WAPM (World Association of Perinatal Medicine) Working Group on COVID-19. Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection

COVID-19 Vaccine Safety in Pregnancy, A Nested Case-Control Study in Births From April 2021 to March 2022, England

OBJECTIVE

Assessment of COVID-19 vaccine safety in pregnancy using population-based data.

DESIGN

Matched case-control study nested in a retrospective cohort.

SETTING

April 2021-March 2022, England.

POPULATION OR SAMPLE

All pregnant individuals aged between 18 and 50 years with valid health records.

METHODS

Individuals identified from the national Maternity Services Data Set (MSDS) had their records linked to hospital admission, national COVID-19 vaccine and COVID-19 testing databases. Matching included participant's age and estimated week of conception. We compared outcomes across multiple COVID-19 vaccine exposures using conditional multivariable logistic regression, adjusting for demographic and health characteristics.

MAIN OUTCOME MEASURES

Adverse pregnancy, maternal and neonatal outcomes.

RESULTS

514 013 individuals were included. We found lower odds of giving birth to a baby who was low birthweight (aOR = 0.86, 95% CI: 0.79-0.93), preterm (aOR = 0.89, 95% CI: 0.85-0.92) or who had an Apgar score < 7 at 5 min of age (aOR = 0.89, 95% CI: 0.80-0.98) for individuals who received at least one dose of COVID-19 vaccine during pregnancy. The odds of admission to intensive care unit during pregnancy were lower in those vaccinated (aOR = 0.85, 95% CI: 0.76-0.95). There was no association between vaccination in pregnancy and stillbirth, neonatal death, perinatal death and maternal venous thromboembolism in pregnancy.

CONCLUSIONS

COVID-19 vaccines are safe to use in pregnancy. Our findings generated important information to communicate to pregnant individuals and health professionals to support COVID-19 maternal vaccination programmes.

Evaluation of the Effect of Early-Onset Steroid Treatment in the COVID-19-Positive Pregnant Women on Pregnancy Outcomes

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Acute respiratory distress and preterm delivery are the two major complications induced by SARS-CoV-2 infection during pregnancy. In the presence of dyspnea, the use of systemic corticosteroids was recommended in pregnant and non-pregnant groups. Our primary aim was to investigate the effect of early-onset steroid treatment on mortality and adverse effects in pregnant women with COVID-19. Our secondary aim was to investigate the effect of steroid treatment on the length of hospital stay and intensive care unit (ICU) stay, and duration of treatment. The study also investigated infection, preterm birth, and ideal body weight (lbw) in newborns.

METHODS

In this retrospective study, 253 patients were divided into three groups according to steroid administration. In Group 1 patients (n:112), treatment was started at the time of hospitalization. In Group 2 patients (n:90), treatment was started at least 24 h after hospitalization. Group 3 consisted of patients (n:51) who did not receive steroid treatment. Methylprednisolone (32 mg/day) was given to pregnant patients with a gestational age below 24 weeks or above 34 weeks, and dexametazone (6 mg/day) was given in four doses followed by 32 mg/day methylprednisolone for the others (whose baby was at a gestational age of 24 weeks and above but less than 34 weeks).

RESULT

The hospital stay, ICU stay, and steroid administration time were significantly lower in the Group 1 when compared to the others (p < 0.05). The steroid treatment requirement was 4.4 days in Group 1 and 5.7 days in Group 2 (p < 0.05). While no death was observed in Group 1, one patient died in Group 2 and three patients died in Group 3. There was no difference between the groups in terms of complications, including preterm labor.

CONCLUSIONS

No death was also observed with early-onset treatment. Early-onset treatment may be beneficial for fewer hospitalizations, fewer ICU stays, and less mechanical ventilation requirement in pregnant women with COVID-19. In addition, with early treatment, the total number of steroid administration days was reduced, which is important in terms of reducing the risk of side effects.

COVID-19 infection during pregnancy and risk of early and late spontaneous miscarriages: A matched case-control population-based study

OBJECTIVES

To evaluate the effect of COVID-19 during the first trimester on the rate of first- and second-trimester miscarriages. Secondary aims include the effect on stillbirths and the correlation between symptom severity and pregnancy outcomes.

METHODS

A retrospective matched case-control population-based study extracted data from electronic medical records of a nationwide database of the second largest healthcare organization that provides medical services to over 2 000 000 patients in Israel. Pregnancy outcomes in COVID-19-positive pregnant patients in 2020 were compared with an age- and gestational-week-matched 1:2 case-control cohort of pre-pandemic pregnant patients that received medical care in 2019.

RESULTS

Of 68 485 pregnant women treated in 2020, 2333 were COVID-19-positive during pregnancy: 215 during the first trimester, 791 during the second trimester, and 1327 during the third trimester. We compared these data with the control cohort of 4580 pre-pandemic pregnant patients. The rate of spontaneous miscarriage was significantly higher 146/2187 (6.3%) in COVID-19-positive patients versus 214/4580 (4.7%), (P < 0.01, odds ratio 1.34, 95% confidence interval 1.094-1.691). Most miscarriages occurred during the first trimester in both groups, yet the rates were significantly higher in the study group (5.4% vs 3.8%, P < 0.01). There was no association between COVID-19 severity and miscarriage risk.

CONCLUSION

COVID-19 diagnosis during early pregnancy increased the rate of spontaneous miscarriage in our cohort compared with an age- and gestational-week-matched pre-pandemic control group.

Impact of perioperative COVID-19 infection on postoperative complication in cesarean section using Korean National Health insurance data

The vulnerability during pregnancy has raised concerns about the potential impact of COVID-19 on obstetric anesthesia, an essential aspect of maternal care during cesarean section procedures. To evaluate the influence of COVID-19 infection on obstetric anesthesia during cesarean section, we analyzed the data from Korean National Health Insurance System (NHIS). This retrospective study utilized data from Korean NHIS. We included patients admitted with operation codes specific to cesarean section between January 1, 2020, and December 31, 2021. We classified patients into a COVID (+) group with a diagnosis code (U071) 30 days around surgery and a COVID (-) group without the code in the same period. The primary outcome was 30-day mortality that was defined as death within 30 days of admission due to any causes. Secondary outcomes were pulmonary complications (pneumonia, acute respiratory distress syndrome [ARDS], pulmonary thromboembolism [PTE], or unexpected postoperative mechanical ventilation), ICU admission, cardiac arrest, myocardial infarction [MI], other thromboembolic events, surgical site infection, sepsis, acute renal failure [ARF], and hepatic failure. Among 75,268 patients who underwent cesarean section, 107 had a COVID-19 diagnosis code, while 75,161 did not. After 1:4 propensity score matching (PSM), 535 patients were included in each group. 30-day mortality showed no significant differences between the two groups both before and after PSM. The COVID (+) group demonstrated significantly elevated rates of pneumonia, ARDS, PTE, and surgical site infection both before and after PSM. Hospital length of stay and admission costs were also significantly longer and higher, respectively, in the COVID (+) group before and after PSM. In subgroup analysis, no differences were observed in mortality and postoperative complications based on the anesthesia method after matching. COVID-19 infection is associated with increased rates of postoperative complications, including pneumonia, ARDS, PTE, surgical site infection, longer hospital stays, and increased admission costs, in patients who underwent cesarean section.

Outcomes of SARS-CoV-2 infection in early pregnancy-A systematic review and meta-analysis

INTRODUCTION

Available data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and pregnancy outcomes mostly refer to women contracting the infection during advanced pregnancy or close to delivery. There is limited information on the association between SARS-CoV-2 infection in early pregnancy and outcomes thereof.

MATERIAL AND METHODS

We aimed to systematically review the maternal, fetal and neonatal outcomes following SARS-CoV-2 infection in early pregnancy, defined as <20 weeks of gestation (PROSPERO Registration 2020 CRD42020177673). Searches were carried out in PubMed, Medline, EMBASE, and Scopus databases from January 2020 until April 2023 and the WHO database of publications on coronavirus disease 2019 (COVID-19) from December 2019 to April 2023. Cohort and case-control studies on COVID-19 occurring in early pregnancy that reported data on maternal, fetal, and neonatal outcomes were included. Case reports and studies reporting only exposure to SARS-CoV-2 or not stratifying outcomes based on gestational age were excluded. Data were extracted in duplicate. Meta-analyses were conducted when appropriate, using R meta (R version 4.0.5).

RESULTS

A total of 18 studies, 12 retrospective and six prospective, were included in this review, reporting on 10 147 SARS-CoV-2-positive women infected in early pregnancy, 9533 neonates, and 180 882 SARS-CoV-2 negative women. The studies had low to moderate risk of bias according to the Newcastle-Ottawa quality assessment Scale. The studies showed significant clinical and methodological heterogeneity. A meta-analysis could be performed only on the outcome miscarriage rate, with a pooled random effect odds ratio of 1.44 (95% confidence interval 0.96-2.18), showing no statistical difference in miscarriage in SARS-CoV-2-infected women. Individual studies reported increased incidences of stillbirth, low birthweight and preterm birth among neonates born to mothers affected by COVID-19 in early pregnancy; however, these results were not consistent among all studies.

CONCLUSIONS

In this comprehensive systematic review of available evidence, we identified no statistically significant adverse association between SARS-CoV-2 infection in early pregnancy (before 20 weeks of gestation) and fetal, neonatal, or maternal outcomes. However, a 44% increase in miscarriage rate is concerning and further studies of larger sample size are needed to confirm or refute our findings.

Casirivimab and Imdevimab for Pregnant Women Hospitalized for Severe Coronavirus Disease 2019

OBJECTIVE

Our objective was to evaluate the safety and efficacy of casirivimab/imdevimab therapy in pregnant women with severe coronavirus disease 2019 (COVID-19) requiring oxygen therapy.

STUDY DESIGN

This was a prospective case series study aimed to evaluate the safety and efficacy of casirivimab/imdevimab therapy in unvaccinated pregnant women with severe COVID-19. Inclusion criteria were severe acute respiratory syndrome coronavirus 2 infection documented with polymerase chain reaction, pregnancy, severe COVID-19 requiring oxygen therapy, duration of symptoms of 10 days or less, and able to provide informed consent. Vaccinated women and those with mild-to-moderate disease were excluded from the study. Included patients received casirivimab and imdevimab as a single intravenous dose of 4,000/4,000 mg. Women were also treated with low molecular weight heparin, steroids, and antibiotics, if necessary. The primary outcome was maternal death. Secondary outcomes were the rate of adverse events during infusion or within 72 hours and the rate of abortion.

RESULTS

Thirteen hospitalized unvaccinated pregnant women with severe COVID-19 requiring oxygen and treated with casirivimab/imdevimab were included in the study. We observed no maternal death, and no patients required intubation or admission to the intensive care unit. No abortion or fetal loss was recorded. Nine pregnancies were still ongoing, and there were three cesarean deliveries and one vaginal delivery. Two were preterm deliveries (at 31 and 34 weeks), and two were term deliveries.

CONCLUSION

Casirivimab/imdevimab therapy may be considered as a therapy in unvaccinated pregnant women with severe COVID-19.

Potential Toxic Metal Concentration and Risk Assessment in Agricultural Soil and Lentil Crop (Lens culinaris Medik) in Dawunt Woreda, Northwest Wollo, Ethiopia

Health implications for the population due to consuming contaminated crops have been a great concern worldwide. This study aimed to measure the levels of potential toxic elements in lentils and their growing soil in Dawunt Woreda, Ethiopia. Accordingly, 15 soil samples along with the lentil samples were collected to measure the level of potential toxic elements, including chromium (Cr), manganese (Mn), iron (Fe), lead (Pb), cadmium (Cd), copper (Cu), and cobalt (Co), by using an inductively coupled plasma optical emission spectrometer and for assessing the potential ecological and human health risk. The wet digestion method using aqua regia (HCl/HNO3 3 : 1) was employed for soil and lentil sample preparation. The mean concentrations of Fe, Mn, Co, Cu, Cd, Pb, and Cr in the lentil sample were 60.4, 9.68, 0.75, 5.7, 0.25, 0.9, and 1.15 mg/kg, respectively. In soil, the mean concentrations of Fe, Mn, Co, Cu, Cd, Pb, and Cr were 649, 19.9, 3.32, 40.0, 15.2, 1.83, and 69.1 mg/kg, respectively. All of the potential toxic metals in agricultural soil and lentil samples were found to be below the reference level set by the World Health Organization, except Cd, in the soil samples. Five single metal and three cumulative pollution index parameters were employed for the data and results showed that Fe, Cu, and Cr moderately pollute the soil and are highly contaminated by Cd. The cumulative pollution indices also confirmed that the extent of soil pollution varied from highly contaminated to moderate contamination. The possible health risks at various exposure routes have also been estimated. The single-metal and cumulative-metals health risks (cancer and noncancer) of adults and children due to chronic exposure to soil and consumption of lentils were estimated using the health quotient and health index values as per the United States Environmental Protection Agency guidelines. Thus, the results revealed no significant adverse health risks (cancer and noncancer) for adults and children. Therefore, the inhabitants in the study area have no significant health impacts due to either the consumption of lentil crops or exposure to agricultural soil particles.

COVID-19 in pregnant women: a systematic review and meta-analysis on the risk and prevalence of pregnancy loss

BACKGROUND

Pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are more likely to experience preterm birth and their neonates are more likely to be stillborn or admitted to a neonatal unit. The World Health Organization declared in May 2023 an end to the coronavirus disease 2019 (COVID-19) pandemic as a global health emergency. However, pregnant women are still becoming infected with SARS-CoV-2 and there is limited information available regarding the effect of SARS-CoV-2 infection in early pregnancy on pregnancy outcomes.

OBJECTIVE AND RATIONALE

We conducted this systematic review to determine the prevalence of early pregnancy loss in women with SARS-Cov-2 infection and compare the risk to pregnant women without SARS-CoV-2 infection.

SEARCH METHODS

Our systematic review is based on a prospectively registered protocol. The search of PregCov19 consortium was supplemented with an extra electronic search specifically on pregnancy loss in pregnant women infected with SARS-CoV-2 up to 10 March 2023 in PubMed, Google Scholar, and LitCovid. We included retrospective and prospective studies of pregnant women with SARS-CoV-2 infection, provided that they contained information on pregnancy losses in the first and/or second trimester. Primary outcome was miscarriage defined as a pregnancy loss before 20 weeks of gestation, however, studies that reported loss up to 22 or 24 weeks were also included. Additionally, we report on studies that defined the pregnancy loss to occur at the first and/or second trimester of pregnancy without specifying gestational age, and for second trimester miscarriage only when the study presented stillbirths and/or foetal losses separately from miscarriages. Data were stratified into first and second trimester. Secondary outcomes were ectopic pregnancy (any extra-uterine pregnancy), and termination of pregnancy. At least three researchers independently extracted the data and assessed study quality. We calculated odds ratios (OR) and risk differences (RDs) with corresponding 95% CI and pooled the data using random effects meta-analysis. To estimate risk prevalence, we performed meta-analysis on proportions. Heterogeneity was assessed by I2.

OUTCOMES

We included 120 studies comprising a total of 168 444 pregnant women with SARS-CoV-2 infection; of which 18 233 women were in their first or second trimester of pregnancy. Evidence level was considered to be of low to moderate certainty, mostly owing to selection bias. We did not find evidence of an association between SARS-CoV-2 infection and miscarriage (OR 1.10, 95% CI 0.81-1.48; I2 = 0.0%; RD 0.0012, 95% CI -0.0103 to 0.0127; I2 = 0%; 9 studies, 4439 women). Miscarriage occurred in 9.9% (95% CI 6.2-14.0%; I2 = 68%; 46 studies, 1797 women) of the women with SARS CoV-2 infection in their first trimester and in 1.2% (95% CI 0.3-2.4%; I2 = 34%; 33 studies; 3159 women) in the second trimester. The proportion of ectopic pregnancies in women with SARS-CoV-2 infection was 1.4% (95% CI 0.02-4.2%; I2 = 66%; 14 studies, 950 women). Termination of pregnancy occurred in 0.6% of the women (95% CI 0.01-1.6%; I2 = 79%; 39 studies; 1166 women).

WIDER IMPLICATIONS

Our study found no indication that SARS-CoV-2 infection in the first or second trimester increases the risk of miscarriages. To provide better risk estimates, well-designed studies are needed that include pregnant women with and without SARS-CoV-2 infection at conception and early pregnancy and consider the association of clinical manifestation and severity of SARS-CoV-2 infection with pregnancy loss, as well as potential confounding factors such as previous pregnancy loss. For clinical practice, pregnant women should still be advised to take precautions to avoid risk of SARS-CoV-2 exposure and receive SARS-CoV-2 vaccination.

Outpatient Use of Monoclonal Antibodies Casirivimab and Imdevimab in Pregnancy for Mild-to-Moderate Coronavirus Disease 2019

OBJECTIVE

The aim of this study was to report the use casirivimab/imdevimab therapy in pregnant women with moderate coronavirus disease 2019 (COVID-19).

STUDY DESIGN

We report 12 cases of unvaccinated pregnant patients with mild-to-moderate COVID-19 treated with casirivimab/imdevimab.

RESULTS

Twelve unvaccinated pregnant patients with mild-to-moderate COVID-19 received casirivimab/imdevimab at the dose of 1200/1200 mg by intravenous infusion over 60 minutes. All women were managed outpatient. None experienced severe adverse drug reaction and none progressed to severe disease.

CONCLUSION

Casirivimab/imdevimab should be considered for outpatient treatment of unvaccinated pregnant women with mild-to-moderate COVID-19 to decrease the risk of severe disease.

KEY POINTS

· Casirivimab/imdevimab is not well studied in pregnant women.. · Casirivimab/imdevimab in pregnant women with mild-to-moderate COVID-19 decreases the risk of severe disease.. · Casirivimab/imdevimab in pregnant women with mild-to-moderate COVID-19 is well tolerated..

Severe Covid-19 in pregnant and postpartum women admitted to an intensive care unit: A retrospective cohort study

BACKGROUND

SARS-CoV-2 infection is associated with worse maternal and fetal outcomes. This study aims to describe the characteristics of pregnant and postpartum women with severe Covid-19 admitted to ICU.

METHODS AND FINDINGS

It's a retrospective cohort study evaluating pregnant and postpartum women referenced to a specialized ICU between May 2020 and June 2022. Covid-19 was confirmed with RT-PCR or rapid antigen test on a nasopharyngeal swab. Variables were described by median and IQR when numerical, and by frequency and percentage when categorical. OR with 95% CI were calculated for the evaluation of factors related to death. P-values were calculated using Pearson's ꭓ2-test, Fisher's exact test, Wilcoxon rank sum test, and Kruskall-Wallis test, and statistical significance was established as < 0·05. Missing data were excluded. All statistical analysis were performed using R software version 4.2.2. Of the 101 admissions, 85 (84·2%) were of pregnant women. Obesity (23·0%) and systemic arterial hypertension (13·0%) were the most prevalent medical conditions. Sixty-six (65·3%) were admitted using some type of oxygen support. Forty-seven (46·5%) evolved to mechanical ventilation. There were 61 events considered obstetric complications, with 8 stillbirths/fetal losses. The overall lethality was 15·8%. Pregnancy interruption, need for non-invasive mechanical ventilation, level of oxygen support at admission, prone maneuver, hemodialysis, and healthcare-related infections were factors associated with death. Evaluating the WHO 7-category ordinary scale, there was a trend of increase in the risk of death with higher punctuation, with a statistically significant difference of women with 5 (OR = 7·27; 95% IC = 1·17-194; p = 0·031) or 6 points (OR = 12·0; 95% IC = 1·15-391; p = 0·038) when compared to the ones with 3 points, i.e., of women admitted with a high-flow non-rebreathing mask or invasive mechanical ventilation, compared with the ones admitted at room air, respectively. The main limitations of this study are the relatively small number of participants, and the use of data derived of medical records-which are susceptible to misclassification and variable amounts of missing data.

CONCLUSIONS

Pregnant and postpartum women with severe Covid-19 have high lethality and a high incidence of clinical and obstetric complications. These findings support that this population should be prioritized in public health strategies that address Covid-19.

The impact of COVID-19 pandemic on obstetrics and gynecology hospitalization rate and on reasons for seeking emergency care: a systematic review and meta-analysis

BACKGROUND

During the lockdown due to COVID-19 pandemic, utilization of emergency care units has been reported to be reduced for obstetrical and gynaecological reasons. The aim of this systematic review is to assess if this phenomenon reduced the rate of hospitalizations for any reason and to evaluate the main reasons for seeking care in this subset of the population.

METHODS

The search was conducted using the main electronic databases from January 2020 to May 2021. The studies were identified with the use of a combination of: "emergency department" OR "A&E" OR "emergency service" OR "emergency unit" OR "maternity service" AND "COVID-19" OR "COVID-19 pandemic" OR "SARS-COV-2" and "admission" OR "hospitalization". All the studies that evaluated women going to obstetrics & gynecology emergency department (ED) during the COVID-19 pandemic for any reason were included.

RESULTS

The pooled proportion (PP) of hospitalizations increased from 22.7 to 30.6% during the lockdown periods, in particular from 48.0 to 53.9% for delivery. The PP of pregnant women suffering from hypertensive disorders increased (2.6 vs 1.2%), as well as women having contractions (52 vs 43%) and rupture of membranes (12.0 vs 9.1%). Oppositely, the PP of women having pelvic pain (12.4 vs 14.4%), suspected ectopic pregnancy (1.8 vs 2.0), reduced fetal movements (3.0 vs 3.3%), vaginal bleeding both for obstetrical (11.7 vs 12.8%) and gynecological issues (7.4 vs 9.2%) slightly reduced.

CONCLUSION

During the lockdown, an increase in the proportion of hospitalizations for obstetrical and gynecological reasons has been registered, especially for labor symptoms and hypertensive disorders.

Comparison between the demographic shift clinical severity and outcome of the first two waves of COVID-19 in pregnancy in a tertiary hospital in India

OBJECTIVE

To study and compare the maternal and neonatal outcomes of COVID-19 in pregnancy during the two waves of the pandemic in India.

METHODS

This observational, retrospective cohort study on pregnant women with SARS-CoV-2 infection was conducted in a 2700-bed tertiary referral center in South India from March 1, 2020 to June 30 2021. The clinical presentation, severity, and maternal and neonatal outcomes of COVID-19 were compared between the two waves.

RESULTS

A total of 623 pregnant women tested positive for SARS-CoV-2 infection in our institute; 379 (60.8%) were diagnosed during the first wave and 244 (39.2%) in the second wave. Most of the affected women (81.1%) were in their third trimester. Maternal mortality rate was 823 per 100 000 live births. Composite maternal outcome (increasing requirement for ventilation, pulmonary embolism, disease progression) were more pronounced during the second wave (2.1% vs 6.1%). Between the two waves, both maternal (1 vs 3; P = 0.162) and perinatal (3.2% vs 6.7%; P = 0.065) deaths were higher during the second wave. The cesarean section rate was high during the first wave (48% vs 32.4%; P < 0.001). Preterm births were comparable between the two waves (19.5% vs 22%; P < 0.500).

CONCLUSION

The women presented with more severe illness during the second wave of COVID-19. There was higher perinatal mortality, but the maternal mortality was similar between the two waves.

Reduced maternal immunity and vertical transfer of immunity against SARS-CoV-2 variants of concern with COVID-19 exposure or initial vaccination in pregnancy

Introduction

As the SARS-CoV-2 pandemic continues to evolve, we face new variants of concern with a concurrent decline in vaccine booster uptake. We aimed to evaluate the difference in immunity gained from the original SARS-CoV-2 mRNA vaccine series in pregnancy versus SARS-CoV-2 exposure during pregnancy against recent variants of concern.

Study Design

This is a retrospective analysis of previously collected samples from 192 patients who delivered between February 2021 and August 2021. Participants were categorized as 1) COVID vaccine: mRNA vaccine in pregnancy, 2) COVID-exposed, and 3) controls. The primary outcome was neutralizing capacity against wild-type, Delta, and Omicron-B1 between cohorts. Secondary outcomes include a comparison of cord-blood ID50 as well as the efficiency of vertical transfer, measured by cord-blood:maternal blood ID50 for each variant.

Results

Pregnant women with COVID-19 vaccination had a greater spike in IgG titers compared to both those with COVID-19 disease exposure and controls. Both COVID exposure and vaccination resulted in immunity against Delta, but only COVID vaccination resulted in significantly greater Omicron ID-50 versus controls. The neutralizing capacity of serum from newborns was lower than that of their mothers, with COVID-vaccination demonstrating higher cord-blood ID50 vs wildtype and Delta variants compared to control or COVID-exposed, but neither COVID-exposure nor vaccination demonstrated significantly higher Omicron ID50 in cord-blood compared to controls. There was a 0.20 (0.07-0.33, p=0.004) and 0.12 (0.0-0.24, p=0.05) increase in cord-blood:maternal blood ID50 with COVID vaccination compared to COVID-19 exposure for wild-type and Delta respectively. In pair-wise comparison, vertical transfer of neutralization capacity (cord-blood:maternal blood ID50) was greatest for wild-type and progressively reduced for Delta and Omicron ID50.

Conclusion

Pregnant patients with either an initial mRNA vaccination series or COVID-exposure demonstrated reduced immunity against newer variants compared to wild-type as has been reported for non-pregnant individuals; however, the COVID-vaccination series afforded greater cross-variant immunity to pregnant women, specifically against Omicron, than COVID-disease. Vertical transfer of immunity is greater in those with COVID vaccination vs COVID disease exposure but is reduced with progressive variants. Our results reinforce the importance of bivalent booster vaccination in pregnancy for both maternal and infant protection and also provide a rationale for receiving updated vaccines as they become available.

Fetal death from SARS-CoV-2 mediated acute placental failure

INTRODUCTION

We demonstrate the nonlinear severity of symptoms of SARS-CoV-2 infection in the mother leading to fetal death after acute placental failure.

METHODS

Careful clinical evaluation, real-time RT-PCR molecular microbiologic testing, isolation of a viable virus, and autopsy with histologic results were used to investigate the possible vertical transmission of SARS-CoV-2 infection from mother to fetus.

RESULTS

Histologic changes in the placenta correlate with SARS-CoV-2 infection. Total nucleic acid isolated from vaginal swabs, fresh placental tissue, and deparaffinized tissue showed a high viral load of SARS-CoV-2. Complete genome sequencing confirmed the presence of the SARS-CoV-2 Delta variant.

DISCUSSION

Several methods have been used to confirm SARS-CoV-2-mediated acute placental failure, all of which were conclusive. It should be noted that careful periodic fetal well-being checks are required in women infected with SARS-CoV-2, regardless of the severity of symptoms. Most of the cases described with fetal death occurred in the third trimester.

[Epidemiological characterization of COVID-2019 in Mexican pregnant women: a cohort study]

Background

COVID-19 in pregnancy can increase the risk of complications due to the cardiorespiratory and immunological changes typical of pregnancy.

Objective

To report the epidemiological characterization of COVID-19 in Mexican pregnant women.

Material and methods

Cohort study on pregnant women with a positive COVID-19 test, which were followed until delivery and one month later.

Results

758 pregnant women were included in the analysis. Mothers' mean age was 28.8 ± 6.1 years; the majority were workers 497 (65.6%) and with an urban origin (482, 63.6%); the most common blood group was O with 458 (63.0%); 478 (63.0%) were nulliparous women and more than 25% had some comorbidities; the average gestation weeks at infection were 34.4 ± 5.1 weeks; only 170 pregnant women (22.4%) received vaccination; the most frequent vaccine was BioNTech Pfizer (96, 60%); there were no serious adverse events attributed to vaccination. The mean gestational age at delivery was 35.4 ± 5.2 weeks; 85% of pregnancies were cesarean section; the most frequent complication was prematurity (406, 53.5%), followed by preeclampsia (199, 26.2%); there were 5 cases of maternal death and 39 cases of perinatal death.

Conclusions

COVID-19 in pregnancy increases the risk of preterm birth, preeclampsia, and maternal death. Vaccination against COVID-19 in this series showed no risk for pregnant women and their newborns.

Fetal brain biometry and cortical development after maternal SARS-CoV-2 infection in pregnancy: A prospective case-control study

OBJECTIVES

To assess cerebral growth and the development of fetal cortex using neurosonography in fetuses from pregnancies experiencing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) according to infection timing.

METHODS

Pregnancies with by SARS-CoV-2 during first and second trimesters were prospectively studied and matched with unaffected controls. Enclosed women underwent neurosonography at 30-34 weeks of gestation and corpus callosum (CC) and cerebellar vermis (CV) lengths measured. Further Sylvian fissure (SF), insula. Parieto-occipital fissure (POF), and calcarine sulci fissures (CSF) depths were obtained. The ultrasonographic variables considered were normalized with fetal head size.

RESULTS

One hundred and seventy four consecutive pregnancies experiencing SARS COV 2 infection (81 before 14 weeks and 93 later) and 131 not affected pregnancies were considered. General and pregnancy characteristics were similar between the three groups of women. No significant differences existed in CC and CV lengths across groups. Similarly, insula, SF, POF And CSF depth did not result changed in fetuses of affected mothers.

CONCLUSIONS

SARS-CoV-2 infection does nor resulted associate with differential fetal cortical development or brain growth in mildly symptomatic pregnant women. This information may be useful to reassure infected mothers on the health of their fetuses.

Knowledge and attitudes of pregnant women on maternal immunization against COVID-19 in Croatia

OBJECTIVES

The aim of this study was to assess pregnant women's knowledge and attitudes regarding maternal COVID-19 immunization during pregnancy.

METHODS

A cross-sectional study was performed in two teaching hospitals between May and October 2021 in Zagreb, Croatia. During antenatal clinic visit pregnant women were approached and asked to fill out a predesigned questionnaire about their knowledge and attitudes towards COVID-19 vaccination. Collected data was later analyzed.

RESULTS

A total of 430 women participated in the study. Only 16% of women expressed their willingness to be vaccinated against COVID-19 if offered, despite that 71% of them believe that COVID-19 might be a serious illness in pregnant women. The most important obstacle in having better acceptance of the vaccines is in the assumption that the vaccines are not safe for pregnant women (73%) or the fetus (75%), or that the vaccines are not effective (41%). The relationship exists between acceptance of vaccination in general and willingness to get other vaccines in pregnancy and readiness to be vaccinated against COVID-19 in pregnancy. Only one out of 55 women who were not adherent to the current vaccination recommendations in Croatia would accept the COVID-19 vaccine during pregnancy if offered. 21 (5%) women stated that vaccination against influenza and pertussis during pregnancy is necessary and 13 (62%) of them would get vaccinated against COVID-19 if offered.

CONCLUSIONS

This study showed that the crucial reasons for refusing vaccination against COVID-19 among pregnant women in Croatia are the concerns about the vaccines' effectiveness and safety. All healthcare providers should put more effort into education of pregnant women on risks of COVID-19, as well as on the benefits and safety of the vaccines.

Perinatal Transmission of SARS-CoV-2 Infection and Its Clinical Attributes: A Single-Center Study From Western Uttar Pradesh

Background Globally, severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) has infected millions of people to date. The morbidity and mortality associated with SARS-CoV-2 are higher in diabetics than those with chronic kidney disease and in the elderly. In pregnant women, it causes an increased risk for preeclampsia/eclampsia, infections, intensive care unit (ICU) admission, maternal mortality, and preterm birth. In neonates, SARS‑CoV‑2 infection has been found to cause stillbirths, growth retardation, premature delivery, increased neonatal intensive care unit (NICU) admission, and need for oxygen support. The neonate can get infected by vertical or horizontal transmission. As most studies have focussed on transmission at the time of birth only, in this study, we explored both vertical and horizontal transmission along with the clinical attributes of those born to mothers with SARS‑CoV‑2 infection. Methodology A prospective observational study was conducted in the Department of Pediatrics of a tertiary care hospital over 12 months from October 2020 to October 2021. All reverse transcription-polymerase chain reaction (RT-PCR) SARS-CoV-2-positive pregnant females admitted to the facility during the study duration were included. The enrolled mothers were followed till delivery. The mothers and neonates were managed per standard guidelines. Delivery details and neonatal outcomes were recorded. Coronavirus disease 2019 sampling in newborn babies was done at birth (within 24 hours) using a nasopharyngeal swab sample for RTPCR along with cord blood for SARS-CoV-2 immunoglobulin M (IgM). Complete blood count, C-reactive protein, serum electrolytes, random blood sugar, and chest X-ray were obtained for all babies at birth and thereafter according to requirement. In those roomed in with their mother, RT-PCR was repeated at the time of discharge or if they became symptomatic. Results A total of 44 mother-neonate dyads were included in the study. Cord blood IgM for SARS‑CoV‑2 was negative for all neonates, while throat swab RT-PCR was positive for two (4.5%) neonates immediately after birth. Overall, 13.6% of the neonates were premature, 27.2% of the neonates had low birth weight (<2,500 g), and 6.8% had very low birth weight (<1,500 g). Among those admitted to the NICU, 18.2% had respiratory distress; 4.5% had fever, lethargy, and poor feeding; and hyperbilirubinemia requiring phototherapy was observed in 11.3% of the neonates. Moreover, 4.5% of the neonates had hypocalcemia on initial investigations. Mortality was seen in 2.2% (1/44) of the neonates. Rooming-in and breastfeeding were seen in 68.2% of the neonates. The horizontal transmission was seen in one (3.3%) roomed-in neonate. Conclusions Perinatal transmission of SARS‑CoV‑2 infection does occur but its rate is not significant. Furthermore, with proper infection prevention and control measures, the risk of perinatal transmission can be decreased. Breastfeeding and rooming-in do not increase infection transmission if the mother takes all precautions.

Haemorrhage of human foetal cortex associated with SARS-CoV-2 infection

Maternal viral infection and immune response are known to increase the risk of altered development of the foetal brain. Given the ongoing global pandemic of coronavirus disease 2019 (COVID-19), investigating the impact of SARS-CoV-2 on foetal brain health is of critical importance. Here, we report the presence of SARS-CoV-2 in first and second trimester foetal brain tissue in association with cortical haemorrhages. SARS-CoV-2 spike protein was sparsely detected within progenitors and neurons of the cortex itself, but was abundant in the choroid plexus of haemorrhagic samples. SARS-CoV-2 was also sparsely detected in placenta, amnion and umbilical cord tissues. Cortical haemorrhages were linked to a reduction in blood vessel integrity and an increase in immune cell infiltration into the foetal brain. Our findings indicate that SARS-CoV-2 infection may affect the foetal brain during early gestation and highlight the need for further study of its impact on subsequent neurological development.

Vaccination options for pregnant women during the Omicron period

Omicron exhibits reduced pathogenicity in general population than the previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants. However, the severity of disease and pregnancy outcomes of Omicron infection among pregnant women have not yet been definitively established. Meanwhile, substantial proportions of this population have doubts about the necessity of vaccination given the reports of declining efficacy of coronavirus disease 2019 (COVID-19) vaccines. Herein, we comprehensively discuss the clinical outcomes of infected pregnant women during the Omicron period and summarize the available data on the safety and efficacy profile of COVID-19 vaccination. The results found that the incidence of moderate and severe disease, maternal mortality, pregnancy loss, preterm delivery, stillbirth, preeclampsia/eclampsia, and gestational hypertension during the Omicron period are similar to those during the Pre-Delta period. In view of the effects of mass vaccination and previous natural infection on disease severity, the virulence of Omicron in pregnant women may be comparable to or even higher than that of the Pre-Delta variant. Moreover, the currently approved COVID-19 vaccines are safe and effective for pregnant women. Particularly, those who received a second or third dose had significantly less severe disease with little progression to critical illness or death compared with those who were unvaccinated or received only one dose. Therefore, in the case of the rapid spread of Omicron, pregnant women should still strictly follow preventive measures to avoid infection and receive the COVID-19 vaccine in a timely manner.

Why maternal mortality in the world remains tragedy in low-income countries and shame for high-income ones: will sustainable development goals (SDG) help?

Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal mortality (MM) and morbidity are a public health issue, with scarce knowledge on their levels and causes in low-income (LIC) countries. The data on MM and morbidity should rely on population-based studies which are non-existent. Therefore, maternal mortality ratio (MMR) estimates are based mostly on the mathematical models. MMR declined from 430 per 100,000 live births (LB) in 1990 to 211 in 2017. Absolute numbers of maternal deaths were 585,000 in 1990, 514,500 in 1995 and less than 300,000 nowadays. Regardless of reduction, MM remains neglected tragedy especially in LIC. Millennium Development Goals (MDGs) declared reduction MMR by three quarters between 2000 and 2015, which failed. Target of Sustainable Development Goals (SDGs) was to decrease MMR to 70 per 100,000 LB. Based on the data from the country report on SDGs in 10 countries with the highest absolute number of maternal deaths it can be concluded that the progress has not been made in reaching the targeted MMR. To reduce MMR, inequalities in access to and quality of reproductive, maternal, and newborn health care services should be addressed, together with strengthening health systems to respond to the needs and priorities of women and girls, ensuring accountability to improve quality of care and equity.

Thromboprophylaxis in Pregnant Women with COVID-19: An Unsolved Issue

SARS-CoV-2 infection in pregnant women is of growing interest due to controversy over the use of antiplatelet and/or anticoagulant drugs during pregnancy and postpartum. Pregnant women are susceptible to develop severe forms of viral infections due to pregnancy-related immune alterations, changes in lung functions, and hypercoagulability. The association of pregnancy with SARS-CoV-2 infection can cause an increased incidence of thrombotic complications, especially in the case of patients with some genetic variants that favor inflammation and thrombosis. Compared to the general population, pregnant women may be at increased risk of thrombotic complications related to COVID-19. The lack of extensive clinical trials on thromboprophylaxis and extrapolating data from non-pregnant patients lead to major discrepancies in treating pregnant women with COVID-19. Currently, a multidisciplinary team should determine the dose and duration of prophylactic anticoagulant therapy for these patients, depending on the disease severity, the course of pregnancy, and the estimated due date. This narrative review aims to evaluate the protective effect of thromboprophylaxis in pregnant women with COVID-19. It is unknown at this time whether antiplatelet or anticoagulant therapy initiated at the beginning of pregnancy for various diseases (preeclampsia, intrauterine growth restriction, thrombophilia) offers a degree of protection. The optimal scheme for thromboprophylaxis in pregnant women with COVID-19 must be carefully established through an individualized decision concerning gestational age and the severity of the infection.

Risk factors for severe disease and impact of severity on pregnant women with COVID-19: a case-control study based on data from a nationwide survey of maternity services in Japan

OBJECTIVE

To identify independent risk factors for severe COVID-19 in pregnant women and to evaluate the impact of disease severity on preterm birth.

DESIGN

A case-control study based on data from a nationwide questionnaire-based survey of maternity services in Japan.

SETTING

A questionnaire was mailed to all 2135 delivery institutions in Japan between July and August 2021. A total of 1288 institutions responded (60% of all delivery institutions in Japan). 566 facilities reported having cared for pregnant women with COVID-19, and 722 facilities reported having had no such patients.

PARTICIPANTS

One thousand and forty-three hospitalised and non-hospitalised pregnant women diagnosed with COVID-19 between July 2020 and 30 June 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was progression to severe COVID-19. The secondary outcome was preterm birth due to COVID-19 infection.

RESULTS

56 cases (5.4%) were severe, and 987 (94.6%) were non-severe. Multivariable logistic regression analysis showed that gestational age≥24 weeks (adjusted OR (aOR) 6.68, 95% CI 2.8 to 16.0) and maternal age≥32 years (aOR 2.40, 95% CI 1.3 to 4.3) were independently associated with severe cases. Using the Kaplan-Meier method, the probability of continued pregnancy at 14 days after diagnosis for severe cases was 0.57 between 24 and 31 weeks' gestation and 0.27 between 32 and 36 weeks' gestation. The probability for non-severe cases was 1.0 between 24 and 31 weeks' gestation and 0.8 between 32 and 36 weeks' gestation. Among the patients with COVID-19 in the preterm period, preterm birth due to infection was significantly more common in severe than non-severe cases (48% vs 6%, p< 0.0001).

CONCLUSIONS

Severe COVID-19 in pregnant women was associated with gestational age≥24 weeks and maternal age≥32. The rate of preterm delivery due to the infection was significantly higher in severe COVID-19 cases.

SARS-CoV-2 Seroconversion and Pregnancy Outcomes in a Population of Pregnant Women Recruited in Milan, Italy, between April 2020 and October 2020

The possible link between SARS-CoV-2 infection and adverse pregnancy outcomes has so far demonstrated heterogeneous results in terms of maternal, fetal, and neonatal complications. We aim to investigate the correlation between SARS-CoV-2 seroconversion and/or neutralization titer and pregnancy outcomes. We analyzed a population of 528 pregnant women followed up from the first trimester of gestation until delivery. For each woman, we collected a first blood sample between 11 and 13 weeks of gestation and a second sample in the perinatal period (between peripartum and puerperium) to assess the presence of SARS-CoV-2 antibodies and/or microneutralization titer (MN titer). Data on pregnancy outcomes (gestational age at delivery, preterm birth before 34 weeks, hypertensive disorders, gestational diabetes, and abnormal fetal growth) were collected. We observed that serologic status per se is not associated with major pregnancy complications. On the contrary, the MN titer was associated with increased odds of gestational diabetes. Although we mainly reported asymptomatic SARS-CoV-2 infections and the absence of severe maternal and neonatal adverse outcomes, SARS-CoV-2 infection might challenge the maternal immune system and explain the moderate increase in adverse outcome odds.

Mixed Intervillositis in SARS-CoV-2 Infection Associated with Fetal Death: A Case Report

Maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been shown in epidemiological studies to be associated with an increased risk of stillbirth. Several histopathologic features of placental SARS-CoV-2 infection have been proposed as potential causes of fetal death. We present a case of an otherwise healthy G3P1 women with mild symptoms of SARS-CoV-2 infection at 23 6/7 weeks of gestation. At 25 2/7 weeks, she presented with signs and symptoms of preterm labor and decreased fetal movements. Fetal death was diagnosed at admission. Placental pathology showed pronounced placental mixed intervillositis. Inflammatory infiltrate caused extreme narrowing of intervillous space leading to placental malfunction and fetal death. Placental tissue SARS-CoV-2 infection was confirmed by positive immunohistochemistry staining of syncytiotrophoblasts with spike protein antibody. The case presented suggests that SARS-CoV-2 associated inflammatory placental changes pose an elevated risk for the fetus.

Women perception of SARS-CoV-2 vaccination during pregnancy and subsequent maternal anxiety: a prospective observational study

OBJECTIVE

The use of Coronavirus 2 (SARS-CoV-2) vaccine in pregnant women is controversial and still not performed in Italy. Our objective was to evaluate the propensity of a population of Italian women to receive the vaccine and its psychological impact.

METHODS

A prospective, observational study was performed on pregnant women attending Ospedale Cristo Re Università Roma TorVergata. A multi-section questionnaire was sent to each included woman on the first day of available SARS-CoV-2 vaccination. Part-A was finalized to acquire maternal characteristics and to test the women's perception of vaccinations in pregnancy and their fear-induced by vaccines. Part-B included the State-Trait-Anxiety-Inventory (STAI) a validated test for scoring trait anxiety (basal anxiety, STAI-T) and state anxiety (STAI-S). An abnormal value of STAI was considered when ≥40. Comparisons of maternal variables were performed according to their vaccine attitude.

RESULTS

The questionnaire was completed by 161 women (80.5% of the population considered). A positive attitude toward the vaccine was present in 136 (84.5%) women (positive) while the remaining 25.5% considered the vaccine not useful (negative). Among the former group 52.9% were favorable to obtain the vaccine during pregnancy despite the current national limitations, a percentage significantly higher (p = .02) than in the negative groups. Women with a negative attitude to the vaccine had a lower educational (p = .002) and employment level (p = .016) when compared to the positive group. In all the women a significant increase of STAI-S from STAI-T values was evidenced (p < .0001). The incidence of abnormal STAI T values (basal anxiety) was similar between the 2 groups (p = .81), while there was a significant increase of STAI-S values in the negative group (negative 88.0%; vs positive 63.4%; p = .018).

CONCLUSIONS

The majority of pregnant women considered have a positive attitude to SARS-CoV-2 vaccine. Vaccine campaign seems to increase the maternal level of anxiety and this increase is more marked with a negative attitude toward the vaccine.

COVID-19 vaccine and pregnancy outcomes: A systematic review and meta-analysis

OBJECTIVES

To explore perinatal outcomes in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-vaccinated pregnant women compared with unvaccinated counterparts.

METHODS

Search was conducted using Web of Science, Scopus, ClinicalTrial.gov, MEDLINE, Embase, OVID, and Cochrane Library as electronic databases. We included observational studies evaluating pregnant women undergoing SARS-CoV-2 vaccination and compared pregnancy and perinatal outcomes with those in unvaccinated women. Categorical variables were assessed using odds ratio (OR) with 95% confidence interval (CI), whereas for continuous variables, the results were expressed as mean difference with their 95% CI. All analyses were performed by adopting the random effect model of DerSimonian and Laird.

RESULTS

There was no difference in the probability of having a small-for-gestational-age fetus (OR 0.97, 95% CI 0.85-1.09; P = 0.570), but we observed a reduced probability of a non-reassuring fetal monitoring, a reduced gestational age at delivery, and a reduced probability of premature delivery in vaccinated pregnant women versus unvaccinated ones.

CONCLUSION

The probability of small for gestational age is similar between vaccinated and unvaccinated pregnant women, and the former also had a slightly reduced rate of premature delivery.

The impact of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes

The rapidly evolving COVID-19 pandemic has resulted in an upsurge of scientific productivity to help address the global health crisis. One area of active research is the impact of COVID-19 on pregnancy. Here, we provide an epidemiological overview about what is known about the effects of maternal SARS-CoV-2 infection and COVID-19 vaccination on maternal-fetal outcomes, and identify gaps in knowledge. Pregnant people are at increased risk for severe COVID-19, and maternal SARS-CoV-2 infection increases the risk of negative maternal-fetal outcomes. Despite this elevated risk, there have been high rates of vaccine hesitancy, heightened by the initial lack of safety and efficacy data for COVID-19 vaccination in pregnancy. In response, retrospective cohort studies were performed to examine the impact of COVID-19 vaccination during pregnancy. Here, we report the vaccine's efficacy during pregnancy and its impact on maternal-fetal outcomes, as well as an overview of initial studies on booster shots in pregnancy. We found that pregnant people are at risk for more severe COVID-19 outcomes, maternal SARS-CoV-2 infection is associated with worse birth outcomes, COVID-19 vaccine hesitancy remains prevalent in the pregnant population, and COVID-19 vaccination and boosters promote better maternal-fetal outcomes. The results should help reduce vaccine hesitancy by alleviating concerns about the safety and efficacy of administering the COVID-19 vaccine during pregnancy. Overall, this review provides an introduction to COVID-19 during pregnancy. It is expected to help consolidate current knowledge, accelerate research of COVID-19 during pregnancy and inform clinical, policy, and research decisions regarding COVID-19 vaccination in pregnant people.

Trends in Caesarean Section Rate According to Robson Group Classification among Pregnant Women with SARS-CoV-2 Infection: A Single-Center Large Cohort Study in Italy

BACKGROUND

Since there is no available data on temporal trends of caesarean section (CS) rates in pregnant women with COVID-19 through the pandemic, we aimed to analyze the trends in caesarean section rate in a large cohort of pregnant women with COVID-19, according to the Robson Ten Group Classification System of deliveries.

METHODS

We prospectively enrolled pregnant women with a diagnosis of COVID-19 who delivered in our center between March 2020 and November 2021. Deliveries were classified, according to the Robson group classification, and according to three time periods: (1) deliveries from March 2020 to December 2020; (2) deliveries from January 2021 to April 2021; (3) deliveries from May 2021 to November 2021. We compared pregnancy characteristics and incidence of caesarean section, according to the Robson category in the total population, and according to the three time periods.

RESULTS

We included 457 patients matching the inclusion criteria in our analysis. We found that overall CS rate significantly decreased over time from period 1 to period 3 (152/222, 68.5% vs. 81/134, 60.4% vs. 58/101, 57.4%, χ2 = 4.261, p = 0.039). CS rate significantly decreased over time in Robson category 1 (48/80, 60% vs. 27/47,57.4% vs. 8/24, 33.3%, χ2 = 4.097, p = 0.043) and Robson category 3 (13/42, 31% vs. 6/33, 18.2% vs. 2/22, 9.1%, χ2 = 4.335, p = 0.037). We also found that the incidence of induction of labor significantly increased over time (8/222, 3.6% vs. 12/134, 9% vs. 11/101, 10.9%, χ2 = 7.245, p = 0.027).

CONCLUSION

Our data provide an overview of the temporal changes in the management and obstetric outcome of COVID-19 pregnant women through the pandemic, confirming that standards of obstetrical assistance for pregnancies complicated by SARS-CoV-2 infection improved over time.

Maternal and neonatal immune response to SARS-CoV-2, IgG transplacental transfer and cytokine profile

SARS-CoV-2 infected pregnant women are at increased risk of severe COVID-19 than non-pregnant women and have a higher risk of adverse pregnancy outcomes like intrauterine/fetal distress and preterm birth. However, little is known about the impact of SARS-CoV-2 infection on maternal and neonatal immunological profiles. In this study, we investigated the inflammatory and humoral responses to SARS-CoV-2 in maternal and cord blood paired samples. Thirty-six pregnant women were recruited at delivery at Hospital Sant Joan de Déu, Barcelona, Spain, between April-August 2020, before having COVID-19 available vaccines. Maternal and pregnancy variables, as well as perinatal outcomes, were recorded in questionnaires. Nasopharyngeal swabs and maternal and cord blood samples were collected for SARS-CoV-2 detection by rRT-PCR and serology, respectively. We measured IgM, IgG and IgA levels to 6 SARS-CoV-2 antigens (spike [S], S1, S2, receptor-binding domain [RBD], nucleocapsid [N] full-length and C-terminus), IgG to N from 4 human coronaviruses (OC43, HKU1, 229E and NL63), and the concentrations of 30 cytokines, chemokines and growth factors by Luminex. Mothers were classified as infected or non-infected based on the rRT-PCR and serology results. Sixty-four % of pregnant women were infected with SARS-CoV-2 (positive by rRT-PCR during the third trimester and/or serology just after delivery). None of the newborns tested positive for rRT-PCR. SARS-CoV-2 infected mothers had increased levels of virus-specific antibodies and several cytokines. Those with symptoms had higher cytokine levels. IFN-α was increased in cord blood from infected mothers, and in cord blood of symptomatic mothers, EGF, FGF, IL-17 and IL-15 were increased, whereas RANTES was decreased. Maternal IgG and cytokine levels showed positive correlations with their counterparts in cord blood. rRT-PCR positive mothers showed lower transfer of SARS-CoV-2-specific IgGs, with a stronger effect when infection was closer to delivery. SARS-CoV-2 infected mothers carrying a male fetus had higher antibody levels and higher EGF, IL-15 and IL-7 concentrations. Our results show that SARS-CoV-2 infection during the third trimester of pregnancy induces a robust antibody and cytokine response at delivery and causes a significant reduction of the SARS-CoV-2-specific IgGs transplacental transfer, with a stronger negative effect when the infection is closer to delivery.

Clinical Manifestation and Obstetric Outcomes in Pregnant Women with SARS-CoV-2 Infection at Delivery: A Retrospective Cohort Analysis

This retrospective cohort study aimed to analyze the clinical manifestations, complications, and maternal-fetal outcomes in patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during delivery. The cohort included 61 pregnant women positive for SARS-CoV-2 infection at the time of delivery. Patients were divided into two groups: symptomatic and asymptomatic. We found a significantly higher rate of leukocytosis (p < 0.00078) and lymphopenia (p < 0.0024) in symptomatic women compared with asymptomatic ones. Other laboratory parameters, such as CRP (p = 0.002), AST (p = 0.007), LDH (p = 0.0142), ferritin (p = 0.0036), and D-dimer (p = 0.00124), were also significantly more often increased in the group of symptomatic pregnant women. Overall, symptomatic pregnant women with SARS-CoV-2 infection at the delivery show more often altered laboratory parameters compared with asymptomatic ones; nevertheless, they have a slightly higher but non-significant rate of preterm delivery, cesarean section, as well as lower neonatal birth weight and Apgar score, compared with asymptomatic women.

Systematic review and critical evaluation of quality of clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy

OBJECTIVE

To systematically identify and critically assess the quality of clinical practice guidelines for the management of SARS-CoV-2 infection in pregnancy.

DATA SOURCES

Medline, Scopus, and ISI Web of Science databases were searched until February 15, 2022.

STUDY ELIGIBILITY CRITERIA

Inclusion criteria were clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy. The risk of bias and quality assessments of the included clinical practice guidelines were performed using the Appraisal of Guidelines for REsearch and Evaluation II tool, which is considered the gold standard for quality assessment of clinical practice guidelines. To define a clinical practice guideline as of good quality, we adopted the cutoff score proposed by Amer et al: if the overall clinical practice guideline score was >60%, it was recommended.

METHODS

The following clinical points related to the management of pregnant women with SARS-CoV-2 infection were addressed: criteria for maternal hospitalization, recommendations for follow-up fetal growth scan, specific recommendations against invasive procedures, management of labor, timing of delivery, postpartum care, and vaccination strategy.

RESULTS

A total of 28 clinical practice guidelines were included. All recommended hospitalization only for severe disease; 46.1% (6/13) suggested a fetal growth scan after SARS-CoV-2 infection, whereas 23.1% (3/13) did not support this practice. Thromboprophylaxis with low-molecular-weight heparin was recommended in symptomatic women by 77.1% (7/9) of the clinical practice guidelines. None of the guidelines recommended administering corticosteroids only for the presence of SARS-CoV-2 infection in preterm gestation, unless specific obstetrical indication exists. Elective induction of labor from 39 weeks of gestation was suggested by 18.1% (2/11) of the clinical practice guidelines included in the present review, whereas 45.4% (5/11) did not recommend elective induction unless other obstetrical indications coexisted. There were 27% (3/11) of clinical practice guidelines that suggested shortening of the second stage of labor, and active pushing was supported by 18.1% (2/11). There was general agreement among the clinical practice guidelines in not recommending cesarean delivery only for the presence of maternal infection and in recommending vaccine boosters at least 6 months after the primary series of vaccination. The Appraisal of Guidelines for REsearch and Evaluation II standardized domain scores for the first overall assessment of clinical practice guidelines had a mean of 50% (standard deviation±21.82%), and 9 clinical practice guidelines scored >60%.

CONCLUSION

A significant heterogeneity was found in some of the main aspects of the management of SARS-CoV-2 infection in pregnancy, as reported by the published clinical practice guidelines.

COVID-19 and Gestational Diabetes: The Role of Nutrition and Pharmacological Intervention in Preventing Adverse Outcomes

Pregnant women with GDM affected by COVID-19 seem to be at higher risk of adverse maternal and neonatal outcomes, especially those with overweight or obesity. Good glycemic control seems to be the most effective measure in reducing the risk of GDM and severe COVID-19. For such purposes, the Mediterranean diet, micronutrient supplementation, and physical activity are considered the first line of treatment. Failure to achieve glycemic control leads to the use of insulin, and this clinical scenario has been shown to be associated with an increased risk of adverse maternal and neonatal outcomes. In this review, we explore the current evidence pertaining to the pathogenesis of SARS-CoV-2 leading to the main complications caused by COVID-19 in patients with GDM. We also discuss the incidence of complications caused by COVID-19 in pregnant women with GDM according to their treatment.

Are in-hospital COVID-19-related mortality and morbidity in pregnancy associated with gestational age?

OBJECTIVE

Pregnancy involves dynamic changes in the maternal immune system, thus potentially affecting women's response to infection. The aim of this study was to investigate whether gestational age at the time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with mortality and morbidity related to coronavirus disease 2019 (COVID-19) in hospitalized pregnant women.

METHODS

This was a cohort study of pregnant women with confirmed SARS-CoV-2 infection at any gestational age (categorized into trimesters) who were hospitalized in Brazil from February 2020 to November 2021. Sociodemographic and epidemiological characteristics, signs and symptoms, comorbidities, interventions, vaccination status and type of healthcare establishment were obtained from a nationwide database. Multivariate logistic and Cox regression analyses were used to identify independent risk factors for in-hospital COVID-19-related mortality and morbidity (defined as time from hospital admission to recovery).

RESULTS

A total of 7461 SARS-CoV-2-infected pregnant women were included in the study (9.3%, 28.4% and 62.3% in the first, second and third trimesters, respectively). After adjustment for sociodemographic, epidemiological and clinical characteristics, and intervention-related variables, gestational age at infection was found not to be associated with COVID-19-related mortality and morbidity. Women admitted to establishments with an obstetric center, compared to hospitals without, were 38% less likely to die from SARS-CoV-2 infection (adjusted odds ratio, 0.62; 95% CI, 0.48-0.80), while patients who received private not-for-profit healthcare had a 13% shorter time to recovery (adjusted hazard ratio, 1.13; 95% CI, 1.07-1.20) compared to those who received public healthcare.

CONCLUSIONS

Despite a higher percentage of women being admitted in the third trimester, we found no association between gestational age and COVID-19 mortality and morbidity. The previously reported increase in morbidity and mortality in the third trimester in pregnant women with COVID-19 may be attributable to other gestational-age-affected variables for which adjustment was made in our study. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

RNA Viruses, Pregnancy and Vaccination: Emerging Lessons from COVID-19 and Ebola Virus Disease

Pathogenic viruses with an RNA genome represent a challenge for global human health since they have the tremendous potential to develop into devastating pandemics/epidemics. The management of the recent COVID-19 pandemic was possible to a certain extent only because of the strong foundations laid by the research on previous viral outbreaks, especially Ebola Virus Disease (EVD). A clear understanding of the mechanisms of the host immune response generated upon viral infections is a prime requisite for the development of new therapeutic strategies. Hence, we present here a comparative study of alterations in immune response upon SARS-CoV-2 and Ebola virus infections that illustrate many common features. Vaccination and pregnancy are two important aspects that need to be studied from an immunological perspective. So, we summarize the outcomes and immune responses in vaccinated and pregnant individuals in the context of COVID-19 and EVD. Considering the significance of immunomodulatory approaches in combating both these diseases, we have also presented the state of the art of such therapeutics and prophylactics. Currently, several vaccines against these viruses have been approved or are under clinical trials in various parts of the world. Therefore, we also recapitulate the latest developments in these which would inspire researchers to look for possibilities of developing vaccines against many other RNA viruses. We hope that the similar aspects in COVID-19 and EVD open up new avenues for the development of pan-viral therapies.

The impact of withholding nitrous oxide in labour during the COVID-19 pandemic on maternal and neonatal outcomes

Nitrous oxide is commonly used in Australia for labour analgesia. Its use in labour is potentially associated with aerosol generation. During the first wave of the COVID-19 pandemic of 2020, nitrous oxide was suspended on many birthing units to reduce the risk of transmission. We aimed to determine the impact of withholding nitrous oxide for labour analgesia, during the COVID-19 pandemic, on epidural rates, opioid analgesia use, and maternal and neonatal outcomes. Withholding nitrous oxide for labour analgesia did not alter epidural rates but did significantly increase opioid analgesia use. Caesarean section rates, post-partum blood loss and neonatal APGAR scores did not change.

SARS-CoV-2 during pregnancy and associated outcomes: Results from an ongoing prospective cohort

BACKGROUND

The COVID-19 pandemic is an ongoing global health threat, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Questions remain about how SARS-CoV-2 impacts pregnant individuals and their children.

OBJECTIVE

To expand our understanding of the effects of SARS-CoV-2 infection during pregnancy on pregnancy outcomes, regardless of symptomatology, by using serological tests to measure IgG antibody levels.

METHODS

The Generation C Study is an ongoing prospective cohort study conducted at the Mount Sinai Health System. All pregnant individuals receiving obstetrical care at the Mount Sinai Healthcare System from 20 April 2020 onwards are eligible for participation. For the current analysis, we included participants who had given birth to a liveborn singleton infant on or before 22 September 2020. For each woman, we tested the latest prenatal blood sample available to establish seropositivity using a SARS-CoV-2 serologic enzyme-linked immunosorbent assay. Additionally, RT-PCR testing was performed on a nasopharyngeal swab taken during labour. Pregnancy outcomes of interest (i.e., gestational age at delivery, preterm birth, small for gestational age, Apgar scores, maternal and neonatal intensive care unit admission, and length of neonatal hospital stay) and covariates were extracted from medical records. Excluding individuals who tested RT-PCR positive at delivery, we conducted crude and adjusted regression models to compare antibody positive with antibody negative individuals at delivery. We stratified analyses by race/ethnicity to examine potential effect modification.

RESULTS

The SARS-CoV-2 seroprevalence based on IgG measurement was 16.4% (95% confidence interval 13.7, 19.3; n=116). Twelve individuals (1.7%) were SARS-CoV-2 RT-PCR positive at delivery. Seropositive individuals were generally younger, more often Black or Hispanic, and more often had public insurance and higher pre-pregnancy BMI compared with seronegative individuals. None of the examined pregnancy outcomes differed by seropositivity, overall or stratified by race/ethnicity.

CONCLUSION

Seropositivity for SARS-CoV-2 without RT-PCR positivity at delivery (suggesting that infection occurred earlier during pregnancy) was not associated with selected adverse maternal or neonatal outcomes among live births in a cohort sample from New York City.

Obstetric and perinatal outcomes in parturients with active SARS-CoV-2 infection during labor and delivery: a retrospective cohort study

BACKGROUND

The COVID-19 pandemic is an ongoing global healthcare crisis that negatively affects pregnant women. Although patients with an acute infection during pregnancy have been widely studied, information regarding labor and delivery while infected is sparse. The aim of the study was to ascertain maternal, obstetrical, and perinatal outcomes of women who gave birth while infected with SARS-CoV-2.

METHODS

Patients diagnosed with COVID-19 during pregnancy at a tertiary medical center in 4/20-2/21 were identified by a retrospective database search. Those with an active intrapartum SARS-CoV-2 infection were compared with those who recovered at least 10 days before labor and delivery.

RESULTS

Of the 176 women included in the study, 84 had a SARS-CoV-2 infection at the time of delivery and 92 had recovered from the infection. There was no statistically significant between-group difference in mean gestational age at delivery (39 weeks for both, p = 0.71) and overall rate of cesarean delivery (26.2% vs 17.4%, respectively, p = 0.35) or non-elective cesarean delivery (10.71% vs 4.34%, respectively, p = 0.48). In the active-infection group, the rate of severe disease was 2.4%, and of critical disease (with intensive care unit admission, mechanical ventilation, and ECMO), 3.6%, compared to zero for both in the recovered group. No differences were found between the groups in adverse perinatal outcomes.

CONCLUSION

Delivery is safe and feasible in women with active SARS-CoV-2 infection. Nevertheless, we found a non-significant trend for more severe disease and for cesarean delivery and urgent cesarean delivery (for COVID-19-related indications) in women with an intrapartum SARS-CoV-2 infection.

A Ranking of the Most Common Maternal COVID-19 Symptoms: A Systematic Review

As the coronavirus disease 2019 (COVID-19) continues to devastate health systems worldwide, there is particular concern over the health and safety of one high-risk group, pregnant women, due to their altered immune systems. Since health workers regularly rely on symptoms to inform clinical treatment, it became critical to maintain a ranked list of COVID-19 symptoms specific to pregnant women. This systematic review investigated the prevalence of common COVID-19 symptoms in pregnant women and compared the ranked list of symptoms to articles of various sizes. Articles were included if they discussed pregnant women diagnosed with COVID-19 using polymerase chain reaction testing, and women present symptoms of COVID-19 and were published between December 1, 2019, and December 1, 2021; while articles were excluded if they did not report on pregnant women with COVID-19 displaying symptoms of COVID-19. Articles were identified on OVID MedLine and Embase in January of 2022. The risk of bias and quality appraisal was assessed using a nine-item modified Scottish Intercollegiate Guidelines Network checklist for case-control studies. The search results included 78 articles that described 41,513 pregnant women with 42 unique COVID-19 symptoms. When ranked, the most common symptoms were found to be cough (10,843 cases, 16.02%), fever (7,653 cases, 11.31%), myalgia (6,505 cases, 9.61%), headache (5,264 cases, 7.78%), and dyspnea (5,184 cases, 7.66%). When compared to other articles in the literature with sample sizes of n = 23,434, n = 8,207, and n = 651, the ranking largely aligned with those in other articles with large sample sizes and did not align with the results of articles with small sample sizes. The symptom ranking may be used to inform testing for COVID-19 in the clinic. Research is rapidly evolving with the ongoing nature of the pandemic, challenging the generalizability of the results.

A comparison of COVID-19 vaccination status among pregnant Israeli Jewish and Arab women and psychological distress among the Arab women

The public debate surrounding the COVID-19 vaccine is especially intense regarding pregnant women, who are concerned with its effects on themselves and their fetus, and a vulnerable at-risk population for psychological distress. We aimed at describing differences in vaccination status between pregnant Jewish and Arab women and understanding factors contributing to psychological distress among Arab women. Pregnant women (n = 860) aged 19-46 completed self-report questionnaires during the national vaccination program (March-April 2021). The questionnaires related to background, COVID-19-related vaccination status and intentions in this regard, COVID-19-related anxiety, and the Mental Health Inventory-Short Form. Data were analyzed using descriptive statistics, t- and chi-square tests, Pearson correlations, and a hierarchical regression. Considerably fewer Jewish women had been infected and more were vaccinated than Arab women. Poorer health, lower economic status, being a mother, not being vaccinated, higher anxiety over economic damage, a family member being infected, delivery, and raising the baby contributed to higher distress. Findings offer novel insights for nurses in their efforts to encourage vaccination, highlighting the need to understand women's concerns during the vulnerable period of pregnancy.

Association of Disease Severity and Death Outcome with Vaccination Status of Admitted COVID-19 Patients in Delta Period of SARS-COV-2 in Mixed Variety of Vaccine Background

To understand the effectual role of COVID-19 vaccination, we must analyze its effectiveness in dampening the disease severity and death outcome in patients who acquire infection and require hospitalization. The goal of this study was to see if there was an association between disease progression in admitted COVID-19 patients and their prior vaccination exposure. A prospective cohort study based on 1640 admitted COVID-19 patients were carried between June 2021 and October 2021. Depending on vaccination exposure they were divided into vaccinated (exposed) and unvaccinated (unexposed) groups, excluding partially vaccinated patients. Disease severity was assessed at admission on severity index scale. Disease progression to mortality or need of mechanical ventilation and survival were taken as outcome. Absolute difference with 95%CI and Risk Ratio were calculated using cross tabulation, Chi square test and multivariable logistic regression analysis. Among 1514 total analyzed cohort (median age, 53 years [IQR, 17,106]; 43.7% from 46 to 65 years of age group, 56.2% males,33.4% with no comorbid factor for disease progression) 369(24.4%) were vaccinated breakthrough cases and 1145(75.6%) were unvaccinated controls. 556(36.7%) progressed to death or mechanical ventilation, 958(63.3%) patients survived and were discharged home. Disease progression to death or mechanical ventilation was significantly associated with decreased likelihood of vaccination (24.9% among vaccinated breakthrough vs 40.5% unvaccinated controls, [Absolute difference −15.6% 95%CI (−10.2% to −20.6%); RR 0.615 95%CI (0.509, 0.744); p <.001]). This association was stronger for old age population and for increase time span between second dose of vaccine and onset of symptoms. There was no statistically significant difference among different types of vaccination and occurrence of outcome when compared to unvaccinated controls (RR 0.607(0.482, 0.763); 0.673(0.339, 1.33) and 0.623(0.441, 0.881) for Inactivated virus vaccine, mRNA and Adenovirus vector-based vaccine respectively. The patients who were fully vaccinated against SARS-COV-2 die or shift to mechanical ventilation less frequently than unvaccinated COVID-19 admitted patients.

Clinical Characteristics and Outcomes of COVID-19 During Pregnancy-a Retrospective Cohort Study

The course of COVID-19 has been shown to be worse in pregnant women compared with their non-pregnant counterparts. The aim of this study is to share our experience treating pregnant women with COVID-19 and to establish a cohort for future studies of the long-term effects of the disease. We reviewed medical records of all SARS-CoV-2-positive pregnant women who were treated at our hospital for any reason, be it COVID-19 related or not, between April 2020 and February 2021. We extracted data regarding medical history, course of pregnancy, delivery, and neonatal outcomes. A total of 193 SARS-CoV-2-positive pregnant women were treated at our establishment during the study period, half of which were asymptomatic. Sixteen were hospitalized for COVID-19 symptoms, the most common being fatigue/malaise (58%) and cough (48%). Three women required mechanical ventilation and extracorporeal membrane oxygenation treatment. One hundred forty-four SARS-CoV-2-positive women were delivered during the study period. Of them, 24 (17%) underwent induction of labor, and four (17%) were due to symptomatic COVID-19. One hundred fifteen (80%) experienced vaginal delivery, and 29 (20%) underwent cesarean delivery. Neonatal outcomes were favorable; only 2% of 5-min Apgar scores were < 7, and all umbilical cord pH levels were > 7.1. Six infants tested positive for SARS-CoV-2; they were all asymptomatic, and none required treatment for viral infection. COVID-19 during pregnancy is a disease with potential substantial adverse maternal and neonatal outcomes. There is still much unknown regarding the long-term effects of the disease on parturients and their offspring.

Internistische Notfälle bei der schwangeren Patientin

Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.

Stillbirth in COVID-19 Affected Pregnancies: A Double Whammy for the Mother

Introduction

Pregnant women represent a high-risk group especially during the COVID-19 pandemic, suffering at the expense of pandemic restrictions and landing up in adverse maternofetal outcomes including stillbirth. Fetal demise along with COVID-19 disease acts as a double blow to these mothers. Literature is still limited on its impact on maternofetal outcomes.

Methods

A prospective, observational study was conducted in a tertiary care hospital in Delhi, India from April 15, 2020 to April 14, 2021, wherein all pregnant mothers with SARS-CoV-2 infection in the hospital who delivered a stillborn baby were enrolled and analyzed for incidence of stillbirth. These women were evaluated for risk factors and causes for stillbirth.

Results

Out of 15859 deliveries in the institute, there were 330 viable births among COVID-19 affected pregnancies. The incidence of stillbirth was 7.2% (24/330). The institutional delivery rate fell by 43% during the pandemic. The majority of cases were unbooked, from rural areas and of low socioeconomic status (p<0.01). The most significant risk factor and cause for stillbirth was an associated comorbidity (75%, p<0.001), notably severe forms of hypertensive disorders of pregnancy (HDP, 41.6%, p=0.002), followed by preterm labour (58.3%) and preterm premature rupture of membranes (PPROM, 29.1%, p<0.001). HDP remained the main cause of macerated stillbirths while maternal fever (50%, p<0.001) was the main cause of fresh stillbirth. Major modifiable factors were lack of awareness of when to seek care (83.3%), financial reasons (75%), commutation problems (87.5%), distance to hospitals (50%) and delayed referral (41.6%).

Conclusion

Improved policy-making, with an emphasis on telemedicine, COVID-19 preparedness alongside amped up vaccination and healthcare workers training will help reduce adverse maternofetal outcomes.

Italian neonatologists and SARS-CoV-2: lessons learned to face coming new waves

The aim of this review was threefold: (a) to retrieve all SARS-CoV-2 evidences published by Italian neonatologists working in maternity centers and NICUs during the pandemic; (b) to summarize current evidence for the management of term and preterm infants with a SARS-CoV-2-related illness; and (c) to provide an update for dealing with the second wave of COVID-19 and discuss open questions. A review was conducted using MEDLINE/PubMed and the national COVID-19 registry of the Italian Society of Neonatology including citations from December 1, 2019 to October 28, 2020. Sixty-three articles were included. Collected data were divided into the following topics: (a) antenatal management, (b) management in delivery room, (c) postnatal management, (d) mother-baby dyad and breastfeeding management, (e) neonatal emergency transport system reorganization, (f) parents' management and perspective during SARS-CoV-2 pandemic, and (g) future perspective. Evidences have evolved over the pandemic period and the current review can be useful in the management of the mother-neonate dyad during SARS-CoV-2 future waves. Italian neonatologists have played an active role in producing official guidelines and reporting data that have contributed to improve the care of neonates. A joint European action plan is mandatory to face COVID-19 in neonates with more awareness. IMPACT: A joint European action plan is mandatory to face COVID-19 in neonates with more awareness. This review summarizes the available evidences from neonatal COVID-19 management in Italy analyzing all the published paper in this specific field of interest. The current review can be useful in the management of the mother-neonate dyad during the SARS-CoV-2 future waves.

Infections at the maternal-fetal interface: an overview of pathogenesis and defence

Infections are a major threat to human reproductive health, and infections in pregnancy can cause prematurity or stillbirth, or can be vertically transmitted to the fetus leading to congenital infection and severe disease. The acronym 'TORCH' (Toxoplasma gondii, other, rubella virus, cytomegalovirus, herpes simplex virus) refers to pathogens directly associated with the development of congenital disease and includes diverse bacteria, viruses and parasites. The placenta restricts vertical transmission during pregnancy and has evolved robust mechanisms of microbial defence. However, microorganisms that cause congenital disease have likely evolved diverse mechanisms to bypass these defences. In this Review, we discuss how TORCH pathogens access the intra-amniotic space and overcome the placental defences that protect against microbial vertical transmission.