Prenatal and neonatal complications of COVID-19: A systematic review.

BACKGROUND AND AIMS: The outbreak of coronavirus disease 2019 (COVID-19) over the past year has affected public health worldwide. During pregnancy, the maternal immune system and inflammatory responses are widely suppressed. Pregnancy-related immune system suppression could make the mother vulnerable to infectious diseases like SARS-COV-2. However, current data suggest little to no possibility of COVID-19 transmission in pregnant women to the fetus during pregnancy or childbirth. This systematic review focused on the possible complications of COVID-19 infection in the fetus and newborn babies including the possibility and evidence of vertical transmission by reviewing articles published during the first year of the COVID-19 pandemic.
METHODS: We conducted a systematic search using keywords on PubMed, Embase, and Scopus databases. The studies followed a title/abstract and a full-text screening process, and the eligible articles were included in the study.
RESULTS: In total, 238 published papers were identified using a systematic search strategy (44 articles met the inclusion criteria and were included in the final review). In all studies, a total of 2375 women with signs and symptoms of COVID-19, who were in the second and third trimester of pregnancy, were assessed mild to moderate pneumonia was one of the most common symptoms. Seventy-three percent of the women did not present any comorbidity, 19% had a fever, 17% had to cough as the most frequent clinical signs and symptoms, 7.5% had pulmonary changes with chest scans, 8% had increased C reactive protein, and 9.4% had decreased lymphocytes (lymphocytopenia). A total of 2716 newborns and fetal were assessed; the delivery method of 1725 of them was reported, 913 (53%) through C-section delivery, and 812 through normal vaginal delivery (47%). Of total newborns, 13 died (five died along with the mother), and 1965 were tested for SARS-CoV-2:118 tested positive. In a study, vertical transmission in seven cases was reported in total of 145 cases assessed.
CONCLUSION: It appeared that most pregnant COVID patients were mildly ill, and there is currently no convincing evidence to support the vertical transmission of COVID-19 disease. Therefore, neonates do not represent any additional risk for adverse outcomes neither during the prenatal period nor after birth.

INTRODUCTION

The outbreak of coronavirus disease 2019 (COVID‐19) over the past year has affected public health worldwide and led to many deaths. , As of January 8, 2021, a total of 86 436 449 clinically confirmed COVID‐19 positive and 1 884 341 death reported globally. Mothers and newborns are at‐risk populations and need special attention.

During pregnancy, the maternal immune system and inflammatory responses are widely suppressed, and the fetus in the womb without the mother’s immune system attacking. Pregnancy‐related immune system suppression could make the mother vulnerable to infectious diseases and increases the risk of being infected, including coronavirus‐related diseases. , Studies exploring the indirect adverse events of COVID‐19 on the population have reported that pregnant women are at greater potential risk. , , Maternal death, stillbirth, ruptured ectopic pregnancy, and maternal depression have had significant increase during the pandemic, albeit the symptoms and severity of COVID‐19 are as mild in most pregnant women as in the general population. , , , Moreover, the findings of a study showed asymptomatic infection in one‐third of pregnant women. The most common symptoms reported in COVID‐19‐positive pregnant women are fever, shortness of breath, diarrhea, and cough. In some severe cases, mechanical ventilation was performed , , , , , and maternal deaths were reported. , , In a systematic review of the effects of COVID‐19 on perinatal and maternal outcomes, the findings of studies from high‐income countries (HICs) and low‐income and middle‐income countries (LMICs) showed a significant heterogeneity in the incidence of pregnancy complications; meaning that the adverse outcomes were much higher in LMICs. It also found that lack of immediate healthcare response in LMICs was responsible for heterogeneity of most of the outcomes rather than the stringent lockdown measures. The COVID‐19 pandemic has manifested several lacunae in healthcare systems around the world, widening the gap between HICs and LMICs.

There are still many challenges related to SARS‐CoV‐2 infection in newborns and approaching the respiratory involvement in the case of infection. However, the possibility of COVID‐19 transmission from pregnant women to the fetus during pregnancy or childbirth is still unknown. , The consequences of pregnancy‐related diseases could be detrimental to both mother and fetus. , Although most studies considered the vertical transmission unlikely, , , , , , , a recent case report of a newborn with a positive early test indicated the possibility of vertical transfer in the uterus. Additionally, four births with COVID‐19 have been reported in recent studies. , , Several clinical symptoms such as fever, , disseminated intravascular coagulation, feeding intolerance, bleeding, cyanosis, birthing problems, , rash, edema, dyspnea, , and pneumonia39 have been reported in neonates born from mothers infected with COVID‐19.

One of the World Health Organization (WHO) millennium development goals is to preserve pregnant mother's and babies' lives ; therefore, knowing how coronavirus affects maternal and fetal health can help to prevent complications. This systematic review focused on the possible complications of COVID‐19 infection in the fetus and newborns by reviewing articles published during the SARS‐CoV‐2 pandemic in the past year.

METHODS

Design

We conducted a systematic search using keywords on PubMed, Embase, and Scopus databases. The identified records were screened by title/abstract to meet the inclusion criteria. Following this step, the full text of the included studies were evaluated based on the parameters mentioned in Section 2.2.Two researchers then extracted the data of the retrieved articles for drafting this systematic review.

Search strategy

We utilized the following search strategy using the approach mentioned in [C].

[Neonatal*] OR [Newborn*] OR [Maternal*] OR [Prenatal*] OR [Fetus*] OR [Fetal*] OR [Embryo*] (Title/Abstract)

[Covid‐19] OR [SARS‐CoV‐2] OR [SARS‐CoV2] OR [Novel coronavirus] OR [2019‐nCoV] (Title/Abstract)

[A] AND [B]

Eligibility criteria

We performed the systematic search and included the original studies cohering to the aim of our study from December 2019 to August 2021.

The exclusion criteria were the following:

Reviews and other nonoriginal studies

Ongoing studies and clinical trials

Laboratory and animal studies

Abstracts, conference abstracts, and articles not possessing an available full‐text

RESULTS

In total, 238 documents were identified using a systematic search strategy. After the initial review of the retrieved articles, duplicates were removed and the title and abstract of the remaining sources were reviewed. Based on the selection criteria, 44 articles were eventually included in the final review (Tables 1 and 2).

TABLE 1

Symptoms of COVID‐19 in pregnant women reported in the included studies

ID	Study	Country	Maternal age (years)	GA on admission (weeks)	Symptoms								Other symptoms
					Fatigue	Shortness of breath	Dyspnea	Sore throat	Cough	Fever	Diarrhea/GI symptoms	Malaise
1	Zheng et al. 44	China	33, 29	36 + 3, 39 + 4	—	—	—	—	—	√	—	—	Limb asthenia fetal distress
2	Zamaniyan et al. 24	Iran	22	32	—	—	√	—	√	√	—	—	Myalgia, anorexia, nausea (maternal death)
3	Yu et al. 45	China	30–34	37–41 + 2	—	Yes	—	—	√	√	√	—	Liver function abnormality
4	Wu et al. 46	China	29, 59	35–36, 37–38, 39‐41	—	√	—	—	√	√	√	—	Vomiting PROM fetal distress
5	Wu X 47	China	24–37	6–40	—	—	—	—	√	√	—	—	Fetal intrauterine hypoxia—Nasal obstruction PROM Threatened abortion
6	Spencer et al. 48	USA	33	39	—	—	—	—	√	√	—	√	d‐transposition of the great arteries with an intact ventricular septum
7	Santana‐Cabrera 49	Spain	44	29 + 2	—	—	—	—	√	√	√	—	Odynophagia
8	Salvatore et al. 50	USA	NR	Median 38 (27–41)	—	√	—	—	√	√	√	—	Rhinorrhea, myalgia, headaches, anosmia, or ageusia
9	Pirjani et al. 51	Iran	30.97	36.57	√	—	√	—	√	√	√	—	Myalgia, pharyngalgia, tachycardia, tachypnea, hemoptysis, headache, anosmia, vomiting, dysgeusia
10	Oncel et al. 52	Turkey	NR	37, 35	—	—	—	—	—	—	—	—	Maternal death (4.8%)
11	Liu et al. 53	China	26–38	35 + 2–41 + 2	—	—	√	—	√	√	√	—	—
12	Liu et al. 54	China	32	37.41	—	—	—	—	√	√	√	—	—
13	Lowe and Bopp 55	Australia	31	40 + 2	—	—	—	—	—	√	—	—	—
14	Martínez‐Perez et al. 56	Spain	35 (19–43), 33 (19–48)	39 + 1, 38 + 3	—	—	—	—	—	—	—	—	Oxygen supplementation at admission PROM
15	Khan et al. 33	China	27–34	31–39	—	—	—	√	√	√	—	—	—
16	Koumoutsea et al. 57	Canada	40, 23	35 + 3, 35 + 2	—	—	—	—	√	√	—	—	Tachycardic, progressive thrombocytopenia, declining fibrinogen, and rising APTT with concomitant improvement in neutrophil count, Mild
17	Khan et al. 39	China	28, 33, 27	34 + 6, 39 + 1, 38 + 2	—	—	—	—	√	√	—	—	—
18	Juusela et al. 58	USA	26, 45	39 + 2, 33 + 6	—	√	√	—	—	√	—	—	Tachycardia, pulmonary edema, acute heart failure, tachypnea. Tachycardia, acute heart failure
19	Hantoushzadeh et al. 23	Iran	25–49	24–38	—	√	√	√	√	√	—	√	ARDS = 5 Rhinorrhea, Viral pneumonia, acute hypoxemia, persistent hypoxia, end‐organ failure tachycardia, acute renal failure, septic shock and disseminated intravascular coagulopathy, left heart failure, lymphopenia, tachypnea, hypoxemia, hemoptysis
20	Griffin et al. 59	USA	—	39.0 ± 1.4	—	√	√	—	—	√	√	√	—
21	Ferrazzi et al. 60	Italy	21–44	34–37<	—	—	√		√	√	√	√	Pneumonia
22	Dos Santos Beozzo et al. 61	Brazil	—	33 4/7–38 4/7	—	—	—	—	√	—	—	—	Sepsis and urinary tract infection
23	Antoun et al. 62	UK	29.3 ± 2.9	38.7 ± 1.4	—	√	√	—	√	—	√	—	Chest pain, abdominal pain
24	Buonsenso et al. 63	Italy	—	17‐38	—	√	—	—	√	√	—	—	Ageusia/anosmia Relative lymphocytopenia
25	Abasse et al. 64	France	36	33	—	—	√	√	√	—	—	—	Bronchiectasis
26	Alonso Díaz et al. 65	Spain	41	38 + 4	—	—	—	—	—	√	—	—	Pneumonia
27	Alzamora et al. 17	Peru	41	33	√	—	√	√	—	√	—	—	—
28	Coronado Munoz et al. 66	USA	21	36	—	—	—	—	—	—	—	—	—
29	Iqbal et al. 34	USA	34	39	—	—	—	—	√	√	—	√	Chills
30	Kalafat et al. 67	Turkey	32	35 + 3	—	—	√	√	√	—	—	—	Pneumonia
31	Kulkarni et al. 68	India	24	38 + 2	—	—	—	—	—	√	—	—	Body ache
32	Kelly et al. 69	USA	—	33	—	—	—	—	—	√	—	—	Tachycardia, tachypnea, lymphopenia, mild elevation of liver enzymes, atelectasis
33	Villar et al. 70	UK	30.2 ± 6.1	37.9 ± 3.3	—	√	√	—	√	√	√	—	Infection requiring antibiotics, 1.6% death, ICU admission
34	Al‐Matary et al. 71	Saudi Arabia	32	38	√	‐	√	√	√	√	√	√	Premature birth, preeclampsia, leukopenia, neutropenia, thrombocytopenia, death, rise in ALT and AST, myalgia, chest pain
35	Angelidou et al. 72	USA	30.4 ± 6.3	37.9 ± 2.6	—	—	—	—	—	—	—	—	—
36	Rabiei et al. 73	Iran	38	29 + 2	—	—	—	—	√	√	—	—	Myalgia
37	Puneet et al. 74	India	24.7 ± 2.4	36.6 ± 3.3	—	—	—	—	—	—	—	—	—
38	Oncel et al. 75	Turkey	—	35	—	—	—	—	—	—	—	—	Death, admission to ICU
39	Mullins et al. 76	UK	31.8 ± 5.5	—	√	√	—	—	√	√	√	—	Chest pain, anosmia, hoarse voice, myalgia, abdominal pain, delirium. death
40	Akbarian‐Rad et al. 77	Iran	—	37 ± 3.19	—	—	√	—	—	√	—	—	Lymphopenia, pulmonary involvement
41	Hcini et al. 78	France	—	25	√	√	—	—	√	√	√	—	Headache, loss of taste and smell
42	Di Guardo et al. 43	Italy	—	36 + 5	—	—	—	—	—	—	—	—	Death, admission to ICU
43	Teixeira et al. 79	Brazil	28	38	√	—	√	√	√	√	√	—	Headache, ageusiam, myalgia, chest pain, chills
44	Halici‐Ozturk et al. 80	Turkey	—	30.58 ± 5.8	√	√	√	√	√	√	√	—	—

Abbreviations: ALT, alanine aminotransferase; APTT, activated partial thromboplastin time; ARDS, acute respiratory distress syndrome; AST, aspartate aminotransferase; GA, gestational age; GI, gastrointestinal; ICU, intensive care unit; PROM, preterm premature rupture of membranes.

TABLE 2

Neonatal outcomes of pregnancies with COVID‐19 reported in the included studies

ID	Study	Birth weight	Neonatal medical complication							Other complication	Neonatal mortality
			Pneumonia	Shortness of breath	Dyspnea	Respiratory tract symptoms	Cough	Fever	Vomiting
1	Zheng et al. 44	2520, 3520	√	—	—	—	—	—	√	Congenital talipesequinovarus (clubfoot) myocardial injury	—
2	Zamaniyan et al. 24	2350	—	—	—	—	—	√	—	—	—
3	Yu et al. 45	3200–3500	—	√	—	—	—	—	—	Mild pulmonary infection	—
4	Wu Y. T 46	2760–3570	—	√	—	—	√	√	√	Necrotizing enterocolitis, stuffy nose, pneumonia—like lung image	—
5	Wu et al. 47	NR	—	—	—	—	—	—	—	Neonatal jaundice	—
6	Spencer et al. 48	3320	—	—	—	—	—	—	—	d‐transposition of the great arteries with an intact ventricular septum	—
7	Santana—Cabrera 49	NR	—	—	—	—	—	—	—	—	—
8	Salvatore et al. 50	3110, 3410	—	—	—	—	—	—	—	Feeding intolerance and short bowel syndrome	—
9	Pirjani et al. 51	NR	—	—	—	—	—	—	—	—	—
10	Oncel et al. 52	3140, 2465	—	—	—	—	√	√	—	Tachypnea Feeding intolerance	√
11	Liu et al. 53	2500–4120	—	—	—	—	—	—	—	—	—
12	Liu et al. 54	3001	—	—	—	—	—	—	—	Investigating laboratory results of the neonates	—
13	Lowe and Bopp 55	—	—	—	—	—	—	—	—	—	—
14	Martínez‐Perez et al. 56	3060, 3210	√	—	—	—	—	—	—	NICU admission	—
15	Khan et al. 33	2960–3300	—	—	—	—	—	—	—	NRDS NICU admission	—
16	Koumoutsea et al. 57	2.93, 2.54	—	—	—	—	—	—	—	—	—
17	Khan et al. 39	2.890, 3.500, 3.730	—	—	—	—	—	—	—	—	—
18	Juusela et al. 58	—	—	—	—	—	—	—	—	—	—
19	Hantoushzadeh et al. 23	1180–3200	Neonatal pneumonia	—	—	—	—	—	—	Fetal tachycardia	√
20	Griffin et al. 59	3348 ± 474	—	—	—	—	—	—	—	—	—
21	Ferrazzi et al. 60	840–4040	—	—	—	√	—	—	—	Gastrointestinal symptoms, respiratory symptoms	—
22	Dos Santos Beozzo et al. 61	2980, 2130, 3600	—	—	—	√	—	√	—	Respiratory distress The head grade II intraventricular hemorrhage, bleeding in the stool, and anemia Nasal congestion and a runny nose	—
23	Antoun et al. 62	3139 g ± 437	Bacterial pneumonia	—	—	—	—	—	—	—	—
24	Buonsenso et al. 63	—	—	—	—	—	—	—	—	Sinus bradycardia, hypocalcemia	—
25	Abasse et al. 64	1830	√	√	√	√	—	√	—	—	—
26	Alonso Díaz et al. 65	2500	—	√	√	√	—	—	—	Intermittent hyperpnoea with mild intercostal retractions	—
27	Alzamora et al. 17	2970	—	√	√	√	√	—	—	—	—
28	Coronado Munoz et al. 66	—	—	—	√	√	—	√	—	Hypotension, tachycardia, hypothermia, tachypnea, and reduced feeding	—
29	Iqbal et al. 34	—	—	—	—	—	√	√	—	—	—
30	Kalafat et al. 67	—	—	—	√	√	√	√	—	—	—
31	Kulkarni et al. 68	3200	—	—	—	—	—	√	—	Thrombocytopenia and elevated inflammatory markers (CRP/procalcitonin/ferritin), elevated d‐dimers	—
32	Kelly et al. 69	—	—	—	—	—	—	—	—	—	—
33	Villar et al. 70	2960 ± 700	—	√	√	—	—	—	—	Low birth weight	√
34	Al‐Matary et al. 71	—	—	√	√	√	—	—	—	Lymphopenia, neutropenia, thrombocytopenia, low hempglobin level, hyperbilirubinemia, fetal death	—
35	Angelidou et al. 72	31 116.3 ± 655.6	—	Yes	√	√	—	√	√	Hypotonia	√
36	Rabiei et al. 73	1390	—	—	—	—	—	—	—	NICU admission	√
37	Puneet et al. 74	2600 ± 600	—	—	—	—	—	—	—	NICU admission, Fetal distress	√
38	Oncel et al. 75	2465	—	√	√	—	—	—	—	NICU admission	—
39	Mullins et al. 76	—	—	—	—	—	—	—	—	—	√
40	Akbarian‐Rad et al. 77	3077.50 ± 697.64	—	√	√	—	—	—	—	Transient tachypnea	—
41	Hcini et al. 78	3090	—	—	—	—	—	—	—	Respiratory distress, NICU admission	—
42	Di Guardo et al. 43	—	—	√	√	—	—	—	—	Tachycardia, internal hemorrhage, DIC, acute fetal distress	√
43	Teixeira et al. 79	2500	—	—	—	—	—	—	—	—	—
44	Halici‐Ozturk et al. 80	—	—	—	—	—	—	—	—	—	—

Abbreviations: DIC, disseminated intravascular coagulation; NICU, neonatal intensive care unit; NRDS, neonatal respiratory distress syndrome.

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Tables 1 and 2 describe the characteristics of pregnant women and newborns associated with COVID‐19. A total of 2716 newborns and fetuses were assessed. Also, 2375 women in their second and third trimester, admitted with signs and symptoms of COVID‐19; in several studies, the condition of the mothers was not assessed. In women, the most common manifestation was mild to moderate pneumonia. Near three in four women did not present with any comorbidities (73%). The most frequent clinical symptoms were fever (19%) and cough (17%). In terms of the imaging findings, chest CT scans were reported in some studies, which revealed pulmonary changes in 7.5% of women; the most common change was bilateral or unilateral ground‐glass opacities (98%). Laboratory examinations revealed increased C reactive protein (8%) and decreased lymphocytes (lymphocytopenia) (9.4%). Of the 2716 infants, the delivery method of 1725 of them was reported, 913 (53%) through Cesarean‐section delivery and 812 through normal vaginal delivery (NVD) (47%). Of the total newborns, 13 died; five died along the mother. Also, 10 fetal death occurred before birth. A total of 1965 newborns were tested for SARS‐CoV‐2, of which 118 (6%) tested positive. In a study, vertical transmission in seven cases were reported in the total 145 assessed cases.

DISCUSSION

The SARS‐CoV‐2 virus caused the COVID‐19 pandemic that started in Wuhan, China, in December 2019. , Mothers and neonates have been one the most vulnerable population in the pandemic situations due to the weakened immune system of the expectant mother. This maternal immune reaction is to prevent the fetus from being rejected as a foreign body by the mother's immune system. Therefore, the maternal inflammatory responses are diminished to prevent fetal rejection. , Although these responses are essential for a normal reaction to infections, in the case of COVID‐19, it can be hypothesized that their decline might help by lowering the severity of the disease symptoms caused by inflammatory reactions. However, pregnant women might carry higher risks for severe COVID‐19 compared to nonpregnant patients. The results from the present review indicate that one‐third of pregnant women who tested positive for COVID‐19 were asymptomatic that is approximately similar to the general population. , , ,

In the present review, women were often in their second and third trimesters of pregnancy. Besides, the available data do not show any clear relation between GAI (general admission 1) and infection in mothers or neonates. Likewise, there was no association between maternal age and neonatal complications. Birth weights mostly ranged between 2000 and 4000 g, and Villar et al. demonstrated low birth weight as a complication of COVID‐19 in the neonates.

According to findings, cough and fever were the most common symptoms in mothers. , Other relatively common symptoms included dyspnea, diarrhea, and cardiac symptoms such as tachycardia. , , However, fever and respiratory tract symptoms such as cough and dyspnea were the most common symptoms in neonates. , But one of the most important and noticeable findings were cardiovascular problems, particularly tachycardia and hypotension. , ,

Neonatal pulmonary changes in chest CT scans were mostly unilateral or bilateral ground‐glass opacities. The most common laboratory findings were the increase of C‐reactive protein and decrease of lymphocytes (lymphocytopenia). Although less than half of neonatal patients had comorbidities (12%), fetal distress was the most common. Five neonatal death occurred along with the mother. However, other neonatal deaths did not involve maternal death (n = 8). Pneumonia was also one of the most common neonatal complications of COVID‐19 disease reported in other reviews. ,

This study comes with limitations. Some of the included studies lacked information related to the severity of the complications in the neonates. Some also did not report the final status of the newborns and whether they were cured or not, or had short‐ or long‐term sequels. Also it will be useful if the studies mention the long‐term outcomes of the patients and the impact of the disease and its possible complications in longer periods. On the other hand, there were also some limitations related to the data about the mothers in a portion of the studies, for example, the starting date of COVID‐19 and the duration of the disease. We also did not perform a statistical analysis. Neverthless, this study provided some important information related to perinatal and neonatal complications of COVID‐19 and future well‐designed meta‐analyses can increase our awareness of this disease more.

CONCLUSION

Evidence suggests that vertical transmission in the uterus is responsible for COVID‐19 in neonates that makes neonatal infection through the umbilical cord unlikely. , , , , , , , In addition, parental infection is less severe due to the suppression of immune system during pregnancy. Neonates do not present any additional risk for COVID‐19 complications during the prenatal period. However, further epidemiological studies are recommended to explore the possibility of mother‐to‐child (vertical) transmission of COVID‐19 and determine the potential perinatal complications.

FUNDING

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this manuscript.

AUTHOR CONTRIBUTION

The conception and design of the study: Esmaeil Mehraeen and SeyedAhmad SeyedAlinaghi

Methodology: Esmaeil Mehraeen, SeyedAhmad SeyedAlinaghi, and Amirali Karimi

Acquisition of data: Amirali Karimi, Peyman Mirghaderi, Pegah Mirzapour, and Alireza Barzegary

Writing—original draft preparation Zahra Pashaei, Alireza Barzegary, Amirali Karimi, Seyed Peyman Mirghaderi, Pegah Mirzapour, Marcarious M. Tantuoyir, Omid Dadras, Kowsar Qaderi and Zoha Ali

Writing—review and editing: SeyedAhmad SeyedAlinaghi, Zahra Pashaei and Fabricio Voltarelli

Validation: Esmaeil Mehraeen, Fabricio Voltarelli, Omid Dadras, SeyedAhmad SeyedAlinaghi, and Zahra Pashaei

TRANSPARENCY STATEMENT

Esmaeil Mehraeen affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

AVAILABILITY OF DATA AND MATERIAL

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

CONSENT TO PUBLICATION

Not applicable.