Accepted Article

Article type : Review Article

REVIEW ARTICLE
COVID-19 infection in pregnant women: Review of maternal and fetal outcomes
Deemah Salem1,2,*, Fawzi Katranji3, Talah Bakdash4
1Department of Obstetrics and Gynecology, Mohammad Bin Rashid University of
Medicine and Health Sciences, Dubai, UAE
2Department of Obstetrics and Gynecology, Genesis Healthcare Center, Dubai, UAE
3Department of Pulmonary Medicine, Michigan State University School of Osteopathic
Medicine, East Lansing, MI, USA
4University of Kansas School of Medicine, Kansas City, KS, USA
*Correspondence
Deemah Salem, Genesis Healthcare Center, Office 205, Building 49, Dubai Healthcare
City, Dubai, United Arab Emirates
Email: Drdeemah@[Link]
Keywords
Adverse effects; COVID-19; Fetal outcome; Hospital admission; Maternal outcome;
Pregnant women; SARS-CoV-2; Vertical transmission
Synopsis
SARS-CoV-2 infections in pregnancy have been associated with increased risk of
admission to hospital but not with increased maternal and fetal death, and vertical utero-
transmission.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/IJGO.13533
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Accepted Article
Abstract
Pregnant women, their fetuses, and newborns are likely to represent a high-risk
population during the current coronavirus disease 2019 (COVID-19) pandemic caused by
severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Literature on the
outcomes of COVID-19 infections during pregnancy is slowly building up. The aim of the
present review was to gather evidence from relevant articles published in English from
January to August 2020 in Medline and Google Scholar. The review revealed that
pregnant women who become COVID-19-positive are usually either asymptomatic or
mild-to-moderately symptomatic, similar to non-pregnant women. Pneumonia is one of
the most common outcomes in pregnant women with COVID-19. However, it cannot be
conclusively said that SARS-CoV-2 infection increases the risk of maternal, fetal, and
neonatal complications. Pregnant women with COVID-19 with co-morbidities have
increased risks of complications: there are regional variations in the rates of adverse
outcomes reported. Though uncommon, the review shows that vertical transmission is
possible. Additionally, the third trimester seems to be the most vulnerable period of
infection. This aspect needs to be researched further to activate surveillance programs at
the end of second trimester. Overall, it is necessary to monitor pregnant women before
and after delivery, and their infants, during this pandemic.

1 INTRODUCTION
In December 2019, a viral outbreak emerged from Wuhan in the Hubei province of China,
reportedly being caused by a novel coronavirus. It has now spread worldwide and is one
of the most severe public health threats [1]. The virus was named severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease was called
coronavirus disease 2019 (COVID-19) [1]. On March 11, 2020, WHO announced COVID-
19 as a “pandemic” [2]. Previously, a total of six coronavirus species belonging to the
genus Alphacoronavirus (HCoV-229E and HCoV- NL63) and Betacoronavirus (HCoV-
OC43, HCoV-HKU1, severe acute respiratory syndrome CoV [SARS-CoV], and Middle
East respiratory syndrome [MERS-CoV]) were known to infect humans [3]. With the
emergence of SARS-Cov-2, there are now seven species of coronavirus infecting
humans [4].

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 The physiologic and immunologic changes during pregnancy may result in systemic
Accepted Article
effects that predispose women towards complications from respiratory infections leading
to maternal and fetal mortality and morbidity [5, 6]. Both SARS-CoV and MERS-CoV
were known to be associated with adverse outcomes in pregnant women with greater
mortality rates than the general population [3, 7]. With SARS-CoV-2 rapidly spreading, it
is reasonable to contemplate that pregnant women are likely to get infected [4].
Worldwide concerns have been raised about the risk of intrauterine transmission of this
virus from the mother to the fetus [8, 9]. The clinical characteristics and possibility of
transmission of COVID-19 in pregnant women vertically or during delivery are still unclear
[8–10].
The questions that require immediate attention include the following: whether the
symptoms of the disease in pregnant women with COVID-19 differ from symptoms in
non-pregnant women; whether complications of the disease and mortality rate are higher
in pregnant women than in non-pregnant women; and whether there is a chance of
premature delivery or fetal mortality, or even vertical transmission of the disease [11, 12].
Finding answers to these questions are crucial for planning effective obstetrical
management for pregnant women with COVID-19.
Given the importance of the issue, the present narrative review collates the literature
assessing the effect of COVID-19 infection in pregnancy, including the maternal and fetal
outcomes of COVID-19, vertical transmission, as well as the benefits of screening for
COVID-19 in pregnant women.

2 MATERIALS AND METHODS

A detailed literature search was carried out using databases such as Medline and Google
Scholar. The following search terms were combined using Boolean operators “AND/OR”:
“COVID-19”; “SARS-CoV-2”; “Maternal effect”; “Maternal outcome”; “Fetal effect”; “Fetal
outcome”; “Vertical transmission”; “Pregnancy outcome”; “Antenatal”; “Perinatal”; and
“Screening.” Relevant literature reporting both maternal and fetal outcomes of COVID-19
during pregnancy and published in English from January 1, 2020, to August 31, 2020,
was retrieved. The retrieved literature was filtered to include only systematic reviews,
meta-analyses, clinical trials, retrospective real-world studies, case series, and narrative
reviews. No randomized trials were retrieved. Publications covering only maternal or fetal

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 outcomes and those for which full text was not available were not included. In addition,
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publications covering the treatment and/or management of COVID-19 and/or its
outcomes in pregnancy were not included in the narrative review. Of the remaining
publications, the authors have tried to present a mix of different types of publications
reporting unique data.
3 TRANSMISSION OF SARS-COV-2
The principal transmission routes for SARS-CoV-2 include droplets and aerosols, mainly
through inhalation of respiratory droplets produced by coughing or sneezing by infected
persons. Moreover, transmission also occurs via hand to mouth/nose route from infected
droplets deposited on different surfaces and objects [13, 14]. The virus transmission
could potentially occur in individuals at a distance of 1 meter from the infected person
[14].

4 PREGNANCY AND SUSCEPTIBILITY TOWARDS SARS-COV-2 INFECTION

COMPARED TO NON-PREGNANT WOMEN
Pregnancy causes physiological changes in the respiratory and circulatory systems as
well as alterations in immunological reactions. These are the primary factors that are
likely to make pregnant women more vulnerable to viral infections [15]. The common
changes in the respiratory system that are likely to increase the susceptibility of a
pregnant woman to respiratory infections include reduced functional residual volumes,
elevation of the diaphragm, relaxation of ligaments in the ribs, increased pulmonary
hypertension resulting in hyperventilation, and even hypoxic respiratory failure [15, 16].
Altered cell immunity increases pregnant women’s risk of an immunocompromised state,
thereby making them more prone to develop worst outcomes [15, 16]. Moreover, viral
infection in pregnancy can result in modification of the cardiovascular system, increased
metabolic rate and consumption of oxygen, higher pulmonary vascular resistance, and
even heart failure [15]. Additionally, during the third trimester of pregnancy, the probability
of physical dyspnea is high (due to increased maternal oxygen demands, gestational
anemia, and consumption of fetal oxygen) leading to further worsening of breathing
difficulties [16].
It is important to note that pregnant women are susceptible to SARS-CoV-2 infection [4].
However, despite there being many respiratory, circulatory, and immunological factors

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 that could increase a pregnant woman’s risk of SARS-CoV-2 infection, the data available
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so far do not reflect an increased risk. In their literature review, Selim et al. [17] report
very small absolute risks of SARS-CoV-2 infection in pregnancy. Also, there is no
evidence to date that pregnant women are more susceptible to SARS-CoV-2 infection
than non-pregnant women [17]. In general, the unique immunologic changes of
pregnancy are thought to suppress the virulence of the virus [17].
The symptoms of COVID-19 in pregnant women are thought to be due to the direct effect
of the virus on the mothers [17]. The disease course of SARS-CoV-2 in pregnant women
seems to be either asymptomatic or with mild to moderate symptoms (fever and cough),
similar to non-pregnant women [16, 18, 19]. In pregnant women presenting with severe
symptoms (e.g. hypoxia, pneumonia, etc.), enhanced angiotensin-converting enzyme 2
(ACE-2) expression is thought to be linked to severity of symptoms [17]. A recent meta-
analysis reported that less than 20% of pregnant women need admission to the intensive
care unit (ICU) [20].
In a Chinese study on hospitalized pregnant women with COVID-19, 77% had fever and
23% reported dyspnea. Of these cases, 23% improved with treatment and discharged
with ongoing pregnancy, while 46% had preterm labor at 32–36 weeks of pregnancy.
Only 7.6% developed severe pneumonia and even multi-organ dysfunction, requiring ICU
care and extracorporeal membrane oxygenation [4]. The rate of critical care in pregnant
women with COVID-19 was similar to that reported in the general population (7.6% vs
5%) [4].
Chen et al. [21] reported epidemiological, clinical, and laboratory characteristics and
outcomes of 118 pregnant women with confirmed SARS-CoV-2 infection in China.
Among them, 92% had mild disease and 8% had severe disease with hypoxemia. The
condition of one patient was critical, requiring non-invasive mechanical ventilation, which
was continued even after delivery. Six women developed severe disease after delivery;
94% were discharged without any complications and no death was reported [21]. The risk
of severe disease among pregnant women was comparable with the risk reported in the
general population suffering from COVID-19 across mainland China [21].

4 PREGNANCY OUTCOMES IN COVID-19

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 COVID-19 infection is very new. Data on clinical outcomes of pregnant women suffering
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from COVID-19 are therefore relatively scarce [22]. Selim et al. [17] report that SARS
infection (but not SARS-CoV-2 infection) has been associated with a higher risk for
intrauterine growth retardation, premature births, and spontaneous abortion. This is also
reflected in a publication that shows that compared to maternal outcomes in SARS-CoV
and MERS-CoV infections, the maternal outcomes in SARS-CoV-2 are more favorable,
with lower morbidity and mortality, with case fatality rates of 18%, 25%, and 0%,
respectively [16]. However, recently a meta-analysis of 13 publications (n=114) reported
preterm births, neonatal pneumonia, and respiratory distress syndrome in infants born of
COVID-19-positive mothers [20]. There are also regional variations in the rate of maternal
and neonatal complications. A meta-analysis by Dubey et al. [23] reported that the rates
of cesarean deliveries and adverse pregnancy outcomes were substantially higher in
Chinese studies (91% and 21%) compared to American (40% and 15%) and European
studies (38% and 19%). Similarly, the rates of preterm births were lower in American
studies (12%) compared to Chinese and European studies (17% and 19%, respectively).
Therefore, since the infection is new, care should be taken to monitor COVID-19-positive
pregnant women to prevent adverse maternal and fetal outcomes.
The reported maternal and fetal outcomes in pregnant women infected with COVID-19
are outlined in Table 1.

5 MATERNAL OUTCOMES IN COVID-19

As more and more data become available, it is becoming clear that maternal
complications are common in pregnant women infected with SARS-CoV-2 [20, 23].
Maternal complications in mothers positive for COVID-19 mostly included pneumonia [4,
24–26]. Other reported complications are premature rupture of membranes (PROM), pre-
term deliveries, fetal distress, increased cesarean deliveries, lymphopenia, elevated C-
reactive protein, gestational hypertension, diabetes, pre-eclampsia, placenta previa,
oligohydramnios, polyhydramnios, hypothyroidism, abnormal umbilical cord, and sinus
tachycardia [4, 12, 20, 23, 26–31]. In the past, SARS infection was found to increase the
risk of fetal distress, and gestational diabetes and pre-eclampsia are known to be higher
in MERS infection, but no such correlation can be established for SARS-CoV-2 [31].
However, morbidity and mortality were found to be quite low in pregnant patients with

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 COVID-19 [11, 12, 21, 24, 28, 30, 32, 33]. In general, a systematic review of the literature
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shows that pregnant women positive for COVID-19 with co-morbidities are more likely to
develop complications than those without [34].
Pneumonia
Pneumonia is one of the most common outcomes in pregnant women infected with
COVID-19 [4, 24–26]. Severe cases of pneumonia and respiratory conditions requiring
ventilation support are one of the main causes of admission to hospital [4, 25, 26].
However, a meta-analysis of data from nine publications including 87 pregnant women
with SARS-CoV-2 infection concluded that most pregnant women had mild to moderate
COVID-19 pneumonia, similar in clinical characteristics to that seen in an adult population
[35].
A retrospective study reported pneumonia among 96.3% of the pregnant patients with
confirmed COVID-19, with 3.7% of patients having severe pneumonia [24]. In a case-
control study in China, 94% of the pregnant women with confirmed COVID-19 showed
typical chest computed tomography (CT) images of COVID-19 pneumonia. However, the
majority were asymptomatic upon admission to hospital, and none experienced severe
respiratory failure during hospital stay and none died [26]. In another single-center
Chinese study, mild pneumonia was diagnosed in all pregnant patients with COVID-19 at
the time of admission to hospital for delivery. However, no acute respiratory distress
syndrome and aggravation of pneumonia were observed in the whole course [22]. Even
though all parturient patients required oxygen support, none required mechanical
ventilation and the recovery was good [22]. In their single-center case-control study
(n=55; 13 cases, 42 controls), Yang et al. [36] reported that pregnant women with
confirmed SARS-CoV-2 infection did not have expectoration, myalgia, or dyspnea;
however, their pulmonary CT scan images resembled COVID-19 pneumonia with ground-
glass opacity (46.2%), patch-like shadow (23.1%), pleural effusion (38.5%), and pleural
thickening (7.7%). Although the pleural effusion was significantly higher in pregnant
women than non-pregnant women, none showed any adverse effects [36].

In a case series from Iran with nine pregnant women in the second or third trimester, the
initial symptoms at the time of presentation in all of them were fever, dry cough, and
dyspnea, and three patients later developed COVID-19 pneumonia. Seven women died

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 and two survived: one was critically ill and dependent on a ventilator; and the other was
Accepted Article
cured after a prolonged hospital stay. Neither of them had pre-existing co-morbidities
[37].

Other adverse outcomes of COVID-19 in pregnant women

Reports of worse clinical outcomes in pregnant women with COVID-19, and even death,
are also reported from countries outside of China, mainly the United States [38]. In a
study from the USA, out of 67.4% patients with symptoms of COVID-19, 15% required
antenatal admission. Among them, 9.3% developed severe disease and 4.7% developed
critical disease requiring admission to the ICU and oxygen supplementation 6 days
postpartum after a successful induction of labor [7]. This was similar to the data for non-
pregnant patients with COVID-19 (15% severe and 5% critical) [7]. A case series from the
USA reported adverse outcomes in 28.5% pregnant patients with COVID-19 including
shortness of breath, dyspnea, cardiomyopathy, and moderately reduced left ventricular
ejection fractions and hypokinesis, leading to admission to the ICU [39]. However,
another case series of pregnant women with confirmed COVID-19 from the U.S.A
reported no pregnancy complications or maternal deaths but reported one fetal demise at
14 weeks of gestation [33]. Recently, the U.S. Centers for Disease Control and
Prevention (CDC) presented a surveillance report of women (pregnant and non-pregnant)
with laboratory-confirmed COVID-19. The pregnant women are found to have a higher
probability of hospitalization than non-pregnant women (1.5% vs 0.9%), particularly
admission to the ICU for mechanical ventilation (0.5% vs 0.3%). However, the risk of
mortality was similar in both groups [40].
Fetal outcomes in pregnant women with COVID-19
Neonatal outcomes of COVID-19 mostly included preterm birth (39%), fetal distress
(43%), intrauterine growth retardation (10%), miscarriage (2%), and perinatal death (7%)
[16]. A systematic review by Yang et al. [8] reported the following adverse fetal and
neonatal outcomes of COVID-19: preterm birth (21.3%); fetal distress (10.7%); stillbirth
(1.2%); neonatal death (1.2%); and neonatal asphyxia (1.2%). Other studies reported
46%, 44.4%, 33.3%, 23.5%, 21%, and 4% cases of preterm delivery [4, 12, 21, 25, 26,
36]. In contrast, a case series reported full-term delivery in 100% of patients with COVID-
19 [41]. Fetal distress and PROM were reported in 22.2% of cases in a review [42], and

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 neonatal distress in 5.3% cases of a single-center study from China [36]. Two other
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studies respectively mentioned fetal distress in 30% and 19% as well as PROM in 10%
and 13% of patients with confirmed COVID-19 [4, 26]. Chen et al. [21] reported the
incidence of abortions (spontaneous and induced) among 6% of pregnant women with
COVID-19 infection. The current data do not suggest a high risk of abortion or premature
gestational loss, amniotic fluid abnormality, cyanosis, and congenital defects in neonates
in mothers infected with COVID-19 [11].

6 CHANCES OF INTRAUTERINE VERTICAL TRANSMISSION OF SARS-COV-2

INFECTION
The risk of vertical transmission can theoretically exist in COVID-19 since angiotensin-
converting enzyme 2 (ACE-2) receptors are significantly expressed in the placenta with
which SARS-CoV-2 may bind and enter. Intrauterine vertical transmission may typically
occur through trans-placenta, or ingestion or aspiration of cervicovaginal secretions [32,
43]. Multiple studies confirmed the absence of SARS-CoV-2 isolates in the amniotic fluid,
cord blood, breast milk sample, and neonatal throat swabs of the infected mother,
indicating that intrauterine transmission, transmission during vaginal delivery, or through
lactation was not possible [11, 12, 16, 32, 42]. In the majority of the cases, the infected
women gave birth to healthy babies with an Apgar score above 7 and negative reverse
transcription polymerase chain reaction (RT-PCR) test results [11, 22, 32]. Furthermore,
the placental pathology of three pregnant patients with COVID-19 showed no
morphological changes linked with the infection; all three placentas tested negative to
RT-PCR and there was no maternal-fetal transmission [44]. However, a systematic
review and meta-analysis of the available data provide no conclusive evidence of vertical
transmisison of SARS-CoV-2 to date, except for a small risk in the third trimester [45].
Therefore, actual risk of intrauterine vertical transmission can only be ascertained
through RT-PCR tests on amniotic fluid, placenta, and cord blood [45].
Benefits of screening of pregnant women during COVID-19 pandemic
The diagnosis of COVID-19 is based on comprehensive contact, travel history, and
precise laboratory tests. According to WHO recommendations, RT-PCR testing of
samples from the respiratory tract should be performed for the identification and
laboratory confirmation of cases of COVID-19 [14]. Moreover, WHO has suggested the

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 use of antibody-detecting rapid tests for surveillance of the disease rather than for patient
Accepted Article
care [14].

SARS-CoV-2 is highly contagious and can spread from both symptomatic and pre-
symptomatic patients [14]. A high proportion of pre-symptomatic patients with COVID-19
exist worldwide [7]. Due to a large number of pre-symptomatic pregnant patients with
COVID-19, universal screening of pregnant women and implementing strict infection
control measures to manage suspected or confirmed patients are essential to provide
safety to both mothers and neonates as well as healthcare workers [40]. According to the
guidelines of the American College of Obstetricians and Gynecologists (ACOG) and the
Royal College of Obstetricians and Gynaecologists (RCOG), every pregnant woman is at
high risk and should take preventive measures including wearing masks, washing hands,
and strictly maintaining social distancing when interacting with others [46, 47].
ACOG and RCOG guidelines stated that COVID-19 testing is critical for pregnant women
to prevent transmission of the disease [46, 47]. All pregnant women admitted to the
hospital for maternity care should be asked for SARS-CoV-2 testing, irrespective of
whether they have symptoms. For women who tested negative on admission, repeat
testing should be offered 5–7 days later if they remain as inpatients [46]. Pregnant
women with suspected COVID-19 or with symptoms suggestive of COVID-19 should be
tested on priority [47]. Moreover, for pregnant women from areas of high prevalence,
universal testing is strongly recommended due to an increased probability of presentation
of asymptomatic patients to labor and delivery units from these areas [47]. It is important
to note that RT-PCR is often not able to detect SARS-CoV-2 infection and therefore
some pregnant women with COVID-19 pneumonia may be missed unless a CT scan is
performed [30].

7 STRENGTHS AND LIMITATIONS

The present narrative review has several limitations. Most of the studies included in the
systematic reviews and meta-analyses are from China. Thus, there is regional bias due
to genetic and environmental factors and the level of medical care available in China. The
majority of the literature is case reports, case series, or retrospective studies where the
methodology is poor, and the evidence cannot be considered high level. There are very

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 few case-control studies and no large randomized trials comparing pregnant women
Accepted Article
positive for COVID-19 with matched pregnant women without COVID-19 infection.
Additionally, like most narrative reviews, the present review also has a selection bias.
However, the present narrative review does highlight the fact that COVID-19 infection
occurs in pregnant women and can be associated with poor maternal and fetal outcomes.
Neonates born of pregnant women with COVID-19 can get infected and therefore vertical
transmission is possible. Additionally, RT-PCR may not be a conclusive test to diagnose
SARS-CoV-2 infection in pregnant women as some pregnant women with CT-confirmed
COVID-19 infection are RT-PCR negative. The present review also highlights that the
majority of pregnant women get infected in the third trimester.

8 CONCLUSION
There is currently limited knowledge about SARS-CoV-2 infections in pregnancy. Based
on the available data, the clinical characteristics of pregnant women with COVID-19
seem to resemble those of non-pregnant women. It cannot be conclusively said that
SARS-CoV-2 infection increases the risk of maternal, fetal, and neonatal complications.
Increased risks of maternal, fetal, and neonatal complications are noted in pregnant
women positive for COVID-19 with co-morbidities. There are regional variations in the
rates of adverse outcomes reported. Though vertical transmission is noted in very few
cases, the review shows that it is possible. Additionally, the third trimester seems to be
the most vulnerable period of infection and this aspect needs to be researched further to
activate surveillance programs at the end of the second trimester. Further studies are
warranted to assess whether the higher rates of adverse outcomes reported in mothers
with COVID-19 with co-morbidities are due to the co-morbidities or whether the SARS-
CoV-2 infection worsens the disease course in these mothers. Multicenter global trials
are required to look into the reasons for regional variations and understand why some
regions report very few adverse outcomes. This would be helpful in developing a
screening, diagnostic, and management algorithm to reduce adverse outcomes in
mothers with COVID-19.

Author contributions

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 DS was responsible for the design, planning, and writing of the manuscript. FK and TB
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were responsible for the literature data analysis for the review.
Acknowledgments
The authors acknowledge Turacoz Healthcare Solutions ([Link]) for
assistance with the manuscript writing.
Conflicts of interest
The authors have no conflicts of interest.

References
1. Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus Disease 2019
(COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol.
2020:13.
2. WHO Director-General's opening remarks at the Mission briefing on COVID-19 -
12 March 2020. Available at [Link]
general-s-opening-remarks-at-the-mission-briefing-on-covid-19---12-march-2020:
Accessed on May 29th 2020.
3. Della Gatta AN, Rizzo R, Pilu G, et al. Coronavirus disease 2019 during
pregnancy: a systematic review of reported cases. Am J Obstet Gynecol. 2020:1-7.
4. Liu Y, Chen H, Tang K, et al. Clinical manifestations and outcome of SARS-CoV-2
infection during pregnancy. J Infect. 2020.
5. DA S. An Analysis of 38 Pregnant Women with 2 COVID-19, Their Newborn
Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus
Infections and Pregnancy Outcomes. Arch Pathol Lab Med. 2020:1-25.
6. Mascio DD, Khalil A, Saccone G, et al. Outcome of Coronavirus spectrum
infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and
meta-analysis. Am J Obstet Gynecol. 2020.
7. Breslin N, Baptiste C, Gyamfi-Bannerman C, Martinez R, Bernstein K, Ring L, et
al. Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant
women: two weeks of confirmed presentations to an affiliated pair of New York City
hospitals. Am J Obstet Gynecol. 2020.
8. Yang Z, Wang M, Zhu Z, et al. Coronavirus disease 2019 (COVID-19) and
pregnancy: a systematic review. J Matern Fetal Neonatal Med. 2020:1-4.

This article is protected by copyright. All rights reserved

 9.
Accepted Article Kotlyar AM, Grechukhina O, Chen A, Popkhadze S, Grimshaw A, Tal O, et al.
Vertical transmission of coronavirus disease 2019: a systematic review and meta-
analysis. Am J Obstet Gynecol. 2020.
10. Walker KF, O'Donoghue K, Grace N, Dorling J, Comeau JL, Li W, et al. Maternal
transmission of SARS‐COV‐2 to the neonate, and possible routes for such transmission:
A systematic review and critical analysis. BJOG: An International Journal of Obstetrics &
Gynaecology. 2020;127(11):1324-36.
11. Panahi L, Amiri M, S. P. Risks of Novel Coronavirus Disease (COVID-19) in
Pregnancy; a Narrative Review. Arch Acad Emerg Mede. 2020;8(1):1-5.
12. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical
transmission potential of COVID-19 infection in nine pregnant women: a retrospective
review of medical records. The Lancet. 2020.
13. Lu Q, Y S. Coronavirus disease (COVID‐19) and neonate: What neonatologist
need to know. J Med Virol. 2020;92:564-7.
14. World Health Organization Q&A on coronaviruses (COVID-19)-April 12, 2020.
Available at: [Link]
2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses. Accessed on July 2020. In:
WHO, editor.
15. Zhao X, Jiang Y, Zhao Y, et al. Analysis of the susceptibility to COVID-19 in
pregnancy and recommendations on potential drug screening. Eur J Clin Microbiol Infect
Dis. 2020.
16. Dashraath P, Wong JLJ, Lim MXK, et al. Coronavirus disease 2019 (COVID-19)
pandemic and pregnancy. Am J Obstet Gynecol. 2020.
17. Selim M, Mohamed S, Abdo M, Abdelhaffez A. Is COVID-19 Similar in Pregnant
and Non-Pregnant Women? Cureus. 2020;12(6):e8888.
18. Matar R, Alrahmani L, Monzer N, Debiane LG, Berbari E, Fares J, et al. Clinical
Presentation and Outcomes of Pregnant Women with COVID-19: A Systematic Review
and Meta-Analysis. Clin Infect Dis. 2020.
19. Hirshberg JS, Stout MJ, Raghuraman N. Coronavirus disease 2019 infection
among asymptomatic and symptomatic pregnant women: two weeks of confirmed
presentations to an affiliated pair of New York City hospitals. American Journal of
Obstetrics & Gynecology Mfm. 2020;2(3).

This article is protected by copyright. All rights reserved

 20.
Accepted Article Capobianco G, Saderi L, Aliberti S, Mondoni M, Piana A, Dessole F, et al. COVID-
19 in pregnant women: A systematic review and meta-analysis. Eur J Obstet Gynecol
Reprod Biol. 2020;252:543-58.
21. Chen L, Li Q, Zheng D, Jiang H, Wei Y, Zhou L, et al. Clinical Characteristics of
Pregnant Women with Covid-19 in Wuhan, China. N Engl J Med. 2020.
22. Liu D, Li L, Wu X, et al. Pregnancy and Perinatal Outcomes of Women With
Coronavirus Disease (COVID-19) Pneumonia: A Preliminary Analysis. AJR. 2020;215:1-
6.
23. Dubey P, Reddy SY, Manuel S, Dwivedi AK. Maternal and neonatal characteristics
and outcomes among COVID-19 infected women: An updated systematic review and
meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;252:490-501.
24. Yang H, Hu B, Zhan S, et al. Effects of SARS-CoV-2 infection on pregnant women
and their infants: A retrospective study in Wuhan, China. Arch Pathol Lab Med. 2020.
25. Khan S, Peng L, Siddique R, et al. Impact of COVID-19 infection on pregnancy
outcomes and the risk of maternal-to-neonatal intrapartum transmission of COVID-19
during natural birth. Infect Control Hosp Epidemiol. 2020:1-3.
26. Li N, Han L, Peng M, et al. Maternal and neonatal outcomes of pregnant women
with COVID-19 pneumonia: a case-control study. Clin Infect Dis. 2020.
27. Zimmermann P, Curtis N. COVID-19 in Children, Pregnancy and Neonates: A
Review of Epidemiologic and Clinical Features. Pediatr Infect Dis J. 2020;39(6):469-77.
28. Elshafeey F, Magdi R, Hindi N, Elshebiny M, Farrag N, Mahdy S, et al. A
systematic scoping review of COVID‐19 during pregnancy and childbirth. International
Journal of Gynecology & Obstetrics. 2020;150(1):47-52.
29. Zaigham M, Andersson O. Maternal and perinatal outcomes with COVID-19: A
systematic review of 108 pregnancies. Acta Obstet Gynecol Scand. 2020;99(7):823-9.
30. Smith V, Seo D, Warty R, Payne O, Salih M, Chin KL, et al. Maternal and neonatal
outcomes associated with COVID-19 infection: A systematic review. Plos one.
2020;15(6):e0234187.
31. Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C.
Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal
outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2020:1-13.

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 32.
Accepted Article Fan C, Lei D, Fang C, et al. Perinatal Transmission of COVID-19 Associated
SARS-CoV-2: Should We Worry? Clin Infect Dis. 2020.
33. Fox NS, S. M. COVID-19 in Pregnant Women: Case Series From One Large New
York City Obstetrical Practice. Am J perinatol. 2020.
34. Hessami K, Homayoon N, Hashemi A, Vafaei H, Kasraeian M, Asadi N. COVID-19
and maternal, fetal and neonatal mortality: a systematic review. J Matern Fetal Neonatal
Med. 2020:1-6.
35. Kasraeian M, Zare M, Vafaei H, Asadi N, Faraji A, Bazrafshan K, et al. COVID-19
pneumonia and pregnancy; a systematic review and meta-analysis. J Matern Fetal
Neonatal Med. 2020:1-8.
36. yang H, Sun G, Tang F, et al. Clinical features and outcomes of pregnant women
suspected of coronavirus disease 2019. J Infect. 2020;16(3):1-5.
37. Hantoushzadeh S, Shamshirsaz AS, Aleyasin A, et al. Maternal Death Due to
COVID-19 Disease. Am J Obstet Gynecol. 2020.
38. DA S. The Effects of Pregnancy on Women with COVID-19: Maternal and Infant
Outcomes. Clin Infect Dis. 2020.
39. Juusela A, Nazir M, M. G. Two Cases of COVID-19 Related Cardiomyopathy in
Pregnancy. Am J Obstet Gynecol MFM. 2020.
40. Ellingtion S, Strud P, Tong VT, et al. Morbidity and Mortality Weekly Report
(MMWR). In: Prevention CfDCa, editor.: CDC; June 2020. p. 769-75.
41. Chen Y, Peng H, Wang L, et al. Infants Born to Mothers With a New Coronavirus
(COVID-19). Front Pediatr. 2020:1-5.
42. Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, et al. Vertical Transmission of
Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A
Review. Fetal and Pediatr Pathol. 2020.
43. Alzamora MC, Paredes T, Caceres D, et al. Severe COVID-19 during Pregnancy
and Possible Vertical Transmission. Am J Perinatol. 2020.
44. Chen S, Huang B, Luo DJ, et al. Pregnancy With New Coronavirus Infection:
Clinical Characteristics and Placental Pathological Analysis of Three Cases. Zhonghua
Bing Li Xue Za Zhi. 2020;49(5):418-23.
45. Yang Z, Liu Y. Vertical Transmission of Severe Acute Respiratory Syndrome
Coronavirus 2: A Systematic Review. Am J Perinatol. 2020;37(10):1055-60.

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 46.
Accepted Article (RCOG) RCoOaG. Coronavirus (COVID-19) Infection in Pregnancy June 2020
[Available from: [Link] Accessed on August
25th 2020
47. (ACOG) TACoOaG. Novel Coronavirus 2019 (COVID-19) July 2020 [Available
from: [Link]
advisory/articles/2020/03/novel-coronavirus-2019: Accessed on august 25th 2020

Table 1. Pregnancy outcomes in women with COVID-19 seen in various studies.

Author and Country Study Study Maternal effects Fetal effects
year design population
with COVID-
19 infection
(n)
Capobianco et China Systematic 13  Most  Most
al. [20], July review and publications commonly reported frequent neonatal
2020 meta- (n=114) symptoms: fever complications:
analysis (retrospective and cough pneumonia and
studies,  Maternal respiratory distress
cohort study, complications syndrome
case series, pooled prevalence:  Infected
and case 45.0% (95% CI 24.0 infants pooled
reports) –67.0) proportion: 6.0%
 Admission (95% CI 2.0–12.0)
to ICU: <20%
 Preterm
infants pooled
proportion: 23.0%
(95% CI 11.0–39.0)

Dubey et al. Global Systematic 61  Most  Low birth

[23], July 2020 review and publications common weight: 7%
meta- (790 COVID- presentations: fever,  Neonatal
analysis 19-positive cough, and dyspnea COVID-19 infection:
women and (not requiring 1%
548 infants) mechanical
ventilation)

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Accepted Article  Lymphopeni
a: 46%
 Elevated
CRP: 48%
 Cesarean
delivery: 72%
 Adverse
pregnancy
outcomes (preterm
births and
death/stillbirth or
early terminated
pregnancies): 27%
Elshafeey et Global Systematic 33  Mild  RT‐PCR
al. [28], April review publications symptoms (95.6%), positive: 1.6%
2020 (385 COVID- severe (3.6%),  Neonatal
19 positive critical (0.8%) death: 0.4%
pregnant  Mechanicall
women and y ventilated: 1.5%
256 infants)  Maternal
mortality: 0.3%
 Cesarean
delivery: 69.4%
Zaigham and Global Systematic 18  Most  Intrauterine
Andersson review of publications presented at third death: 1
[29], April case series (n=108) trimester: 68%  IUGR: 1
2020 and case  Most
reports presenting
symptoms: fever
and cough
 Lymphocyto
penia: 59%
 Elevated
CRP: 70%
 Cesarean
delivery: 91%
 Admission

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Accepted Article to ICU: 3 patients

Smith et al. Global Systematic 9 publications  Symptomati  Admission to

[30], June review on COVID- c: 67.4% NICU: 76.92%
2020 19-positive  RT-PCR  Low birth
pregnant inferior to CT-based weight: 42.8%
women diagnosis: 31.7%
(n=92)  Mechanical
ventilation and ICU:
1 patient
 Maternal
mortality: 0%
 Caesarean
delivery: 80%
 Preterm
births: 63.8%
 Fetal
distress: 61.1%
Trocado et al. China Systematic 8 publications  Most  Neonatal
[31], July 2020 review of commonly reported death: 2%
case series symptoms: fever  Severe
and case (55%), cough neonatal asphyxia:
reports (38%), and fatigue 0%
(11%)  Positive for
 PROM: 5% Sars-CoV-2: 2%
 Fetal  Pneumonia
distress: 14% but negative for
 Postpartum SARS-CoV-2: 13%
fever: 8%

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 Li et al. [26],
Accepted Article China Case- 16 confirmed,  Fever and  No infant
March 2020 control 18 suspected cough at the time of with COVID-19
study presentation in few infection
patients  None
 Most had developed severe
COVID-19 neonatal
pneumonia complications
 None had
respiratory failure
 All had
cesarean delivery
apart from 2
Chen et al. China Retrospecti 9  7 patients  9 live births;
[12], February ve study had fever, sore no neonatal asphyxia
2020 throat, myalgia, and  1 min Apgar
cough score 8–9 and 5-min
 None score 9–10
developed COVID-  No evidence
19 pneumonia of intrauterine
 None died transmission of
disease
Liu et al. [4], China Retrospecti 13  Cesarean  No evidence
March 2020 ve study delivery: 77% suggested vertical
 Pregnancy transmission of
complications disease
included preterm
delivery (46%), fetal
distress (30%),
PROM (10%), and
stillbirth (10%)
 Admission
to ICU: 1 patient
Yang et al. China Retrospecti 13 confirmed  Mild  57
[36], April ve study symptoms with newborns; all tested
2020 fever and dry negative for SARS-
cough, no CoV-2
expectoration

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Accepted Article  Cesarean
delivery: 69%:
vaginal delivery:
31%
 No serious
complications or
death
Yang et al. China Retrospecti 27  Viral  24 live
[24], May 2020 ve study pneumonia: 26 births, of which 23
 Severe were full-term with
pneumonia after good Apgar score
delivery: 1 patient  23 newborns
 No maternal tested negative for
deaths SARS-CoV-2
 Pre-term infection
delivery due to  1 newborn
PROM: 1 had high IgG and
IgM levels 2 h after
birth but tested
negative in repeated
RT-PCR
Liu et al. [22], China Retrospecti 15  Mild  No cases of
July 2020 ve study symptoms in all neonatal death or
patients with asphyxia with normal
COVID-19 Apgar scores at 1
pneumonia min and 5 min
 No adverse  No neonates
effects were infected
 Cesarean
delivery: 67%;
vaginal delivery: 7%

Abbreviations: ARDS, acute respiratory distress syndrome; CI, confidence interval;

COVID-19, coronavirus disease 2019, CRP, C-reactive protein; IgG, immunoglobulin G;
IgM, immunoglobulin M; ICU, intensive care unit; IUGR, intrauterine growth retardation;
NICU, neonatal intensive care unit; PROM, premature rupture of membranes; RT-PCR,

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 reverse transcription polymerase chain reaction; SARS-CoV-2, severe acute respiratory
Accepted Article
symptom coronavirus 2.

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