COVID-19 in pregnancy may significantly affect fetal growth

Objective. Whilst most cases of COVID-19 in pregnancy evolve uneventfully, some others have a poor outcome, such as preterm birth and HDP. The effect of COVID-19 on fetal growth still has to be addressed and appears controversial. Our study aims to focus on fetal growth velocity across the trimesters in pregnancy affected with COVID-19. Materials and Methods. This is a multicentric prospective observational study on data from COVID-19 pregnancies referred to the centers of Careggi University Hospital and S. Stefano Hospital in Prato from 2020 to 2022, included in the local branch of ItOSS surveillance. Fetal growth was evaluated across the three trimesters of pregnancy by abdominal circumference (AC) and expected fetal weight (EFW). Both AC, and EFW plus birthweight were used to calculate growth velocity (Vannuccini et al., 2017). Results. Data from a cohort of 211 cases was collected. The majority (80%) of COVID-19 cases occurred in the third trimester. Of note, the percentage of gestational diabetes (12.3%) and preterm births (7.1%) was comparable to the general population. Mean birthweight was 3259 +/- 509 g. The percentage of cesarean sections was acceptable (13.7%). Concerning the velocity of growth, AC decreased from the second to third trimester to reach values < 10th centile in 24% of cases and < 5th percentile in 17% of cases, even in presence of 2% of hypertensive disorders (HDP). Fetal growth restriction according to Gordjin et al. (2015) was antenatally identified in 4.7% of cases. Fetal growth > 95th centile occurred in 5.7% of cases. At birth, the cumulative percentage of small for gestational age newborns defined as birth weight < 2500 g resulted 5.2%. A significant percentage of newborns required NICU assistance (7.8%). Conclusions. Regardless of the association and prevalence of preterm birth, SGA and HDP in pregnant women, fetal growth appears to be affected by COVID-19 with a higher incidence of impaired growth velocity compared to the general population.

Third level care experience during SARS-CoV-2 pandemic

Objective. As the SARS-CoV-2 Pandemic has widely changed pregnancy experience and assessment, the inpatient and outpatient services have had to be re-organized. Since March 2020, Careggi University Hospital (CUH) has provided a dedicated COVID-pathway: spaces for women with unknown swab status and a COVID-19 ward delivery room. The aim of this study is to analyze the inpatient and outpatient COVID-19 related activities in CUH. Materials and Methods. We prospectively collected data from consecutive COVID-19 pregnancies referred from 2020 to 2022, included in the local branch of the ItOSS surveillance. All patients experienced COVID-19 in pregnancy at various stages of severity and gestational ages. Results. From March 2020 to June 2022, 165 COVID-19 deliveries occurred (169 newborns), while 16 pregnant positive women were admitted without delivering. A single emergency C-section (CS) was performed because of Sars-CoV-2 related ARDS, 15 women experienced serious maternal morbidity and 5 needed ECMO. A single maternal death occurred four months after delivery (C-section). Considering ECMO supported cases during pregnancy or postpartum, the first one tested positive for COVID-19 during the second trimester. She developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a CS at term was performed following obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation and experienced a precipitous vaginal delivery at 31 weeks+6 days of gestation while on ECMO. She was discharged 1 month later in good general conditions. The third patient was an obese (BMI 38) 43-year-old woman who had performed an IVF with embryo donation;she tested positive at 38 weeks+2 days of gestation. A CS was performed because of the worsening of her condition. After the delivery she was admitted in ICU and she underwent ECMO. She died 143 days after the CS by sepsis and multiple organ failure (MOF). For all these pregnancies neonatal outcomes were positive. No perinatal death occurred and only one baby tested positive for SARS-CoV-2 infection at nasal swab sampling (case 3). The anesthesiology team performed neuroassial analgesia intrapartum in all the positive women who needed/requested it. Monoclonal Antibodies (mAbs) have been widely used to treat mild to moderate COVID-19 outpatients (NIH and RCOG recommendations) at risk for developing severe disease. Regarding this specifical therapy, an essential role in the management of the pregnant outpatient was played by the Infectious Disease Department. All patients above 28 weeks requiring hospitalization received LMWH prophylaxis, which was administrated under 28 weeks only in presence of additional risk factors (obesity, IVF, etc.). All new mothers received a ten days LMWH prophylaxis. On the outpatient side, we performed 22 teleconsultations, 43 obstetric ultrasounds (including I trimester screening), 90 obstetric checks with clinical evaluation and home therapy management, 32 fetal monitoring and 47 naso-pharingeal swabs. Conclusions. At Careggi Hospital Maternal Department an extensive re-organization of inpatient and outpatient services has been performed in order to guarantee good practice and management of all pregnant women during the SARS-CoV-2 pandemic. This was only possible thanks to a wide multidisciplinary group which enhanced every professional.

Maternal-neonatal outcomes of pregnant women with COVID-19 requiring extracorporeal membrane support: A case series

INTRODUCTION Pregnant women are considered a high-risk group for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Compared with non-pregnant women of reproductive age, pregnant women with severe coronavirus disease 2019 (COVID-19) were less likely to report symptoms;however, they seem to be more likely to need hospitalization, admission to an intensive care unit (ICU) and invasive ventilation and to experience acute respiratory distress syndrome (ARDS). In case of ARDS and critical COVID-19 infection the World Health Organization (WHO) recommends the use of extracorporeal membrane oxygenation (ECMO). However, available data on ECMO in pregnant women with critical COVID-19 are very limited. In these case series, we report maternal and fetal outcomes of 3 critically ill pregnant women who required ECMO support for COVID-19. METHODS We reviewed the literature about pregnant women underwent ECMO due to ARDS caused by COVID-19. Then, we compared the available literature with our case series, focusing on maternal and fetal outcomes. RESULTS Our cohort comprises three women: two of them underwent ECMO during pregnancy and the other one just after delivery. The first patient tested positive for COVID-19 during the second trimester (19th week of gestation), she developed ARDS and underwent ECMO for 38 days;in this period, infectious (isolation of methicillin-susceptible Staphylococcus aureus (MSSA) in the Broncho-Alveolar Lavage (BAL) fluid) and thrombotic (clot in right atrium) complications were reported. She was discharged in good general conditions after cesarean-section [CS] (due to previous one) at term. The second patient tested positive during the third trimester (28th week of gestation) and underwent ECMO due to sudden worsening of hypoxia not responding to conventional treatments. She experienced a precipitous vaginal delivery at 32 weeks 2 days of gestation, complicated by postpartum hemorrhage and neonatal complications due to prematurity. Infectious (BAL positivity for MSSA and blood cultures positives for E. Coli) and thrombotic (pulmonary embolism) maternal complications were also reported. She was discharged about a month after delivery in good general conditions. The third woman is an obese patient (BMI 51) with pregnancy obtained with heterologous ICSI, infected by COVID-19 during the third trimester. She underwent CS at 38 weeks of gestation due to the worsening of clinical parameters and subsequently was placed on ECMO;to date, after two months, she is still in critical conditions, with ECMO. Despite that, neonatal outcome is reassuring. The first two newborns were never tested positive for COVID-19;the third one was tested positive after 14 day after delivery, without any clinical consequence. CONCLUSIONS ECMO is a feasible treatment in pregnant women with severe COVID-19. According to the available literature, our case-series showed that complications associated with ECMO in pregnant patients were consistent with those reported in general population including bleeding, thrombosis, infectious and vascular complications, while the most commonly reported fetal complication is preterm delivery. Collecting and sharing data is imperative to allow a better comprehension of the disease and to improve the standard of treatment.

Fetal growth in covid pregnancy: Better than expected?

INTRODUCTION The COVID pandemic has widely affected the pregnancy experience, being a novel risk factor for maternalfetal morbidity/mortality, preterm birth and, as recently hypothesized, preeclampsia. The aim of our study was to investigate the impact of COVID in pregnancy on fetal growth. METHODS Data from ultrasound reports of 73 consecutive pregnancies enrolled in the local ItOSS surveillance on COVID and pregnancy were analyzed. All patients had experienced COVID in pregnancy at various stages of severity. Eight cases were excluded as they did not fit the aim of the study. Fetal abdominal circumference (AC) in 2nd and 3rd trimester were compared for each case, and then with the neonatal birthweight, in order to clarify the possible presence of growth defects/accelerations. RESULTS No case of AC <10° centile was reported neither in the 2nd nor in the 3rd trimester. Interestingly, the percentage of SGA at birth was 5.6%. The same percentage of neonates had pH <7.10 at birth. Only one case presented an AC drop >40 centiles. LGA neonates, with AC >90° centile, accounted for 22.5%, including 8.4% of cases that presented an acceleration of growth velocity from 2nd to 3rd trimester. During the 3rd trimester to birth interval, we observed 8.4% of decrease and 2.8% increase of growth velocity, respectively, in terms of percentiles of expected birthweight vs neonatal birthweight. CONCLUSIONS Data about fetal growth in COVID pregnancies are overall encouraging. No case of defined FGR was observed. Conversely, acceleration of growth from 2nd to 3rd trimester was higher than expected. This may be accountable on poor metabolic status due to the prolonged use of corticosteroids or on lack of regular glycemic screening/nutrition due to pandemic.

Clinical findings and disease severity in hospitalized pregnant women with coronavirus disease 2019 (COVID-19)

OBJECTIVE: To investigate the clinical evolution of coronavirus disease 2019 (COVID-19) in hospitalized pregnant women and potential factors associated with severe maternal outcomes. METHODS: We designed a prospective multicenter cohort study of pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who were admitted to 12 Italian maternity hospitals between February 23 and March 28, 2020. Clinical records, laboratory and radiologic examinations, and pregnancy outcomes were collected. A subgroup of patients with severe disease was identified based on intensive care unit (ICU) admission, delivery for respiratory compromise, or both. RESULTS: Seventy-seven patients were included, 14 of whom had severe disease (18%). Two thirds of the patients in the cohort were admitted during the third trimester, and 84% were symptomatic on admission. Eleven patients underwent urgent delivery for respiratory compromise (16%), and six were admitted to the ICU (8%). One woman received extracorporeal membrane oxygenation;no deaths occurred. Preterm delivery occurred in 12% of patients, and nine newborns were admitted to the neonatal intensive care unit. Patients in the severe subgroup had significantly higher pregestational body mass indexes (BMIs) and heart and respiratory rates and a greater frequency of fever or dyspnea on admission compared with women with a nonsevere disease evolution. CONCLUSION: In our cohort, one in five women hospitalized with COVID-19 infection delivered urgently for respiratory compromise or were admitted to the ICU. None, however, died. Increased pregestational BMI and abnormal heart and respiratory rates on admission were associated with severe disease.

A generalized action plan for obstetric hospitals and outpatient clinics during the suspected or confirmed COVID-19 pandemic

This summary paper presents a generalized action plan for hospitals and outpatient clinics during the COVID-19 coronavirus pandemic. Now the pandemic is the most relevant global challenge. Taking into account that the medical world does not have much clinical experience with COVID-19 and other coronaviruses, such as SARS-CoV and MERS-CoV, thoroughness and caution in assessing and treating pregnant women is an extremely urgent topic. The authors of this article summarized the world experience in managing patients with coronavirus disease and brought it into a unique algorithm that was considered most rational.