• Users Online: 605
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
INVITED COMMENTARY
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 83-86

Pregnancy: COVID-19 demeanour


1 Department of Physiology, Eastern Medical College, Cumilla, Bangladesh
2 Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur, Malaysia

Date of Submission26-Oct-2021
Date of Decision27-Oct-2021
Date of Acceptance01-Nov-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Mainul Haque
Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, 57000 Kuala Lumpur
Malaysia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_154_21

Rights and Permissions

How to cite this article:
Jahan I, Haque M. Pregnancy: COVID-19 demeanour. Adv Hum Biol 2022;12:83-6

How to cite this URL:
Jahan I, Haque M. Pregnancy: COVID-19 demeanour. Adv Hum Biol [serial online] 2022 [cited 2022 Aug 15];12:83-6. Available from: https://www.aihbonline.com/text.asp?2022/12/1/83/334594






  Introduction Top


The current coronavirus disease 2019 (COVID-19) pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Since its first identification in Wuhan, China, in December 2019, COVID-19 has spread globally at an accelerated rate with rapid increases in cases and mortality.[1],[2] In January 2020, the World Health Organization (WHO) declared it an international crisis as it has become a major global health threat.[3] The International Committee on Taxonomy of Viruses renamed the virus from 2019 novel coronavirus (2019-nCoV) to SARS-CoV-2.[4] Coronaviruses are enveloped, non-segmented, single-stranded ribonucleic acid viruses causing diseases from common colds to severe fatal diseases.[4] Epidemiological studies indicated that people of any age are at risk of infection, and the severity is associated with age and comorbidities.[5] Compromised immune function, presence of multiple comorbidities that include respiratory, cardiac, endocrine disorders, cancer, geriatric issues, obesity, and pregnancy are spotted as top risk factors for COVID-19.[6],[7]

Pregnancy is one of the most pleasant and critical periods in most women's lives. Nevertheless, since the COVID-19 pandemic is emerging, pregnancy and childbirth are put under challenging conditions. Several issues have contributed to increasing concerns amongst people, particularly amongst pregnant women, including the stressful news of the number of infected individuals and the death toll, the diverse symptoms and complications caused by the disease and our limited knowledge about the disease.[8]


  Clinical Presentation Top


Pregnancy is associated with physical, emotional and social changes.[9] Physiological changes during pregnancy include reduced functional residual volumes, diaphragm elevation, oedema of respiratory tract mucosa and changes in cellular immunity.[10] Due to the modulation of the immune system, pregnant women are more susceptible to viral infections and may experience severe symptoms that can worsen outcomes.[10] The WHO has reported no apparent difference in the risk of developing clinical symptoms between non-pregnant and pregnant women of reproductive age during the pandemic.[11],[12] Patients most commonly present with mild symptoms of the infection, including fever, cough, fatigue and shortness of breath, and some may be asymptomatic.[10],[11],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Some studies have reported no maternal complications, such as postpartum COVID-19 infection and preterm labour.[11],[15],[17] Previous studies reported that during the epidemics of H1N1 influenza, the Middle East respiratory syndrome and SARS caused pregnant women adverse clinical outcomes such as death, spontaneous abortion, premature birth and foetal death.[1],[24] Viral pneumonia is one of the leading causes of pregnancy deaths worldwide.[25]

Diagnosis

A real-time reverse transcriptase–polymerase chain reaction assay is the gold standard for diagnosis.[4] More leucocytosis and elevated C-reactive protein levels are detected in biochemical findings of pregnant women. Most of the patients showed typical changes on chest computed tomography, with multiple patchy ground-glass shadows.[4]

Medical Treatments

Mothers' treatment was individualised depending on their condition, and the treatment included antibiotic, antiviral, oxygen therapy and anti-inflammatory therapy. Some patients may require mechanical ventilation, haemodialysis and extracorporeal membrane oxygenation.[26]

Pregnancy-related anxiety

There is very little information about the effect of COVID-19 in pregnancy till now.[27] Pregnant women are at significant risk by COVID-19 as pregnancy-related physiologic changes in the anatomy and the function of the lungs and impaired immunity occur during the period.[28] During epidemics and pandemics, fear over affliction and death and disturbances in daily activities due to the necessity of quarantining may increase anxiety.[28] Uncertainties over transmission routes and doubts about national readiness for pandemic management affect people's adherence to preventive measures and cause psychological strains.[29],[30] The sources of concern and anxiety for pregnant women during pandemics also include concern over quarantine-related loneliness during and after delivery, limited access to healthcare services due to fear over affliction, increased requests for delivery through elective caesarean section, concerns related to the frequent use of disinfectants and concerns over child care, breastfeeding and vaccination.[31] Fear, worry and anxiety during pregnancy have negative physical and psychological impacts on pregnant women. Previous studies suggest that pregnancy stress may also lead to mother–infant relationship disorder, antenatal and postpartum depression, increased physical problems and an increased risk of pre-eclampsia.[32],[33],[34] The COVID-19 pandemic has reduced pregnant women's access to routine prenatal care services due to fear of the rapid spread of the disease, lack of an effective treatment or vaccine, the necessity of quarantining and its subsequent loneliness during affliction, stigmatisation and despair and concerns over contamination with the virus in healthcare settings.[35],[36]

In comparison with previous studies before the pandemic, women's worries about socioeconomic matters have increased. COVID-19 pandemic has negatively affected the economy almost in all countries leading to an increased poverty rate.[37],[38] Women are experiencing higher levels of worry about household livelihood and expenses than in the pre-pandemic period. Governments and charities should expand their programmes for providing financial support to pregnant women in low-income families to decrease their socioeconomic concerns.[39]

Pregnancy-related outcomes

Many studies reported asymptomatic newborns born to mothers with COVID-19 infection. One study by Zhu et al. has reported neonatal COVID-19 symptoms to include shortness of breath, fever and gastrointestinal symptoms such as vomiting and abdominal distension.[11] The study by Yu et al. also reported similar symptoms.[17] Other studies have reported maternal and foetal complications, including preterm delivery, respiratory distress, foetal distress and Premature rupture of membranes (PROM).[11]

Transmission of this virus from infected mother to foetus has been debated since the beginning of the COVID-19 pandemic.[40],[41],[42],[43] Vertical maternal–foetal transmission with severe foetal consequences may occur with maternal infection with toxoplasma, other, rubella, cytomegalovirus and herpes agents and Zika virus.[44],[45],[46] As the foetal organs develop during the first trimester of pregnancy, maternal infections at this stage may be more severe compared to later stages of pregnancy.[44],[45] Abortion in mothers with COVID-19 is inflammation and placental insufficiency due to the virus's direct effect on the placenta.[47],[48] Therefore, foetal death can be an outcome of COVID-19 in pregnancy.[49]

Mode of delivery

There has been no evidence of vertical transmission of COVID-19;[11],[13] COVID-19 is not an indication for caesarean section. The mode and timing of delivery should be individualised based on the severity of the disease, existing comorbidities and obstetric indications. Early cord clamping may minimise the risk of viral transmission by avoiding longer, close contact with the infected mother. Regional and general anaesthesia can be considered during the delivery, depending on the patient's clinical condition.[50]


  Conclusion Top


Although extensive research is being done worldwide with urgency to understand the impact of COVID-19 on pregnancy and postpartum, there is a long way to go to truly understand the accurate picture. The timing of pregnancy and entry time of the infection in the body have different outcomes at delivery needs to be investigated by conducting large clinical trials in different geographical and cultural settings. Cohort studies might investigate the long-term consequences of this virus on neonates and infants. Fortunately, we are on the way to several incredible vaccines that can begin to bring an end to this pandemic. The fast availability and accessibility of these vaccines to pregnant women are vital in reducing their current risk. It is crucial to assess the safety of these vaccines for expectant mothers and ensure equitable distribution across the world irrespective of geographic locations, socioeconomic status, culture and ethnicity.

Recommendation

In reproductive healthcare programmes worldwide, programme managers are concerned about the couples planning to have babies in this pandemic. They recommend that couples during this time ensure informed decision-making while taking risks associated with pregnancies during the COVID-19 pandemic. In this case, long-term contraceptive methods such as implants and intrauterine devices (copper T) might be beneficial, according to them.[51] Public health authorities should plan for situations like this in advance and adopt appropriate measures to reduce pregnant women's concerns.[37] The Centres for Disease Control and Prevention stated that pregnant women should rigorously follow the same steps suggested by healthcare providers.[52] Expectant mothers are advised to follow the national guideline of staying alert and safe by maintaining social distancing, practicing caution when outside the home and ensuring appropriate use of face masks. They should take additional care by keeping them mobile and hydrated to reduce the complications due to blood clots, be active through regular exercise, have a healthy and balanced diet and take essential supplements such as folic acid and Vitamin D.[37]

Summary

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There has been a rapid increase in cases and deaths since it was identified in Wuhan, China, in early December 2019. Limited data about the clinical characteristics of pregnant women with COVID-19 have been reported till now. Because of the maternal physiologic and immune function changes during pregnancy, pregnant women are possibly at a higher risk of being infected with SARS-CoV-2 and developing more complicated clinical events.

Information on SARS and the Middle East respiratory syndrome (MERS) may provide the effects of COVID-19 during pregnancy. Even though SARS and MERS have been associated with miscarriage, intrauterine death, foetal growth restriction and high case fatality rates, the clinical course of COVID-19 pneumonia in pregnant women has been similar to non-pregnant women. In addition, pregnant women do not appear to be at a higher risk of catching COVID-19 or suffering from more severe disease than other adults of similar age. Moreover, there is no evidence that the virus can be transmitted to the foetus during pregnancy or childbirth. Babies and young children are also known to only experience mild forms of COVID-19. We summarise the possible symptoms, treatments and pregnancy outcomes of women infected with COVID-19 during pregnancy.

Consent for Publication

The author reviewed and approved the final version and has agreed to be accountable for all aspects of the work, including any accuracy or integrity issues.

Disclosure

The author declares that they do not have any financial involvement or affiliations with any organisation, association or entity directly or indirectly with the subject matter or materials presented in this article. This includes honoraria, expert testimony, employment, ownership of stocks or options, patents or grants received or pending or royalties.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
    
2.
Abuelgasim E, Saw LJ, Shirke M, Zeinah M, Harky A. COVID-19: Unique public health issues facing Black, Asian and minority ethnic communities. Curr Probl Cardiol 2020;45:100621.  Back to cited text no. 2
    
3.
Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet 2020;395:470-3.  Back to cited text no. 3
    
4.
Wang CL, Liu YY, Wu CH, Wang CY, Wang CH, Long CY. Impact of COVID-19 on Pregnancy. Int J Med Sci 2021;18:763-7.  Back to cited text no. 4
    
5.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.  Back to cited text no. 5
    
6.
Mirzadeh M, Khedmat L. Pregnant women in the exposure to COVID-19 infection outbreak: The unseen risk factors and preventive healthcare patterns. J Matern Fetal Neonatal Med 2020:1-2.  Back to cited text no. 6
    
7.
Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect 2020;81:e16-25.  Back to cited text no. 7
    
8.
Corbett GA, Milne SJ, Hehir MP, Lindow SW, O'Connell MP. Health anxiety and behavioral changes of pregnant women during the COVID-19 pandemic. Eur J Obstet Gynecol Reprod Biol 2020;249:96-7.  Back to cited text no. 8
    
9.
Ahmadi A, Sahebalzamani SS, Ghavami F, Shafiee Y, Ashtiani AF. Effects of psychological interventions on postpartum depression, anxiety and infants' weight in primipara women. Prev Care Nurs Midwifery J 2014;4:19-31.  Back to cited text no. 9
    
10.
Liu W, Wang Q, Zhang Q, Chen L, Chen J, Zhang B, et al. Coronavirus disease 2019 (COVID-19) during pregnancy: A case series. 2020. 5-28.  Back to cited text no. 10
    
11.
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020;395:809-15.  Back to cited text no. 11
    
12.
Aylward B, Liang W, Dong X, Eckmanns T, Fisher D, Ihekweazu C. Report of the WHO China Joint Mission on Coronavirus Disease 2019 (COVID-19) Beijing: World Health Organization; 2020.  Back to cited text no. 12
    
13.
Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9:51-60.  Back to cited text no. 13
    
14.
Liu Y, Chen H, Tang K, Guo Y. Withdrawn: Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect 2020:S0163-4453(20)30109-2.  Back to cited text no. 14
    
15.
Wang X, Zhou Z, Zhang J, Zhu F, Tang Y, Shen X. A case of 2019 novel coronavirus in a pregnant woman with preterm delivery. Clin Infect Dis 2020;71:844-6.  Back to cited text no. 15
    
16.
Liu D, Li L, Wu X, Zheng D, Wang J, Yang L, et al. Pregnancy and perinatal outcomes of women with coronavirus disease (COVID-19) pneumonia: A preliminary analysis. AJR Am J Roentgenol 2020;215:127-32.  Back to cited text no. 16
    
17.
Yu N, Li W, Kang Q, Xiong Z, Wang S, Lin X, et al. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID- 19 in Wuhan, China: A retrospective, single-center, descriptive study. Lancet Infect Dis 2020;20:559-64.  Back to cited text no. 17
    
18.
Li Y, Zhao R, Zheng S, Chen X, Wang J, Sheng X, et al. Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2, China. Emerg Infect Dis 2020;26:1335-6.  Back to cited text no. 18
    
19.
Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al. Perinatal transmission of 2019-Corona virus disease-associated severe acute respiratory distress syndrome Corona virus-2: Should we worry? Clin Infect Dis 2021;72:862-4.  Back to cited text no. 19
    
20.
Wang S, Guo L, Chen L, Liu W, Cao Y, Zhang J, et al. A case report of neonatal 2019 coronavirus disease in China. Clin Infect Dis 2020;71:853-7.  Back to cited text no. 20
    
21.
Zambrano LI, Fuentes-Barahona IC, Bejarano-Torres DA, Bustillo C, Gonzales G, Vallecillo-Chinchilla G, et al. A pregnant woman with COVID-19 in Central America. Travel Med Infect Dis 2020;36:101639.  Back to cited text no. 21
    
22.
Iqbal SN, Overcash R, Mokhtari N, Saeed H, Gold S, Auguste T, et al. An Uncomplicated delivery in a patient with COVID-19 in the United States. N Engl J Med 2020;382:e34.  Back to cited text no. 22
    
23.
Lee DH, Lee J, Kim E, Woo K, Park HY, An J. Emergency cesarean section on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) confirmed patient. Korean J Anesthesiol 2020;73:347-51.  Back to cited text no. 23
    
24.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 24
    
25.
Dashraath P, Wong JLJ, Lim MX, Lim ML, Li S, Biswas A, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31.  Back to cited text no. 25
    
26.
Ashraf MA, Keshavarz P, Hosseinpour P, Erfani A, Roshanshad A, Pourdast A, et al. Coronavirus disease 2019 (COVID-19): A systematic review of pregnancy and the possibility of vertical transmission. J Reprod Infertil 2020;21:157-68.  Back to cited text no. 26
    
27.
Zanardo V, Manghina V, Giliberti L, Vettore M, Severino L, Straface G. Psychological impact of COVID-19 quarantine measures in northeastern Italy on mothers in the immediate postpartum period. Int J Gynecol Obstet 2020;150:184-8.  Back to cited text no. 27
    
28.
Haghdoost SM, Gol MK. The necessity of paying more attention to the neurological and psychological problems caused by COVID-19 pandemic during pregnancy. Int J Womens Health Reprod Sci 2020;8:243-4.  Back to cited text no. 28
    
29.
Kamate SK, Agrawal A, Chaudhary H, Singh K, Mishra P, Asawa K. Public knowledge, attitude and behavioral changes in an Indian population during the influenza (H1N1) outbreak. J Infect Dev Ctries 2009;4:7-14.  Back to cited text no. 29
    
30.
Al Najjar NS, Attar LM, Farahat FM, Al Thaqafi A. Psycho behavioral responses to the 2014 Middle East respiratory syndrome-novel coronavirus [MERS CoV] among adults in two shopping malls in Jeddah, western Saudi Arabia. East Mediterr Health J 2017;22:817-23.  Back to cited text no. 30
    
31.
Rashidi Fakari F, Simbar M. Coronavirus pandemic and worries during pregnancy; a letter to editor. Arch Acad Emerg Med 2020;8:e21.  Back to cited text no. 31
    
32.
Areskog B, Uddenberg N, Kjessler B. Postnatal emotional balance in women with or without antenatal fear of childbirth. J Psychosom Res 1984;28:213-20.  Back to cited text no. 32
    
33.
Saisto T, Salmela-Aro K, Nurmi JE, Halmesmäki E. Psychosocial characteristics of women and their partners fearing vaginal childbirth. BJOG 2001;108:492-8.  Back to cited text no. 33
    
34.
Krishnamurti T, Davis AL, Simhan HN. Worrying yourself sick? Association between pre-eclampsia onset and health-related worry in pregnancy. Pregnancy Hypertens 2019;18:55-7.  Back to cited text no. 34
    
35.
Shahyad S, Mohammadi MT. Psychological impacts of COVID-19 outbreak on mental health status of society individuals: A narrative review. J Mil Med 2020;22:184-92.  Back to cited text no. 35
    
36.
Martini J, Petzoldt J, Einsle F, Beesdo-Baum K, Höfler M, Wittchen HU. Risk factors and course patterns of anxiety and depressive disorders during pregnancy and after delivery: A prospective-longitudinal study. J Affect Disord 2015;175:385-95.  Back to cited text no. 36
    
37.
Pak A, Adegboye OA, Adekunle AI, Rahman KM, McBryde ES, Eisen DP. Economic consequences of the COVID-19 outbreak: The need for epidemic preparedness. Front Public Health 2020;8:241.  Back to cited text no. 37
    
38.
Martin A, Markhvida M, Hallegatte S, Walsh B. Socio-economic impacts of COVID-19 on household consumption and poverty. Econ Disaster Clim Chang 2020;4:1-27.  Back to cited text no. 38
    
39.
Mortazavi F, Mehrabadi M, KiaeeTabar R. Pregnant women's well-being and worry during the COVID-19 pandemic: A cross-sectional study. BMC Pregnancy Childbirth 2021;21:59.  Back to cited text no. 39
    
40.
Shmakov RG, Prikhodko A, Polushkina E, Shmakova E, Pyregov A, Bychenko V, et al. Clinical course of novel COVID-19 infection in pregnant women. J Matern Fetal Neonatal Med 2020:1-7.  Back to cited text no. 40
    
41.
Mimouni F, Lakshminrusimha S, Pearlman SA, Raju T, Gallagher PG, Mendlovic J. Perinatal aspects on the COVID-19 pandemic: A practical resource for perinatal-neonatal specialists. J Perinatol 2020;40:820-6.  Back to cited text no. 41
    
42.
Muhidin S, Behboodi Moghadam Z, Vizheh M. Analysis of maternal coronavirus infections and neonates born to mothers with 2019-nCoV; a systematic review. Arch Acad Emerg Med 2020;8:e49.  Back to cited text no. 42
    
43.
Parazzini F, Bortolus R, Mauri PA, Favilli A, Gerli S, Ferrazzi E. Delivery in pregnant women infected with SARS-CoV-2: A fast review. Int J Gynaecol Obstet 2020;150:41-6.  Back to cited text no. 43
    
44.
Silasi M, Cardenas I, Kwon JY, Racicot K, Aldo P, Mor G. Viral infections during pregnancy. American J Reprod Immunol 2015;73:199-213.  Back to cited text no. 44
    
45.
Alvarado MG, Schwartz DA. Zika virus infection in pregnancy, microcephaly, and maternal and fetal health: What we think, what we know, and what we think we know. Arch Pathol Lab Med 2017;141:26-32.  Back to cited text no. 45
    
46.
Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: Lessons from SARS, MERS, and other human coronavirus infections. Viruses 2020;12:194.  Back to cited text no. 46
    
47.
Wastnedge EA, Reynolds RM, van Boeckel SR, Stock SJ, Denison FC, Maybin JA, et al. Pregnancy and COVID-19. Physiol Rev 2021;101:303-18.  Back to cited text no. 47
    
48.
Prochaska E, Jang M, Burd I. COVID-19 in pregnancy: Placental and neonatal involvement. Am J Reprod Immunol 2020;84:e13306.  Back to cited text no. 48
    
49.
Richtmann R, Torloni MR, Oyamada Otani AR, Levi JE, Crema Tobara M, de Almeida Silva C, et al. Fetal deaths in pregnancies with SARS-CoV-2 infection in Brazil: A case series. Case Rep Womens Health 2020;27:e00243.  Back to cited text no. 49
    
50.
Society of Obstetrics, Anaesthesia, and Perinatology. Interim Considerations for Obstetric Anesthesia Care related to COVID-19. This is interim guidance based on expert opinion and published recommendations from the WHO and CDC. 2020. Available at https://wfsahq.org/wp-content/uploads/SOAP_COVID-19_Obstetric_Anesthesia_Care_031620-2_.pdf [Accessed October 1, 2021].  Back to cited text no. 50
    
51.
Gazi R, Oishee LM. Pregnancy and postpartum in the context of COVID-19. Reprod Syst Sex Disord 2021;10:1-3.  Back to cited text no. 51
    
52.
Rasmussen SA, Kissin DM, Yeung LF, MacFarlane K, Chu SY, Turcios-Ruiz RM, et al. Preparing for influenza after 2009 H1N1: Special considerations for pregnant women and newborns. Am J Obstet Gynecol 2011;204 6 Suppl 1:S13-20.  Back to cited text no. 52
    




 

Top
 
 
  Search
 
Similar in PUBMED
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  Clinical Present...
  In this article
Introduction
Conclusion
References

 Article Access Statistics
    Viewed618    
    Printed34    
    Emailed0    
    PDF Downloaded71    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]