отделения реанимации и интенсивной терапии (ОРИТ), и им чаще требовалось проведение искусственной вентиляции легких (ИВЛ) [7,8]. На второй волне пандемии доля беременных женщин и родильниц, поступивших в ОРИТ с COVID-19, значительно увеличилась, это позволяет предположить, что вариант B.1.1.7 (альфа) оказал повышенное пагубное влияние на беременных женщин по сравнению с первой волной [7,8]. ...
... Беременные в 6 раз чаще нуждались в госпитализации, в т. ч. в отделения реанимации и интенсивной терапии (ОРИТ), и им чаще требовалось проведение искусственной вентиляции легких (ИВЛ) [7,8]. На второй волне пандемии доля беременных женщин и родильниц, поступивших в ОРИТ с COVID-19, значительно увеличилась, это позволяет предположить, что вариант B.1.1.7 (альфа) оказал повышенное пагубное влияние на беременных женщин по сравнению с первой волной [7,8]. Появление дельта-штамма SARS-CoV-2 сопровождалось в три раза большим увеличением критических состояний у беременных и родильниц и значительным ростом неблагоприятных перинатальных исходов и материнской смертности [9,10]. ...
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Introduction. Pregnant women may be at increased risk for severe COVID-19 illness. Pregnant women are more likely to be hospitalized at ICU, needed the mechanical ventilation compared to nonpregnant women of childbearing age. Building on the experience of the effective use of the exogenous surfactant for influenza A/H1N1 treatment of pregnant women with COVID-19, the surfactant therapy has also been included in the treatment. The objective. To evaluate the effectiveness of surfactant therapy in the integrated treatment of severe COVID-19 pneumonia of pregnant women and postpartum women. Materials and methods. The study included 135 pregnant and postpartum women with severe COVID-19 pneumonia. All of them received antiviral, anticoagulant, anticytokine and anti-inflammatory therapy. 68 patients (main group) with an initially more severe course of the disease and a greater degree of lung damage (p = 0.026) received inhalations with Surfactant-BL, 67 patients (control group) did not receive the surfactant therapy. Patients received Surfactant-BL through a mesh-nebulizer at a dose of 75 mg 2 times a day for 3–5 days. Result . Patients of the main group showed decreasing risks of requiring the noninvasive ventilation (27.9% vs. 52.2%, р = 0.014) and artificial lung ventilation (2.9% vs. 11.9%, p = 0.047), the length of stay in the intensive care unit (ICU) was reduced (10.6 vs. 13.1 inpatient days, р = 0.045). Сomplications such as pneumomediastinum and pneumothorax occurred less frequently in the surfactant therapy group (24.2% vs. 52.4%, p = 0.037) with a high extent of lung damage (CT-3–4). With early surfactant therapy in the standard oxygen therapy stage or high-flow oxygenation, gas exchange indicators were restored faster, thus avoiding mechanical ventilation and has reduced the duration of intensive care (р = 0.004) and prevented deaths. Conclusion . The use of surfactant therapy for pneumonia associated with COVID-19 in pregnant and postpartum women against the background of ongoing complex therapy helps to prevent further lung damage, reduce the mechanical ventilation risk and improve oxygenation earlier, especially with early start of surfactant therapy.
... On April 26, this recommendation was expanded to include all pregnant women [16]. Although the exact figures for pregnant women are unclear, we anticipated that enough pregnant women would have been vaccinated to make it possible to evaluate vaccine effectiveness in pregnant women: Brazil combines a sufficient vaccine coverage (more than 50% of the population with two doses) [17], more than 21 million cases and 600,000 deaths (October 2021) [18], and a considerable number of maternal deaths [19,20]. ...
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Background More doses of CoronaVac have been administered worldwide than any other COVID-19 vaccine. However, the effectiveness of COVID-19 inactivated vaccines in pregnant women is still unknown. We estimated the vaccine effectiveness (VE) of CoronaVac against symptomatic and severe COVID-19 in pregnant women in Brazil. Methods We conducted a test-negative design study in all pregnant women aged 18–49 years with COVID-19-related symptoms in Brazil from March 15, 2021, to October 03, 2021, linking records of negative and positive SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) tests to national vaccination records. We also linked records of test-positive cases with notifications of severe, hospitalised or fatal COVID-19. Using logistic regression, we estimated the adjusted odds ratio and VE against symptomatic COVID-19 and against severe COVID-19 by comparing vaccine status in test-negative subjects to test-positive symptomatic cases and severe cases. Results Of the 19,838 tested pregnant women, 7424 (37.4%) tested positive for COVID-19 and 588 (7.9%) had severe disease. Only 83% of pregnant women who received the first dose of CoronaVac completed the vaccination scheme. A single dose of the CoronaVac vaccine was not effective at preventing symptomatic COVID-19. The effectiveness of two doses of CoronaVac was 41% (95% CI 27.1–52.2) against symptomatic COVID-19 and 85% (95% CI 59.5–94.8) against severe COVID-19. Conclusions A complete regimen of CoronaVac in pregnant women was effective in preventing symptomatic COVID-19 and highly effective against severe illness in a setting that combined high disease burden and marked COVID-19-related maternal deaths.
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Resumo: A pandemia de covid-19 acentuou os conflitos e dilemas decorrentes das desigualdades de gênero. O Objetivo de Desenvolvimento Sustentável (ODS 5) busca "al-cançar a igualdade de gênero e empoderar todas as mulheres e meninas" e, no atual con-texto brasileiro, tal análise deve abarcar os desafios pré e pós-pandemia. Nesse sentido, o objetivo deste ensaio é promover reflexões acerca desses desafios, abrangendo a violência contra a mulher, a precarização do trabalho e renda, a invisibilização das mulheres pretas na sociedade, o incremento dos riscos para a população feminina encarcerada e a inserção da desigualdade de gênero na pandemia: ODS 5 no cenário pós-covid-19.
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The far‐reaching, negative effects of the COVID‐19 pandemic have impacted healthcare, economic, public safety, and social systems globally. The public safety measures put in place in the United States during the COVID‐19 pandemic, including sheltering in places orders and shutdowns of schools and places of work, negatively impacted the employment status and increased time spent in domestic work and childcare for women. In this paper, we review and analyze the impacts, both direct and indirect, of COVID‐related policies on the lives of women. Specifically, we outline how the progression of policies aimed at addressing both public safety and economic recovery during the COVID‐19 pandemic affected women's health, paid and unpaid work, and wellbeing. We will focus on the impacts of policies implemented in the United States in comparison to policies that were implemented globally to address similar issues during the first two years of the COVID‐19 pandemic. Finally, we conclude with recommendations for policies that could prevent similar disparate impacts on women in future crises.
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A partir do ano de 2020 o mundo foi marcado pela pandemia de Covid-19, doença causada pelo vírus SARS-CoV-2 (novo Coronavírus). Tratou-se da mais grave crise sanitária que o mundo experimentou nos últimos 100 anos, com milhões de casos e milhares de óbitos, em todos os países do planeta (WHO, 2020 apud NASCIMENTO JUNIOR et al., 2020a). Em que pesem os esforços mundiais e as evidências científicas acumuladas para o enfrentamento dessa pandemia, vários autores como Nussbaumer-Streit et al. que as medidas mais e cientes de controle da pandemia são o distanciamento social e o lockdown, a proteção das economias mundiais, a atenção e o cuidado à população vulnerável. Somamos a isso a corrida por vacinas e cazes que garantam a imunidade das populações. O Estado de Santa Catarina, área de estudo deste trabalho, compreende uma área de apenas 1,12% do território nacional. Possui 295 municípios, densidade demográ ca de 65,27 habitantes por quilômetro quadrado, Índice de Desenvolvimento Humano (IDH) em 2010 de 0,774 (terceiro do País, considerado alto) e possuía em 2020, 7.252.502 habitantes, de acordo com o Instituto Brasileiro de Geogra a e Estatística (IBGE) Cidades (https://cidades.ibge.gov.br/brasil/sc/panoramaIBGE, 2020). O município mais populoso é Joinville com 597.698 habitantes, porém, a capital do Estado é Florianópolis, que possui em torno de 508.826 habitantes. De acordo com o site do Governo do Estado de Santa Catarina https://www.sc.gov.br/conhecasc/econo-mia (2021), a economia catarinense é bastante diversi cada e está organizada em vários polos distribuídos por diferentes regiões do Estado. A diversidade de climas, paisagens e relevos estimula o desenvolvimento de inúmeras atividades, da agricultura ao turismo, atraindo investidores de segmentos distintos e permitindo que a riqueza não que concentrada em apenas uma área. A Grande Florianópolis destaca-se nos setores de tecnologia, turismo, serviços e construção civil. O Norte é polo tecnológico, moveleiro e metalomecânico. O Oeste concentra atividades de produção alimentar e de móveis. O Planalto Serrano tem a indústria de papel, celulose e da madeira. O Sul destaca-se pelos segmentos do vestuário, plásticos descartáveis, car-bonífero e cerâmico. No Vale do Itajaí, predomina a indústria têxtil e do vestuário, naval e de tecnologia. Na região costeira do Estado também se destacam as atividades pesqueiras. O turismo é um ponto forte na economia catarinense, principalmente pelo Estado ser recortado por importantes rodovias, como a BR-101, que além de articular os municípios costeiros do Estado, também liga dois Estados da Federação, Paraná e Rio Grande do Sul. (Parte da Introdução)
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A obra aqui se apresenta, “Educação e Direitos Humanos: teoria, prática e desafios em tempos de pandemia”, constitui-se de capítulos de diversos autores, mas conectados pelos direitos humanos. Abordam-se diferentes temáticas na área de educação, mas também de outros direitos humanos. Ressalta-se que a grande maioria dos capítulos refere-se a situações teóricas e práticas observadas, pesquisadas ou vividas durante a pandemia de COVID-19, crise sanitária declarada no início de 2020.
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Objectives To describe a national cohort of pregnant women admitted to hospital with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the UK, identify factors associated with infection, and describe outcomes, including transmission of infection, for mothers and infants. Design Prospective national population based cohort study using the UK Obstetric Surveillance System (UKOSS). Setting All 194 obstetric units in the UK. Participants 427 pregnant women admitted to hospital with confirmed SARS-CoV-2 infection between 1 March 2020 and 14 April 2020. Main outcome measures Incidence of maternal hospital admission and infant infection. Rates of maternal death, level 3 critical care unit admission, fetal loss, caesarean birth, preterm birth, stillbirth, early neonatal death, and neonatal unit admission. Results The estimated incidence of admission to hospital with confirmed SARS-CoV-2 infection in pregnancy was 4.9 (95% confidence interval 4.5 to 5.4) per 1000 maternities. 233 (56%) pregnant women admitted to hospital with SARS-CoV-2 infection in pregnancy were from black or other ethnic minority groups, 281 (69%) were overweight or obese, 175 (41%) were aged 35 or over, and 145 (34%) had pre-existing comorbidities. 266 (62%) women gave birth or had a pregnancy loss; 196 (73%) gave birth at term. Forty one (10%) women admitted to hospital needed respiratory support, and five (1%) women died. Twelve (5%) of 265 infants tested positive for SARS-CoV-2 RNA, six of them within the first 12 hours after birth. Conclusions Most pregnant women admitted to hospital with SARS-CoV-2 infection were in the late second or third trimester, supporting guidance for continued social distancing measures in later pregnancy. Most had good outcomes, and transmission of SARS-CoV-2 to infants was uncommon. The high proportion of women from black or minority ethnic groups admitted with infection needs urgent investigation and explanation. Study registration ISRCTN 40092247.
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COVID‐19, the illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), is the deadliest pandemic to occur in this century. Common symptoms of COVID‐19 include cough, myalgia, fever, chest pain, and headache. However, its clinical presentation ranges from completely asymptomatic to acute respiratory distress syndrome.[1] Pregnant women are susceptible to community spread of COVID‐19 because they cannot postpone interactions with healthcare professionals and other women receiving obstetric care.
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Background In December 2019, a novel coronavirus was identified as the cause of many pneumonia cases in China and eventually declared as a pandemic as the virus spread globally. Few reports were published on the outcome of surgical procedures in diagnosed COVID-19 patients and even fewer on the surgical outcomes of asymptomatic undiagnosed COVID-19 surgical patients. We aimed to review all published data regarding surgical outcomes of preoperatively asymptomatic untested coronavirus disease 2019 (COVID-19) patients.Methods This report is a review on the perioperative period in COVID-19 patients who were preoperatively asymptomatic and not tested for COVID-19. Searches were conducted in PubMed April 4th, 2020. All publications, of any design, were considered for inclusion.ResultsFour reports were identified through our literature search, comprising 64 COVID-19 carriers, of them 51 were diagnosed only in the postoperative period. Synthesis of these reports, concerning the postoperative outcomes of patients diagnosed with COVID-19 during the perioperative period, suggested a 14/51 (27.5%) postoperative mortality rate and severe mostly pulmonic complications, as well as medical staff exposure and transmission.ConclusionsCOVID-19 may have potential hazardous implications on the perioperative course. Our review presents results of unacceptable mortality rate and a high rate of severe complications. These observations warrant further well-designed studies, yet we believe it is time for a global consideration of sampling all asymptomatic patients before surgical treatment.
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Background: In Brazil, hospital childbirth care is available to all, but differences in access and quality of care result in inequalities of maternal health. The objective of this study is to assess the infrastructure and staffing of publicly financed labor and birth care in Brazil and its adequacy according to clinical and obstetric conditions potentially associated with obstetric emergencies. Methods: Nationwide cross-sectional hospital-based study "Birth in Brazil: national survey into labor and birth" conducted in 2011-2012. Data from 209 hospitals classified as public (public funding and management) or mixed (public or private funding and private management) that generate estimates for 1148 Brazilian hospitals. Interview with hospital managers provided data for the structure adequacy assessment covering four domains: human resources, medications, equipment for women emergency care and support services. We conducted analysis of the structure adequacy rate according to type of hospital (public or mixed), availability of ICU and the woman obstetric risk using the X (2) test to detect differences in categorical variables with the level of statistical significance set at p <0.05. Results: Global rate of adequacy of 34.8 %: 42.2 % in public hospitals and 29.0 % in mixed hospitals (p < 0.001). Public and mixed hospitals with ICU had higher scores of adequacy than hospitals without ICU (73.3 % × 24.4 % public hospitals; 40.3 % × 10.6 % mixed hospitals). At a national level, 32.8 % of women with obstetric risk were cared for in hospitals without ICU and 29.5 % of women without risk were cared for in hospitals with ICU. Inequalities were observed with the North, Northeast and non-capital regions having the lower rates of hospitals with ICU. Conclusions: The majority of maternity wards across the country have a low rate of adequacy that can affect the quality of labor and birth care. This holds true for women at high obstetric risk, who suffer the possibility of having their care compromised by failures of hospital infrastructure, and for women at low obstetric risk, who may not receive the appropriate care to support the natural evolution of their labor when in a technological hospital environment.
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As of June 16, 2020, the coronavirus disease 2019 (COVID-19) pandemic has resulted in 2,104,346 cases and 116,140 deaths in the United States.* During pregnancy, women experience immunologic and physiologic changes that could increase their risk for more severe illness from respiratory infections (1,2). To date, data to assess the prevalence and severity of COVID-19 among pregnant U.S. women and determine whether signs and symptoms differ among pregnant and nonpregnant women are limited. During January 22-June 7, as part of COVID-19 surveillance, CDC received reports of 326,335 women of reproductive age (15-44 years) who had positive test results for SARS-CoV-2, the virus that causes COVID-19. Data on pregnancy status were available for 91,412 (28.0%) women with laboratory-confirmed infections; among these, 8,207 (9.0%) were pregnant. Symptomatic pregnant and nonpregnant women with COVID-19 reported similar frequencies of cough (>50%) and shortness of breath (30%), but pregnant women less frequently reported headache, muscle aches, fever, chills, and diarrhea. Chronic lung disease, diabetes mellitus, and cardiovascular disease were more commonly reported among pregnant women than among nonpregnant women. Among women with COVID-19, approximately one third (31.5%) of pregnant women were reported to have been hospitalized compared with 5.8% of nonpregnant women. After adjusting for age, presence of underlying medical conditions, and race/ethnicity, pregnant women were significantly more likely to be admitted to the intensive care unit (ICU) (aRR = 1.5, 95% confidence interval [CI] = 1.2-1.8) and receive mechanical ventilation (aRR = 1.7, 95% CI = 1.2-2.4). Sixteen (0.2%) COVID-19-related deaths were reported among pregnant women aged 15-44 years, and 208 (0.2%) such deaths were reported among nonpregnant women (aRR = 0.9, 95% CI = 0.5-1.5). These findings suggest that among women of reproductive age with COVID-19, pregnant women are more likely to be hospitalized and at increased risk for ICU admission and receipt of mechanical ventilation compared with nonpregnant women, but their risk for death is similar. To reduce occurrence of severe illness from COVID-19, pregnant women should be counseled about the potential risk for severe illness from COVID-19, and measures to prevent infection with SARS-CoV-2 should be emphasized for pregnant women and their families.
Article
Objective To describe the course over time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in French women from the beginning of the pandemic until mid-April, the risk profile of women with respiratory complications, and short-term pregnancy outcomes. Methods We collected a case series of pregnant women with COVID-19 in a research network of 33 French maternity units between March 1 and April 14, 2020. All cases of SARS-CoV-2 infection confirmed by a positive result on real-time reverse transcriptase polymerase chain reaction tests of a nasal sample and/or diagnosed by a computed tomography chest scan were included and analyzed. The primary outcome measures were COVID-19 requiring oxygen (oxygen therapy or noninvasive ventilation) and critical COVID-19 (requiring invasive mechanical ventilation or extracorporeal membrane oxygenation, ECMO). Demographic data, baseline comorbidities, and pregnancy outcomes were also collected. Results Active cases of COVID-19 increased exponentially during March 1-31, 2020; the numbers fell during April 1-14, after lockdown was imposed on March 17. The shape of the curve of active critical COVID-19 mirrored that of all active cases. By April 14, among the 617 pregnant women with COVID-19, 93 women (15.1%; 95%CI 12.3-18.1) had required oxygen therapy and 35 others (5.7%; 95%CI 4.0-7.8) had had a critical form of COVID-19. The severity of the disease was associated with age older than 35 years and obesity, as well as preexisting diabetes, previous preeclampsia, and gestational hypertension or preeclampsia. One woman with critical COVID-19 died (0.2%; 95%CI 0-0.9). Among the women who gave birth, rates of preterm birth in women with non-severe, oxygen-requiring, and critical COVID-19 were 13/123 (10.6%), 14/29 (48.3%), and 23/29 (79.3%) before 37 weeks and 3/123 (2.4%), 4/29 (13.8%), and 14/29 (48.3%) before 32 weeks, respectively. One neonate in the critical group died from prematurity. Conclusion COVID-19 can be responsible for significant rates of severe acute, potentially deadly, respiratory distress syndromes. The most vulnerable pregnant women, those with comorbidities, may benefit particularly from prevention measures such as a lockdown.
Article
Nordic countries have a long tradition of collecting health related population data meticulously and reporting them transparently. Such data provide firm grounds for making good decisions and as a result the public health institutions in Scandinavia enjoy the trust of society. The Covid‐19 pandemic has, however, resulted in a completely new situation as we are now exploring in uncharted waters. Based on reports from China,1,2,3 Italy,4 USA5 and perhaps with the good intention of reducing anxiety among this vulnerable population group, it has been widely publicized that pregnant women are not at increased risk of susceptibility, infectivity and severity of COVID‐19 compared to the general population or non‐pregnant women, although a systematic review of 108 cases of laboratory confirmed pregnancies with COVID‐19 has reported the possibility of increased risk of severe disease among pregnant women.6
Article
Background Despite 2.5 million infections and 169,000 deaths worldwide (current as of April 20, 2020), no maternal deaths and only a few pregnant women afflicted with severe respiratory morbidity had been reported to be related to COVID-19 disease. Given the disproportionate burden of severe and mortal respiratory disease previously documented among pregnant women following other related coronavirus outbreaks (SARS-CoV in 2003 and MERS-CoV) and influenza pandemics over the last century, the absence of reported maternal morbidity and mortality with COVID-19 disease is unexpected. Objectives To describe maternal and perinatal outcomes and death in a case series of pregnant women with COVID-19 disease. Study design We describe here a multi-institution adjudicated case series from Iran which includes 9 pregnant women diagnosed with severe COVID-19 disease during their latter 2nd or 3rd trimester. All 9 pregnant women were diagnosed with SARS-CoV-2 infection by rRT-PCR nucleic acid testing (NAT). Outcomes of these women were compared to their familial/household members with exposure to the affected patient on or after their symptom onset. All data were reported at death or after a minimum of 14 days from date of admission with COVID-19 disease. Results Among 9 pregnant women with severe COVID-19 disease, at the time of reporting 7 of 9 died, 1 of 9 remains critically ill and ventilator-dependent, and 1 of 9 recovered after prolonged hospitalization. We obtained self-verified familial/household cohort data in all 9 cases, and in each and every instance the maternal outcomes were more severe when compared to other high and low-risk familial/household members (n=33 members for comparison). Conclusion We report herein maternal deaths due to COVID-19 disease. Until rigorously collected surveillance data emerges, it is prudent to be aware of the potential for maternal death among pregnant women diagnosed with COVID-19 disease in their latter trimester(s).
Article
Background: In December, 2019, a pneumonia associated with the 2019 novel coronavirus (2019-nCoV) emerged in Wuhan, China. We aimed to further clarify the epidemiological and clinical characteristics of 2019-nCoV pneumonia. Methods: In this retrospective, single-centre study, we included all confirmed cases of 2019-nCoV in Wuhan Jinyintan Hospital from Jan 1 to Jan 20, 2020. Cases were confirmed by real-time RT-PCR and were analysed for epidemiological, demographic, clinical, and radiological features and laboratory data. Outcomes were followed up until Jan 25, 2020. Findings: Of the 99 patients with 2019-nCoV pneumonia, 49 (49%) had a history of exposure to the Huanan seafood market. The average age of the patients was 55·5 years (SD 13·1), including 67 men and 32 women. 2019-nCoV was detected in all patients by real-time RT-PCR. 50 (51%) patients had chronic diseases. Patients had clinical manifestations of fever (82 [83%] patients), cough (81 [82%] patients), shortness of breath (31 [31%] patients), muscle ache (11 [11%] patients), confusion (nine [9%] patients), headache (eight [8%] patients), sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and vomiting (one [1%] patient). According to imaging examination, 74 (75%) patients showed bilateral pneumonia, 14 (14%) patients showed multiple mottling and ground-glass opacity, and one (1%) patient had pneumothorax. 17 (17%) patients developed acute respiratory distress syndrome and, among them, 11 (11%) patients worsened in a short period of time and died of multiple organ failure. Interpretation: The 2019-nCoV infection was of clustering onset, is more likely to affect older males with comorbidities, and can result in severe and even fatal respiratory diseases such as acute respiratory distress syndrome. In general, characteristics of patients who died were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia. Further investigation is needed to explore the applicability of the MuLBSTA score in predicting the risk of mortality in 2019-nCoV infection. Funding: National Key R&D Program of China.