Universal COVID-19 testing in the obstetric population: impacts on public health

Mariane de Oliveira Menezes Carla Betina Andreucci Marcos Nakamura-Pereira Roxana Knobel Cláudia Garcia Magalhães Maíra Libertad Soligo Takemoto About the authors

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. Since the disease only emerged recently, numerous questions remain to be answered. For example, there are still many doubts concerning the potential for transmission by asymptomatic and pre-symptomatic carriers, thus far there is no provenly effective specific treatment, and it is not known whether acquired immunity after the infection exists or how long it lasts. Measures to reduce transmission are recommended, such as social isolation, hygiene, and use of face masks, besides specific personal protective equipment for health professionals 11. Agência Nacional de Vigilância Sanitária. Nota Técnica GVIMS/GGTES/ANVISA, n. 04/2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2). https://www20.anvisa.gov.br/segurancadopaciente/index.php/noticias/176-nota-tecnica-n-04-2020-gvims-ggtes-anvisa-atualizada (acessado em 10/Jun/2020).
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,22. Departamento de Atenção Hospitalar, Domiciliar e de Urgência, Secretaria de Atenção Especializada, Ministério da Saúde. Protocolo de Manejo Clínico da Covid-19 na Atenção Especializada. Brasília: Ministério da Saúde; 2020.,33. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Nota Técnica COSMU/CGCIVI/DAPES/SAPS/MS no 12/2020. https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/nota-tecnica-no-12-2020-cosmu-cgcivi-dapes-saps-ms/ (acessado em 10/Jun/2020).
https://portaldeboaspraticas.iff.fiocruz...
.

As of July 7, 2020, the disease had already caused 542,798 deaths in the world 44. Worldometer. Coronavirus cases. https://www.worldometers.info/coronavirus/coronavirus-cases/#daily-cases (acessado em 10/Jun/2010).
https://www.worldometers.info/coronaviru...
, notably with a wide diversity of clinical patterns and multiplicity of organs and systems affected. However, its effect during pregnancy and postpartum is still not completely known. Preliminary data appeared to indicate that pregnant and postpartum women were not more susceptible to COVID-19 55. Chen L, Li Q, Zheng D, Jiang H, Wei Y, Zou L, et al. Clinical characteristics of pregnant women with Covid-19 in Wuhan, China. N Engl J Med 2020; 382:e100.,66. Yan J, Guo J, Fan C, Juan J, Yu X, Li J, et al. Coronavirus disease 2019 (COVID-19) in pregnant women: a report based on 116 cases. Am J Obstet Gynecol 2020; 223:111.e1-111.e14.. However, more recent data suggest the possibility of unfavorable pregnancy outcomes, perhaps related to the body’s adaptations to gestation, especially in the cardiovascular and immune systems, also affected by coronaviruses 77. Amorim MMR, Takemoto MLS, Fonseca EB. Maternal deaths with coronavirus disease 2019: a different outcome from low- to middle-resource countries? Am J Obstet Gynecol 2020; [Online ahead of print].,88. Breslin N, Baptiste C, Gyamfi-Bannerman C, Miller R, Martinez R, Bernstein K, et al. COVID-19 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 MFM 2020; 2:100118.,99. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, Seferovic MD, Aski SK, Arian SE, et al. Maternal death due to COVID-19 disease. Am J Obstet Gynecol 2020; 223:109.E1-109.E16.,1010. Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369:m2107.,1111. Collin J, Byström E, Carnahan A, Ahrne M. Pregnant and postpartum women with SARS-CoV-2 infection in intensive care in Sweden. Acta Obstet Gynecol Scand 2020; 99:819-22.. Although evidence of vertical transmission of the virus is still scarce, there are reports of neonatal infection 1212. Juan J, Gil MM, Rong Z, Zhang Y, Yang H, Poon LCY. Effects of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcomes: a systematic review of 266 pregnancies. Ultrasound Obstet Gynecol 2020; 56:15-27., in addition to the increased risk of prematurity due to the exacerbation of clinical symptoms in pregnant women with the infection 66. Yan J, Guo J, Fan C, Juan J, Yu X, Li J, et al. Coronavirus disease 2019 (COVID-19) in pregnant women: a report based on 116 cases. Am J Obstet Gynecol 2020; 223:111.e1-111.e14.,1010. Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369:m2107., amplifying the potential impacts of COVID-19 on pregnancy, besides the immediate effects on maternal or fetal health. In addition, the literature has reported concerns related to the increased risk of adverse maternal and perinatal outcomes in resource-constrained contexts, particularly Brazil and other Latin American countries 77. Amorim MMR, Takemoto MLS, Fonseca EB. Maternal deaths with coronavirus disease 2019: a different outcome from low- to middle-resource countries? Am J Obstet Gynecol 2020; [Online ahead of print].,1313. Buekens P, Alger J, Bréart G, Cafferata ML, Harville E, Tomasso G. A call for action for COVID-19 surveillance and research during pregnancy. Lancet Glob Health 2020; 8:e877-8.. Currently, 160 maternal deaths associated with COVID-19 have been published in the world as of July 7, 2020. Of these, 7 in were Iran, 7 in Mexico, 5 in the UK, 16 in the USA, 1 in France, and 124 in Brazil 99. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, Seferovic MD, Aski SK, Arian SE, et al. Maternal death due to COVID-19 disease. Am J Obstet Gynecol 2020; 223:109.E1-109.E16.,1010. Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369:m2107.,1414. Kayem G, Lecarpentier E, Deruelle P, Bretelle F, Azria E, Blanc J, et al. A snapshot of the Covid-19 pandemic among pregnant women in France. J Gynecol Obstet Hum Reprod 2020; 101826.,1515. Lumbreras-Marquez MI, Campos-Zamora M, Lizaola-Diaz de Leon H, Farber MK. Maternal mortality from COVID-19 in Mexico. Int J Gynaecol Obstet 2020; 150:266-7.,1616. Ellington S, Strid P, Tong VT, Woodworth K, Galang RR, Zambrano LD, et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:769-75.,1717. Takemoto MLS, Menezes MO, Andreucci CB, Nakamura-Pereira M, Amorim MMR, Katz L, et al. The tragedy of COVID-19 in Brazil: 124 maternal deaths and counting. Int J Gynaecol Obstet 2020; [Online ahead of print]..

One quite relevant aspect of COVID-19 for public health is the lack of knowledge on prevalence of the virus in asymptomatic or oligosymptomatic individual with nonspecific viral symptoms. In all the world, there is a familiar difficulty with universal testing of the population, especially in low and middle-income countries 1818. Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in low- and middle-income countries. JAMA 2020; 323:1549-50.. Even before the pandemic, Brazil had experienced difficulties in reducing or even stabilizing the country’s maternal mortality rates 1919. Cirelli JF, Surita FG, Costa ML, Parpinelli MA, Haddad SM, Cecatti JG. The burden of indirect causes of maternal morbidity andmortality in the process of obstetric transition: a cross-sectional multicenter study. Rev Bras Ginecol Obstet 2018; 40:106-14.. In this context, the determination of COVID-19 prevalence in women during pregnancy, labor, and postpartum is essential for strategic planning of obstetric and neonatal care.

Due to the health system’s universal overload (chronic, and aggravated by the pandemic’s demand), barriers to access have hindered prenatal follow-up of normal-risk and high-risk pregnant women, described internationally as a triggering factor for worse maternal and neonatal outcomes 2020. Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health 2020; 8:E901-8.. Universal testing of the obstetric population could help plan childbirth care during the pandemic 2121. Sutton D, Fuchs K, D'Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020; 382:2163-4.,2222. Khalil A, Hill R, Ladhani S, Pattisson K, O'Brien P. SARS-CoV-2 in pregnancy: symptomatic pregnant women are only the tip of the iceberg. Am J Obstet Gynecol 2020; [Epub ahead of print].. Aspects that would be impacted directly by knowledge of COVID-19 diagnosis in asymptomatic, pre-symptomatic, or oligosymptomatic pregnant and postpartum women include:

(i) Evaluation of the need for organizational structuring of rooming-in wards, where postpartum women and their newborn infants share the same space, often cramped 33. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Nota Técnica COSMU/CGCIVI/DAPES/SAPS/MS no 12/2020. https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/nota-tecnica-no-12-2020-cosmu-cgcivi-dapes-saps-ms/ (acessado em 10/Jun/2020).
https://portaldeboaspraticas.iff.fiocruz...
;

(ii) Adequacy of use, supply, and distribution of personal protective equipment (PPE), with rational use, aimed at protecting the healthcare team, a group that is also highly vulnerable to the novel coronavirus infection 2323. Bandyopadhyay S, Baticulon RE, Kadhum M, Alser M, Ojuka DK, Badereddin Y, et al. Infection and mortality of healthcare workers worldwide from COVID-19: a scoping review. medRxiv 2020; 2 jun. https://www.medrxiv.org/content/10.1101/2020.06.04.20119594v1.
https://www.medrxiv.org/content/10.1101/...
;

(iii) Timely adoption of measures to prevent infection during labor and childbirth, the immediate postpartum, and rooming-in, including specific guidance to maintain breastfeeding 2424. Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Nota Técnica DAPES/SAPS/MS no 7/2020. https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/gestantes-nota-tecnica-no-6-2020-cosmu-cgcivi-dapes-saps-ms/ (acessado em 10/Jun/2020).
https://portaldeboaspraticas.iff.fiocruz...
;

(iv) Adequate guidelines for hospital discharge, including health education for maintaining shelter- in-place and precautions to reduce household transmission.

Six publications of case series have evaluated universal testing programs for COVID-19 in pregnant women admitted to maternity hospitals during labor, for other obstetric reasons or clinical complications (Table 1). The studies were conducted in the USA, UK, Portugal, and Japan 2121. Sutton D, Fuchs K, D'Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med 2020; 382:2163-4.,2222. Khalil A, Hill R, Ladhani S, Pattisson K, O'Brien P. SARS-CoV-2 in pregnancy: symptomatic pregnant women are only the tip of the iceberg. Am J Obstet Gynecol 2020; [Epub ahead of print].,2525. Dória M, Peixinho C, Laranjo M, Varejão AM, Silva PT. Covid-19 during pregnancy: a case series from an universally tested population from the north of Portugal. Eur J Obstet Gynecol Reprod Biol 2020; 250:261-2.,2626. Ochiai D, Kasuga Y, Iida M, Ikenoue S, Tanaka M. Universal screening for SARS-CoV-2 in asymptomatic obstetric patients in Tokyo, Japan. Int J Gynecol Obstet 2020; 150:268-9.,2727. Campbell KH, Tornatore JM, Lawrence KE, Illuzzi JL, Sussman LS, Lipkind HS, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in Southern Connecticut. JAMA 2020; 323:2520-2.,2828. Vintzileos W, Muscat J, Hoffmann E, Vo D, John N, Vertichio R, et al. Screening all pregnant women admitted to labor and delivery for the virus responsible for COVID-19. Am J Obstet Gynecol 2020; [Epub ahead of print].. The studies generally pointed to universal testing as a strategy that would positively impact the planning of health management and healthcare activities, both clinically (better monitoring of pregnant and postpartum women with COVID-19 diagnosis), organizationally (adoption of measures to prevent transmission to healthcare professionals, the obstetric population in general, and infants), and scientifically (knowledge of COVID-19 prevalence in this subgroup).

Table 1
Findings from case series of universal COVID-19 testing in the obstetric population.

In the above-mentioned studies, women were tested regardless of the presence of COVID-19 symptoms or contact with known cases of the disease, by collecting swab samples at hospital admission, analyzed with RT-PCR (reverse-transcriptase polymerase chain reaction). As shown in Table 1, the publications in New York, USA, showed the highest percentage of positive cases among all the studies cited. This finding is expected, since at the time of testing, New York had the worst epidemiological situation (Figure 1). The proportion of SARS-CoV-2-positive pregnant women varied from 3.8% to 11.7% in the other localities.

Figure 1
Prevalence of COVID-19 in pregnant women and proportion of COVID-19 cases per million inhabitants in each context.

Considering the differences in testing criteria, case definition, and containment measures in each country and local context, the ability to compare these data or extrapolate their applicability to other contexts is limited. However, using the information on cumulative COVID-19 cases in each context on the final date of data collection in the respective studies 2929. Department of Health, New York State. New York State statewide COVID-19 testing. https://health.data.ny.gov/Health/New-York-State-Statewide-COVID-19-Testing/xdss-u53e (acessado em 10/Jun/2020).
https://health.data.ny.gov/Health/New-Yo...
,3030. Connecticut Open Data. Office of policy and management. COVID-19 tests, cases, hospitalizations and deaths (Statewide). 2020. https://data.ct.gov/Health-and-Human-Services/COVID-19-Tests-Cases-Hospitalizations-and-Deaths-S/rf3k-f8fg (acessado em 10/Jun/2020).
https://data.ct.gov/Health-and-Human-Ser...
,3131. World Health Organization. COVID-19 situation reports. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports (acessado em 8/Jun/2020).
https://www.who.int/emergencies/diseases...
and population data 3232. The World Bank. The World Bank data: population, total. 2020. https://data.worldbank.org/indicator/sp.pop.totl (acessado em 10/Jun/2020).
https://data.worldbank.org/indicator/sp....
,3333. U.S. Census Bureau. QuickFacts: United States. 2020. https://www.census.gov/quickfacts/fact/table/US/PST045219 (acessado em 10/Jun/2020).
https://www.census.gov/quickfacts/fact/t...
, it is possible to calculate the proportion of COVID-19 cases per million inhabitants in each context (Figure 1). Based on this contextualization, one can anticipate that Brazil, compared to other localities, would have at least intermediate COVID-19 prevalence in pregnant women if universal testing policies were adopted. Considering that differences in the number of tests performed per million inhabitants in the various countries reflect different magnitudes of underreporting, it would be reasonable to anticipate an even more critical situation in Brazil. For example, the three scenarios in the USA would represent between 15,538 and 26,594 tests per million inhabitants 2929. Department of Health, New York State. New York State statewide COVID-19 testing. https://health.data.ny.gov/Health/New-York-State-Statewide-COVID-19-Testing/xdss-u53e (acessado em 10/Jun/2020).
https://health.data.ny.gov/Health/New-Yo...
,3030. Connecticut Open Data. Office of policy and management. COVID-19 tests, cases, hospitalizations and deaths (Statewide). 2020. https://data.ct.gov/Health-and-Human-Services/COVID-19-Tests-Cases-Hospitalizations-and-Deaths-S/rf3k-f8fg (acessado em 10/Jun/2020).
https://data.ct.gov/Health-and-Human-Ser...
,3333. U.S. Census Bureau. QuickFacts: United States. 2020. https://www.census.gov/quickfacts/fact/table/US/PST045219 (acessado em 10/Jun/2020).
https://www.census.gov/quickfacts/fact/t...
. In Brazil, as of June 10, the number of recorded COVID-19 tests represented 4,706 per million inhabitants 44. Worldometer. Coronavirus cases. https://www.worldometers.info/coronavirus/coronavirus-cases/#daily-cases (acessado em 10/Jun/2010).
https://www.worldometers.info/coronaviru...
, potentially indicating the existence of a much higher number of cases than officially recorded, which would be reflected (by extension) in the estimated COVID-19 prevalence in the obstetric population.

These studies also report data on the percentage of pregnant women with COVID-19 who were asymptomatic at admission, ranging from 66.6% to 100% (Table 1). Importantly, the definition of suspected cases in many contexts in Brazil still necessarily include the presence of fever, which limits eligibility for testing, even in patients hospitalized with other symptoms suggestive of COVID-19, but who do not present fever. Likewise, a literature review compiling data from case series found that only about 50% of obstetric patients with COVID-19 were febrile at hospital admisstion 1212. Juan J, Gil MM, Rong Z, Zhang Y, Yang H, Poon LCY. Effects of coronavirus disease 2019 (COVID-19) on maternal, perinatal and neonatal outcomes: a systematic review of 266 pregnancies. Ultrasound Obstet Gynecol 2020; 56:15-27.. According to the Epidemiological Bulletin3434. Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico Especial: COE-COVID 19 2020; (17). https://www.saude.gov.br/images/pdf/2020/May/29/2020-05-25---BEE17---Boletim-do-COE.pdf.
https://www.saude.gov.br/images/pdf/2020...
of the Brazilian Ministry of Health, which reports the profile of pregnant women with severe acute respiratory syndrome (SARS) due to COVID-19 in Brazil, only 72.9% of the cases presented fever, which shows that even among severe cases, more than one-fourth were afebrile.

These data emphasize the need for universal testing of obstetric patients as an urgent strategy to protect pregnant and postpartum women and their infants, as well as health professionals during the pandemic, allowing adequate planning of referral flows, care during labor and childbirth, and heightened surveillance focused on the prevention of deaths and near misses. Universal testing will help decrease the pandemic’s impact on women, especially more vulnerable pregnant women, who bear the heaviest burden of maternal mortality.

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    Secretaria de Vigilância em Saúde, Ministério da Saúde. Boletim Epidemiológico Especial: COE-COVID 19 2020; (17). https://www.saude.gov.br/images/pdf/2020/May/29/2020-05-25---BEE17---Boletim-do-COE.pdf
    » https://www.saude.gov.br/images/pdf/2020/May/29/2020-05-25---BEE17---Boletim-do-COE.pdf

Publication Dates

  • Publication in this collection
    03 Aug 2020
  • Date of issue
    2020

History

  • Received
    12 June 2020
  • Reviewed
    09 July 2020
  • Accepted
    11 July 2020
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