COVID-19 case reporting
1.
In which country do you work?
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Republic of the
Congo, Democratic Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
2.
Are you reporting a case from a private or a public centre?
Public centre
Private centre
3.
Your profession is:
Gynaecologist
Reproductive Urologist/Andrologist
ART clinician
Nurse
Embryologist
Lab technician
Quality manager
Other (please specify)
4.
Please enter a patient reference number from your clinic. The patient reference number can be used for submitting further details of the case at a later stage via email to (please specify). Please note that this reference number should not contain any patient identifiers.
5.
Please add your email address so we can contact you for further updates on this case
6.
Was the COVID-19 infection in the patient confirmed with laboratory tests?
Yes, by RT-PCR
Yes, by antibody test
No, but there is a strong suspicion of a COVID-19 infection
No
7.
At what stage of the pregnancy did the patient have symptoms and was tested?
During the MAR treatment (including 15 days after embryo transfer)
First trimester
Second trimester
Third trimester
At delivery
8.
Which symptoms did the patient have (check all that apply)?
High fever (>37,5°C)
Cough
Pneumonia
Anosmia (no smell)
Ageusia (Loss of taste)
Gastrointestinal symptoms
No symptoms
Other symptoms (please specify)
9.
Was the patient hospitalized?
No
Yes, in a general ward
Yes, with respiratory support
Yes, in the intensive care unit
Yes, in the intensive care unit with respiratory support
10.
Are you aware of antiviral treatments used?
I do not have this information
Yes (please specify)
11.
Did the patient recover?
No, the patient died
No, the patient is/was still in recovery
Yes
If she was hospitalized, please specify duration (in days):
12.
How did the patient achieve pregnancy?
Ovulation induction
IUI
IVF
ICSI
Donor IUI
Donor sperm IVF/ICSI
Oocyte donation
FER (frozen embryo replacement)
FOR (frozen oocyte replacement)
PGT-A
PGT-M
PGT-SR
Surrogacy
Embryo donation
13.
Please provide any relevant medical background history for the patient (what diseases did she suffer from?)
14.
Where there any pregnancy complications (check all that apply)
No pregnancy complications
Miscarriage
Ectopic pregnancy
Excessive bleeding
Pre-eclampsia
Intrauterine growth restriction
Stillbirth
Preterm birth (< 37 weeks)
Very preterm birth (< 32 weeks)
Extremely preterm birth (< 28 weeks)
Maternal death
Other (please specify)
15.
What was the mode of delivery?
Vaginal
Emergency C-section
Scheduled C-section
16.
What was the gestational age at delivery (in weeks)?
17.
Where there any neonatal complications? (check all that apply)
There were no neonatal complications
Respiratory symptoms
Fever
Other (please specify)
18.
What was the birth weight of the newborn?
Normal (> 2500g)
Low (< 2500g)
Very low (< 1500g)
Extremely low (< 1000g)
19.
What were the APGAR scores at 1 minute?
20.
What were the APGAR scores at 5 minutes?
21.
Was the COVID-19 infection tested in the newborn?
Yes, Positive test result
Yes, negative test result
Not tested
22.
What was the COVID-19 infection test result in the newborn? (Mark all that apply)
IgM antibody test Positive test result
IgM antibody test Negative test result
IgM antibody test not tested
IgG antibody test Positive test result
IgG antibody test Negative test result
IgG antibody test not tested
RT-PCR test Positive test result
RT-PCR test Negative test result
RT-PCR not tested
Please comment or provide further details
23.
Please make any further comments with regards to this case