Objective: To determine the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed coronavirus disease 2019 (covid-19). Design: Living systematic review and meta-analysis. Data sources: Medline, Embase, Cochrane database, WHO COVID-19 database, China National Knowledge Infrastructure (CNKI), and Wanfang databases from 1 December 2019 to 27 April 2021, along with preprint servers, social media, and reference lists. Study selection: Cohort studies reporting the rates, clinical manifestations (symptoms, laboratory and radiological findings), risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed covid-19. Data extraction: At least two researchers independently extracted the data and assessed study quality. Random effects meta-analysis was performed, with estimates pooled as odds ratios or risk difference and proportions with 95% confidence intervals. All analyses are updated regularly. Results: 435 studies were included. Overall, 9% (95% confidence interval 7% to 10%; 149 studies, 926 232 women) of pregnant and recently pregnant women attending or admitted to hospital for any reason were diagnosed as having suspected or confirmed covid-19. The most common clinical manifestations of covid-19 in pregnancy were fever and cough (both 36%). Compared with non-pregnant women of reproductive age, pregnant and recently pregnant women with covid-19 were less likely to report symptoms of fever, dyspnoea, cough, and myalgia. The odds of admission to an intensive care unit (odds ratio 2.61, 95% confidence interval 1.84 to 3.71; I ² =85.6%), and invasive ventilation (2.41, 2.13 to 2.71; I ² =0%) were higher in pregnant and recently pregnant than non-pregnant women of reproductive age. Overall, 970 pregnant women (0.2%, 123 studies, 179 981 women) with confirmed covid-19 died from any cause. In pregnant women with covid-19, non-white ethnicity, increased maternal age, high body mass index, any pre-existing maternal comorbidity including chronic hypertension and diabetes, and pregnancy specific complications such as gestational diabetes and pre-eclampsia, were associated with serious complications (severe covid-19, admission to an intensive care unit, invasive ventilation, and maternal death). Compared to pregnant women without covid-19, those with the disease had increased odds of maternal death (odds ratio 6.09, 95% confidence interval 1.82 to 20.38; I ² =76.6%), of admission to the intensive care unit (5.41, 3.59 to 8.14; I ² =57.0%), caesarean section (1.17, 1.01 to 1.36; I ² =80.3%), and of preterm birth (1.57, 1.36 to 1.81; I ² =49.3%). The odds of stillbirth (1.81, 1.38 to 2.37, I ² =0%), and admission to the neonatal intensive care unit (2.18, 1.46 to 3.26, I ² =85.4%) were higher in babies born to women with covid-19 versus those without covid-19. Conclusion: Pregnant and recently pregnant women with covid-19 attending or admitted to the hospitals for any reason are less likely to manifest symptoms such as fever, cough, dyspnoea, and myalgia, but are more likely to be admitted to the intensive care unit or needing invasive ventilation than non-pregnant women of reproductive age. Pre-existing comorbidities, non-white ethnicity, chronic hypertension, pre-existing diabetes, high maternal age, and high body mass index are risk factors for severe covid-19 outcomes in pregnancy. Pregnant women with covid-19 versus without covid-19 are more likely to deliver preterm and have an increased risk of maternal death and of being admitted to the intensive care unit. Their babies are more likely to be admitted to the neonatal intensive care unit. Systematic review registration: PROSPERO CRD42020178076. Readers’ note: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 2 of the original article published on 1 September 2020 ( BMJ 2020;370:m3320), and previous updates can be found as data supplements ( https://www.bmj.com/content/370/bmj.m3320/related#datasupp ). When citing this paper please consider adding the update number and date of access for clarity.

Objectives: To assess the rates of SARS-CoV-2 positivity in babies born to mothers with SARS-CoV-2 infection, the timing of mother-to-child transmission and perinatal outcomes, and factors associated with SARS-CoV-2 status in offspring. Design: Living systematic review and meta-analysis. Data sources: Major databases between 1 December 2019 and 25 April 2022. Study selection: Cohort studies of pregnant and recently pregnant women (including after abortion or miscarriage) who sought hospital care for any reason and had a diagnosis of SARS-CoV-2 infection, and also provided data on offspring SARS-CoV-2 status and risk factors for positivity. Case series and case reports were also included to assess the timing and likelihood of mother-to-child transmission in SARS-CoV-2 positive babies. Data extraction: Two reviewers independently extracted data and assessed study quality. A random effects model was used to synthesise data for rates, with associations reported using odds ratios and 95% confidence intervals. Narrative syntheses were performed when meta-analysis was inappropriate. The World Health Organization classification was used to categorise the timing of mother-to-child transmission (in utero, intrapartum, early postnatal). Results: 643 studies (343 cohort studies, 300 case series and case reports; 44 552 mothers, 30 822 babies) were included. Overall, 2.7% (95% confidence interval 2.1% to 3.5%; 210 studies, 24 040 babies) born to mothers with SARS-CoV-2 infection tested positive for the virus with reverse transcriptase polymerase chain reaction (RT-PCR). Of the 1107 SARS-CoV-2 positive babies with data on the timing of exposure and type and timing of tests, 32 had confirmed mother-to-child transmission: 20 in utero (857 assessed), three intrapartum (35 assessed), and nine during the early postnatal period (144 assessed). Of the 1213 SARS-CoV-2 positive babies with outcome data, 64 were stillbirths, 36 were neonatal deaths, and nine were early pregnancy losses; 1104 babies were alive at the end of follow-up. Severe maternal covid-19 (odds ratio 3.5, 95% confidence interval 1.5 to 8.1), maternal death (14.1, 4.1 to 48.0), maternal postnatal infection (5.0, 1.2 to 20.1), caesarean section (1.4, 1.1 to 1.8), and preterm delivery (1.5, 1.2 to 1.9) were associated with SARS-CoV-2 positivity in offspring. Positivity rates in offspring using RT-PCR varied between regions, ranging from 0.1% (95% confidence interval 0.0% to 0.5%) in studies from North America to 8.5% (4.6% to 13.3%) in studies from Latin America and the Caribbean. Conclusion: SARS-CoV-2 positivity rates are low in babies born to mothers with SARS-CoV-2 infection. Evidence confirms vertical transmission of SARS-CoV-2, although this is rare. Severity of maternal covid-19 is associated with SARS-CoV-2 positivity in offspring. Systematic review registration: PROSPERO CRD42020178076. Readers’ note: This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 1 of the original article published on 16 March 2022 ( BMJ 2022;376:e067696), and previous updates can be found as data supplements ( https://www.bmj.com/content/376/bmj-2021-067696/related#datasupp ).

A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.

Surgical repair of Tetralogy of Fallot has excellent outcomes, with over 90% of patients alive at 30 years. The ideal time for surgical repair is between 3 and 11 months of age. However, the symptomatic neonate with Tetralogy of Fallot may require earlier intervention: either a palliative intervention (right ventricular outflow tract stent, ductal stent, balloon pulmonary valvuloplasty, or Blalock-Taussig shunt) followed by a surgical repair later on, or a complete surgical repair in the neonatal period. Indications for palliation include prematurity, complex anatomy, small pulmonary artery size, and comorbidities. Given that outcomes after right ventricular outflow tract stent palliation are particularly promising – there is low mortality and morbidity, and consistently increased oxygen saturations and increased pulmonary artery z-scores – it is now considered the first-line palliative option. Disadvantages of right ventricular outflow tract stenting include increased cardiopulmonary bypass time at later repair and the stent preventing pulmonary valve preservation. However, neonatal surgical repair is associated with increased short-term complications and hospital length of stay compared to staged repair. Both staged repair and primary repair appear to have similar long-term mortality and morbidity, but more evidence is needed assessing long-term outcomes for right ventricular outflow tract stent palliation patients.

Background: Pregnant and recently pregnant women infected with SARS-CoV-2 are at increased risk of death and serious complications than those without the infection. The extent of variation in mortality rates in pregnant women with SARS-CoV-2 infection across regions, and the causes of death are not known. We systematically reviewed all available evidence on the variation in mortality rates in pregnant women with SARS-CoV-2 infection across geographical and country income groups, and the reported cause of death. Methods: We searched major databases (December 2019–January 2023) including Medline, LILACS, BIREME and Embase. We included studies that reported deaths in at least 10 consecutive pregnant or recently pregnant women with confirmed SARS-CoV-2 infection and assessed the studies’ risk of bias. We calculated the summary estimates of any cause of death as proportions with 95% CIs using a multilevel random-effects logistic regression model. Subgroup analyses were performed by geographical region and country income groups. We used International Statistical Classification of Diseases and Related Health Problems-Maternal Mortality to categorise the reported cause of death. Findings: From 1 326 315 citations, we included 169 studies (319 172 women with confirmed SARS-CoV-2 infection; 4253 women died). The overall rate of unspecified maternal death was 0.87% (95% CI 0.64% to 1.16%). There were significant differences between geographical regions in rates of maternal mortality, with the highest rates in Sub-Saharan Africa (3.48%; 95% CI 0.66% to 16.42%) and Latin America and the Caribbean (3.16%, 95% CI 1.53% to 6.43%). Rates of maternal mortality varied by country income groups, with the highest rates in low-income countries (4.66%, 95% CI 0.75% to 24.07%). Among women with reported cause of death, 98.6% (2,390/2,423) of deaths were attributable to COVID-19. Interpretation: Rates of deaths in pregnant and recently pregnant women with SARS-CoV-2 infection vary significantly across regions and by country income groups, with the highest burden in Sub-Saharan Africa and low-income countries. COVID-19 is the main reported cause of death. PROSPERO registration number: CRD42020224120.

Introduction: Anatomical knowledge is an essential part of surgical practice. However, its delivery lacks a standardised approach across medical school curricula. A student-led anatomy programme was implemented at a single institution, using near-peer teaching and Anatomage virtual dissection. This study aims to describe the methodology of this programme and determine the benefit of a near-peer taught anatomy course. Method: The programme was organised by senior medical students, utilising Anatomage virtual dissection and techniques in line with Bigg’s constructive alignment. Attendees were asked to complete questionnaires with Likert scales (0-10) and open answer text to determine learners’ benefit. Both quantitative and qualitative analyses are presented. Results: 73 students attended eight sessions from January to March 2020. Students reported a statistically significant (p < 0.01) increase in confidence after the sessions of 3.74±1.83. The quality and relevance of the teaching also scored highly (9.32±0.89 and 9.47±0.86 respectively). Qualitatively, students praised the "informal learning environment”, the structure of the sessions, the handout provided, and the interactivity of anatomage technology. Conclusions: This study demonstrates how virtual dissection technology and near-peer teaching can derive significant benefit to undergraduate students, in line with previously published data.