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Research Article

The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study

[version 1; peer review: 2 approved with reservations, 1 not approved]
PUBLISHED 27 Feb 2023
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This article is included in the Emerging Diseases and Outbreaks gateway.

Abstract

Background: COVID-19-infected pregnant women may be asymptomatic or symptomatic. Symptomatic tend to have a severe infection and could be at increased risk of complications such as preterm birth, NICU, and stillbirth. This study aimed to identify the most common signs and symptoms and assess the pre-existing risk of COVID-19 infection during pregnancy:  length of hospital stay, premature labor, and complications according to the severity of COVID-19 illness.
Methods: This retrospective study was conducted in the obstetric and gynecological wards of 359 pregnant women. After reviewing medical records, patient and disease data were collected.
Results: Most patients were asymptomatic and mild. The most common signs and symptoms were fever, cough, and dyspnea. COVID-19 infected pregnant with a medical history of hypertension, or diabetes had more severe COVID-19 infection. COVID-19-infected pregnant women with severe illness or aged ≥ 40 years had a prolonged hospital stay. Severe COVID-19 disease was significantly associated with preterm birth, stillbirth, and the need for a neonatal intensive care unit.
Conclusion: Severe COVID-19 infection in pregnancy is linked to pregnancy and birth complications, mainly among pregnant women with a positive medical history.

Keywords

COVID-19, pregnancy, pregnancy outcomes, risk factors, severity

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the source of the coronavirus disease 19 (COVID-19), a highly contagious and dangerous viral illness that led to a global pandemic a significant loss of human life.1 Severe acute respiratory syndrome coronavirus infection in pregnant women can cause either asymptomatic or symptomatic disease (mild, moderate, severe, and critical).2,3 Although the risk of developing severe illness is minimal, pregnant women with COVID-19 are more likely to do so than non-pregnant people. In addition, after adjusting for age, race/ethnicity, and underlying medical conditions, pregnant women had noticeably higher rates of intensive care unit (ICU) admission, mechanical ventilation, extracorporeal membrane oxygenation, and mortality.4

Contrary to pregnant and previously pregnant women without the illness, COVID-19-positive pregnant women had a higher risk of stillbirth and preterm birth.5 In addition, pregnancy-related physiological and immunological changes substantially impact the severity and effects of viral infections.6 For example, increased ACE2 expression, changes in the immune system to ensure the acceptance of the fetus, and changes in the respiratory system causing hyperventilation are all factors that could enhance vulnerability to COVID-19 infection during pregnancy.7

Compared to non-pregnant women, pregnant women with COVID-19 are less likely to experience symptoms. Being overweight or obese, being older than 35 years, and having pre-existing comorbidities (hypertension, diabetes, lung diseases) are all variables that increase the risk of developing a severe illness.8 To determine how long COVID-19 patients stay in hospitals, it is critical to examine their risk factors. According to a study from China in 2022, patients aged ≥ 45 and those with severe COVID-19 infection tended to stay longer in the hospital.9

The advantages of COVID-19 immunization, which include a decreased risk of severe illness and hospitalization for the pregnant woman and a reduced risk of hospitalization for the newborn in the first six months of life, should be discussed with expectant mothers.10 All eligible individuals, including those who are pregnant, nursing, or planning a pregnancy, should receive a COVID-19 vaccine or a series of vaccines, according to recommendations from the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and CDC. If a person is qualified, the booster dosages are also included.11 The primary objectives of this study were to identify the most common symptoms associated with COVID-19 infection during pregnancy and assess the pre-existing risk of hospitalization, preterm delivery, and other complications related to COVID-19 illness, taking into account the severity of the disease.

Methods

Ethical considerations

The institutional scientific and ethical committees of the Faculty of Pharmacy, Mustansiriyah University, and the Baghdad Health Directorate, Al-Karkh, formally approved the research protocol on November 10, 2021 (Ethics Board approval code: 2021099).

Consent

Since the data has been anonymized, and because it is impracticable to obtain consent. The ethical committee waived the need for consent to participate. There is sufficient protection of participants’ privacy and an adequate plan to protect the confidentiality of data.

Study design

This observational retrospective study was carried out in the obstetrics and gynecology wards of Al-Yarmouk Teaching Hospital and Karkh Hospital for childbirth between November 15, 2021, and August 27, 2022, where pregnant women with COVID-19 were admitted to the hospital for treatment or to give birth.

Sample size

The sample size was determined and computed using the computer application G*Power 3.1.9.7 (RRID: SCR 013726). The smallest total sample size was 314 patients, with an effect size of 0.20 and 95% power at a two-tailed alpha of 0.05 and a 95% confidence interval (f). After reviewing the hospital’s medical records or files, the biostatistics department provided 450 patient records; only 359 were selected for the research, while the rest fulfilled the exclusion criteria Figure 1.

c5efd3fc-fd4f-4126-a531-97740071004d_figure1.gif

Figure 1. Study participants flowchart.

Inclusion criteria

  • 1. Pregnant women with COVID-19 positive PCR or Rapid test results with or without symptoms.

  • 2. Pregnant women were admitted for the treatment of COVID-19.

  • 3. Pregnant women with COVID-19 were admitted for delivery.

Exclusion criteria

  • 1. Medical records of COVID-19-infected pregnant women with missing data (unknown PCR or rapid test)

  • 2. Pregnant women with other viral infections

  • 3. In vitro fertilization (IVF) pregnancy.

Data collection

Information was gathered using the research team’s specially created data collection form to match the study’s objectives. Information on the patient’s age, gestational age, comorbidities (diabetes, hypertension, and anemia), and gynecological and obstetrical history (parity, gravidity, abortion, and the number of previous C-sections). Pregnancy outcomes and birth status (abortion, preterm birth, stillbirth, and requirement for NICU).

The severity of COVID-19 infection was categorized according to the following1214:

Asymptomatic: No symptoms.

Mild disease: Fever, cough, sore throat, nausea, vomiting, diarrhea, loss of taste or smell but no dyspnea; normal O2 saturation and standard chest X-ray.

Moderate disease: Symptoms of mild disease plus evidence of lower respiratory tract infection (exam and imaging), O2 saturation ≥ 94% on room air.

Severe disease: Symptoms of moderate disease but O2 saturation < 94%, PaO2/FiO2 < 300 mmHg, respiratory frequency > 30 breaths per minute, or lung infiltrates > 50%.

Critical disease: Symptoms of severe disease but intubated with respiratory failure, septic shock, and multiorgan dysfunction.

Bias

Since research operations, data collection, data entry, and data quality assurance are unplanned, retrospective cohort studies are frequently thought to have a higher bias. Using old data may affect any of these categories. But the authors of this study were keen to ensure that every eligible individual has an equal probability of selection. The research developed for settings considered, data completeness and quality assessment were conducted to ensure less bias during sample selection and study procedure.

Statistical analyses

The collected data were analyzed using SPSS version 25 statistical program for Windows (RRID: SCR 016479). The data are presented as mean ± standard deviation, number, and frequency. The chi-squared test was used to determine the significance of the associations between related categorical variables. Odds ratios were used to quantify the relationship between exposure and disease. Binary logistic regression was used to predict the relationship between independent and predicted variables. A two-sample t-test was used to determine the significance of differences between the means of the numerical data. A P-value less than 0.05 were considered a discrimination point for significance.

Results

Characteristics of COVID-19 infected pregnant women

The mean age of COVID-19-infected pregnant women was 26.78-year ± 6.694 standard deviation (between 15-46 years), gestational age was 35.77-week ± 6.133 standard deviation (between 6-42 weeks), and birth weight at delivery was 2937.10 gram ± 607.457 standard deviation. Eight women were in the first trimester (2.2%), 15 in the second trimester (4.2%), and the majority of the cases (336) were in the third trimester (93.6%) as presented in Table 1.

Table 1. Characteristics of COVID-19 infected pregnant women.

VariableNMeanSD
Age35926.78 year6.694
Gestational age35935.77 week6.133
Birth weight2832936.22 gram605.797
TrimesterFirst82.2%
Second154.2%
Third33693.6%

The severity of COVID-19 among pregnant women

Data present that 43.5% of the cases were asymptomatic, 35.4% were mild, 13.9% were moderate, and 7.2% were severe COVID-19 cases (Figure 2).

c5efd3fc-fd4f-4126-a531-97740071004d_figure2.gif

Figure 2. Distribution of COVID-19-infected pregnant women according to the severity.

Length of hospital stay according to age and severity of COVID-19 infected pregnant women

Study findings revealed that COVID-19-infected pregnant women with severe infection or aged ≥40 years had more extended hospital stays (≥3 days) than those with non-severe illness or aged less than 40 years (P-value < 0.05) (Table 2).

Table 2. Length of Hospital Stay according to age and severity of COVID-19 Infected Pregnant Women.

SeverityHospital stayP-valueOdd Ratio95%CI
≥3 days<3 days
N%N%
Severe (n = 26)830.8%1869.2%0.004**3.4501.41-8.47
Not severe (n = 333)3811.4%29588.6%
Age ≥ 40635.31164.70.004**4.1181.44-11.74
Age < 404011.730288.3

** P-value < 0.01 was considered highly significant.

Distribution of signs and symptoms of COVID-19 infected pregnant women according to the severity

Table 3 shows those COVID-19-infected pregnant women who suffered from fever, cough, shortness of breath, and dyspnea had significantly more severe COVID-19 infection than those who did not suffer from the above clinical manifestations. P value = 0.001 for all conditions. Other symptoms didn’t differ among severity P-value > 0.05.

Table 3. Distribution of COVID-19 signs and symptoms according to the severity.

SymptomsSevere (n = 26)Not severe (n = 333)P-value
N%N%
Fever2412.8%16387.2%0.001**
Cough1418.4%6281.6%0.001**
SOB/dyspnea2044.42555.6%0.001**
Diarrhea16.7%1493.3%0.930
Vomiting314.3%1885.7%0.199
Nausea112.5%787.5%0.495
Musculoskeletal pain17.7%1292.3%0.949
Headache413.3%2686.7%0.179
Weakness414.3%2485.7%0.134
Loss of smell or taste16.3%1593.8%0.875
Sore throat212.8%1387.2%0.352

** P-value < 0.01 was considered highly significant.

Prediction of signs and symptoms

Table 4 showed that fever and shortness of breath were the most predictable signs and symptoms that may result in severe COVID-19 after adjustment for other symptoms that showed a significant association with the severity of COVID-19 condition according to the chi-square test presented in Table 3.

Table 4. Prediction of signs and symptoms that may result in severe COVID-19.

Sign/symptomsBS.E.WalddfP-valueExp(B)
Fever1.7490.8174.5810.032*5.747
Cough-0.7130.6191.32910.2490.490
SOB/dyspnea3.6760.63233.8310.001**39.51
Constant-4.4461.09216.5910.0010.012

* P-value < 0.05 was considered significant.

** P-value < 0.01 was considered highly significant.

Distribution of COVID-19 medications

Table 5 shows that COVID-19-infected pregnant women who received multiple antibiotics, oxygen therapy, steroids, enoxaparin, and CPAP had significantly more severe COVID-19 infection than those who did not need the above treatments. P-value = 0.001 for all conditions.

Table 5. Distribution of medications among pregnant women according to the severity.

VariablesSevere (n = 26)Not severe (n = 333)P-value
N%N%
AntibioticsNo antibiotics11.2%8198.8%0.001**
One antibiotic105.7%16594.3%
Multiple antibiotics1514.7%8785.3%
AntiviralNo anti-viral237.5%28592.5%0.686
Antiviral35.9%4894.1%
O22295.7%14.3%0.001**
Steroids1720.7%6579.3%0.001**
Supplement46.6%5793.4%0.821
Enoxaparin1815.9%9584.1%0.001**
CPAP4100.0%00.0%0.001**

** P-value < 0.01 was considered highly significant.

Distribution of risk factors of COVID-19 pregnant women according to the severity

Table 6 presents the distribution of the recorded risk factors according to COVID-19 severity. Pregnant women with a history of diabetes, hypertension, and previous cesarean sections presented with a significant predominance of severe cases. The mean age of severe COVID-19-infected pregnant women was significantly higher than that of not severe cases (P-value = 0.001), while gestational age did not reveal any difference between severity types (P-value > 0.05).

Table 6. Distribution of risk factors of COVID-19 pregnant women according to the severity.

Risk factorsSevere (n = 26)Not severe (n = 333)P-value
N%N%
Diabetes436.4%763.6%0.001**
Hypertension1431.1%3168.9%0.001**
Anemia1510.1%13489.9%0.082
Previous cesarean1510.9%12389.1%0.036*
Risk factorsSevereNot severePV
NMeanSDNMeanSD
Age2632.197.45133326.356.4550.001**
Gestational age2635.234.75233335.816.2320.658

* P-value < 0.05 was considered significant.

** P-value < 0.01 was considered highly significant.

Predictions of risk factors after adjustment of other independent factors

After adjustment for other risk factors, hypertension was found to be the most predictive risk factor for severe COVID-19 infection among pregnant women with a positive medical history (Table 7), according to the chi-square test presented in Table 6.

Table 7. Predictions of risk factors after adjustment of other independent factors.

Risk factorsBS.E.WalddfP-valueExp(B)
DM1.4580.7683.60410.0584.297
HT2.2160.46223.05710.001**9.173
Previous C/S-0.3050.4590.44210.5060.737
Constant-3.9501.6545.70710.0170.019

** P-value < 0.01 was considered highly significant.

Pregnancy outcomes and birth status among COVID-19 infected pregnant women

Figure 3 shows that 5.1% of pregnancies ended with abortion, and 31.22% needed NICU and 6.4% ended with stillbirths among all the studied cases. Pregnancy outcomes according to the severity of covid-19 infection, as presented in Table 5, showed that 35% (7 out of 20) of stillbirth deliveries were in mothers with severe COVID-19 infection, which is significantly higher than stillbirth in non-severe cases, 65% (13 out of 294). (P-value = 0.001), (OR = 8.8), (95%CI = 3.1-24.8). Severe COVID-19-infected pregnant women delivered 13.9% (11 out of 79) of babies requiring NICU admission, significantly higher than mothers with non-severe infection (28%; 68 out of 239) (P-value = 0.014), (OR = 2.8), (95%CI = 1.2-6.4). Severe COVID-19-infected pregnant women delivered 19.4% (14 of 72) of preterm babies, significantly higher than mothers with non-severe infections (24.6%, 58/235) (P-value = 0.001), (OR = 5.16), (95%CI = 2.23-11.95) (see Table 8).

c5efd3fc-fd4f-4126-a531-97740071004d_figure3.gif

Figure 3. Pregnancy outcomes and birth status (X-axis represents the percentage, and Y-axis represents the complications).

Table 8. Pregnancy outcomes according to the severity of covid-19 infection.

VariableStillbirthNICUAbortionPreterm
N%N%N%N%
Severe (n = 25)735.01113.916.31419.4
Not severe (n = 333)1365.06886.11593.85880.6
P-value0.001**0.014*0.8420.001**
Odd ratio8.82.80.8115.16
95%CI3.1-24.81.2-6.40.1-6.42.23-11.95

* P-value < 0.05 was considered significant.

** P-value < 0.01 was considered highly significant.

Discussion

In the current study, the mean age of the 359 pregnant women was approximately 26 years, and most of them were admitted to the hospital in the third trimester (gestational age of 35.77 weeks). These data agree with others, where the higher hospitalization rate of pregnant women with COVID-19 was in the third trimester.15,16

Recently, human health has been severely threatened by COVID-19 infections that can range in severity from asymptomatic to severe (O2 saturation < 94%, hypoxia, lung involvement, and increased respiratory rate) or critical (multiorgan dysfunction and respiratory failure).17 According to recent research, pregnant women are more likely to experience severe illnesses, including the need for hospitalization, ICU admission, and mechanical ventilation.18 Asymptomatic and mild pregnancy cases (43.5%, 35.4%) in the current study represented the most hospitalized cases, while severe cases represented the least (7.2%) of the total cases. These results agree with previous studies, which revealed that most COVID-19-infected pregnant women were asymptomatic and had mild cases.19,20

The length of hospital stay (LOHS) was defined as the duration between the patient’s admission to the hospital and discharge. Data on duration of stay provide insights into the effectiveness of care over time, including associations between length of stay and hospital-acquired conditions (HACs). For example, extended hospital stays have been linked to high mortality rates for specific diseases and an increased risk of hospital-acquired infections. The current study showed that patients who experienced significantly extended LOHS (equal to or more than three days) were those with severe COVID-19 infection and those aged ≥ 40 years. This result agrees with Wang et al. in 2022, who reported similar findings concerning the age and severity of illness with hospital stay.9

The most common symptoms of COVID-19 are fever, cough, dyspnea, and myalgia.5,21 COVID-19-infected pregnant women in this study had a fever, cough, shortness of breath, and other signs and symptoms such as nausea, vomiting, diarrhea, headache, weakness, and loss of smell or taste, which occurred in a small percentage of the included cases. These results agree with Gillian et al. in 2020, who reported that fever, cough, and SOB were the most common symptoms in pregnant women with COVID-19 infection.22 The common symptoms were more pronounced among severe COVID-19 infected pregnant women (P-value = 0.001) than those with mild or moderate cases. After adjusting for other signs and symptoms, fever and shortness of breath were the most predictable indicators of severity using binary logistic regression. Although Lian et al., in 2021, stated similar results regarding fever but argued by considering cough as a predictor of developing severe illness,23 the reason behind this argument may be due to pregnancy itself, as the shortness of breath may occur in normal pregnancy by excluding the pathological causes. It is a challenge for clinicians to differentiate.24

The data obtained in this study documented the use of multiple antibiotics in severe cases, representing 14.7% of total medications. Cephalosporins were the most commonly used group in 73% of the cases, followed by macrolides, doxycycline, and aminoglycosides. However, the use of carbapenems, quinolones, and penicillins was much lower. The use of multiple antibiotics among COVID-19-infected pregnant women, despite several guidelines that recommend antibiotics, except in the presence of secondary bacterial infection.25,26

Medical oxygen is an essential medicine in treating COVID-19 and is used mainly to alleviate the severity of the infection.27 According to the Society for Maternal-Fetal Medicine, the target SpO2 for pregnant women should be higher than that recommended for the general population (SpO2 92%) owing to the increased O2 demand during pregnancy.28 Oxygen therapy was used in 23 patients in this study; of them, 22 patients had severe COVID-19 infection, all of whom showed improvement in clinical status and alleviation of the severity of the disease. According to numerous randomized trials, systemic corticosteroid therapy enhances clinical outcomes and lowers mortality in COVID-19 hospitalized patients who require supplementary oxygen.2931 In contrast, systemic corticosteroids have not been proven beneficial and may even be harmful in COVID-19 hospitalized patients who do not need additional oxygen.32,33 In Pregnant women at risk of premature delivery, a brief course of betamethasone or Dexamethasone, which is known to cross the placenta, is frequently used to reduce neonatal complications of prematurity and decrease maternal mortality.34,35 In 22.8% of the cases included in this study, corticosteroids were used for both maternal and fetal purposes; however, pregnant women with COVID-19 infection who received corticosteroids had a more severe COVID-19 disease than those who did not (P = 0.001), so the more severe infection results in greater corticosteroid use, which is in line with national guidelines.

Inflammation and prothrombotic conditions have been linked to COVID-19, and fibrin breakdown products, fibrinogen, and D-dimer levels have increased.36 Some studies have linked the elevation of these markers to worse clinical outcomes.37,38 In addition, pregnant women have a higher risk of thromboembolism than non-pregnant women because pregnancy is a hypercoagulable state.39 Although there are no data for or against the use of anticoagulant therapy in the context of COVID-19 during pregnancy, the American College of Obstetricians and Gynecologists (ACOG) advises that VTE prophylaxis can be considered for pregnant women hospitalized with COVID-19, especially for those with severe disease. In the current study, enoxaparin was used in 31.5% of the cases, and its use was significantly associated with severe COVID-19 in pregnant women compared to those with non-severe disease (P = 0.001). Moreover, patients with COVID-19 successfully used CPAP to avoid endotracheal intubation. However, there is little information regarding the use of CPAP in expecting mothers with acute respiratory failure (ARF) caused by SARS-CoV-2 pneumonia.40 In this study, CPAP use was significantly associated with severe COVID-19 in pregnant women (P = 0.001), and there was no need for it in the non-severe cases.

Numerous risk factors have been linked to the progression of COVID-19 into a severe and critical stage, including advanced age, male sex, and underlying comorbidities such as hypertension, diabetes, obesity, chronic lung diseases, heart, liver, and kidney diseases, tumors, and pregnancy.41,42 In the current study, COVID-19-infected pregnant women with a history of diabetes, hypertension, and previous cesarean section presented with a significant predominance of severe cases. In addition, the mean age of severe COVID-19-infected pregnant women was significantly higher (32.19 years) than that of non-severe patients. Allotey et al. 2020 mentioned that pregnant women with diabetes, hypertension, BMI > 30, and age > 35 years tend to have severe COVID-19 infection.5 Pregnant women with previous C-sections tend to have a severe infection, which may be due to the increased number of C-sections accompanied by additional complications.43 Also, individuals with COVID-19 with high blood pressure are related to higher mortality; the severity of COVID-19 may be exacerbated by inflammation and dysfunction of the immune system, gastrointestinal tract, and renin-angiotensin-aldosterone system; in addition, changes in innate cellular immunity contribute to high glucose environment, besides to more virulent growth of microbes.44,45

After adjusting for risk factors that showed a significant association with the severity of infection (hypertension, diabetes, and previous C-section), predictions of risk factors were made using binary logistic regression to determine the most predictable risk factor. The test revealed that the incidence of COVID-19-infected pregnant women presenting with hypertension and diabetes developing severe infection was 9.173 and 4.297, respectively. These results are in agreement. In addition, Lian et al., in 2021, stated that patients with advanced age, H.T., and hypertension tend to have more severe COVID-19 infection.23

Because COVID-19 affects both the mother and the fetus and negatively impacts pregnancy outcomes, pregnant women with the infection need particular care and attention.46 This study explored the association between the severity of COVID-19 and adverse pregnancy outcomes. Among the entire study population, 6.3% (n = 20) of pregnant women had a stillbirth, 25% (n = 79) were admitted to the NICU, 4.8% (n = 16) had an abortion, and 22.6% (n = 72) had preterm delivery. There were 26 cases of COVID-19-infected pregnant women who presented with severe infection (delivery occurred in 25 patients) and had a higher rate of stillbirth deliveries (7 out of 25). In addition, admission to the NICU was higher among severe COVID-19-infected pregnant women (11 out of 24) and had preterm delivery (14 out of 25) than among non-severe cases. These results agree with those of Dileep et al. in 2022, who reported a strong association between the severity of COVID-19 infection and preterm birth, NICU admission, and low birth weight.46 Another study reported severe COVID-19 disease in pregnant women was associated with preterm and stillbirth deliveries.47

Study limitations

The collected data were retrospectively limited to two hospitals during one year. As a result, some of the collected data (particularly laboratory investigations) were not generally distributed in the patient’s records. In addition, the medical staff did not document important information, such as weight and body mass index (BMI), which strongly contributes to severity.

Conclusions

Most COVID-19-infected pregnant women tend to have asymptomatic or mild cases of infection. However, severe COVID-19 illness is linked to pregnancy and birth complications, mainly among pregnant women with a positive medical history.

Comments on this article Comments (1)

Version 1
VERSION 1 PUBLISHED 27 Feb 2023
  • Reader Comment 28 Mar 2023
    Yasir Elsanousi, Division of Medical & Health Services, Alsabeel Charitable Health Center, Omdurman, Sudan
    28 Mar 2023
    Reader Comment
    Thank you for this important research.
    My comments toward improvement of this manuscript:

    (A) Major Concern:
    1) The Title: is not fully informative as it reflects only a single ... Continue reading
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Sami Salih O and Khalid Abdulridha M. The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2023, 12:220 (https://doi.org/10.12688/f1000research.131229.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 17 Oct 2023
Joao Eudes Magalhaes, Faculdade de Ciências Médicas, Universidade de Pernambuco, Recife, Brazil 
Not Approved
VIEWS 3
I received this manuscript on pregnancy outcomes and their correlation with the severity of COVID with enthusiasm. Although there is already a substantial body of literature published on the subject, it is always important to understand regional realities.

... Continue reading
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Magalhaes JE. Reviewer Report For: The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2023, 12:220 (https://doi.org/10.5256/f1000research.144044.r210968)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 08 Oct 2023
Erin Oakley, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA 
Approved with Reservations
VIEWS 6
First, I commend the authors on a thoughtful and thorough study of COVID-19 severity in pregnancy. The analysis is well done and will be useful to inform the body of knowledge around risk factors for severe COVID-19 (and related poor ... Continue reading
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Oakley E. Reviewer Report For: The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2023, 12:220 (https://doi.org/10.5256/f1000research.144044.r206633)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 15 Aug 2023
Hayder Adnan Fawzi, Department of Pharmacy, Al-Mustafa University ‎College, Baghdad, Iraq 
Approved with Reservations
VIEWS 9
The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study

Methods: Data collection    

Where the information came from the patients? Datasheet or by other means? Please emphasize more about ... Continue reading
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Fawzi HA. Reviewer Report For: The impact of COVID-19 severity on pregnancy outcomes among Iraqi women: a retrospective observational study [version 1; peer review: 2 approved with reservations, 1 not approved]. F1000Research 2023, 12:220 (https://doi.org/10.5256/f1000research.144044.r193261)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (1)

Version 1
VERSION 1 PUBLISHED 27 Feb 2023
  • Reader Comment 28 Mar 2023
    Yasir Elsanousi, Division of Medical & Health Services, Alsabeel Charitable Health Center, Omdurman, Sudan
    28 Mar 2023
    Reader Comment
    Thank you for this important research.
    My comments toward improvement of this manuscript:

    (A) Major Concern:
    1) The Title: is not fully informative as it reflects only a single ... Continue reading
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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