Preeclampsia and COVID-19: results from the INTERCOVID prospective longitudinal study

Trimester and severity of SARS-CoV-2 infection during pregnancy and risk of hypertensive disorders in pregnancy

OBJECTIVE

SARS-CoV-2 infection during pregnancy has been linked with an increased risk of hypertensive disorders of pregnancy (HDP). The aim of this study was to examine how both trimester and severity of SARS-CoV-2 infection impact HDP.

METHODS

We conducted a cohort study of SARS-CoV-2-infected individuals during pregnancy (n = 205) and examined the association between trimester and severity of infection with incidence of HDP using modified Poisson regression models to calculate risk ratios (RR) and 95% confidence intervals (CI). We stratified the analysis of trimester by severity to understand the role of timing of infection among those with similar symptomatology and also examined timing of infection as a continuous variable.

RESULTS

Compared to a reference cohort from 2018, SARS-CoV-2 infection did not largely increase the risk of HDP (RR: 1.17; CI:0.90, 1.51), but a non-statistically significant higher risk of preeclampsia was observed (RR: 1.33; CI:0.89, 1.98), in our small sample. Among the SARS-CoV-2 cohort, severity was linked with risk of HDP, with infections requiring hospitalization increasing the risk of HDP compared to asymptomatic/mild infections. Trimester of infection was not associated with risk of HDP, but a slight decline in the risk of HDP was observed with later gestational week of infection. Among patients with asymptomatic or mild symptoms, SARS-CoV-2 in the first trimester conferred a higher risk of HDP compared to the third trimester (RR: 1.70; CI:0.77, 3.77), although estimates were imprecise.

CONCLUSION

SARS-CoV-2 infection in early pregnancy may increase the risk of HDP compared to infection later in pregnancy.

COVID-19 is associated with early emergence of preeclampsia: results from a large regional collaborative

Objective: To investigate the relationship between preeclampsia and SARS-CoV-2 infection during pregnancy. Methods: This was a retrospective cohort study of pregnant women between March and October 2020. Pregnant patients admitted to 14 obstetrical centers in Michigan, USA formed the study population. Of the N = 1458 participants, 369 had SARS-CoV-2 infection (cases). Controls were uninfected pregnancies that were delivered in the same obstetric unit within 30 days of the index case. Robust Poisson regression was used to estimate relative risk (RR) of preterm and term preeclampsia and preeclampsia involving placental lesions. The analysis included adjustment for relevant clinical and demographic risk factors.Results: SARS-CoV-2 infection during pregnancy increased the risk of preeclampsia [adjusted aRR = 1.69 (1.26-2.26)], preeclampsia involving placental lesions [aRR = 1.97(1.14-3.4)] and preterm preeclampsia 2.48(1.48-4.17). Although the highest rate of preeclampsia was observed in patients infected with SARS-CoV-2 who were symptomatic (18.4%), there was increased risk even in asymptomatic SARS-CoV-2 infected patients (14.2%) relative to non-infected controls (8.7%) (p < 0.05). This association with symptomatology was also noted with preterm preeclampsia for which the rate doubled from 2.7% in controls to 5.2% in asymptomatic cases and reached 11.8% among symptomatic cases (p < 0.05). The rate of preterm preeclampsia among cases of pregnant people self-identified as Black reached 10.1% and was almost double the rate of the reminder of the group of infected pregnancies (5.3%), although the rate among uninfected was almost the same (2.7%) for both Black and non-Black groups (interaction p = 0.05).Conclusions: Infection with SARS-CoV-2 increases the risk of preeclampsia even in the absence of symptoms, although symptomatic persons are at even higher risk. Racial disparities in the development of preterm preeclampsia after SARS-CoV-2 infection may explain discrepancies in prematurity between different populations.

Physical development of infants born to patients with COVID-19 during pregnancy: 2 years of age

Background

SARS-CoV-2 infection during pregnancy and pandemic circumstances could negatively impact infant development. This study aimed to investigate the physical development, common pediatric illness incidence, and healthcare utilization over the first 2 years of life of infants born to COVID+ and COVID- patients. Comparisons were also made with infants born pre-pandemic.

Methods

This is a retrospective observational study at a major academic health system in New York City. Participants include all infants born to birthing persons with SARS-CoV-2 infection during pregnancy (N = 758) and without (N = 9,345) from 03/01/2020 to 08/17/2022, infants born pre-pandemic (N = 3,221) from 03/01/2017 to 08/17/2019, and birthing persons of all infants.

Results

There were no differences in weight, length, or head circumference curves between pandemic infants born to COVID+ and COVID- patients over the first 2 years of life (p > 0.05, repeated ANOVA). Annualized incidence of illness occurrence and healthcare utilization were similar between groups. Compared to pre-pandemic infants, the length of pandemic (COVID-) infants was lower from birth to 9 months (p < 0.0001). Pandemic infants additionally had more adverse perinatal outcomes including increased stillbirth (0.75% vs. 0.12%, p = 0.0001) and decreased gestational age (38.41 ± 2.71 vs. 38.68 ± 2.55 weeks, Cohen's d = -0.10, p < 0.0001), birthweight (2,597 ± 335 vs. 3,142 ± 643 g, Cohen's d = -1.06, p < 0.0001), and birth length (48.08 ± 4.61 vs. 49.09 ± 3.93 cm, Cohen's d = -0.24, p < 0.0001).

Conclusions

Birthing persons' SARS-CoV-2 infection status, birthing persons' profiles, and pandemic circumstances negatively affected perinatal outcomes, newborn physical development, and healthcare utilization. These findings draw clinical attention to the need to follow infants closely and implement enrichment to ensure optimal developmental outcomes.

Calcitriol prevents SARS-CoV spike-induced inflammation in human trophoblasts through downregulating ACE2 and TMPRSS2 expression

SARS-CoV-2, the causative virus of COVID-19, increases the risk of pregnancy complications including hypertensive disorders and placental inflammation. The spike glycoprotein mediates viral cell entry by interacting with the angiotensin-converting enzyme (ACE)2 in conjunction with the transmembrane serine protease 2 (TMPRSS2). ACE1, ACE2 and renin are components of the renin-angiotensin system (RAS), which regulates blood pressure. As the placenta expresses all these proteins, it is a target for SARS-CoV-2 and a source of blood pressure modulators. Noteworthy, an ACE1/ACE2 ratio imbalance can lead to RAS dysregulation and a bad prognosis in COVID-19 patients. Calcitriol, the most active vitamin D metabolite, negatively regulates RAS, reduces inflammation, and enhances antiviral immunity, thereby protecting against COVID-19 severity. However, contrasting information exists on the regulatory role of calcitriol upon RAS components and SARS-CoV-2 receptors; while the impact of calcitriol on spike-induced inflammation in placental cells has not been explored. Thus, we studied the effects of calcitriol on these parameters using the trophoblast cell line HTR-8/SVneo and primary syncytiotrophoblasts. By RT-qPCR, ELISA, and immunocytochemistry, we found that the spike enhanced proinflammatory cytokines expression and secretion, while calcitriol significantly downregulated this effect. Calcitriol also diminished ACE1, ACE2, TMPRSS2, and renin gene expression, as well as ACE1/ACE2 mRNA ratio. CONCLUSIONS: In the human placenta, calcitriol reduced the gene expression of main RAS components and TMPRSS2, resulting in the inhibition of spike-induced inflammation. This outcome suggest that vitamin D participates in restricting SARS-CoV-2 placental infection by rendering trophoblasts less permissive to infection while helping to regulate maternal blood pressure and decreasing inflammation.

COVID-19 and Its Potential Impact on Children Born to Mothers Infected During Pregnancy: A Comprehensive Review

Pregnancy is a vulnerable period of time during which pregnant people are prone to infections like COVID-19, which can increase risks for both the mother and fetus. These infections may lead to complications such as preterm birth, developmental delays, and congenital abnormalities. While COVID-19 poses additional risks like placental dysfunction and neonatal infections, studies on long-term effects remain limited. Ongoing research and monitoring are essential to understand and mitigate potential cognitive and developmental challenges in children born to mothers infected with COVID-19. This review aims to guide clinicians in managing these risks throughout childhood. Maternal COVID-19 infection during pregnancy can have significant implications for fetal development, even if the newborn is not infected at birth. The release of inflammatory cytokines may cross the placental barrier, potentially disrupting fetal brain development and increasing the risk of long-term cognitive and behavioral issues, such as ADHD or autism. Placental dysfunction, caused by inflammation or thrombosis, can lead to intrauterine growth restriction (IUGR), preterm birth, or hypoxia, affecting both neurological and respiratory health in newborns. Furthermore, a compromised fetal immune system can increase susceptibility to autoimmune conditions and infections. The early diagnosis and management of infections during pregnancy are crucial in mitigating risks to both the mother and fetus. Swift intervention can prevent complications like preterm birth and long-term developmental challenges, ensuring better health outcomes for both the mother and child. Long-term monitoring of children born to mothers infected with COVID-19 is necessary to understand the full extent of the virus's impact. This review evaluates the long-term systemic effects of maternal COVID-19 infection during pregnancy on fetuses, newborns, and children, focusing beyond vertical transmission. It highlights the broader impacts on fetal development, offering insights to help clinicians manage potential issues that may arise later in life.

Socioeconomic status as a risk factor for SARS-CoV-2 infection in pregnant women

OBJECTIVES

Due to the association between COVID-19 and adverse pregnancy outcomes, pregnant women are considered to be a vulnerable patient group. Studies have shown that low socioeconomic status (SES) is a risk factor for SARS-CoV-2 infection. COVID-19 and low SES are likely to have a synergistic adverse effect. This study aimed to evaluate the socioeconomic background, indicated by self-reported SES, educational level, and financial situation, in pregnant women who were positive for SARS-CoV-2.

METHODS

A case-control study was conducted, including all pregnant women with positive SARS-CoV-2 PCR tests at Kepler University Hospital Linz between May 2020 and August 2021 (n=150) and a control group matched 1:1 relative to gestational age at birth (n=150). Data were collected using written questionnaires and medical records from the hospital information system.

RESULTS

Lower self-reported socioeconomic status (p=0.029) and lower education level (p=0.003) were detected in the COVID group. Mothers in the COVID group were significantly younger (p=0.024). However, after adjustment for educational attainment, younger age was not confirmed as a risk factor for SARS-CoV-2 infection during pregnancy (p=0.326). The social gradient was not explained by the assumed mediators and confounders.

CONCLUSIONS

These findings confirm an association between lower socioeconomic status and the risk of SARS-CoV-2 infection during pregnancy. Since both socioeconomic factors and COVID-19 impose negative effects on pregnancy outcomes, health inequalities should be taken into consideration when implementing SARS-CoV-2 prevention measures and when providing health care for pregnant women from disadvantaged communities.

Time series analysis of comprehensive maternal deaths in Brazil during the COVID-19 pandemic

The effects of the COVID-19 pandemic on comprehensive maternal deaths in Brazil have not been fully explored. Using publicly available data from the Brazilian Mortality Information (SIM) and Information System on Live Births (SINASC) databases, we used two complementary forecasting models to predict estimates of maternal mortality ratios using maternal deaths (MMR) and comprehensive maternal deaths (MMRc) in the years 2020 and 2021 based on data from 2008 to 2019. We calculated national and regional standardized mortality ratio estimates for maternal deaths (SMR) and comprehensive maternal deaths (SMRc) for 2020 and 2021. The observed MMRc in 2021 was more than double the predicted MMRc based on the Holt-Winters and autoregressive integrated moving average models (127.12 versus 60.89 and 59.12 per 100,000 live births, respectively). We found persisting sub-national variation in comprehensive maternal mortality: SMRc ranged from 1.74 (95% confidence interval [CI] 1.64, 1.86) in the Northeast to 2.70 (95% CI 2.45, 2.96) in the South in 2021. The observed national estimates for comprehensive maternal deaths in 2021 were the highest in Brazil in the past three decades. Increased resources for prenatal care, maternal health, and postpartum care may be needed to reverse the national trend in comprehensive maternal deaths.

Placental Drug Delivery to Treat Pre-Eclampsia and Fetal Growth Restriction

Pre-eclampsia and fetal growth restriction (FGR) continue to cause unacceptably high levels of morbidity and mortality, despite significant pharmaceutical and technological advances in other disease areas. The recent pandemic has also impacted obstetric care, as COVID-19 infection increases the risk of poor pregnancy outcomes. This review explores the reasons why it lacks effective drug treatments for the placental dysfunction that underlies many common obstetric conditions and describes how nanomedicines and targeted drug delivery approaches may provide the solution to the current drug drought. The ever-increasing range of biocompatible nanoparticle formulations available is now making it possible to selectively deliver drugs to uterine and placental tissues and dramatically limit fetal drug transfer. Formulations that are refractory to placental uptake offer the possibility of retaining drugs within the maternal circulation, allowing pregnant individuals to take medicines previously considered too harmful to the developing baby. Liposomes, ionizable lipid nanoparticles, polymeric nanoparticles, and adenoviral vectors have all been used to create efficacious drug delivery systems for use in pregnancy, although each approach offers distinct advantages and limitations. It is imperative that recent advances continue to be built upon and that there is an overdue investment of intellectual and financial capital in this field.

Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study

BACKGROUND

In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk for severe COVID-19-related complications and maternal morbidity and mortality.

OBJECTIVE

This study aimed to analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes when Omicron was the variant of concern.

STUDY DESIGN

INTERCOVID-2022 was a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes and to assess vaccine effectiveness. Women diagnosed with laboratory-confirmed COVID-19 during pregnancy were compared with 2 nondiagnosed, unmatched women recruited concomitantly and consecutively during pregnancy or at delivery. Mother-newborn dyads were followed until hospital discharge. The primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index, severe perinatal morbidity and mortality index, preterm birth, neonatal death, referral to neonatal intensive care unit, and diseases during the neonatal period. Vaccine effectiveness was estimated with adjustment for maternal risk profile.

RESULTS

We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) nondiagnosed mothers. Among the diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (relative risk, 0.46; 95% confidence interval, 0.23-0.91) the risk of being diagnosed with COVID-19 when compared with those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically indicated preterm birth, respiratory distress syndrome, and number of days in the neonatal intensive care unit. Newborns of unvaccinated mothers had double the risk for neonatal death (relative risk, 2.06; 95% confidence interval, 1.06-4.00) when compared with those of nondiagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the highest vaccine effectiveness (64%; 95% confidence interval, 10%-86%). Vaccine effectiveness was not as high for messenger RNA vaccines only. Vaccine effectiveness against moderate or severe neonatal outcomes was much lower, namely 13% in the booster-vaccinated group (all vaccines) and 25% and 28% in the completely and booster-vaccinated groups, respectively (messenger RNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women ≤100 days (14 weeks) before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks). Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk for infecting newborns.

CONCLUSION

When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk for neonatal death. Neonates of vaccinated mothers had a decreased risk for preterm birth and adverse neonatal outcomes. Because the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19, mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.

COVID-19 diagnosis, vaccination during pregnancy, and adverse pregnancy outcomes of 865,654 women in England and Wales: a population-based cohort study

Background

The extent to which COVID-19 diagnosis and vaccination during pregnancy are associated with risks of common and rare adverse pregnancy outcomes remains uncertain. We compared the incidence of adverse pregnancy outcomes in women with and without COVID-19 diagnosis and vaccination during pregnancy.

Methods

We studied population-scale linked electronic health records for women with singleton pregnancies in England and Wales from 1 August 2019 to 31 December 2021. This time period was divided at 8th December 2020 into pre-vaccination and vaccination roll-out eras. We calculated adjusted hazard ratios (HRs) for common and rare pregnancy outcomes according to the time since COVID-19 diagnosis and vaccination and by pregnancy trimester and COVID-19 variant.

Findings

Amongst 865,654 pregnant women, we recorded 60,134 (7%) COVID-19 diagnoses and 182,120 (21%) adverse pregnancy outcomes. COVID-19 diagnosis was associated with a higher risk of gestational diabetes (adjusted HR 1.22, 95% CI 1.18-1.26), gestational hypertension (1.16, 1.10-1.22), pre-eclampsia (1.20, 1.12-1.28), preterm birth (1.63, 1.57-1.69, and 1.68, 1.61-1.75 for spontaneous preterm), very preterm birth (2.04, 1.86-2.23), small for gestational age (1.12, 1.07-1.18), thrombotic venous events (1.85, 1.56-2.20) and stillbirth (only within 14-days since COVID-19 diagnosis, 3.39, 2.23-5.15). HRs were more pronounced in the pre-vaccination era, within 14-days since COVID-19 diagnosis, when COVID-19 diagnosis occurred in the 3rd trimester, and in the original variant era. There was no evidence to suggest COVID-19 vaccination during pregnancy was associated with a higher risk of adverse pregnancy outcomes. Instead, dose 1 of COVID-19 vaccine was associated with lower risks of preterm birth (0.90, 0.86-0.95), very preterm birth (0.84, 0.76-0.94), small for gestational age (0.93, 0.88-0.99), and stillbirth (0.67, 0.49-0.92).

Interpretation

Pregnant women with a COVID-19 diagnosis have higher risks of adverse pregnancy outcomes. These findings support recommendations towards high-priority vaccination against COVID-19 in pregnant women.

Funding

BHF, ESRC, Forte, HDR-UK, MRC, NIHR and VR.

SARS-CoV-2 seroprevalence and preeclampsia markers in Mozambican pregnant women with perinatal loss

BACKGROUND

SARS-CoV-2 infection during pregnancy is known to be associated with poor pregnancy outcomes, including pre-eclampsia (PE), prematurity, perinatal and maternal mortality. Data on the burden of SARS-CoV-2 infection among pregnant women and their offspring in Sub-Saharan Africa is limited. We aimed to estimate SARS-CoV-2 seroprevalence and determine PE biomarkers in Mozambican pregnant women with perinatal loss.

METHODS

A cross-sectional study was conducted among women who had a fetal or an early neonatal death at the Maputo Central Hospital (MCH), Mozambique. Anti-SARS-CoV-2 IgG/IgM were determined in maternal and umbilical cord blood and PE biomarkers (sFlt-1 and PIGF) in maternal blood. SARS-CoV-2 RT-PCR was performed in placenta and fetal lung biopsies from participants found to be SARS-CoV-2 seropositive.

RESULTS

A total of 100 COVID-19 unvaccinated women were included in the study from March 2021 to April 2022. Total SARS-CoV-2 antibodies were detected in 68 [68%; 95CI (58 - 76)] maternal and 55 [55%; 95CI (54 - 74)] cord blood samples. SARS-CoV-2 IgM was detected in 18 cord blood samples and a positive placental RT-PCR in three of these participants. The proportion of women with moderate to high sFlt-1/PIGF ratio was higher in SARS-CoV-2 seropositive women than in those seronegative (71.2% vs 28.8%, p = 0.339), although the difference was not statistically significant.

CONCLUSIONS

SARS-CoV-2 seroprevalence among Mozambican women with perinatal loss was high during the second pandemic year, and there was evidence of vertical transmission in stillbirths. Findings also suggest that maternal SARS-CoV-2 infection may increase the risk of developing PE.

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

COVID-19 in Pregnancy: An Update for Clinicians

In this review, we will discuss the risks of COVID-19 on maternal, obstetric, and neonatal outcomes. We will also review the safety of COVID-19 vaccination in pregnancy, as well as review the management of COVID-19 in pregnancy.

The experience of pregnant women and their families who were infected with covid-19 before vaccination: A qualitative approach within a multicenter study in Brazil

BACKGROUND

Pregnant and postpartum women infected by COVID-19 are at increased risk of adverse outcomes, including negative effects on their mental health. Brazilian maternal mortality rate due to COVID-19 is 2.5 times higher than overall mortality rates. This study aimed to understand how pregnant/postpartum women experienced the COVID-19 suspicion/investigation or confirmed infection in different Brazilian cities, the pandemic's consequences to women and their families, and their needs to improve maternal health services during public health emergencies.

METHODS

We conducted a qualitative study with 27 women with COVID-19 and 6 of their family members, as part of a multicenter study among 15 maternity hospitals in Brazil. We applied in-depth interviews through telephone calls when women received the diagnostic or had a suspect infection and after 60 days. Another semi-structured interview was applied to their close family members. The interviews were considered through thematic analysis.

RESULTS

From the thematic content analysis three major themes emerged from the first and second interviews: (Cucinotta and Vanelli, 2020) assistance received by the woman and newborn in the medical services; (World Health Organization (WHO) 2021) stigma/fear of contamination from health workers and from family and friends reported by the women; (Allotey et al., 2020) the COVID-19 pandemic impact.

CONCLUSION

Before the availability of the COVID-19 vaccine, pregnant women experienced fear of death, hospitalization, quarantine, loss of family members, and financial repercussions, resulting in physical, psychological, and socioeconomic impacts on these women's lives.

Placental SARS-CoV-2 Infection and Its Implications for Increased Risk of Adverse Pregnancy Outcomes

OBJECTIVE

 Pregnant women are at increased risk of coronavirus disease 2019 (COVID-19). This could be explained through the prism of physiologic and immunologic changes in pregnancy. In addition, certain immunological reactions originate in the placenta in response to viral infections.This study aimed to investigate whether severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) can infect the human placenta and discuss its implications in the pathogenesis of adverse pregnancy outcomes.

STUDY DESIGN

 We conducted a retrospective cohort study in which we collected placental specimens from pregnant women who had a laboratory-confirmed SARS-CoV-2 infection. We performed RNA in situ hybridization assay on formalin-fixed paraffin-embedded tissues to establish the in vivo evidence for placental infectivity by this corona virus. In addition, we infected trophoblast isolated from uninfected term human placenta with SARS-CoV-2 variants to further provide in vitro evidence for such an infectivity.

RESULTS

 There was a total of 21 cases enrolled, which included 5 cases of spontaneous preterm birth (SPTB) and 2 intrauterine fetal demises (IUFDs). Positive staining of positive-sense strand of SARS-CoV-2 virions was detected in 15 placentas including 4 SPTB and both IUFDs. In vitro infection assay demonstrated that SARS-CoV-2 virions were highly capable of infecting both cytotrophoblast and syncytiotrophoblast.

CONCLUSION

 This study implies that placental SARS-CoV-2 infection may be associated with an increased risk of adverse obstetrical outcomes.

KEY POINTS

· SARS-CoV-2 can effectively infect human placenta.. · Such infectivity is confirmed by in vitro experiments.. · Placental SARS-CoV-2 corelates with adverse obstetrical outcomes..

Impact of SARS-CoV-2 infection during pregnancy on the placenta and fetus

Pregnant people and their fetuses are vulnerable to adverse health outcomes from coronavirus 2019 disease (COVID-19) due to infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has been associated with higher rates of maternal mortality, preterm birth, and stillbirth. While SARS-CoV-2 infection of the placenta and vertical transmission is rare, this may be due to the typically longer time interval between maternal infection and testing of the placenta and neonate. Placental injury is evident in cases of SARS-CoV-2-associated stillbirth with massive perivillous fibrin deposition, chronic histiocytic intervillositis, and trophoblast necrosis. Maternal COVID-19 can also polarize fetal immunity, which may have long-term effects on neurodevelopment. Although the COVID-19 pandemic continues to evolve, the impact of emerging SARS-CoV-2 variants on placental and perinatal injury/mortality remains concerning for maternal and perinatal health. Here, we highlight the impact of COVID-19 on the placenta and fetus and remaining knowledge gaps.

[Pregnant women with COVID-19 ARDS on the intensive care unit]

BACKGROUND

Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease progression. Comorbidities, such as chronic arterial hypertension, diabetes mellitus, advanced maternal age and high body mass index, may predispose to severe disease. The management of pregnant COVID-19 patients on the intensive care unit (ICU) is challenging and requires careful consideration of maternal, fetal and ethical issues.

OBJECTIVE

Description and discussion of intensive care treatment strategies and perinatal anesthesiological management in patients with COVID-19 acute respiratory distress syndrome (CARDS).

MATERIAL AND METHODS

We analyzed the demographic data, maternal medical history, clinical intensive care management, complications, indications and management of extracorporeal membrane oxygenation (ECMO) and infant survival of all pregnant patients treated for severe CARDS in the anesthesiological ICU of a German university hospital between March and November 2021.

RESULTS

The cohort included 9 patients with a mean age of 30.3 years (range 26-40 years). The gestational age ranged from 21 + 3 weeks to 37 + 2 weeks. None of the patients had been vaccinated against SARS-CoV‑2. Of the nine patients seven were immigrants and communication was hampered by inadequate Central European language skills. Of the patients five had a PaO2/FiO2 index < 150 mm Hg despite escalated invasive ventilation (FiO2 > 0.9 and a positive end-expiratory pressure [PEEP] of 14 mbar) and were therefore treated with repeated prolonged prone positioning maneuvers (5-14 prone positions for 16 h each, a total of 47 prone positioning treatments) and 2 required treatment with inhaled nitric oxide and venovenous ECMO. The most common complications were bacterial superinfection of the lungs, urinary tract infection and delirium. All the women and five neonates survived. All newborns were delivered by cesarean section, two patients were discharged home with an intact pregnancy and two intrauterine fetal deaths were observed. None of the newborns tested positive for SARS-CoV‑2 at birth.

CONCLUSION

High survival rates are possible in pregnant patients with CARDS. The peripartum management of pregnant women with CARDS requires close interdisciplinary collaboration and should prioritize maternal survival in early pregnancy. In our experience, prolonged prone positioning, an essential evidence-based cornerstone in the treatment of ARDS, can also be safely used in advanced stages of pregnancy. Inhaled nitric oxide (iNO) and ECMO should be considered as life-saving treatment options for carefully selected patients. For cesarean section, neuraxial anesthesia can be safely performed in patients with mild CARDS if well planned but the therapeutic anticoagulation recommended for COVID-19 may increase the risk of bleeding complications, making general anesthesia a more viable alternative, especially in severe disease.

Neonatal-perinatal collaboration during the COVID-19 pandemic

The COVID-19 pandemic required perinatal clinicians to address the individual medical needs of the pregnant person and the fetus as well as the interdependent considerations of the maternal/newborn dyad. Regional, national and international collaborative groups utilized existing structures and in some cases, formed new partnerships to rapidly collect perinatal information. The urgent need to care for at-risk and infected pregnant persons required these groups to develop practical approaches to collect the data needed to safely inform practice. Here we will summarize the findings of five collaborative studies that leveraged differing methods to inform perinatal pandemic care.

Etiologically Based Functional Taxonomy of the Preterm Birth Syndrome

Preterm birth (PTB) is a complex syndrome traditionally defined by a single parameter, namely, gestational age at birth (ie, ˂37 weeks). This approach has limitations for clinical usefulness and may explain the lack of progress in identifying cause-specific effective interventions. The authors offer a framework for a functional taxonomy of PTB based on (1) conceptual principles established a priori; (2) known etiologic factors; (3) specific, prospectively identified obstetric and neonatal clinical phenotypes; and (4) postnatal follow-up of growth and development up to 2 years of age. This taxonomy includes maternal, placental, and fetal conditions routinely recorded in data collection systems.

The Impact of COVID-19 during Pregnancy on Maternal Hemodynamic Function, Angiogenic Markers and Neonatal Outcome

Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in pregnancy are associated with the development of preeclampsia and fetal growth restriction (FGR). Recently, preeclampsia was linked to impaired maternal hemodynamic function. This retrospective study evaluated singleton pregnancies with COVID-19 during pregnancy and healthy pregnant controls matched for gestational age from November 2020 to March 2022. Non-invasive assessment of maternal hemodynamics by continuous wave Doppler ultrasound measurements (USCOM-1A® Monitor) and oscillometric arterial stiffness (Arteriograph) was performed. Overall, 69 pregnant women were included-23 women after COVID-19 during pregnancy and 46 healthy controls. While two women (8.7%) were admitted to the hospital due to COVID-19-related symptoms, none required intensive care unit admission or non-invasive/invasive ventilation. There were no statistically significant differences in the majority of hemodynamic parameters between the two cohorts. The prevalence of FGR was significantly higher in the COVID-19 during pregnancy group (9.5% vs. healthy controls: 0.0%; p = 0.036), especially in nulliparous women. No difference in angiogenic markers and neonatal outcomes were observed between pregnant women after COVID-19 and healthy controls. In conclusion, no significant differences in hemodynamic parameters or neonatal outcome were observed in women with COVID-19 during pregnancy. However, an increased prevalence of FGR could be described.

Extracellular vesicles alter trophoblast function in pregnancies complicated by COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and resulting coronavirus disease (COVID-19) causes placental dysfunction, which increases the risk of adverse pregnancy outcomes. While abnormal placental pathology resulting from COVID-19 is common, direct infection of the placenta is rare. This suggests that pathophysiology associated with maternal COVID-19, rather than direct placental infection, is responsible for placental dysfunction and alteration of the placental transcriptome. We hypothesized that maternal circulating extracellular vesicles (EVs), altered by COVID-19 during pregnancy, contribute to placental dysfunction. To examine this hypothesis, we characterized maternal circulating EVs from pregnancies complicated by COVID-19 and tested their effects on trophoblast cell physiology in vitro . We found that the gestational timing of COVID-19 is a major determinant of circulating EV function and cargo. In vitro trophoblast exposure to EVs isolated from patients with an active infection at the time of delivery, but not EVs isolated from Controls, altered key trophoblast functions including hormone production and invasion. Thus, circulating EVs from participants with an active infection, both symptomatic and asymptomatic cases, can disrupt vital trophoblast functions. EV cargo differed between participants with COVID-19 and Controls, which may contribute to the disruption of the placental transcriptome and morphology. Our findings show that COVID-19 can have effects throughout pregnancy on circulating EVs and circulating EVs are likely to participate in placental dysfunction induced by COVID-19.

Impact of COVID-19 on pregnancy outcomes during delivery admissions: a nationwide analysis with clinical implications

Background

The available literature indicates a link between SARS-CoV-2 infection during pregnancy and a heightened probability of experiencing negative outcomes for both the pregnant patient and the developing fetus. We compared clinical outcomes of pregnant patients with or without COVID-19 hospitalized during delivery.

Methods

Multivariate logistic regression analysis was used to compare outcomes and was adjusted for patient-related, hospital-related, and illness severity indicators.

Results

We identified a total of 3,447,771 pregnant patients admitted between January 1, 2020 and December 31, 2020; 1.3% (n = 46,050) had COVID-19. COVID-19-positive patients had higher rates of in-hospital mortality (0.15% vs 0.05%, adjusted odds ratio [aOR] 5.97, 95% confidence interval [CI] 2.5-14.25, P < 0.001), mechanical ventilation (0.9% vs 0.05%, aOR 14.2, 95% CI 10.7-18.76, P < 0.001), vasopressor use (0.26% vs 0.14%, aOR 1.47, 95% CI 1.07-2.02, P = 0.01), and perinatal maternal complications like preeclampsia (9.66% vs 7.04%, aOR 1.29, 95% CI 1.2-1.39, P < 0.001) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (0.53% vs 0.26%, aOR 1.93, 95% CI 1.43-2.61, P < 0.001) than COVID-19-negative patients.

Discussion

Clinicians should be aware of the heightened risk of complications in pregnant patients with COVID-19 and consider strategies to mitigate them.

Impact of COVID-19 and Vaccination During Pregnancy on Placenta-Mediated Complications (COVIGRO Study)

OBJECTIVES

COVID-19 has been associated with preterm birth (PTB) and placental-mediated complications, including fetal growth restriction and preeclampsia (PE). This study aimed to estimate the impact of COVID-19 and vaccination on adverse pregnancy outcomes and markers of placental function.

METHODS

We performed a study on a prospective cohort of women recruited in the first trimester of pregnancy during the early COVID-19 pandemic period (December 2020 to December 2021). At each trimester of pregnancy, the assessment included a questionnaire on COVID-19 and vaccination status; serological tests for COVID-19 (for asymptomatic infection); measurement of placental growth factor (PlGF) and soluble fms-like tyrosine kinase 1 (sFlt-1) in maternal blood; measurement of mean uterine artery pulsatility index (UtA-PI); and pregnancy outcomes (PTB, PE, birth weight below the fifth and the tenth percentile).

RESULTS

Among 788 patients with complete data, we observed 101 (13%) cases of symptomatic infection and 74 (9%) cases of asymptomatic infection with SARS-CoV-2. Most cases (73%) of infection were among women with previous vaccination or COVID-19 infection before pregnancy. COVID-19 infection was not associated with adverse pregnancy outcomes, abnormal fetal growth, sFlt-1/PlGF ratio, or mean UtA-PI. Vaccination during pregnancy did not influence these outcomes either. We observed no case of severe COVID-19 infection requiring respiratory support.

CONCLUSION

Mild symptomatic or asymptomatic COVID-19 during pregnancy did not influence the risk of adverse pregnancy outcomes and the markers of placental function in predominantly vaccinated women. Fetal growth monitoring is unlikely to be mandatory in women with mild symptoms of COVID-19.

Implication of viruses in the etiology of preeclampsia

Preeclampsia is one of the most common disorders that poses threat to both mothers and neonates and a major contributor to perinatal morbidity and mortality worldwide. Viral infection during pregnancy is not typically considered to cause preeclampsia; however, syndromic nature of preeclampsia etiology and the immunomodulatory effects of viral infections suggest that microbes could trigger a subset of preeclampsia. Notably, SARS-CoV-2 infection is associated with an increased risk of preeclampsia. Herein, we review the potential role of viral infections in this great obstetrical syndrome. According to in vitro and in vivo experimental studies, viral infections can cause preeclampsia by introducing poor placentation, syncytiotrophoblast stress, and/or maternal systemic inflammation, which are all known to play a critical role in the development of preeclampsia. Moreover, clinical and experimental investigations have suggested a link between several viruses and the onset of preeclampsia via multiple pathways. However, the results of experimental and clinical research are not always consistent. Therefore, future studies should investigate the causal link between viral infections and preeclampsia to elucidate the mechanism behind this relationship and the etiology of preeclampsia itself.

Characteristics and Outcomes of Coronavirus Disease- 2019 Among Pregnant Women in Saudi Arabia; a Retrospective Study

Background

Pregnancy-related coronavirus disease 2019 infection ranges from asymptomatic to very serious illness. This study aimed to determine the impact of the COVID-19 infection on pregnant women in the Jazan region of Saudi Arabia.

Methods

Retrospective observational study of women who had COVID-19 positive test in pregnancy admitted in King Fahd Hospital, Abu Arish General Hospital, and Sabya General Hospital, Jazan, Saudi Arabia during the period between March 2020 and March 2022. Data were extracted from the patient's records. Frequency and percentage distributions were calculated for categorical variables. Descriptive studies and regression analysis were conducted to evaluate the association between selected variables and pregnancy outcomes.

Results

Of the 33 pregnant women with confirmed infection, the majority were in their second and third trimester, with approximately 42.4% requiring intensive care unit (ICU) admission and oxygen therapy. The most prevalent symptoms were high respiratory rate and low blood pressure, often accompanied by fever, cough, and shortness of breath. Live births resulted in 54.5% of the cases, while two maternal deaths were reported. Significant associations were found between the need for non-invasive ventilation and timing of infection (p = 0.026), the mode of delivery and timing of infection (p = 0.036), and the mode of delivery and body mass index (BMI) (p = 0.007).

Conclusion

COVID-19 poses significant risks to pregnant women, particularly in the third trimester, and emphasized the importance of early identification of high-risk pregnancies, strategic planning, and enhanced monitoring during antenatal care.

Mendelian randomization supports genetic liability to hospitalization for COVID-19 as a risk factor of pre-eclampsia

Background

Pre-eclampsia and eclampsia are among the major threats to pregnant women and fetuses, but they can be mitigated by prevention and early screening. Existing observational research presents conflicting evidence regarding the causal effects of coronavirus disease 2019 (COVID-19) on pre-eclampsia risk. Through Mendelian randomization (MR), this study aims to investigate the causal effect of three COVID-19 severity phenotypes on the risk of pre-eclampsia and eclampsia to provide more rigorous evidence.

Methods

Two-sample MR was utilized to examine causal effects. Summary-level data from genome-wide association studies (GWAS) of individuals of European ancestry were acquired from the GWAS catalog and FinnGen databases. Single-nucleotide polymorphisms associated with COVID-19 traits at p < 5 × -8 were obtained and pruned for linkage disequilibrium to generate instrumental variables for COVID-19. Inverse variance weighted estimates were used as the primary MR results, with weighted median and MR-Egger as auxiliary analyses. The robustness of the MR findings was also evaluated through sensitivity analyses. Bonferroni correction was applied to primary results, with a p < 0.0083 considered significant evidence and a p within 0.083-0.05 considered suggestive evidence.

Results

Critical ill COVID-19 [defined as hospitalization for COVID-19 with either a death outcome or respiratory support, OR (95% CI): 1.17 (1.03-1.33), p = 0.020] and hospitalized COVID-19 [defined as hospitalization for COVID-19, OR (95% CI): 1.10 (1.01-1.19), p = 0.026] demonstrated suggestive causal effects on pre-eclampsia, while general severe acute respiratory syndrome coronavirus 2 infection did not exhibit a significant causal effect on pre-eclampsia. None of the three COVID-19 severity phenotypes exhibited a significant causal effect on eclampsia.

Conclusions

Our investigation demonstrates a suggestive causal effect of genetic susceptibility to critical ill COVID-19 and hospitalized COVID-19 on pre-eclampsia. The COVID-19 severity exhibited a suggestive positive dose-response relationship with the risk of pre-eclampsia. Augmented attention should be paid to pregnant women hospitalized for COVID-19, especially those needing respiratory support.

Efficacy and safety of hydroxychloroquine for treatment of mild SARS-CoV-2 infection and prevention of COVID-19 severity in pregnant and postpartum women: A randomized, double-blind, placebo-controlled trial

INTRODUCTION

Pregnant women have an increased risk of severe COVID-19. Evaluation of drugs with a safety reproductive toxicity profile is a priority. At the beginning of the pandemic, hydroxychloroquine (HCQ) was recommended for COVID-19 treatment.

MATERIAL AND METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted in eight teaching hospitals in Spain to evaluate the safety and efficacy of HCQ in reducing viral shedding and preventing COVID-19 progression. Pregnant and postpartum women with a positive SARS-CoV-2 PCR (with or without mild COVID-19 signs/symptoms) and a normal electrocardiogram were randomized to receive either HCQ orally (400 mg/day for 3 days and 200 mg/day for 11 days) or placebo. PCR and electrocardiogram were repeated at day 21 after treatment start. Enrollment was stopped before reaching the target sample due to low recruitment rate. Trial registration EudraCT #: 2020-001587-29, on April 2, 2020.

CLINICAL TRIALS

gov # NCT04410562, registered on June 1, 2020.

RESULTS

A total of 116 women (75 pregnant and 41 post-partum) were enrolled from May 2020 to June 2021. The proportion of women with a positive SARS-CoV-2 PCR at day 21 was lower in the HCQ group (21.8%, 12/55) than in the placebo group (31.6%, 18/57), although the difference was not statistically significant (P = 0.499). No differences were observed in COVID-19 progression, adverse events, median change in QTc, hospital admissions, preeclampsia or poor pregnancy and perinatal outcomes between groups.

CONCLUSIONS

HCQ was found to be safe in pregnant and postpartum women with asymptomatic or mild SARS-CoV-2 infection. Although the prevalence of infection was decreased in the HCQ group, the statistical power was insufficient to confirm the potential beneficial effect of HCQ for COVID-19 treatment.

Report of the ISTH registry on pregnancy and COVID-19-associated coagulopathy (COV-PREG-COAG)

Background

Concerns about COVID-19-associated coagulopathy (CAC) in pregnant individuals were raised in early pandemic.

Methods

An ISTH-sponsored COVID-19 coagulopathy in pregnancy (COV-PREG-COAG) international registry was developed to describe incidence of coagulopathy, VTE, and anticoagulation in this group.

Results

All pregnant patients with COVID-19 from participating centers were entered, providing 430 pregnancies for the first pandemic wave. Isolated abnormal coagulation parameters were seen in 20%; more often with moderate/severe disease than asymptomatic/mild disease (49% vs 15%; p < 0.0001). No one met the ISTH criteria for disseminated intravascular coagulopathy (DIC), though 5/21 (24%) met the pregnancy DIC score. There was no difference in antepartum hemorrhage (APH) with asymptomatic/mild disease versus moderate/severe disease (3.4% vs 7.7%; p = 0.135). More individuals with moderate/severe disease experienced postpartum hemorrhage (PPH) (22.4% vs 9.3%; p = 0.006). There were no arterial thrombotic events. Only one COVID-associated venous thromboembolism (VTE) was reported.

Conclusions

Low rates of coagulopathy, bleeding, and thrombosis were observed among pregnant people in the first pandemic wave.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Analysis of the transplacental transmission of SARS CoV-2 virus and antibody transfer according to the gestational age at maternal infection

To quantify transplacental transmission of SARS-CoV-2 virus and antibody transfer in pregnant women and their newborns according to the gestational age at maternal infection. A prospective observational multicenter study including pregnant women with a positive RT-PCR or a positive serology for SARS-CoV-2 and compatible symptoms, from April to December 2020, in 11 French maternities. The study was designed to obtain a systematic collection of mother-infant dyad's samples at birth. SARS-CoV-2 viral load was measured by RT-PCR. IgG and IgM antibodies against the SARS-CoV-2 spike protein were measured by enzyme-linked immunosorbent assay. Antibody concentrations and transplacental transfer ratios were analyzed according to the gestational age at maternal infection. The primary outcome was the rate of SARS CoV-2 materno-fetal transmission at birth. The secondary outcome was the quantification of materno-fetal antibody transfer. Maternal and neonatal outcomes at birth were additionally assessed. Among 165 dyads enrolled, one congenital infection was confirmed {n = 1 (0.63%) IC95% [0.02%; 3.48%]}. The average placental IgG antibody transfer ratio was 1.27 (IC 95% [0.69-2.89]). The transfer ratio increased with increasing time between the onset of maternal infection and delivery (P Value = 0.0001). Maternal and neonatal outcomes were reassuring. We confirmed the very low rate of SARS-CoV-2 transplacental transmission (< 1%). Maternal antibody transfer to the fetus was more efficient when the infection occurred during the first and second trimester of pregnancy.

An Update on COVID-19-Associated Placental Pathologies

COVID-19 pregnancies are associated with increased rates of premature delivery and stillbirths. It is still a matter of debate whether there is a COVID-19-associated pattern of placenta pathology. We updated our previously published results on a systematic literature review and meta-analysis of COVID-19 pregnancies. In total, 38 reports on 3677 placentas were evaluated regarding histopathological changes. Maternal vascular malperfusion (32%), fetal vascular malperfusion (19%), acute and chronic inflammation (20% and 22%) were frequent pathologies. In non-COVID-19 pregnancies, placentas show similar histologic patterns and mainly similar frequencies of manifestation. It has to be taken into account that there might be an observation bias, because some findings are diagnosed as a "pathology" that might have been classified as minor or unspecific findings in non-COVID-19 placentas. COVID-19 placentitis occurs in 1-2% of cases at the most. In conclusion, this updated meta-analysis indicates that COVID-19 infection during pregnancy does not result in an increased rate of a specific placenta pathology and COVID-19 placentitis is rare.

sFlT-1/PlGF ratio as a predictor of preeclampsia in COVID-19 pregnant patients

The association between SARS-CoV-2 infection in pregnancy and preeclampsia is widely debated in numerous studies. The aim of our study was to investigate whether an increased sFlt-1/PlGF ratio is a good marker of preeclampsia in pregnant patients with COVID-19 infection. This single centre prospective study was conducted in the Department of Obstetrics and Gynaecology, at the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw. The study group consisted of 68 COVID-19 pregnant patients and 57 SARS-CoV-2 negative pregnant controls. Serum sFlt-1/PlGF ratio was assessed. The two groups did not differ in terms of the frequency of IVF, nulliparity, history of hypertension, pre-gestational diabetes and chronic kidney disease. The primary outcome was the diagnosis of preeclampsia. Preeclampsia was diagnosed in 10 patients in both groups. The sFlt-1/PlGF ratio higher than 38, considered highly suggestive of developing preeclampsia, was found in 20 patients in the COVID-19 group and 15 patients in the control group. The odds of developing preeclampsia in patients with sFlt-1/PlGF ratio > 38 was approximately 4-fold higher in COVID-19 group and 11-fold higher in controls. Sflt-1/PlGF ratio does not differ significantly between the SARS-CoV-2-positive and SARS-COV-2-negative pregnant patients. The sFlt-1/PlGF ratio > 38 is associated with higher odds of the diagnosis of preeclampsia in both of these groups, and therefore may serve as its marker regardless of COVID-19 infection status.

Respiratory distress in SARS-CoV-2 exposed uninfected neonates followed in the COVID Outcomes in Mother-Infant Pairs (COMP) Study

Respiratory distress (RD) has been reported in SARS-CoV-2 exposed uninfected (SEU) term neonates. Prior studies suggest that prenatal exposure to Coronavirus Disease 19 (COVID-19) may activate an inflammatory cascade in the newborn airway. In this study, we examine the relationship between maternal COVID-19 vaccination and neonatal RD using a longitudinal cohort of mother-infant pairs in Los Angeles, CA. Two-hundred and twenty-one mothers with laboratory confirmed SARS-CoV-2 during pregnancy and 227 exposed fetuses are enrolled in our study. Maternal disease severity and neonatal RD variables were defined based on current accepted clinical criteria. To explore the multifactorial associations between maternal COVID-19 parameters and infant RD, we utilize a multivariable logistic regression model and a proteomic sub-analysis to propose a pathway for the development of RD following in utero exposure to SARS-CoV-2. Unusually high rates of RD are observed in SEU infants (17%). The odds ratio of RD is 3.06 (95% CI:1.08-10.21) in term neonates born to unvaccinated individuals versus those born to individuals vaccinated prior to maternal infection. Proteomic analysis reveals a robust inflammatory response associated with ciliary dysregulation and enhanced IgE production among SEU neonates with RD. Maternal vaccination against COVID-19 reduces the frequency of neonatal RD.

Gene crosstalk between COVID-19 and preeclampsia revealed by blood transcriptome analysis

Background

The extensive spread of coronavirus disease 2019 (COVID-19) has led to a rapid increase in global mortality. Preeclampsia is a commonly observed pregnancy ailment characterized by high maternal morbidity and mortality rates, in addition to the restriction of fetal growth within the uterine environment. Pregnant individuals afflicted with vascular disorders, including preeclampsia, exhibit an increased susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection via mechanisms that have not been fully delineated. Additionally, the intricate molecular mechanisms underlying preeclampsia and COVID-19 have not been fully elucidated. This study aimed to discern commonalities in gene expression, regulators, and pathways shared between COVID-19 and preeclampsia. The objective was to uncover potential insights that could contribute to novel treatment strategies for both COVID-19 and preeclampsia.

Method

Transcriptomic datasets for COVID-19 peripheral blood (GSE152418) and preeclampsia blood (GSE48424) were initially sourced from the Gene Expression Omnibus (GEO) database. Subsequent to that, we conducted a subanalysis by selecting females from the GSE152418 dataset and employed the "Deseq2" package to identify genes that exhibited differential expression. Simultaneously, the "limma" package was applied to identify differentially expressed genes (DEGs) in the preeclampsia dataset (GSE48424). Following that, an intersection analysis was conducted to identify the common DEGs obtained from both the COVID-19 and preeclampsia datasets. The identified shared DEGs were subsequently utilized for functional enrichment analysis, transcription factor (TF) and microRNAs (miRNA) prediction, pathway analysis, and identification of potential candidate drugs. Finally, to validate the bioinformatics findings, we collected peripheral blood mononuclear cell (PBMC) samples from healthy individuals, COVID-19 patients, and Preeclampsia patients. The abundance of the top 10 Hub genes in both diseases was assessed using real-time quantitative polymerase chain reaction (RT-qPCR).

Result

A total of 355 overlapping DEGs were identified in both preeclampsia and COVID-19 datasets. Subsequent ontological analysis, encompassing Gene Ontology (GO) functional assessment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, revealed a significant association between the two conditions. Protein-protein interactions (PPIs) were constructed using the STRING database. Additionally, the top 10 hub genes (MRPL11, MRPS12, UQCRH, ATP5I, UQCRQ, ATP5D, COX6B1, ATP5O, ATP5H, NDUFA6) were selected based on their ranking scores using the degree algorithm, which considered the shared DEGs. Moreover, transcription factor-gene interactions, protein-drug interactions, co-regulatory networks of DEGs and miRNAs, and protein-drug interactions involving the shared DEGs were also identified in the datasets. Finally, RT-PCR results confirmed that 10 hub genes do exhibit distinct expression profiles in the two diseases.

Conclusion

This study successfully identified overlapping DEGs, functional pathways, and regulatory elements between COVID-19 and preeclampsia. The findings provide valuable insights into the shared molecular mechanisms and potential therapeutic targets for both diseases. The validation through RT-qPCR further supports the distinct expression profiles of the identified hub genes in COVID-19 and preeclampsia, emphasizing their potential roles as biomarkers or therapeutic targets in these conditions.

Increased risk of early-onset preeclampsia in pregnant women with COVID-19

OBJECTIVE

To estimate incidence, risk of early and late-onset preeclampsia (PE) and understand their relationship with severity of COVID-19.

METHODS

Pregnant women with COVID-19 (n = 1929) were enrolled from 1 April 2020 to 24 February 2022. Primary outcome measure was incidence and risk of early onset PE in women with COVID-19.

RESULTS

The incidence of early and late-onset PE was 11.4% and 5.6%. Moderate to severe COVID-19 was associated with eight times higher risk of early onset PE [aOR = 8.13 (1.56-42.46), p = 0.0129] compared to asymptomatic group.

CONCLUSIONS

Risk of early onset PE was higher in pregnant women with symptomatic COVID-19 as compared to asymptomatic women.

Hypertensive Disorders in Pregnancy: Global Burden From 1990 to 2019, Current Research Hotspots and Emerging Trends

Hypertensive disorders in pregnancy (HDP) constitute a worldwide health problem for pregnant women and their infants. This study provided HDP burden over 1990 to 2019 by region and age distribution, and predicted changes in related values for the next 25 years. We then conducted an econometric analysis of the author distribution, collaborative networks, keyword burst clustering, and spatio-temporal analysis of HDP-related publications from 2012 to 2022 to access current scientific developments and hotspots. The number of pregnant women with HDP has been increasing over the past 30 years, with regional and age-stratified differences in the burden of disease. Additionally, projections suggest an increase of deaths due to maternal HDP among adolescents younger than 20 years. Current research is mostly centered on pre-eclampsia, with hot keywords including trophoblast, immune tolerance, frozen-thawed embryo transfer, aspirin, gestational diabetes association, and biomarkers. Researches on the pathological mechanism, classification, and subtypes of HDP need to be further advanced.

Hypertension after multisystem inflammatory syndrome in children (MIS-C)

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is associated with SARS-CoV-2. Long-term consequences of MIS-C remain unknown. The objective was to describe the prevalence and clinical predictors of hypertension (HTN) and elevated blood pressure (BP) following MIS-C.

METHODS

A retrospective study of children ≤ 18 years admitted to a tertiary center with MIS-C was performed. HTN and elevated BP were classified as per the 2017 American Academy of Pediatrics Clinical Practice Guidelines and indexed to the 95th percentile. Data included demographics, inpatient clinical measures, and echocardiograms over 1-year follow-up. Data were analyzed using Kruskal-Wallis, chi-square, and logistic regression.

RESULTS

Among 63 children hospitalized with MIS-C (mean age 9.7 ± 4.2 years, 58.7% male, body mass index (BMI) z-score 0.59 ± 1.9), 14% had HTN, and 4% had elevated BP > 30 days post-hospitalization. Multivariate linear regression analysis showed that BMI z-score was significantly associated with higher mean systolic (β = 2.664, CI = 1.307-3.980, p < 0.001) and diastolic (β = 2.547, CI = 0.605-4.489, p = 0.012) BP index > 30 days post-hospitalization. Acute kidney injury (AKI) (23.8%) (OR = 2.977, CI = 1.778-4.987, p < 0.001), peak inpatient serum creatinine (OR = 2.524, CI = 1.344-4.740, p = 0.004), and maximum CRP (OR = 1.009, CI = 1.002-1.016, p = 0.014) were all associated with increased odds of post-hospitalization HTN. Left ventricular hypertrophy was present in 46% while hospitalized, compared to 10% at last follow-up. All had return of normal systolic function.

CONCLUSIONS

Post-hospitalization HTN and elevated BP may be associated with MIS-C. Children with greater BMI or AKI may be at greater risk for developing HTN after MIS-C. MIS-C follow-up requires careful BP monitoring and antihypertensive medication consideration. A higher resolution version of the Graphical abstract is available as Supplementary information.

COVID-19 during pregnancy could potentially affect placental function

OBJECTIVE

COVID-19 is an ongoing pandemic and has been extensively studied. However, the effects of COVID-19 during pregnancy, particularly on placental function, have not been verified. In this study, we used blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) to evaluate whether COVID-19 incidence during pregnancy has any lasting effects with respect to placental oxygenation.

METHODS

This is a case-control study, in which eight cases of singleton pregnancies before 30 weeks gestation with COVID-19 mothers were included. Placental oxygenation was evaluated using BOLD-MRI after 32 weeks of gestation. BOLD-MRI was consecutively performed under normoxia (21% O2), hyperoxia (100% O2), and normoxia for 4 min each. Individual placental time-activity curves were evaluated to calculate the peak score (peakΔR2*) and the time from the start of maternal oxygen administration to the time of peakΔR2* (time to peakΔR2*). Eighteen COVID-19-free normal pregnancies from a previous study were used as the control group.

RESULTS

No significant differences were found between the two groups regarding maternal background, number of days of delivery, birth weight, and placental weight. The parameter peakΔR2* was significantly decreased in the COVID-19 group (8 ± 3 vs. 5 ± 1, p < .001); however, there was no significant difference in time to peakΔR2* (458 ± 74 s vs. 471 ± 33 s, p = .644).

CONCLUSIONS

In this study, BOLD-MRI was used to evaluate placental oxygenation during pregnancy in COVID-19-affected patients. COVID-19 during pregnancy decreased placental oxygenation even post-illness, but had no effect on fetal growth; further investigation of the possible effects of COVID-19 on the fetus and mother is warranted.

COVID-19 and obstetric outcomes: a single-center retrospective experience in a predominantly Black population

Objective: This retrospective, single-center case series was designed to characterize the effects of perinatal COVID-19 diagnosis on obstetric and neonatal outcomes in a predominantly high-risk, urban Black population.Study Design: Data were collected via retrospective chart review on all COVID-19-positive obstetric patients and their neonates who presented to the University of Chicago Medical Center between March 2020 and November 2020, before the availability of the COVID-19 vaccine. Patient demographics, delivery outcomes, COVID-19 symptoms, treatment, and outcomes were analyzed.Results: A total of 56 COVID-19-positive obstetric patients were included in the study, of which four were lost to follow-up before delivery. The median age of patients was 27 years (IQR 23, 32), with 73.2% publicly insured and 66.1% Black. Patients had a median body mass index (BMI) of 31.6 kg/m² (IQR 25.9, 35.5). 3.6% of patients had chronic hypertension, 12.5% had diabetes, and 16.1% had asthma. Perinatal complications were common. Twenty-six patients (50.0%) had a diagnosis of a hypertensive disorder of pregnancy (HDP). 28.8% had gestational hypertension, and 21.2% had preeclampsia (with and without severe features). The rate of maternal ICU admission was 3.6%. Furthermore, 23.5% of patients delivered preterm (<37 weeks gestation), and 50.9% of infants were admitted to the Neonatal Intensive Care Unit (NICU).Conclusion: In our study of a predominantly Black, publicly-insured, unvaccinated group of COVID-19-positive pregnant patients, we found high rates of hypertensive disorders of pregnancy, preterm delivery, and NICU admission compared to rates reported in existing literature before widespread vaccine availability. Our findings suggest that SARS-CoV-2 infection during pregnancy, irrespective of maternal disease severity, may exacerbate existing obstetric health disparities by disproportionately impacting Black, publicly insured patients. Larger comparative studies are needed to better characterize possible racial and socioeconomic disparities in obstetric outcomes in the setting of SARS-CoV-2 infection during pregnancy. These studies should examine the pathophysiology of SARS-CoV-2 infection during pregnancy, as well as potential associations between adverse perinatal outcomes and disparities in access to care, COVID-19 vaccination, and other social determinants of health amongst more vulnerable populations infected with SARS-CoV-2 during pregnancy.

Maternal SARS-COV-2 infection and prematurity: the Southern Michigan COVID-19 collaborative

OBJECTIVE

COVID-19 has been reported to increase the risk of prematurity, however, due to the frequent absence of unaffected controls as well as inadequate accounting for confounders in many studies, the question requires further investigation. We sought to determine the impact of COVID-19 disease on preterm birth (PTB) overall, as well as related subcategories such as early prematurity, spontaneous, medically indicated preterm birth, and preterm labor (PTL). We assessed the impact of confounders such as COVID-19 risk factors, a-priori risk factors for PTB, symptomatology, and disease severity on rates of prematurity.

METHODS

This was a retrospective cohort study of pregnant women from March 2020 till October 1st, 2020. The study included patients from 14 obstetric centers in Michigan, USA. Cases were defined as women diagnosed with COVID-19 at any point during their pregnancy. Cases were matched with uninfected women who delivered in the same unit, within 30 d of the delivery of the index case. Outcomes of interest were frequencies of prematurity overall and subcategories of preterm birth (early, spontaneous/medically indicated, preterm labor, and premature preterm rupture of membranes) in cases compared to controls. The impact of modifiers of these outcomes was documented with extensive control for potential confounders. A p value <.05 was used to infer significance.

RESULTS

The rate of prematurity was 8.9% in controls, 9.4% in asymptomatic cases, 26.5% in symptomatic COVID-19 cases, and 58.8% among cases admitted to the ICU. Gestational age at delivery was noted to decrease with disease severity. Cases were at an increased risk of prematurity overall [adjusted relative risk (aRR) = 1.62 (1.2-2.18)] and of early prematurity (<34 weeks) [aRR = 1.8 (1.02-3.16)] when compared to controls. Medically indicated prematurity related to preeclampsia [aRR = 2.46 (1.47-4.12)] or other indications [aRR = 2.32 (1.12-4.79)], were the primary drivers of overall prematurity risk. Symptomatic cases were at an increased risk of preterm labor [aRR = 1.74 (1.04-2.8)] and spontaneous preterm birth due to premature preterm rupture of membranes [aRR = 2.2(1.05-4.55)] when compared to controls and asymptomatic cases combined. The gestational age at delivery followed a dose-response relation with disease severity, as more severe cases tended to deliver earlier (Wilcoxon p < .05).

CONCLUSIONS

COVID-19 is an independent risk factor for preterm birth. The increased preterm birth rate in COVID-19 was primarily driven by medically indicated delivery, with preeclampsia as the principal risk factor. Symptomatic status and disease severity were significant drivers of preterm birth.

The impact of covid-19 pandemic on pregnancy outcome

BACKGROUND

The acute respiratory disease caused by the coronavirus (COVID-19) has spread rapidly worldwide yet has not been eliminated. The infection is especially deadly in vulnerable populations. The current studies indicate that pregnant women are at greater risk of getting seriously ill. Even though fetuses protect against disease, the additional finding showed that the COVID-19 pandemic could increase fetal and maternal morbidities. In a situation where COVID-19 and new strains of the virus are still not controlled, scientists predicted that the world might experience another pandemic. Consequently, more research about the effects of COVID-19 infection on pregnancy outcomes is needed. This study aimed to compare the pregnancy outcomes of Iranian pregnant women in the first year of the pandemic with the previous year.

METHODS

This prospective cross-sectional study was performed to compare the pregnancy outcome during the COVID-19 pandemic among Iranian pregnant women who gave birth during the pandemic and one year before the pandemic (2019-2020 and 2020-2021). The sample size was 2,371,332 births registered at hospitals and birth centers platforms. The studied variables include stillbirth, congenital anomaly, birth weight, preeclampsia, gestational diabetes, cesarean section, ICU admission, mean of the gestational age at birth, preterm births, NICU admission, neonatal mortality and the percentage of deliveries with at least one complication such as blood transfusion and postpartum ICU admission. Analyzing data was done by using SPSS version 25 software.

RESULTS

We found statistical differences between pregnancy and birth outcomes during the COVID-19 pandemic compared to one year before. The risk of preeclampsia, gestational diabetes, cesarean section, preterm birth and NICU admission were clinically significant. Also, there was a significant decrease in mean gestational age.

CONCLUSION

The COVID-19 pandemic has affected the pregnancy outcome by increasing morbidities and complications during pregnancy, birth, and postpartum. In addition, extensive quarantine outbreaks disrupted the healthcare system and hindered access to prenatal services. It is necessary to develop preventive and therapeutic care protocols for similar pandemic conditions.

SARS-CoV-2 Infection in Late Pregnancy and Childbirth from the Perspective of Perinatal Pathology

This review focuses on SARS-CoV-2 infection in placental and fetal tissues. Viremia is rare in infected pregnant women, and the virus is seldom amplified from placental tissues. Definite and probable placental infection requires the demonstration of viral RNA or proteins using in situ hybridization (ISH) and immunohistochemistry (IHC). Small subsets (1.0-7.9%, median 2.8%) of placentas of SARS-CoV-2-positive women showed definite infection accompanied by a characteristic histopathology named SARS-CoV-2 placentitis (SP). The conventionally accepted histopathological criteria for SP include the triad of intervillositis, perivillous fibrin deposition, and trophoblast necrosis. SP was shown to be independent of the clinical severity of the infection, but associated with stillbirth in cases where destructive lesions affecting more than 75% of the placental tissue resulted in placental insufficiency and severe fetal hypoxic-ischemic injury. An association between maternal thrombophilia and SP was shown in a subset of cases, suggesting a synergy of the infection and deficient coagulation cascade as one of the mechanisms of the pathologic accumulation of fibrin in affected placentas. The virus was amplified from fetal tissues in approximately 40% of SP cases, but definite fetal involvement demonstrated using ISH or IHC is exceptionally rare. The placental pathology in SARS-CoV-2-positive women also includes chronic lesions associated with placental malperfusion in the absence of definite or probable placental infection. The direct viral causation of the vascular malperfusion of the placenta in COVID-19 is debatable, and common predispositions (hypertension, diabetes, and obesity) may play a role.

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States

BACKGROUND

Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19.

RESULTS

Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women.

CONCLUSIONS

Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes.

Does COVID-19 Cause Non-Dıpper Hypertension?

Coronavirus disease 2019 (COVID-19) remains a health problem worldwide. The present study aimed to investigate the effect of blood pressure (BP) on the circadian pattern and prevalence of new-onset non-dipper hypertension in the post-COVID period in patients with known hypertension. This prospective single-center study included 722 patients hospitalized for COVID-19 infection. Ambulatory BP (ABP) data were collected during their initial hospitalization. The ABP data were reassessed 1 month after the patients were discharged. The results were compared with a healthy control group with known hypertension but without COVID-19 infection. After exclusion criteria were applied, the study included 187 patients with COVID-19 and 136 healthy hypertensive controls. Post-COVID ABP showed that patients with COVID-19 had significantly higher mean 24-h systolic and diastolic BP, mean nighttime systolic and diastolic BP, and mean daytime diastolic BP than the control group. In addition, new-onset non-dipper hypertension was significantly higher in patients with COVID-19. This study demonstrated for the first time that the circadian pattern is disturbed and a non-dipper pattern develops in individuals with known hypertension during the post-COVID period.

NT-proBNP-Possible Prognostic Marker in Pregnant Patients with Associated Cardiovascular Risk Factors and SARS-CoV-2 Infection

BACKGROUND

N-terminal pro brain-type natriuretic peptide (NT-proBNP) is a practical biomarker in the clinical pathologies where the ventricle is under stress and particularly stretched in the general population. The study aims to compare the value of NT-proBNP and its importance in the prognosis and severity of the cases involving pregnant patients with SARS-CoV-2 infection and cardiovascular risk factors to those of low-risk pregnant patients, mainly by analysing their symptoms, administered medication, days of hospitalization and severity of the viral disease.

METHODS

The study included a total of eighty-three pregnant patients who underwent natural birth or caesarean section at out hospital. NT-proBNP levels were analyzed at hospital admission as a potential cardiovascular marker. A comparative analysis was performed between pregnant patients with cardiovascular risk factors and pregnant patients without cardiovascular risk factors regarding NT-proBNP values.

RESULTS

Pregnant patients with SARS-CoV-2 infection and cardiovascular risk factors had higher values of NT-proBNP in comparison to pregnant patients without cardiovascular risk factors.

CONCLUSIONS

NT-proBNP testing in pregnant patients with SARS-CoV-2 infection can be a relatively important marker to be taken into consideration when it comes to the management, treatment and outcome of the cases, especially when it comes to women with associated cardiovascular risk factors.

Placental Infection Associated with SARS-CoV-2 Wildtype Variant and Variants of Concern

The original SARS-CoV-2 lineages have been replaced by successive variants of concern (VOCs) over time. The aim of this study was to perform an assessment of the placental infection by SARS-CoV-2 according to the predominant variant at the moment of COVID-19 diagnosis. This was a prospective study of SARS-CoV-2-positive pregnant women between March 2020 and March 2022. The population was divided into pregnancies affected by COVID-19 disease during 2020 (Pre-VOC group) and pregnancies affected after December 2020 by SARS-CoV-2 variants of concern (VOC group). The presence of virus was assessed by RT-PCR, and the viral variant was determined by whole genome sequencing. A total of 104 placentas were examined, among which 54 cases belonged to the Pre-VOC group and 50 cases belonged to the VOC group. Sixteen positive placental RT-PCR tests for SARS-CoV-2 were reported. The NGS analysis confirmed the SARS-CoV-2 lineage in placenta tissue. All samples corresponded to the Pre-VOC group, whereas no placental presence of SARS-CoV-2 was detected in the VOC group (16, 29.6% vs. 0, 0.0% p = 0.000). Preterm birth (9, 16.7% vs. 2, 4%; p = 0.036) and hypertensive disorders of pregnancy (14, 25.9% vs. 3, 6%; p = 0.003) were more frequent in the Pre-VOC group than in the VOC group. Finally, the VOC group was composed of 23 unvaccinated and 27 vaccinated pregnant women; no differences were observed in the sub-analysis focused on vaccination status. In summary, SARS-CoV-2-positive placentas were observed only in pregnancies infected by SARS-CoV-2 wildtype. Thus, placental SARS-CoV-2 presence could be influenced by SARS-CoV-2 variants, infection timing, or vaccination status. According to our data, the current risk of SARS-CoV-2 placental infection after maternal COVID disease during pregnancy should be updated.

Modeling psychotic disorders: Environment x environment interaction

Schizophrenia is a major psychotic disorder with multifactorial etiology that includes interactions between genetic vulnerability and environmental risk factors. In addition, interplay of multiple environmental adversities affects neurodevelopment and may increase the individual risk of developing schizophrenia. Consistent with the two-hit hypothesis of schizophrenia, we review rodent models that combine maternal immune activation as the first hit with other adverse environmental exposures as the second hit. We discuss the strengths and pitfalls of the current animal models of environment x environment interplay and propose some future directions to advance the field.

Risk for stillbirth among pregnant individuals with SARS-CoV-2 infection varied by gestational age

BACKGROUND

Despite previous research findings on higher risks of stillbirth among pregnant individuals with SARS-CoV-2 infection, it is unclear whether the gestational timing of viral infection modulates this risk.

OBJECTIVE

This study aimed to examine the association between timing of SARS-CoV-2 infection during pregnancy and risk of stillbirth.

STUDY DESIGN

This retrospective cohort study used multilevel logistic regression analyses of nationwide electronic health records in the United States. Data were from 75 healthcare systems and institutes across 50 states. A total of 191,403 pregnancies of 190,738 individuals of reproductive age (15-49 years) who had childbirth between March 1, 2020 and May 31, 2021 were identified and included. The main outcome was stillbirth at ≥20 weeks of gestation. Exposures were the timing of SARS-CoV-2 infection: early pregnancy (<20 weeks), midpregnancy (21-27 weeks), the third trimester (28-43 weeks), any time before delivery, and never infected (reference).

RESULTS

We identified 2342 (1.3%) pregnancies with COVID-19 in early pregnancy, 2075 (1.2%) in midpregnancy, and 12,697 (6.9%) in the third trimester. After adjusting for maternal and clinical characteristics, increased odds of stillbirth were observed among pregnant individuals with SARS-CoV-2 infection only in early pregnancy (odds ratio, 1.75, 95% confidence interval, 1.25-2.46) and midpregnancy (odds ratio, 2.09; 95% confidence interval, 1.49-2.93), as opposed to pregnant individuals who were never infected. Older age, Black race, hypertension, acute respiratory distress syndrome or acute respiratory failure, and placental abruption were found to be consistently associated with stillbirth across different trimesters.

CONCLUSION

Increased risk of stillbirth was associated with COVID-19 only when pregnant individuals were infected during early and midpregnancy, and not at any time before the delivery or during the third trimester, suggesting the potential vulnerability of the fetus to SARS-CoV-2 infection in early pregnancy. Our findings underscore the importance of proactive COVID-19 prevention and timely medical intervention for individuals infected with SARS-CoV-2 during early and midpregnancy.