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Open Access

The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis

Shu Qin Wei, Marianne Bilodeau-Bertrand, Shiliang Liu and Nathalie Auger
CMAJ April 19, 2021 193 (16) E540-E548; DOI: https://doi.org/10.1503/cmaj.202604
Shu Qin Wei
Department of Obstetrics and Gynecology (Wei), Centre hospitalier universitaire Sainte-Justine; Centre de recherche du Centre hospitalier de l’Université de Montréal, Department of Social and Preventive Medicine (Auger), School of Public Health, Université de Montréal; Bureau d’information et d’études en santé des populations (Wei, Bilodeau-Bertrand, Auger), Institut national de santé publique du Québec, Montréal, Que.; Centre for Surveillance and Applied Research (Liu), Public Health Agency of Canada, Ottawa, Ont.
MD PhD
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Marianne Bilodeau-Bertrand
Department of Obstetrics and Gynecology (Wei), Centre hospitalier universitaire Sainte-Justine; Centre de recherche du Centre hospitalier de l’Université de Montréal, Department of Social and Preventive Medicine (Auger), School of Public Health, Université de Montréal; Bureau d’information et d’études en santé des populations (Wei, Bilodeau-Bertrand, Auger), Institut national de santé publique du Québec, Montréal, Que.; Centre for Surveillance and Applied Research (Liu), Public Health Agency of Canada, Ottawa, Ont.
MSc
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Shiliang Liu
Department of Obstetrics and Gynecology (Wei), Centre hospitalier universitaire Sainte-Justine; Centre de recherche du Centre hospitalier de l’Université de Montréal, Department of Social and Preventive Medicine (Auger), School of Public Health, Université de Montréal; Bureau d’information et d’études en santé des populations (Wei, Bilodeau-Bertrand, Auger), Institut national de santé publique du Québec, Montréal, Que.; Centre for Surveillance and Applied Research (Liu), Public Health Agency of Canada, Ottawa, Ont.
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Nathalie Auger
Department of Obstetrics and Gynecology (Wei), Centre hospitalier universitaire Sainte-Justine; Centre de recherche du Centre hospitalier de l’Université de Montréal, Department of Social and Preventive Medicine (Auger), School of Public Health, Université de Montréal; Bureau d’information et d’études en santé des populations (Wei, Bilodeau-Bertrand, Auger), Institut national de santé publique du Québec, Montréal, Que.; Centre for Surveillance and Applied Research (Liu), Public Health Agency of Canada, Ottawa, Ont.
MD MSc
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    Figure 1:

    Flow chart for the selection of studies.

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    Figure 2:

    Forest plots of summary crude odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coronavirus disease 2019 (COVID-19) and preeclampsia. (A) Association between COVID-19 and preeclampsia (patients with COVID-19 versus patients without COVID-19). (B) Association between severe COVID-19 and preeclampsia (patients with severe versus mild COVID-19).

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    Figure 3:

    Forest plots of summary crude odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coronavirus disease 2019 (COVID-19) and preterm birth. (A) Association between COVID-19 and preterm birth (patients with COVID-19 versus no COVID-19). (B) Association between symptomatic COVID-19 and preterm birth (patients with symptomatic versus asymptomatic COVID-19). (C) Association between severe COVID-19 and preterm birth (patients with severe versus mild COVID-19).

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    Figure 4:

    Forest plots of summary crude odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coronavirus disease 2019 (COVID-19) and stillbirth.

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    Table 1:

    Summary of pooled results using random-effects models

    OutcomeNo. of studiesNo. of participantsNo. of eventsMean difference (95% CI)OR (95% CI)Heterogeneity, %
    Patients with COVID-19 versus those without COVID-19
     Preeclampsia13424 34428 3261.33 (1.03 to 1.73)31
     Gestational diabetes13425 89040 5671.03 (0.76 to 1.39)54
     Fetal distress3874471.50 (0.64 to 3.53)8
     Stillbirth6413 12213662.11 (1.14 to 3.90)24
     Chorioamnionitis or intra-amniotic infection543684330.85 (0.57 to 1.26)0
     Admission to the ICU5409 73720124.78 (2.03 to 11.25)76
     Cesarean delivery22429 366121 6501.00 (0.82 to 1.23)78
     Postpartum hemorrhage529813550.89 (0.52 to 1.53)55
     Preterm birth18425 35725 0711.82 (1.38 to 2.39)64
     Neonatal sex, male511 98563690.97 (0.71 to 1.33)9
     Gestational age at birth, wk134197−0.24 (−0.49 to 0.00)61
     Birth weight, g132973−68.96 (−130.22 to −7.69)29
     Low birth weight210546782.32 (0.26 to 21.07)85
     Admission to the NICU1056757853.69 (1.39 to 9.82)94
     Neonatal death528381.10 (0.41 to 2.95)0
    Patients with symptomatic versus asymptomatic COVID-19
     Gestational hypertension or preeclampsia841223331.20 (0.92 to 1.56)1
     Gestational diabetes537672561.12 (0.82 to 1.55)0
     Mechanical ventilation310236216.29 (3.88 to 68.47)0
     Admission to the ICU41178977.40 (0.48 to 114.24)76
     Cesarean delivery9423214061.57 (1.32 to 1.85)1
     Preterm birth942335822.29 (1.49 to 3.53)57
     Admission to the NICU423652483.47 (0.38 to 31.49)88
     Neonatal death4938113.67 (0.88 to 15.29)0
    Patients with severe versus mild COVID-19
     Preeclampsia5521404.16 (1.55 to 11.15)0
     Gestational diabetes511401051.99 (1.09 to 3.64)14
     Abnormal liver function43501166.47 (2.60 to 16.09)50
     Lymphopenia45612213.04 (1.93 to 4.79)0
     Admission to the ICU57577015.46 (5.79 to 41.23)0
     Mechanical ventilation59629719.31 (9.38 to 39.72)0
     Cesarean delivery811384522.58 (1.64 to 4.06)43
     Preterm birth1013932774.29 (2.41 to 7.63)61
     Gestational age at birth, wk8709−3.50 (−5.96 to −1.03)91
     Low birth weight2400741.89 (1.14 to 3.12)0
     Admission to the NICU57291603.95 (1.43 to 10.95)79
     Neonatal death38271233.71 (5.18 to 219.44)0
    • Note: CI = confidence interval, COVID-19 = coronavirus disease 2019, ICU = intensive care unit, NICU = neonatal intensive care unit, OR = odds ratio.

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Canadian Medical Association Journal: 193 (16)
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The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis
Shu Qin Wei, Marianne Bilodeau-Bertrand, Shiliang Liu, Nathalie Auger
CMAJ Apr 2021, 193 (16) E540-E548; DOI: 10.1503/cmaj.202604

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The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis
Shu Qin Wei, Marianne Bilodeau-Bertrand, Shiliang Liu, Nathalie Auger
CMAJ Apr 2021, 193 (16) E540-E548; DOI: 10.1503/cmaj.202604
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