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Brazilian Journal of Infectious Diseases

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Original Article • Braz. j. infect. dis 25 (05) • 2021 • https://doi.org/10.1016/j.bjid.2021.101620 copy

Characteristics and outcomes of pregnant women with SARS-CoV-2 infection and other severe acute respiratory infections (SARI) in Brazil from January to November 2020

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background:

Knowledge about COVID-19 in pregnancy is limited, and evidence on the impact of the infection during pregnancy and postpartum is still emerging.

Aim:

To analyze maternal morbidity and mortality due to severe acute respiratory infections (SARI), including COVID-19, in Brazil.

Methods:

National surveillance data from the SIVEP-Gripe (Sistema de Informação de Vigilância Epidemiológica da Gripe) was used to describe currently and recently pregnant women aged 10-49 years hospitalized for SARI from January through November, 2020. SARI cases were grouped into: COVID-19; influenza or other detected agent SARI; and SARI of unknown etiology. Characteristics, symptoms and outcomes were presented by SARI type and region. Binomial proportion and 95% confidence intervals (95% CI) for outcomes were obtained using the Clopper-Pearson method.

Results:

Of 945,460 SARI cases in the SIVEP-Gripe, we selected 11,074 women aged 10-49 who were pregnant (7964) or recently pregnant (3110). COVID-19 was confirmed in 49.4% cases; 1.7% had influenza or another etiological agent; and 48.9% had SARI of unknown etiology. The pardo race/ethnic group accounted for 50% of SARI cases. Hypertension/Other cardiovascular diseases, chronic respiratory diseases, diabetes, and obesity were the most common comorbidities. A total of 362 women with COVID-19 (6.6%; 95%CI 6.0-7.3) died. Mortality was 4.7% (2.2-8.8) among influenza patients, and 3.3% (2.9-3.8) among those with SARI of unknown etiology. The South-East, Northeast and North regions recorded the highest frequencies of mortality among COVID-19 patients.

Conclusion:

Mortality among pregnant and recently pregnant women with SARIs was elevated among those with COVID-19, particularly in regions where maternal mortality is already high.

Keywords:
Pregnancy; Maternal mortality; Severe acute respiratory infections; SARS-CoV-2; Brazil; SIVEP-Gripe

Characteristics	SARI with influenza or other etiological agents (n = 190)		SARI cases with unknown etiology (n = 5415)		COVID-19 cases (n = 5469)
	n	%	n	%	n	%
Age (years), median (IQR)	27	21;32	27	22;33	29	24;34
Age group (years)
10 to 19	33	17.4	836	15.4	534	9.8
20 to 29	82	43.2	2,494	46.1	2,267	41.4
30 to 39	70	36.8	1,766	32.6	2,264	41.4
40 to 49	5	2.6	319	5.9	404	7.4
Race/ethnicity (self-reported)
White	75	39.5	1,597	29.5	1,404	25.7
Black	12	6.3	401	7.4	281	5.1
East Asian	2	1.0	40	0.7	46	0.8
Pardo	78	41.0	2,374	43.8	2,633	48.1
Indigenous	0	0	30	0.6	80	1.5
Missing/unknown	23	12.1	973	18.0	1,025	18.7
Education level
No education	1	0.5	23	0.4	17	0.3
Elementary school	38	20.0	865	16.0	704	12.9
High school	56	29.5	1,229	22.7	1,316	24.1
Higher education	22	11.6	314	5.8	409	7.5
Missing/unknown	73	38.4	2,984	55.1	3,023	55.3
Comorbidities
Hypertension/other cardiovascular disease	14	7.4	522	9.6	562	10.3
Diabetes	8	4.2	292	5.4	421	7.7
Asthma/other chronic lung diseases	14	7.4	513	9.5	241	4.4
Obesity	7	3.7	185	3.4	264	4.8
Immunosuppression/HIV	3	1.6	114	2.1	69	1.3
Chronic hematological diseases or anemia	1	0.5	77	1.4	56	1.0
Neurological disease or depression	3	1.6	58	1.1	47	0.9
Chronic renal disease	0	0	47	0.9	46	0.8
Chronic liver disease or hepatitis	0	0	29	0.5	17	0.3
Tuberculosis	0	0	10	0.2	2	0.04
Other comorbidities	12	6.3	274	5.1	238	4.3
Smoking (former or current)	5	2.6	79	1.5	19	0.3
Gestational age
First trimester	16	8.4	531	9.8	378	6.9
Second trimester	48	25.3	1,102	20.3	985	18.0
Third trimester	86	46.3	1,914	35.3	2,475	45.3
Trimester ignored	9	4.7	182	3.4	238	4.3
Postpartum or post-abortion	31	16.3	1,686	31.1	1,393	25.5
Imaging (X-ray or CT)
Not performed	69	36.3	2,078	38.4	2,039	37.3
Performed	64	33.7	1,519	28.0	1,596	29.2
Missing/unknown	57	30.0	1,818	33.6	1,834	33.5
Region of residence*
Southeast	58	30.5	2,412	44.5	1,852	33.9
Northeast	56	29.5	1,487	27.5	1,668	30.5
Central-West	26	13.7	487	9.0	701	12.8
North	12	6.3	360	6.6	792	14.5
South	38	20.0	669	12.3	454	8.3

Signs and symptoms	SARI with influenza or other etiological agents (n = 190)		SARI cases with unknown etiology (n = 5415)		COVID-19 cases (n = 5469)
	n	%	n	%	n	%
Symptomatic cases, n (%)	190	100	5,159	95.3	5,048	92.3
Fever	134	70.5	2,727	50.4	3,107	56.8
Cough	162	85.3	3,466	64.0	3,550	64.9
Sore throat	80	42.1	1,122	20.7	1,180	21.6
Shortness of breath	113	59.5	2,541	46.9	2,593	47.4
Oxygen saturation < 95%	61	32.1	1,281	23.7	1,351	24.7
Vomiting or nausea	22	11.6	637	11.8	557	10.2
Runny nose or nasal congestion	20	10.5	567	10.5	566	10.3
Headache	22	11.6	592	10.9	828	15.1
Muscle aches	18	9.5	384	7.1	731	13.4
Diarrhea	13	6.8	473	8.7	545	10.0
Fatigue/malaise	12	6.3	352	6.5	503	9.2
Loss of smell	2	1.0	214	3.9	850	15.5
Loss of taste	3	1.6	156	2.9	565	10.3
Chest pain	3	1.6	104	1.9	107	2.0
Abdominal pain	6	3.2	189	3.5	181	3.3
Joint pain (arthralgia)	0	0	18	0.3	18	0.3
Conjunctivitis	0	0	6	0.1	1	0.02
Skin rash or skin ulcers	0	0	9	0.2	8	0.1
Bleeding (hemorrhage)	0	0	6	0.1	12	0.2
Lymphadenopathy	0	0	2	0.04	2	0.04
Other symptoms	15	7.9	366	6.8	337	6.2

Maternal outcomes	SARI with influenza or other etiological agents (n = 190)			SARI cases with unknown etiology (n = 5415)			COVID-19 cases (n = 5469)
Maternal outcomes	n	%	(95% CI)*	n	%	(95% CI)*	n	%	(95% CI)*
Admission to intensive care unit (ICU)	30	15.8	(10.9-21.8)	911	16.8	(15.8-17.8)	1,065	19.5	(18.4-20.5)
ICU length of stay, median (IQR)		4	(1;7)		3	(2;6)		6	(3;13)
Ventilatory support
Not artificially ventilated	110	57.9	(50.5-65.0)	3,142	58.0	(56.7-59.3)	3,022	55.3	(53.9-56.6)
Invasive ventilation	14	7.4	(4.1-12.0)	344	6.3	(5.7-7.0)	455	8.3	(7.6-9.1)
Non-invasive ventilation	42	22.1	(16.4--28.7)	1,144	21.1	(20.0-22.2)	1,223	22.4	(21.3-23.5)
Missing/unknown	24	12.6	(8.3-18.2)	785	14.5	(13.6-15.5)	769	14.1	(13.1-15.0)
Final outcome
Survived	164	86.3	(80.6-90.9)	4,568	84.4	(83.4-85.3)	4,349	79.5	(78.4-80.6)
Death (any cause)	9	4.7	(2.2-8.8)	180	3.3	(2.9-3.8)	362	6.6	(6.0-7.3)
Missing/unknown	17	8.9	(5.3-13.9)	667	12.3	(11.4-13.2)	758	13.9	(12.9-14.8)

Charactheristics	Survivors (n = 4349)		Non-survivors (n = 362)		Without outcome* (n = 758)
	n	%	n	%	n	%
Age group (years)
10 to 19	441	10.1	21	5.8	72	9.5
20 to 29	1,820	41.8	121	33.4	326	43.0
30 to 39	1,771	40.7	180	49.7	313	41.3
40 to 49	317	7.3	40	11.0	47	6.2
Race/ethnicity (self-reported)
White	1,174	27.0	85	23.5	145	19.1
Black	216	5.0	30	8.3	35	4.6
East Asian	35	0.8	4	1.1	7	0.9
Pardo	2,023	46.5	194	53.6	416	54.9
Indigenous	68	1.6	2	0.5	10	1.3
Missing/unknown	833	19.1	47	13.0	145	19.1
Education level
No education	9	0.2	2	0.5	6	0.8
Elementary school	557	12.8	40	11.0	107	14.1
High school	1,024	23.5	90	24.9	202	26.6
Higher education	330	7.6	23	6.3	56	7.4
Missing/unknown	2429	55.8	207	57.2	387	51.1
Comorbidities^⁎⁎
Hypertension or other cardiovascular disease	417	9.6	69	19.1	76	10.0
Diabetes	322	7.4	59	16.3	40	5.3
Asthma or other chronic lung diseases	183	4.2	19	5.2	39	5.1
Obesity	193	4.4	44	12.1	27	3.6
Immunosuppression/HIV	48	1.1	9	2.5	12	1.6
Chronic hematological diseases or anemia	42	1.0	8	2.2	6	0.8
Neurological disease or depression	40	0.9	3	0.8	4	0.5
Chronic kidney disease	27	0.6	6	1.7	13	1.7
Chronic liver disease or hepatitis	13	0.3	3	0.8	1	0.1
Tuberculosis	0	0	2	0.6	0
Other comorbidities	182	4.2	31	8.6	25	3.3
Smoking (former or current)	13	0.3	1	0.3	5	0.7
Gestational age
First trimester	304	7.0	12	3.3	62	8.2
Second trimester	770	17.7	61	16.8	154	20.3
Third trimester	2,040	46.9	105	29.0	330	43.5
Trimester ignored	203	4.7	9	2.5	26	3.4
Postpartum or post-abortion	1,032	23.7	175	48.3	186	24.5
Admission to intensive care unit (ICU)	686	15.8	245	67.7	134	17.7
ICU Length of stay	5 (n = 377)	2;10	11 (n = 139)	4;19	4 (n = 24)	2;15.5
Ventilatory support
Not artificially ventilated	2,594	59.6	39	10.8	389	51.3
Non-invasive ventilation	1001	23.0	64	17.7	158	20.8
Invasive ventilation	191	4.4	213	58.8	51	6.7
Missing	563	12.9	46	12.7	160	21.1

Brazilian Society of Infectious Diseases Rua Augusto Viana, SN, 6º., 40110-060 Salvador - Bahia - Brazil, Telefax: (55 71) 3283-8172, Fax: (55 71) 3247-2756 - Salvador - BA - Brazil
E-mail: bjid@bjid.org.br

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