Background: COVID-19 pandemic originated in China in late 2019, the number of cases are increasing with 2,104,346 cases and 116,140 deaths in the United States, as of June 16, 2020. Pregnant women are a vulnerable population in epidemics or Pandemics. This Review is designed to look in detail the severity of COVID-19 in pregnant women in comparison to non-pregnant women of reproductive age.
Methods: Literature search on PubMed, Google Scholar, Lancet, and Web of Science were conducted.
Results: We have found the evidence of increased risk for severe disease and distinctive symptoms among pregnant women diagnosed with COVID-19 as compared to non-pregnant women.
Conclusions: COVID-19 presents in an atypical fashion in pregnant women with comparatively increased severity of symptoms, compared to COVID-19 positive non pregnant women of reproductive age. These findings can help clinicians to recognize the risk posed by COVID-19 in pregnant women

Abdelhaleem, Ahmed

Durugu, Satya

Eladely, Ahmed A

Imran, Zahid

Salunkhe, Vidyulata

Sangroula, Daisy

English

Introduction: The COVID-19 pandemic originated in China in late 2019; the number of cases is increasing with 2,104,346 cases and 116,140 deaths in the United States as of June 16, 2020. Pregnant women are a vulnerable population in epidemics or pandemics. This review is designed to look in detail at the severity of COVID-19 in pregnant women compared to non-pregnant women of reproductive age.
Methods: Literature searches on PubMed, Google Scholar, the Lancet, and Web of  Science were conducted.
Results: We found evidence of increased risk for severe disease and distinctive symptoms among pregnant women diagnosed with COVID-19 compared to non-pregnant women.
Conclusions: COVID-19 presents in an atypical fashion in pregnant women, with increased severity of symptoms compared to COVID-19-positive non-pregnant women of reproductive age. These findings can help clinicians to recognize the risk posed by COVID-19 in pregnant women

University of Louisville

University of Louisville Journal of Respiratory InfectionsBRIEF REVIEWULJRI | https://doi.org/10.18297/jri/vol4/iss1/59 1AbstractIntroduction: COVID-19 pandemic originated in China in late 2019, the number of cases are increasing with 2,104,346 cases and 116,140 deaths in the United States, as of June 16, 2020. Pregnant women are a vulnerable population in epidemics or Pandemics. This Review is de-signed to look in detail the severity of COVID-19 in pregnant women in comparison to non-preg-nant women of reproductive ageMethods: Literature search on PubMed, Google Scholar, Lancet, and Web of Science were conducted.Results: We have found the evidence of increased risk for severe disease and distinctive symptoms among pregnant women diagnosed with COVID-19 as compared to non-pregnant women.Conclusions: COVID-19 presents in an atypical fashion in pregnant women with comparatively increased severity of symptoms, compared to COVID-19 positive non pregnant women of re-productive age. These findings can help clinicians to recognize the risk posed by COVID-19 in pregnant women.IntroductionCoronavirus disease (COVID-19) pandemic originated in Wuhan China in December, 2019. [1] Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spread rapidly to most parts of the world including the USA. The number of infected people and deaths are still increasing. [2] SARS-CoV-2 has a similar receptor-binding structural component as SARS-CoV-1 which leads to possibility of similar pathogenesis as of SARS-CoV-1 in-fection. [3] Coronavirus affects people of all ages, but it affects immunocompromised people and people with underlying medical conditions such as cancer, chronic kidney disease, COPD, obesity, serious heart conditions, sickle cell disease and type 2 diabetes mellitus with a higher rate of complications. [4] Physiological changes of Pregnancy make women more vulnerable to infections by certain intracellular pathogens includ-ing viruses, intracellular bacteria and parasites. [5] Pregnant women represent high risk population during infectious disease outbreaks. Dominant effect of T- helper 2 system during pregnancy which protects fetus and leaves mother vulnerable to viral infections. [6] Pregnant women were disproportionately affected during SARS-CoV-1 epidemic re-sulting in higher morbidity and mortality. [7]This review discusses the presentation and severity of COVID-19 in pregnant women. Pregnant women can be more prone to severe manifestation of COVID-19, as depicted by their vulnerability to respiratory infections (5). The data regarding clinical characteristics and severity of COVID-19 in pregnant women is limited. Objective of this review is to find whether signs, symptoms and severity differ among pregnant and non-pregnant women with COVID-19.Recommended Citation:Imran, Zahid; Salunkhe, Vidyulata; Eladely, Ahmed; Abdelhaleem, Ahmed; Durugu, Satya; and Sangroula, Daisy (2020). “COVID-19 is Associated with Increased Severity in Preg-nant Women,” The University of Louisville Journal of Respiratory Infections: Vol. 4, Iss. 1, Article 59. Received Date: August 3, 2020Accepted Date: September 4, 2020Published Date: September 16, 2020Copyright: © 2020 The author(s). This origi-nal article is brought to you for free and open access by ThinkIR: The University of Louis-ville’s Institutional Repository. For more infor-mation, please contact thinkir@louisville.edu. This article is distributed under the terms of the Creative Commons Attribution 4.0 Internation-al License (CC BY 4.0), which permits unre-stricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Funding Source: The author(s) received no specific funding for this work.Conflict of Interest: All authors declared no conflict of interest in relation to the main objec-tive of this work.COVID-19 is Associated with Increased Severity in Pregnant WomenZahid Imran1*,MD; Vidyulata Salunkhe1, MPH MD; Ahmed Eladely1, MD; Ahmed Abdelhaleem1, MD; Satya Durugu1, MD; Daisy Sangroula2, MD1Center of Excellence for Research in Infectious Diseases, Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, KY, USA, 2Department of Anesthesiology and Periop-erative Medicine, University of Louisville School of Medicine, Louisville, KY, USA*zahid.imran@louisville.eduULJRI | https://doi.org/10.18297/jri/vol4/iss1/59 2ULJRI COVID-19 is Associated with Increased Severity in Pregnant WomenMethodsAll published articles related to COVID-19’s effect on pregnancy were reviewed. Literature search on PubMed, Google Scholar, Lancet and Web of Science were conducted using keywords including “COVID-19, Pregnancy”, “Coronavirus 2019, Pregnancy”, “SARS-CoV-2, Pregnancy” and “2019-nCoV, Pregnancy” from December 2019 to May 5, 2020.Two studies were included in the analysis. [8,9] These were retrospective studies conducted in China from February to April 2020. These studies compared clinical course and outcomes between pregnant and non-pregnant women with COVID-19. DefinitionsThe severity of disease was classified as follows [8,9]:1. Mild – Mild symptoms without radiological evidence of pneumonia.2. Moderate – Fever and respiratory symptoms are present along with radiological findings of pneumonia.3. Severe – Shortness of breath, with respiratory rate ≥ 30 breaths/minute, or oxygen saturation ≤ 93% at rest, or alve-olar oxygen partial pressure/fraction of inspiration O2 (PaO2/FiO2) ≤ 300 mmHg.4. Critical – Respiratory failure requiring mechanical ventilation, or shock, or other organ failures that required in-tensive care unit admission.Statistical AnalysisThe differences between pregnant and non-pregnant women were analyzed using Chi-square test and p < 0.05 was considered statistically significant.ResultsAs depicted in Table 1, a total of 148 female patients with COVID-19 were analyzed. Among these 59 patients were preg-nant. Age range of the patients included in study was 20-40 years. Our review reported fever (37.28%), cough (37.28%) and dyspnea (16.95%) among pregnant women. Whereas fever (66.29%), cough (53.93%) and dyspnea (16.85%) was seen in non-pregnant women. Fever and cough were more common in non-pregnant women and dyspnea was compa-rable between the two groups.The disease severity of COVID-19 was mild/moderate more among non-pregnant (94.38%) women as compared to pregnant women (79.66%). Severe COVID-19 was more common in pregnant women (20.33%) as compared to non-preg-nant (5.62%) which was statistically significant. Table 1. Clinical haracteristics of COVID-19 positive pregnant vs. nonpregnant women of reproductive age.Characteristics TotalN=148PregnantN=59NonpregnantN=89 PSymptoms, n (%)Fever 81 (54.73) 22 (37.28) 59 (66.29) 0.001Cough 70 (47.29) 22 (37.28) 48 (53.93) 0.069Dyspnea 25(16.89) 10(16.95) 15(16.85) >0.009Abdominal Pain 6 (4.05) 6 (10.17) 0 (0.00) 0.003Signs, n (IQR)Heart rate 86.65 (76.96-102.27) 88.5 (78.55-99.95) 85 (76.57-100.7) NA*Respiratory rate 20.35 (17.85-22.35) 20.35 (18.05-21.65) 20.3 (17.6-22) NASeverity n (%)Mild/Moderate 131 (88.51) 47 (79.66) 84 (94.38) 0.013Severe 17 (11.45) 12 (20.33) 5 (5.62) 0.008Length of Hospital stay, n (IQR) 16.8 (11.41-23.13) 15.65 (11.2-23.22) 18.1 (11.42-22.8) NA*NA=Not ApplicableULJRI | https://doi.org/10.18297/jri/vol4/iss1/59 3ULJRI COVID-19 is Associated with Increased Severity in Pregnant WomenDiscussionOur review showed that pregnancy was associated with higher incidence of severe COVID-19. Most of the COVID-19 positive pregnant patients included in the studies were symptomatic. Our review revealed that fever and cough are present less frequently in pregnant women. Dyspnea is present in a similar proportion among both groups. It is im-portant to note that COVID-19 is more severe in pregnant women and the difference is significant according to the statistical analysis.Pregnancy is considered an immunocompromised state mainly due to the predominance of the T helper-2(Th-2) sys-tem. Th-2 system prevents the rejection of the “foreign” fetus. The balance shift in favor of Th-2, which decreases the functionality of T helper-1 which are responsible for clearing pathogens, especially viruses. Th-1 lymphocytes produce cytokines which are microbicidal and proinflammatory. This increases morbidity by increasing maternal susceptibility to intracellular pathogen and can lead to increase severity of infection. [6]Our review showed pregnant women had less symptoms as compared to non-pregnant women which can cause delay in diagnosis and contact tracing, which can lead to unchecked viral shedding and community transmission. [6] Symptoms like shortness of breath can be difficult to distinguish from pathological dyspnea. In pregnancy, physiologi-cal dyspnea is common due to increased maternal oxygen demand and higher fetal oxygen consumption. Progesterone acts as trigger of the primary respiratory center by increasing the sensitivity of respiratory center to carbon dioxide. [10] Also, gravid uterus results in decreased lung capacity starting at mid-second trimester and progressively decreas-ing towards term, which can cause shortness of air. [11] During pregnancy, gestational rhinitis is also common due to estrogen-mediated hyperemia of the nasopharynx which may mask COVID-19 symptoms. A recent case series of 9 women showed that symptoms of COVID-19 in pregnant women were similar to that of non-pregnant women. Most common symptoms were fever, cough, myalgia, and sore throat. Most common lab finding was lymphopenia. [12] In the CDC reported data of 8,207 pregnant women, symptoms were reported among 65.2% of pregnant women and 90% of non-pregnant women. Cough (>50%) and shortness of breath (30%) was present in similar number among preg-nant and non-pregnant women but pregnant women reported lower incidence of headaches, muscle aches, fever, chills, and diarrhea than non-pregnant women. Among 8,207 COVID-19 positive pregnant women, approximately 31.5% of pregnant women were reported to be hospi-talized compared with 5.8% of non-pregnant women. After adjusting for age, underlying medical conditions and race, pregnant women were significantly more likely to be admitted to the intensive care unit (ICU) (ARR = 1.5, CI= 1.2–1.8) and receive mechanical ventilation (ARR = 1.7, CI = 1.2–2.4). Sixteen (0.2%) COVID-19 related deaths were reported among pregnant women and 208 (0.2%) such deaths were reported among non-pregnant women (ARR = 0.9, CI = 0.5–1.5). [13] 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 mechanical ventilation compared with non-pregnant women, but their risk for death is similar.In conclusion, our data suggest that COVID-19 during pregnancy is associated with high risk for severe disease and a distinctive symptom profile that may delay diagnosis. Therefore, routine SARS-CoV-2 screening in pregnancy will be beneficial in making early diagnosis and facilitate early treatment. Caution should be practiced by pregnant women by regularly washing hands, using hand sanitizer, face mask and minimizing the exposure to symptomatic people. Tele-health is a viable option in pregnant women for minimizing the exposure wherever possible. It is necessary to follow pregnant women pre and post-delivery to ensure proper care and education regarding isolation, breastfeeding and proper care of pregnant woman and the infant. There is need for studies to look into overall impact and long-term out-comes of pregnant women affected by COVID-19.ULJRI | https://doi.org/10.18297/jri/vol4/iss1/59 4ULJRI COVID-19 is Associated with Increased Severity in Pregnant WomenReferences 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020 Feb;395(10223):507–13. https://doi.org/10.1016/S0140-6736(20)30211-7 PMID:320071432. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed. 2020 Mar;91(1):157–60. PMID:321916753. Qiao J. What are the risks of COVID-19 infection in pregnant women? Lancet. 2020 Mar;395(10226):760–2. https://doi.org/10.1016/S0140-6736(20)30365-2 PMID:321513344. Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al.; China Medical Treatment Expert Group for COVID-19. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J. 2020 May;55(5):2000547. https://doi.org/10.1183/13993003.00547-2020 PMID:322176505. Jamieson DJ, Theiler RN, Rasmussen SA. Emerging infections and pregnancy. Emerg Infect Dis. 2006 Nov;12(11):1638–43. https://doi.org/10.3201/eid1211.060152 PMID:172836116. Dashraath P, Wong JL, Lim MX, Lim LM, Li S, Biswas A, et al. Coronavirus disease 2019 (COVID-19) pandem-ic and pregnancy. Am J Obstet Gynecol. 2020 Jun;222(6):521–31. https://doi.org/10.1016/j.ajog.2020.03.021 PMID:322171137. 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Taiwan J Obstet Gynecol. 2017 Aug;56(4):432–6. https://doi.org/10.1016/j.tjog.2017.04.035 PMID:2880559612. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020 Mar;395(10226):809–15. https://doi.org/10.1016/S0140-6736(20)30360-3 PMID:3215133513. Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, et al. Characteristics of Women of Repro-ductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020 Jun;69(25):769–75. https://doi.org/10.15585/mmwr.mm6925a1 PMID:32584795

COVID-19 is Associated with Increased Severity in Pregnant Women

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COVID-19 is Associated with Increased Severity in Pregnant Women

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