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The Incidence, Characteristics and Outcomes of Pregnant Women Hospitalized with Symptomatic And medRxiv preprint doi: https://doi.org/10.1101/2021.01.04.21249195; this version posted January 5, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . 1 The incidence, characteristics and outcomes of pregnant women hospitalized with symptomatic and 2 asymptomatic SARS-CoV-2 infection in the UK from March to September 2020: a national cohort 3 study using the UK Obstetric Surveillance System (UKOSS) 4 5 Covid-19 in pregnancy 6 7 Nicola Vousden1,2 PhD, Kathryn Bunch MA1, Edward Morris MD3, Nigel Simpson MBChB4, Christopher 8 Gale PhD5, Patrick O’Brien MBBCh6, Maria Quigley MSc1, Peter Brocklehurst MSc7 9 Jennifer J Kurinczuk MD1, Marian Knight DPhil1 10 11 1National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of 12 Oxford, UK 13 2School of Population Health & Environmental Sciences, King’s College London, UK 14 3Royal College of Obstetricians and Gynaecologists, London, UK 15 4Department of Women's and Children's Health, School of Medicine, University of Leeds, UK 16 5Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, 17 UK 18 6Institute for Women’s Health, University College London, London, UK 19 7Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, UK 20 21 Corresponding author: 22 Marian Knight, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, 23 University of Oxford, Old Rd Campus, Oxford, OX3 7LF, UK 24 Tel: 01865 289727 Email: [email protected] 25 26 Non-standard abbreviations: 27 Royal College of Obstetricians and Gynaecologists - RCOG 28 NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. 1 medRxiv preprint doi: https://doi.org/10.1101/2021.01.04.21249195; this version posted January 5, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . 29 ABSTRACT 30 Background: 31 Evidence on risk factors, incidence and impact of SARS-CoV-2 infection in pregnant mothers and their 32 babies has rapidly expanded but there is a lack of population level data to inform accurate incidence 33 rates and unbiased descriptions of characteristics and outcomes. The primary aim of this study was to 34 describe the incidence, characteristics and outcomes of hospitalized pregnant women with 35 symptomatic and asymptomatic SARS-CoV-2 in the UK compared to pregnant women without SARS- 36 CoV-2 in order to inform future clinical guidance and management. 37 Methods and Findings: 38 We conducted a national, prospective cohort study of all hospitalized pregnant women with 39 confirmed SARS-CoV-2 from 1st March 2020 to 31st August 2020 using the UK Obstetric Surveillance 40 System (UKOSS) across all 194 hospitals in the UK with a consultant-led maternity unit. Incidence was 41 estimated using the latest national maternity data. Overall, 1148 hospitalized women had confirmed 42 SARS-CoV-2 in pregnancy, 63% of which were symptomatic. Therefore, the estimated incidence of 43 hospitalization with symptomatic SARS-CoV-2 was 2.0 per 1000 maternities (95% CI 1.9-2.2) and for 44 asymptomatic SARS-CoV-2 was 1.2 per 1000 maternities (95% CI 1.1-1.4). Compared to pregnant 45 women without SARS-CoV-2, women hospitalized with symptomatic SARS-CoV-2 were more likely to 46 be overweight or obese (adjusted OR 1.86, 95% CI 1.39-2.48 and aOR 2.07, 95% CI 1.53-2.29 47 respectively), to be of Black, Asian or Other minority ethnic group (aOR 6.24, 95% CI 3.93-9.90, aOR 48 4.36, 95% CI 3.19-5.95 and aOR 12.95, 95% CI 4.93-34.01 respectively), and to have a relevant medical 49 comorbidity (aOR 1.83, 95% CI 1.32-2.54). Compared to pregnant women without SARS-CoV-2, 50 hospitalized pregnant women with symptomatic SARS-CoV-2 were more likely to be admitted to 51 intensive care (aOR 57.67, 95% CI 7.80-426.70) but the absolute risk of poor outcomes was low. 52 Cesarean births and neonatal unit admission were increased regardless of symptom status 53 (symptomatic aOR 2.60, 95% CI 1.97-3.42 and aOR 3.08, 95% CI 1.99-4.77 respectively; asymptomatic 54 aOR 2.02, 95% CI 1.52-2.70 and aOR 1.84, 95% 1.12-3.03 respectively). Iatrogenic preterm births were 2 medRxiv preprint doi: https://doi.org/10.1101/2021.01.04.21249195; this version posted January 5, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . 55 more common in women with symptomatic SARS-CoV-2 (aOR 11.43, 95% CI 5.07-25.75). The risks of 56 stillbirth or neonatal death were not significantly increased, regardless of symptom status but 57 numbers were small. The limitations of this study include the restriction to women hospitalized with 58 SARS-CoV-2, who may by nature of their admission have been at greater risk of adverse outcome. 59 60 Conclusions: 61 We have identified factors that increase the risk of symptomatic and asymptomatic SARS-CoV-2 in 62 pregnancy. The increased risks of cesarean and iatrogenic preterm birth provide clear evidence of the 63 indirect impact of SARS-CoV-2 on mothers and maternity care in high income settings. Clinicians can 64 be reassured that the majority of women do not experience severe complications of SARS-CoV-2 in 65 pregnancy and women with mild disease can be discharged to continue their pregnancy safely. 66 67 3 medRxiv preprint doi: https://doi.org/10.1101/2021.01.04.21249195; this version posted January 5, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . 68 INTRODUCTION 69 70 In March 2020 the World Health Organization declared a global pandemic of novel coronavirus 71 infection (SARS-CoV-2)[1]. Evidence about risk factors, incidence and impact of SARS-CoV-2 infection 72 in pregnant mothers and their babies has rapidly expanded and is vital to planning guidance and policy. 73 The World Health Organization’s (WHO) living systematic review concluded that SARS-CoV-2 infection 74 was associated with increased risk of admission to intensive care for the mother and increased risk of 75 preterm birth and admission to neonatal care for the infant [2]. Women with pre-existing medical 76 comorbidities, older age, high body mass index (BMI) and women of Black, Asian and minority ethnic 77 groups have been reported to be at increased risk of hospitalization[3] or severe outcome [2]. 78 However, the majority of studies to date are case reports, case series and institutional or registry non- 79 population-based cohort studies and there is a lack of population-level data to inform accurate 80 incidence rates and unbiased descriptions of characteristics and outcomes. 81 82 Clinical practice around testing for SARS-CoV-2 among pregnant women in the UK has changed since 83 the start of the pandemic, when predominantly only those with symptoms were tested. Routine 84 screening of all obstetric admissions was recommended by the Royal College of Obstetricians and 85 Gynaecologists (RCOG) on 29th May 2020 [4] and therefore the UK’s obstetric population is unique in 86 that virtually all were tested thereafter, typically at the time of giving birth. The WHO systematic 87 review reported from 11 small observational studies (n=162 women that had universal screening) and 88 suggested that a high proportion of women who tested positive were asymptomatic (74%, 95% CI 89 51%-93%) [2]. Other reports have varied[5, 6], with between 79% (from a total of 55 women)[7] to 90 100% (from a total of 17 women) [8] of those that tested positive on universal screening being 91 asymptomatic. However, these studies were small and were undertaken in single hospitals or regions. 92 No published studies to date have explored the proportion of symptomatic versus asymptomatic 93 SARS-CoV-2 in pregnancy at the population level since universal screening was introduced. 94 4 medRxiv preprint doi: https://doi.org/10.1101/2021.01.04.21249195; this version posted January 5, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . 95 The primary aim of this study was to describe the incidence, characteristics and outcomes of 96 hospitalized pregnant women with symptomatic and asymptomatic SARS-CoV-2 in the UK compared 97 to women without SARS-CoV-2, in order to inform ongoing guidance and management. The second 98 aim was to describe characteristics and outcomes in women with symptomatic SARS-CoV-2 compared 99 to those who remained asymptomatic. 100 101 METHODS 102 103 This on-going national, prospective observational cohort study was conducted using the UK Obstetric 104 Surveillance System (UKOSS) [9].
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