Medline, Embase, the Cochrane databases, CINAHL and Scopus were searched from inception until May 14, 2020 using MeSH terms and free text search terms related to "coronavirus infections", "pregnancy", "breastfeeding". This was supplemented with targeted searches of general medical and obstetric journals for publications related to routine, off-label, and investigational medications used in COVID-19 patients either for symptomatic relief or in the context of clinical trials, and discussions with international experts. In addition, we reviewed product monographs of all drugs, and conducted targeted literature searches involving the use of each drug in pregnant women. Finally, clinical practice recommendations were summarized from pregnancy guidelines of international societies and ongoing trials were reviewed from three clinical trial registries-www.clinicaltrials.gov, Australian New Zealand Clinical Trials Registry (ANZCTR) and the World Health Organization International Clinical Trials Registry Platform (ICTRP). Given the limited experience with the management of COVID-19, research letters, editorials, commentaries, opinion pieces and special communications were included. No language restrictions were applied.

Introduction: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system characterized by severe, antibody-mediated astrocyte loss with secondary demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord. Recent publications have alluded to increased disease activity during pregnancy, and adverse maternal and fetal outcomes in patients with NMOSD. Our objective was to systematically review published literature to help counsel and manage women with NMOSD contemplating pregnancy. Methods: We searched five databases including MEDLINE and EMBASE, for English-language publications describing pregnancies in women with NMOSD. Article selection, data extraction, and risk-of-bias assessment using Joanna Briggs' critical appraisal tool for case reports and case series, were performed in duplicate. Pooled incidences were calculated where possible, and a narrative summary was provided. Results: Of 2,118 identified titles, 22 case reports and seven case series, representing 595 pregnancies in 389 women, were included. The mean maternal age was 28.12 ± 5.19 years. At least 20% of cases were first diagnosed during pregnancy. There were no maternal deaths. Pooled estimates for clinical outcomes could not be obtained due to inadequate reporting. NMOSD-related disability and relapses increased considerably during pregnancy and especially in the immediate postpartum period. Although a high proportion of early pregnancy losses were reported, an association with disease activity or therapeutic interventions could not be established. Apart from one publication which reported an increased risk of preeclampsia, there was no increase in adverse obstetric outcomes including preterm birth, fetal growth restriction or congenital malformations. Initial attacks and relapses were successfully managed with oral or intravenous D'Souza et al. NMOSD and Pregnancy: Systematic Review corticosteroids and immunosuppressants, and refractory cases with immunoglobulin, plasma exchange and immunoadsorption. Conclusion: Increased NMOSD-related disability and relapses during pregnancy the postpartum period may respond to aggressive management with corticosteroids and immunosuppressants such as azathioprine, which are safely administered during pregnancy and lactation. Emerging safety data on monoclonal antibodies during pregnancy, make these attractive options, while intravenous immunoglobulin, plasma exchange and immunoadsorption can be safely used to treat severe relapses. The complex interplay between NMOSD and pregnancy outcomes would be best understood through prospective analysis of data collected through an international registry. Disclosure: Dalia Rotstein has served as a consultant or speaker for Alexion and Roche. She has received research support from Roche Canada. Rohan D'Souza has served as a consultant and speaker for Ferring Canada Inc and Ferring Global Inc, on topics unrelated to this manuscript. The other authors have no relevant relationships to disclose.

The provision of high-quality food is a primary factor in ensuring adequate nourishment and preventing malnourishment-related diseases in Pakistan. This study, therefore, aimed to quantify the impact of income on nutrient consumption in Pakistan, with the hypothesis that income has a primary role in reducing malnourishment in the developing world. To do this, we estimated nutrient–income elasticity—defined as the proportion of change in nutrient consumption in response to a change in income—for total calories, macronutrients, and micronutrients, using the nationally representative Household Integrated Economic Survey data (2010–2011) for Pakistan. Nutrient–income elasticity values were derived using several parametric regression approaches. We also assessed the non-linearity and endogeneity of the relationship. Calorie–income elasticity was found to be significantly different from zero, irrespective of the estimation technique used. Income elasticity for macronutrients and micronutrients was also found to be significantly different from zero, ranging from 0.29 to 0.65. This study, therefore, supports the hypothesis that increased household income likely improves nutrient consumption.