There has been significant work to look at various patient characteristics to gain some understanding into COVID-19 and its clinical effects.
However, while there has certainly been excellent findings on common diagnostic symptoms (e.g., fever, incubation period, etc.) there are some other areas that are interesting, but yet to be explored.
So, we decided to investigate two questions using the Evid Science platform – the goal here is to gain an understanding from a rapidly evolving situation, rather than a deep, traditional Systematic Literature Review (SLR), so please do take these results with those caveats.
Clinical Questions and Findings
1) Does COVID-19 affect birth?
From the limited data we see, most deliveries to women with confirmed COVID-19 were healthy. Both mothers and newborns developed (or maintained) a fever, but perhaps that is to be expected given the occurrence of fever as a symptom of COVID-19.
2) Are gastroenterological symptoms reliable as an initial screener for COVID-19?
Despite reports to the contrary, it does not appear that gastroenterological symptoms, especially diarrhea, are reliable for diagnosis alone. The reported occurrence in COVID-19 patients varied vastly and the overall incidence was less than 10%.
We would love to hear if others can corroborate these findings clinically or if you have another opinion on this to add. Please do reach out.
Note: The data in this report is current as of 4/1/2020 and the situation is changing rapidly. Please be cautious when interpreting these results.
Methods and Results
Does COVID-19 affect birth?
For this quick study we queried the Evid Science platform with the phrase: “COVID-19.” This returns 2,182 papers, of which 248 are primary studies (e.g., observational or trials) that our AI extracted results from.
From this set, we filtered (using Evid Science PICO facets) to any article that mentioned pregnancy as part of the group/intervention. This yielded six articles, of which, four explicitly describe birth outcomes or outcomes related to mothers’ death.[1-4] The full search and screen took 8 minutes (again, the focus is on rapid understanding of the data, not Systematic Literature Review), and the results are presented in Table 1 below.
All of the births were successful (N=25), [2-4] with many mothers presenting symptoms before or during birth.[2-4] Perhaps as expected, due to COVID-19 infection, many of the mothers had or developed fever, as did some of the newborns. Although low-grade fevers were reported, this is not uncommon in cesarean deliveries, and fevers resolved within 24 hours of delivery.
In this sample of studies, mothers with confirmed COVID-19 were able to successfully deliver without major complications. Newborns were healthy and no abnormalities were observed. Of course, this is a very small study, from a rapidly evolving situation, so please be aware of these caveats.
Table 1: Results related to birth and COVID-19 infection
|4 of 9||pregnant women with confirmed 2019-nCoV infection, cases||onset of clinical symptoms occurred before delivery|||
|2 of 9||pregnant women with confirmed 2019-nCoV infection, cases||onset of clinical symptoms occurred, on the day of delivery|||
|2 of 10||neonates||initial symptoms, fever|||
|1 of 10||neonates||Up to now, has died|||
|10 of 11||patients had successful delivery||cesarean deliveries, during the study period|||
|1 of 11||patients had successful delivery||vaginal delivery, during the study period|||
|13 of 15||pregnant women, patients||most common onset symptoms of COVID-19 pneumonia, were fever|||
|0 of 11||pregnant women||cases of neonatal asphyxia, neonatal death, stillbirth, or abortion were reported|||
|0 of 5||newborn||complications were observed in newborn|||
|5 of 5||labors||smoothly processed|||
|5 of 5||pregnant women||developed a low-grade fever (37.5-38.5℃) within 24 hours after delivery|||
|0 of 3||Pregnant patients||By the end of February 25, 2020, developed severe 2019-nCoV pneumonia or died|||
Are gastroenterological symptoms reliable?
It is clear from the literature that fever is highly indicative of potential COVID-19 infection and is therefore relied upon as an initial screener for diagnosis. However, some reports are saying that gastroenterological (GI) symptoms, especially diarrhea, could also be potentially considered as a major symptom. In our data, this does not bear out.
For this analysis we again queried the Evid Science platform with the phrase: “COVID-19.” This returns 2,182 papers, of which 248 are primary studies (e.g., observational or trials) that our AI extracted results from.
We then used the Evid Science PICO filters to filter for outcomes related to GI, GI symptoms, gastroenterological symptoms or diarrhea (and its spelling variants). This yielded 16 articles, and after screening for patient outcomes related to our search, we were left with 11 papers.[5-15] The total process took less than 10 minutes. The results are presented in Table 2.
Across the articles, diarrhea (or sometimes general GI symptoms) occurred in 227 of 2,796 patients, for an overall rate of 8.1%.[5-11,13-18] The average rate across articles was 19.91%, though the rather large standard deviation (22.42%) speaks to the large variance in reported rates. Nonetheless, as more data is collected, it appears the rate is fairly low (less than 10%).
An interesting sub-finding is that the virus was detectible a majority of the time in stool (though not urine).[12,18]
So, while certain symptoms, such as fever, occur commonly enough to serve as an initial indicator, it does not appear that GI symptoms, and diarrhea in particular, do so.
Table 2: GI related results
|1 of 38||patients||less common symptoms were, diarrhoea|||
|2 of 100||Patients||had clinical manifestations of, diarrhoea|||
|3 of 38||patients||most common symptoms at onset of illness were, diarrhoea|||
|55 of 140||patients||gastrointestinal symptoms, were the most common clinical manifestations|||
|42 of 1099||patients||Diarrhea was uncommon|||
|3 of 33||patients||Other symptoms included, diarrhea|||
|21 of 605||cases||symptoms were, gastrointestinal symptom|||
|4 of 8||patients||Virus was detectable in the stool, by polymerase chain reaction but not in urine|||
|6 of 40||patients||main clinical manifestations included, diarrhea|||
|9 of 30||patients||nausea, vomiting or diarrhea|||
|2 of 5||were given antiviral therapy (including oseltamivir), oxygen inhalation, and antibiotics||main complications, diarrhea|||
|74 of 651||enrolled, patients||presented with at least one GI symptom (nausea, vomiting or diarrhoea)|||
|1 of 7||had caesarean section within 3 days of clinical presentation||Clinical manifestations were, diarrhoea|||
|8 of 10||patients||most common symptoms were, diarrhea|||
|10 of 10||patients’ nasopharyngeal swab and stool specimens||positive SARS-CoV-2 RNA signals|||
- Chen S, Huang B, Luo DJ, Li X, Yang F, Zhao Y, Nie X, Huang BX (2020). [Pregnant women with new coronavirus infection: a clinical characteristics and placental pathological analysis of three cases]. Zhonghua bing li xue za zhi = Chinese journal of pathology, 0, E005.
- Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, Xia S, Zhou W (2020). Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Translational pediatrics, 1, 51-60.
- Liu D, Li L, Wu X, Zheng D, Wang J, Yang L, Zheng C (2020). Pregnancy and Perinatal Outcomes of Women With Coronavirus Disease (COVID-19) Pneumonia: A Preliminary Analysis. AJR. American journal of roentgenology,1-6.
- Chen S, Liao E, Shao Y (2020). Clinical analysis of pregnant women with 2019 novel coronavirus pneumonia. Journal of medical virology.
- Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (London, England).
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- Xu XW, Wu XX, Jiang XG, Xu KJ, Ying LJ, Ma CL, Li SB, Wang HY, Zhang S, Gao HN, Sheng JF, Cai HL, Qiu YQ, Li LJ (2020). Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. BMJ (Clinical research ed.), m606.
- Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, Yan YQ, Akdis CA, Gao YD (2020). Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China. Allergy .
- Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS, (2020). Clinical Characteristics of Coronavirus Disease 2019 in China. The New England journal of medicine.
- Wang D, Ju XL, Xie F, Lu Y, Li FY, Huang HH, Fang XL, Li YJ, Wang JY, Yi B, Yue JX, Wang J, Wang LX, Li B, Wang Y, Qiu BP, Zhou ZY, Li KL, Sun JH, Liu XG, Li GD, Wang YJ, Cao AH, Chen YN (2020). [Clinical analysis of 31 cases of 2019 novel coronavirus infection in children from six provinces (autonomous region) of northern China]. Zhonghua er ke za zhi = Chinese journal of pediatrics, 4, E011.
- Cheng JL, Huang C, Zhang GJ, Liu DW, Li P, Lu CY, Li J (2020). [Epidemiological characteristics of novel coronavirus pneumonia in Henan]. Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases, 0, E027.
- Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J, Ng OT, Marimuthu K, Ang LW, Mak TM, Lau SK, Anderson DE, Chan KS, Tan TY, Ng TY, Cui L, Said Z, Kurupatham L, Chen MI, Chan M, Vasoo S, Wang LF, Tan BH, Lin RTP, Lee VJM, Leo YS, Lye DC, (2020). Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. JAMA.
- Wu WS, Li YG, Wei ZF, Zhou PH, Lyu LK, Zhang GP, Zhao Y, He HY, Li XY, Gao L, Zhang XM, Liu H, Zhou N, Guo Y, Zhang XM, Zhang D, Liu J, Zhang Y (2020). [Investigation and analysis on characteristics of a cluster of COVID-19 associated with exposure in a department store in Tianjin]. Zhonghua liu xing bing xue za zhi = Zhonghua liuxingbingxue zazhi, 4, 489-493.
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- Ding Q, Lu P, Fan Y, Xia Y, Liu M (2020). The clinical characteristics of pneumonia patients co-infected with 2019 novel coronavirus and influenza virus in Wuhan, China. Journal of medical virology.
- Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM, Hao SR, Jia HY, Cai H, Zhang XL, Yu GD, Xu KJ, Wang XY, Gu JQ, Zhang SY, Ye CY, Jin CL, Lu YF, Yu X, Yu XP, Huang JR, Xu KL, Ni Q, Yu CB, Zhu B, Li YT, Liu J, Zhao H, Zhang X, Yu L, Guo YZ, Su JW, Tao JJ, Lang GJ, Wu XX, Wu WR, Qv TT, Xiang DR, Yi P, Shi D, Chen Y, Ren Y, Qiu YQ, Li LJ, Sheng J, Yang Y (2020). Epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. Gut.
- Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, Liu Y, Xiao J, Liu H, Deng D, Chen S, Zeng W, Feng L, Wu J (2020). Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. The Lancet. Infectious diseases, , .
- Lo IL, Lio CF, Cheong HH, Lei CI, Cheong TH, Zhong X, Tian Y, Sin NN (2020). Evaluation of SARS-CoV-2 RNA shedding in clinical specimens and clinical characteristics of 10 patients with COVID-19 in Macau. International journal of biological sciences, 10, 1698-1707.