Analysis of the susceptibility to COVID-19 in pregnancy and recommendations on potential drug screening

NETs exacerbate placental inflammation and injury through high mobility group protein B1 during preeclampsia

BACKGROUND

Inflammatory stress at the maternal-fetal interface plays an important role in the occurrence and development of preeclampsia(PE) caused by different etiologies. Many pathological neutrophil extracellular traps (NETs) at the maternal-fetal interface are believed to be among the main pathogenic factors leading to preeclampsia and the worsening of its symptoms. However, the underlying mechanism is largely unclear. This study aimed to elucidate the role of high mobility group box 1 (HMGB1) in NETs involved in the pathogenesis of PE.

METHODS

The concentration of NETs was detected in the plasma of patients with PE using enzyme-linked immunosorbent assay (ELISA). Placental samples were collected from patients with PE to detect the expression of HMGB1 through Western Blot and PCR. For in vitro experiments, human trophoblast HTR-8/SVneo cells were treated with NETs, and their proliferation, invasion, migration, and apoptosis ability; degree of oxidative stress; and secretion of inflammatory factors were detected.

RESULTS

Compared with that in normal pregnant women, an increase in the release of NETs was observed in the peripheral blood of patients with PE. HMGB1 was increased in the placenta of PE patients and colocalized with NETs. The treatment of human trophoblast HTR-8/SVneo cells with NETs resulted in the inhibition of HTR-8/SVneo cell invasion and migration and increases in the release of reactive oxygen species (ROS), and several inflammatory factors (IL-1β, IL-6, IL-8, and TNF-α). These damaging effects can be reversed by the HMGB1 scavenger glycyrrhizin, which indicates that NETs can mediate trophoblast damage and the expression of several inflammatory factors through HMGB1.

CONCLUSION

NETs can cause trophoblast inflammation-related functional damage through HMGB1 during the occurrence and development of preeclampsia. HMGB1 produces a marked effect in the PE cascade of oxidative stress involving NETs. Inhibiting HMGB1 to suppress NETs damage is a possible approach for the future treatment of 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.

Comparing the screening methods for gestational diabetes mellitus before and during the COVID-19 pandemic: A systematic review

BACKGROUND

The oral glucose tolerance test (OGTT) is the gold standard for detecting gestational diabetes mellitus (GDM). However, during the COVID-19 pandemic, screening practices were reevaluated due to the risk of infection associated with the prolonged hospital visit required for the OGTT. Some countries have published novel screening protocols for GDM, suggesting the utilization of hemoglobin A1c (HbA1c), random plasma glucose (RPG), or fasting plasma glucose (FPG) in favor of OGTTs during the pandemic. Therefore, differences in screening methods before and after the epidemic need to be examined.

METHODS

A systematic search was carried out across five electronic databases (Cinahl, Medline, Embase, Pubmed, and Web of Science) between 2016 and 2023. The Critical Appraisal Skills Programme (CASP) checklist for cohort studies was used to evaluate the quality of included papers.

RESULTS

A total of 13 eligible studies were included. Prior to the COVID-19 pandemic, the OGTT was the recommended measure to screen GDM, internationally based on various official guidelines. During the pandemic, it was recommended that HbA1c or FPG, or RPG be used as a substitute for OGTTs. However, the new methods have low sensitivity, may not reflect accurately the prevalence of GDM, and may lead to many false-negative results in women and to adverse pregnancy and neonatal outcomes.

CONCLUSION

The new screening methods for GDM have poor accuracy and a high risk of adverse pregnancy outcomes. Comparatively, targeted screening tests to detect GDM according to the risk level are more effective in an emergency. In the future, the alternatives to OGTTs still need to be further explored in more depth.

Disruption of the Functional Activity of Neutrophil Granulocytes as a Risk Factor for the Development of Lung Damage in Pregnant Women with COVID-19

Currently, the assessment of immune status in patients with COVID-19 is limited to determining the count of polymorphonuclear leukocytes and the phagocytic function of neutrophils, which is insufficient to understand the regulatory role of innate immunity cells in the development of pneumonia. However, no such studies have been conducted in pregnant women with COVID-19. The aim of this study was to investigate the functional state of neutrophil granulocytes in order to identify predictors of pneumonia severity risk in pregnant women with COVID-19. A clinical characterization of pregnant women with COVID-19 in addition to minimal and average lung changes was provided. The composition and ratio of morphological forms of leukocyte cells were studied. Cytochemical studies of neutrophil granulocytes were carried out and calculations of the mean cytological index (MCI) for succinate dehydrogenase, myeloperoxidase, and cationic proteins were performed. The number of NETs in blood smears was counted. Independent predictors of pneumonia severity in pregnant women with COVID-19 were calculated using regression analysis. The quality of the model was assessed using ROC analysis. In pregnant women with COVID-19 and an average volume of lung changes, the number of polymorphonuclear leukocytes (p = 0.03) and band neutrophils (p = 0.002) in the blood was significantly higher than in pregnant women with minimal lung changes. The MCI indicators of succinate dehydrogenase, cationic proteins, and myeloperoxidase in pregnant women with COVID-19 were reduced in relation to the control group (p < 0.0001). In blood smears of pregnant women with COVID-19 and an average volume of lung changes, the number of NETs increased (p = 0.002). Regression analysis showed that succinate dehydrogenase and NETs are independent predictors of pneumonia severity in pregnant women with COVID-19. Our study confirms the prognostic significance of low levels of neutrophilic succinate dehydrogenase and high levels of NETs in the blood of pregnant women with COVID-19. The combination of these two biomarkers is a significant reflection of the severity of pneumonia development in pregnant women with COVID-19. However, further research is needed to identify the mechanisms underlying this association.

A Systematic Patent Review (2008-2023) for Treatment in Pregnancy

INTRODUCTION

During pregnancy, the woman's body undergoes anatomical and physiological changes, making this period susceptible to maternal-fetal diseases and complications. The consequences of not treating pregnant women include premature birth, low birth weight fetuses, and postnatal behavior disorders. Developing new therapies can accelerate the discovery of safe and effective drugs, contributing to designing novel natural and synthetic products to treat complications the pregnancy.

OBJECTIVE

This study aimed to carry out a patent review to identify and explore trends in innovation and therapeutic strategies for treating pregnant women.

METHODS

The Espacenet and WIPO databases were used, with the inclusion criteria being the keywords "pregnancy and drug" and code A61k, from 2008 to 2023, and as exclusion were the access to the patent and focus on human pregnant women.

RESULTS

After the final screening, 32 patents were selected, with strategies for the treatment of diseases in pregnant women. Of these, 20 patents are on preclinical studies on animals and 12 on pregnant women. It was observed that universities lead the ranking of applications (17/32), and China has the highest number of patents (18/32). Most findings contain herbal medicines and/or the association of natural extracts with synthetic drugs.

CONCLUSION

From this perspective, new drug administration systems were also developed, which can be a promising source for obtaining new medicines for the treatment of pregnant women; however, research is still limited and shows a gap in stimulating the rapid development of safe drugs that improve the health of pregnant women.

Efficacy and safety of therapies for COVID-19 in pregnancy: a systematic review and meta-analysis

BACKGROUND

Clinical evidence suggests that pregnant women are more vulnerable to COVID-19, since they are at increased risk for disease progression and for obstetric complications, such as premature labor, miscarriage, preeclampsia, cesarean delivery, fetal growth restriction and perinatal death. Despite this evidence, pregnant women are often excluded from clinical trials, resulting in limited knowledge on COVID-19 management. The aim of this systematic review and meta-analysis is to provide better evidence on the efficacy and safety of available COVID-19 treatment in pregnant women.

METHODS

Four authors searched major electronic databases from inception until 1 st November-2022 for controlled trials/observational studies, investigating outcomes after the administration of anti-SARS-CoV-2 treatments in pregnant women affected by COVID-19. The analyses investigated the cumulative incidence of delivery and maternal outcomes in pregnant women, comparing those taking active medication vs standard care. Risk ratios (RRs) with 95% confidence intervals were calculated. Statistical significance was assessed using the random effects model and inverse-variance method. This systematic review and meta-analysis was conducted in accordance with the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol has been registered in Prospero (number registration: CRD42023397445).

RESULTS

From initially 937 non duplicate records, we assessed the full texts of 40 articles, finally including ten studies. In six studies, including 1627 patients, the use of casirivimab/imdevimab (CAS/IMD), remdesivir, and IFN-alpha 2b significantly decreased the need of cesarean section ((RR = 0.665; 95%CI: 0.491-0.899; p = 0.008; I 2 = 19.5%;) (Table 1, (Fig. 1). Treatments did not decrease the risk of preterm delivery, admission to neonatal ICU, or stillbirth/perinatal loss (p-values > 0.50 for all these outcomes) and did not prevent the progression of disease towards severe degrees (k = 8; 2,374 pregnant women; RR = 0.778; 95%CI: 0.550-1.099; p = 0.15; I 2 = 0%). Moreover, the use of medications during pregnancy did not modify the incidence of maternal death in two studies (Table 2).

CONCLUSIONS

To our analysis, CAS/IMD, remdesivir, and IFN alpha 2b reduced the number of cesarean sections but demonstrated no effect on disease progression and other obstetric and COVID-19 related outcomes. The inability to evaluate the influence of viral load on illness development in pregnant women was attributed to lack of data. In our systematic review, no major side effects were reported. Though, it is essential for the medical community to focus more on clinical trials and less on episodic case reports and case series, with standardization of fetal and maternal outcomes.

A spectrum of pathological changes induced by SARS-COV-2: An observational study in a cohort of pregnant women from Mizoram, India

Background

Maternal infection by SARS-CoV-2 may lead to adverse pregnancy outcomes and causes pathological changes in the placenta. However, consensus regarding characteristic pathological features is lacking. Researchof the placental histopathology in a cohort of women from Mizoram, India, was conducted to relate the SARS-CoV-2 infection's effectswith pregnancy and its outcome.

Materials and methods

The characteristics of 72 pregnant women diagnosed positive for SARS-CoV-2 who eventually delivered at Zoram Medical College Hospital, Mizoram, neonates' well-being, and histopathological features of placentas were studied.

Results

Of 72 women in this study, 59 (81.9%) gave birth at full term. Among these births, 5 were normal vaginal deliveries, while the remaining 67 (93.1%) were delivered via cesarean section. The reasons for cesarean delivery were either related to SARS-CoV-2 infection (n ​= ​49), existing obstetric problems (n ​= ​15) or fetal-distress (n ​= ​5). All deliveries resulted in live births of COVID-negative babies, with 80.6% (n ​= ​58) of the newborns having a birth weight of over 2.5 ​kg. APGAR scores ranged from 4 to 6 in 61 (84.7%) of the babies, and 10 neonates required resuscitation, of which 8 were managed in the neonatal intensive care unit (NICU). The placental histopathology showed increased fibrin thrombi in 8 cases (11.1%), while 20 cases (28%) showed focal infarction, microcalcification levels were elevated in 16 cases (22.2%), and a small percentage of cases (1.4%) exhibited small fibrotic villi and inter-villus agglutination. Placental chorioangiosis was detected in 28 (38.9%) of the cases, while avascular villi were seen in 6 cases. Meconium-stained liquor was observed in a single case. Intervillous hemorrhage was found in 42 cases, whileintervillous inflammation and increased syncytial knots were present in 14 and 5 cases, respectively. The placenta pathology of 10 neonates who required resuscitation/NICU admission was not significantly different from that of the 62 neonates who did not require it. However, a higher proportion of placenta from the asymptomatic group showed no abnormality compared to the symptomatic group (p ​= ​0.046).

Conclusion

SARS-CoV-2 infection causes a range of morphological changes and lesions in the placenta, including chorangiosis, villositis, chorioamnionitis, fetal vascular malperfusion/thrombosis, fibrin-deposition, increased syncytial-knotting, increased microcalcification, increased villous agglutination, focal infarct, intervilloushemorrhage as well as inflammation. Placental histopathological findings from this study can provide additional information to the existing literature on the subject.

Maternal COVID-19 infection and the fetus: Immunological and neurological perspectives

Immunoneuropsychiatry is an emerging field about the interaction between the immune and nervous systems. Infection and infection-related inflammation (in addition to genetics and environmental factors) can act as the etiopathogenesis of neuropsychiatric disorders (NPDs). Exposure to COVID-19 in utero may be a risk factor for developing NPDs in offspring in the future. Maternal immune activation (MIA) and subsequent inflammation can affect fetal brain development. Inflammatory mediators, cytokines, and autoantibodies can pass through the placenta and the compromised blood-brain barrier after MIA, leading to neuroinflammation. Neuroinflammation also affects multiple neurobiological pathways; for example, it decreases the production of the neurotransmitter serotonin. Fetal sex may affect the mother's immune response. Pregnant women with male fetuses have been reported to have decreased maternal and placental humoral responses. This suggests that in pregnancies with a male fetus, fewer antibodies may be transferred to the fetus and contribute to males' increased susceptibility/vulnerability to infectious diseases compared to female infants. Here, we want to discuss maternal COVID-19 infection and its consequences for the fetus, particularly the neurological outcomes and the interaction between fetal sex and possible changes in maternal immune responses.

A Review of the Antiviral Activities of Glycyrrhizic Acid, Glycyrrhetinic Acid and Glycyrrhetinic Acid Monoglucuronide

Licorice, a natural medicine derived from the roots and rhizomes of Glycyrrhiza species, possesses a wide range of therapeutic applications, including antiviral properties. Glycyrrhizic acid (GL) and glycyrrhetinic acid (GA) are the most important active ingredients in licorice. Glycyrrhetinic acid 3-O-mono-β-d-glucuronide (GAMG) is the active metabolite of GL. GL and its metabolites have a wide range of antiviral activities against viruses, such as, the hepatitis virus, herpes virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and so on. Although their antiviral activity has been widely reported, the specific mechanism of action involving multiple links such as the virus itself, cells, and immunity are not clearly established. In this review, we will give an update on the role of GL and its metabolites as antiviral agents, and detail relevant evidence on the potential use and mechanisms of actions. Analyzing antivirals, their signaling, and the impacts of tissue and autoimmune protection may provide promising new therapeutic strategies.

COVID-19 and Pregnancy: Risks and Outcomes

The normal physiologic changes of pregnancy are known to increase susceptibility to respiratory illness. Individuals who are pregnant are more likely to acquire a SARS-CoV-2 infection and develop COVID-19 than the general population; they are at increased risk for hospitalization; ventilator-assisted breathing; and other subsequent maternal, fetal, and neonatal health issues. Although the incidence of infection and subsequent morbidity is increased in pregnancy, mortality does not seem to be increased. Individuals who are vaccinated against COVID-19 before childbirth can pass antibodies to their fetuses via the placenta during pregnancy and to their infants during breastfeeding. It is important for health care providers to be cognizant of the potential impacts of COVID-19 on pregnant individuals and their offspring.

SARS-CoV-2 (COVID-19) as a possible risk factor for neurodevelopmental disorders

Pregnant women constitute one of the most vulnerable populations to be affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the cause of coronavirus disease 2019. SARS-CoV-2 infection during pregnancy could negatively impact fetal brain development via multiple mechanisms. Accumulating evidence indicates that mother to fetus transmission of SARS-CoV-2 does occur, albeit rarely. When it does occur, there is a potential for neuroinvasion via immune cells, retrograde axonal transport, and olfactory bulb and lymphatic pathways. In the absence of maternal to fetal transmission, there is still the potential for negative neurodevelopmental outcomes as a consequence of disrupted placental development and function leading to preeclampsia, preterm birth, and intrauterine growth restriction. In addition, maternal immune activation may lead to hypomyelination, microglial activation, white matter damage, and reduced neurogenesis in the developing fetus. Moreover, maternal immune activation can disrupt the maternal or fetal hypothalamic-pituitary-adrenal (HPA) axis leading to altered neurodevelopment. Finally, pro-inflammatory cytokines can potentially alter epigenetic processes within the developing brain. In this review, we address each of these potential mechanisms. We propose that SARS-CoV-2 could lead to neurodevelopmental disorders in a subset of pregnant women and that long-term studies are warranted.

Factors associated with willingness to take COVID-19 vaccine among pregnant women at Gondar town, Northwest Ethiopia: A multicenter institution-based cross-sectional study

BACKGROUND

Coronavirus disease has spread worldwide since late 2019. Vaccination is critical in controlling this pandemic. However, vaccine acceptance among pregnant women is not well-studied. Therefore, this study aimed to assess the COVID-19 vaccine acceptance and associated factors among pregnant women attending antenatal care clinics in Gondar town, Northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among pregnant women attending antenatal care clinics at Gondar town, Northwest Ethiopia, 2021. About 510 study subjects were selected using a systematic random sampling technique from August 25 to September 10/2021. Data collection was done by using an interviewer-administered, structured questionnaire. Epi-info 7.2 was used to enter data and then exported to SPSS version 25 software for analysis. Bivariable and multivariable binary logistic regression models were used to identify factors associated with the outcome variable. Variables with a p-value < 0.2 in the bivariable analysis were entered into the multivariable analysis to control for possible confounders. Statistical significance is determined using an adjusted odds ratio and 95% confidence interval (CI) at a p-value of < 0.05.

RESULTS

Of 510 participants, 211 (41.4%) were willing to take COVID-19 vaccines. Maternal age ≥ 35 years (AOR: 5.678, 95% CI: 1.775-18.166), having contact history with COVID-19 diagnosed people (AOR: 7.724, 95% CI: 2.183, 27.329), having a pre-existing chronic disease (AOR: 3.131, 95% CI: 1.700-5.766), good knowledge about COVID-19 vaccine (AOR: 2.391, 95% CI: 1.144, 4.998) and good attitude towards COVID-19 vaccine (AOR: 2.128, 95% CI: 1.348) were significantly associated with the outcome variable.

CONCLUSIONS

The willingness to take COVID-19 vaccine among pregnant mothers was low. Age, contact history with COVID-19 diagnosed people, chronic disease, knowledge, and attitude towards COVID-19 vaccine were factors associated with COVID-19 vaccine willingness. To enhance the COVID-19 vaccine acceptance, the government with different stakeholders should strengthen public education about the importance of getting COVID-19 vaccine.

Correlation between psychiatric impact of COVID-19 during pregnancy and fetal outcomes in Egyptian women

The prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) was examined in 238 pregnant women with (n = 146) and without (n = 92) coronavirus disease 2019 (COVID-19) using the State-Trait Anxiety Inventory (STAI), Edinburgh Postnatal Depression Scale (EPDS), and PTSD Checklist for DSM-5 (PCL-5). Fetal outcomes in the same groups were evaluated using the Apgar score. Anxiety and depression scores were significantly higher in women with COVID-19 but PTSD scores were similar in both groups. Infection with COVID-19 was associated with a higher number of fetal deaths or an Apgar score <7. During the COVID-19 pandemic, approximately 46.6% of pregnant women had depression, 5.5% had PTSD, 64.3% had state anxiety, and 60.9% had trait anxiety. Except for PTSD, psychiatric problems and poor fetal outcomes were higher in women with COVID-19 than in those without COVID-19. Lastly, women with COVID-19 were more prone to have a fetus who died or had an Apgar score of <7.

Integrative medicine research for improving female reproductive health during COVID-19

Integrative medicine may have many beneficial effects on women's reproductive health during the COVID-19 pandemic. However, the researches related to it is insufficient. In the future, more researches were needed to help the integrative medicine to become effective interventions.

Placenta, the Key Witness of COVID-19 Infection in Premature Births

Adverse perinatal outcomes, such as increased risks of pre-eclampsia, miscarriage, premature birth, and stillbirth have been reported in SARS-CoV-2 infection. For a better understanding of COVID-19 complications in pregnancy, histopathological changes in the placenta, which is the interface between mother and foetus, could be the place to look at. The aim of this study was to determine placental histopathological changes and their role in preterm birth in pregnant women with SARS-CoV-2 infection. We performed a prospective, observational study in a COVID-only hospital, which included 39 pregnant women with SARS-CoV-2 infection and preterm birth compared with a control group of 39 women COVID-19 negative with preterm birth and a placental pathology exam available. The microscopic examination of all placentas revealed placental infarction (64.1% vs. 30.8%), decidual arteriopathy (66.7% vs. 23.1%), intervillous thrombi (53.8% vs. 38.5%), perivillous fibrin deposits (59% vs. 46.2%), inflammatory infiltrate (69.2% vs. 46.2%), chorangiosis (17.9% vs. 10.3%), and accelerated maturation of the villi (23.1% vs. 28.2%).

Do SARS-CoV-2-Infected Pregnant Women Have Adverse Pregnancy Outcomes as Compared to Non-Infected Pregnant Women?

Purpose

To determine the feto-maternal outcome in pregnant women infected with SARS-CoV-2 in comparison to non-infected pregnant women and plan management strategies.

Patients and Methods

A retrospective review of case records in the Department of Obstetrics and Gynecology for 1 year was conducted. A total of 6468 case files fulfilling the inclusion criteria were enrolled in the study. Patients who tested positive for SARS CoV-2 and fulfilled inclusion criteria were labeled as cases, whereas patients who tested negative were labeled as controls. Outcome measures including lower segment cesarean section (LSCS) rate, maternal and neonatal intensive care admission and feto-maternal mortality were compared between the two groups.

Results

Our hospital was not an exclusive COVID-19 designated center, and 117 patients infected with SARS-CoV-2 fulfilling the inclusion criteria were enrolled in the study. Fever (67.52%), cough (56.41%), and altered smell (45.29%) were the frequently reported symptoms. Pneumonia affected 16.23% of the cases. LSCS rate was significantly higher in the COVID-19-infected patients (72.41%; OR 2.19; 95% CI 1.46-3.34; p<0.001). The rate of maternal ICU admission in COVID-19-infected pregnant women was 11.96% as compared to 0.8% in the non-infected women (OR 16.76; 95% CI 8.72-30.77; p<0.001). We observed a significantly higher maternal mortality in COVID-19-infected women (2.56%) [OR 41.61; 95% CI 7.65-203.5; p<0.001]. Viral RNA was detected in cord blood and nasopharyngeal swab of one neonate. The neonatal death ratio was high in infected mothers (2.6%) [OR 8.6; 95% CI 1.99-27.23; p<0.001].

Conclusion

Significant maternal morbidity, mortality, and neonatal mortality were observed in COVID-19-positive patients.

Synthesis, Antiviral, and Antibacterial Activity of the Glycyrrhizic Acid and Glycyrrhetinic Acid Derivatives

Glycyrrhizic acid and its primary metabolite glycyrrhetinic acid, are the main active ingredients in the licorice roots (glycyrrhiza species), which are widely used in several countries of the world, especially in east asian countries (China, Japan). These ingredients and their derivatives play an important role in treating many diseases, especially infectious diseases such as COVID-19 and hepatic infections. This review aims to summarize the different ways of synthesising the amide derivatives of glycyrrhizic acid and the main ways to synthesize the glycyrrhitinic acid derivatives. Also, to determine the main biological and pharmacological activity for these compounds from the previous studies to provide essential data to researchers for future studies.

Supplementary Information

The online version contains supplementary material available at 10.1134/S1068162022050132.

Generalized Anxiety Disorder and Its Associated Factors Among Pregnant Women During COVID-19 at Public Health Facilities of East Gojjam Zone, 2020: A Multi-Center Cross-Sectional Study

Introduction

Pregnant women suffer from varying levels of generalized anxiety disorder that result in poor obstetrical outcomes. Therefore, this study aimed to assess the prevalence and factors associated with generalized anxiety disorder among pregnant women attending antenatal care during COVID-19 at the public health facilities in the east Gojjam zone.

Methods

A health facility-based cross-sectional study was conducted, from 1–30 December 2020. A total of 847 pregnant women were included in the study using a systematic random sampling technique. We used an interviewer-administered questionnaire to collect the data. Bivariate and multivariable logistic regression was used to identify factors associated with the outcome variable. Statistical significance was determined using a p-value < 0.05 and a 95% confidence level.

Results

The prevalence of generalized anxiety disorder was 43.7%, with a 95% CI (40.28–47.12). Having <3 the number of children (AOR: 1.53; 95% CI: 1.11–2.13, having a negative attitude about COVID (AOR: 1.47; 95% CI: 1.07–2.02 and having a high-risk perception about COVID (AOR: 1.86; 95% CI: 1.34–2.57 were factors significantly associated with generalized anxiety disorder.

Conclusions

The study found that the prevalence of generalized anxiety disorder was high. Having less than three children, having a negative attitude, and having a high-risk perception of COVID were independent risk factors of generalized anxiety disorder. Appropriate interventions should be considered to address generalized anxiety disorder during the pandemic.

Pathological involvement of placenta in COVID-19: a systematic review

The mammalian placenta, which is responsible for bonding between the mother and the fetus, is one of the first organs to develop. Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection has caused a great threat to public health and affected almost all the organs including the placenta. Owing to limited available data on vertical transmission and pathological changes in the placenta of SARS-CoV-2 positive patients, we aim to review and summarize histopathological and ultrastructural changes in the placental tissue following SARS-CoV-2 infection. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were used for review writing. Multiple studies have reported significant pathological changes in the placental tissue of SARS-CoV-2 positive mothers. On the other hand, some studies have demonstrated either no or very little involvement of the placental tissue. The most common pathological changes reported are fetal and maternal vascular malformation, villitis of unknown etiology, thrombus formation in the intervillous space and sub-chorionic space, and chorangiosis. Reports on vertical transmission are less in number. The observations of this review present a strong base for the pathological involvement of the placenta in SARS-CoV-2 infected mothers. However, a smaller number of original studies have been done until now, and most of them have small sample sizes and lack matched control groups, which are the big limitations for drawing an effective conclusion at this stage. Antenatal care can be improved by a better understanding of the correlation between maternal SARS-CoV-2 infection and placental pathology in COVID-19.

Effectiveness and safety of available treatments for COVID-19 during pregnancy: a critical review

BACKGROUND

COVID-19 is a pandemic disease caused by the SARS-CoV-2 and it spread globally in the last few months. The complete lack of specific treatment forced clinicians to use old drugs, chosen for their efficacy against similar viruses or their in vitro activity. Trials on patients are ongoing but the majority of information comes from small case series and single center reports. We aimed to provide a literature review on the putative effectiveness and safety of available treatments for COVID-19 in pregnant women.

METHODS

We reviewed all the available literature concerning the drugs that have been used in the treatment of COVID-19 during pregnancy and whose safe assumption during pregnancy had been demonstrated by clinical studies (i.e. including studies on other infectious diseases). Drugs contra-indicated during pregnancy or with unknown adverse effects were not included in our review.

RESULTS AND CONCLUSIONS

Clinical trials are not often conducted among pregnant patients for safety reasons and this means that drugs that may be effective in general population cannot be used for pregnant women due to the lack of knowledge of side effects in this category of people .The choice to use a specific drug for COVID-19 in pregnancy should take into account benefits and possible adverse events in each single case. In the current situation of uncertainty and poor knowledge about the management of COVID-19 during pregnancy, this present overview may provide useful information for physicians with practical implications.

Effects of SARS-CoV-2 Variants on Maternal Infection and Severity: A Single-Center Experience

Background and aims

Pregnant women are one of the vulnerable groups affected by COVID-19. With the mutation of the virus, the severity of the disease in this vulnerable group may vary in different waves of COVID-19 subtypes. The aim of this study is to define the demographic, clinical, laboratory, and mortality results of pregnant COVID-19 patients according to three time frames (March to December 2020, January to June 2021, and July to November 2021).

Materials and methods

The data of patients admitted to the ICU between March 23, 2020, and November 30, 2021, were retrospectively scanned. Pregnant patients with SARS-CoV-2 PCR test positivity or pregnant patients with COVID-19 who have a negative PCR test but symptoms of COVID-19 and radiological findings consistent with COVID-19 on thorax CT who need intensive care were included in the study. The patients were divided into three groups according to the dates when the Ministry of Health of the Republic of Turkey reported the variants of COVID-19 in Turkey. The nonvariant type was dominant in the first period (March to December 2020), alpha and beta variants were dominant in the second period (January to June 2021), and the delta variant appeared in the last period (July to November 2021). Demographic, clinical, and laboratory findings at the first admission to the ICU and mortality rates of the patients were recorded.

Results

PCR test was performed in all 109 patients, of whom 101 were PCR test positive. In other eight patients, despite the negative PCR test, thorax CT findings were typical of COVID-19 pneumonia, and other bacterial and viral agents were also excluded. The mean age of the patients was 30.53 years, the mean APACHE II score was 9.68, and the mean gestational age was 28.55 weeks. Around 72.5% of the patients were in the third trimester. Of the 101 PCR-positive patients, 20.2% were delta variants, 16.5% alpha or beta variants, and 63.3% were of unknown variants. Five of the patients were vaccinated. The most common symptom was dyspnea (94.5%), and the most common comorbidity was hypothyroidism (9.17%). Invasive mechanical ventilation (IMV) was needed in 44.95% of pregnant patients. The distribution of pregnant patients admitted to the ICU according to the periods March to December 2020, January to June 2021, and July to November 2021 was 16.5%, 21.1%, and 62.4%, respectively (p<0.001). Two groups of patients were compared: those that survived versus those that deceased. Variables predicting mortality were APACHE score, IMV requirement, length of stay in the ICU, prone positioning, Anakinra treatment, and ECMO (extracorporeal membrane oxygenator) requirement, which were significantly higher in the deceased group than in the living group (p<0.001, p<0.001, p=0.001, p<0.001, p<0.001, and p=0.001, respectively). There was no significant difference between the patients' age, gestational age, variants, treatments other than Anakinra, and the number of patients admitted to the ICU in the three periods (p=0.667, p=0.174, p=0.904, and p=0.605, respectively).In the multiple logistic regression analysis for mortality, high APACHE II score and IMV requirement were found as risk factors for mortality.

Conclusion

In the last period of delta variant predominance, pregnant COVID-19 patients were admitted to the ICU significantly more frequently than in the first two periods. Mechanical ventilation requirement and high APACHE II score were determined as risk factors for mortality.

Impact of Pregnancy on Susceptibility and Severity of COVID-19: A Hospital-Based Prospective Observational Study

OBJECTIVE

 Pregnancy is a transient state of immunosuppression. The objective of this study was to ascertain whether pregnant women are more susceptible to coronavirus disease 2019 (COVID-19) than non-pregnant women and the impact of pregnancy on the severity of COVID-19 and associated morbidity and mortality.

METHODS

 A prospective observational study was performed at All India Institute of Medical Sciences (AIIMS) Rishikesh for a period of two months. A total of 42 and 33 COVID-19 positive women were included in the obstetric and non-obstetric cohorts respectively.

RESULTS

 Baseline characteristics were similar in both groups. Approximately 48% of the obstetric cohort had no COVID-19-related symptoms. Whereas, 100% of the non-obstetric cohort was symptomatic and had a significantly higher number of patients presenting with fever, cough, and breathlessness. The obstetric cohort had a significantly higher incidence of mild disease (p=0.009). In the obstetric cohort, the mean gestational age was 32.59 ± 2.57 weeks, with patients spread across all trimesters. Most of the patients with severe disease were in their second trimester. There was no difference in intensive care unit (ICU) admission, duration of ICU stay, duration of hospital stay, and mortality among both groups. A significantly smaller number of patients in the obstetric cohort required ventilatory support (p=0.0002). The maternal mortality rate was 16.67%. All of them had severe diseases requiring ICU admission. The cause of death was attributed to severe COVID pneumonia with septic shock in all cases. The mortality rate was comparatively higher (27.27%) in the non-obstetric group.

CONCLUSION

 Pregnancy, unlike other immunocompromised conditions, does not seem to affect the prognosis of COVID-19 in terms of disease severity or mortality.

Adherence to COVID-19 preventive practice and associated factors among pregnant women in Gondar city, northwest Ethiopia, 2021: Community-based cross-sectional study

Background

Coronavirus disease 2019 (COVID-19) causes more than five million deaths worldwide. Pregnant women are at high risk for infection due to the physiologic change in the immune and cardiopulmonary system and also it increases the risk of severe disease, intensive care unit admission, and receive mechanical ventilation when compared with non-pregnant women. It is associated with adverse maternal and neonatal outcomes. So pregnant women need to have adhered to preventive measures to prevent COVID-19 related consequences. Therefore, this study aimed to assess adherence toCOVID-19 preventive practice and associated factors among pregnant women in Gondar city, northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from July 1^st to 30^th, 2021, in Gondar city. A cluster sampling technique was employed to select 678 pregnant women. Data were collected using a pre-tested, face-to-face interviewer-administered questionnaire. Data were entered into EPI DATA version 4.6 and exported to SPSS version 25 for analysis. Both bivariable and multivariable logistic regression analysis was fitted to identify associated factors. Adjusted odds ratio with a 95% confidence interval was used to report the association between covariates and the outcome variable.

Results

The prevalence of good adherence to COVID-19 preventive practice was 44.8% (95% CI: 41.3, 48.7). Maternal age (≤24 years) [AOR = 2.89, 95% CI: 1.37, 6.10], maternal education (secondary school) [AOR = 2.95, 95% CI: 1.58, 5.53] and (college and above) [AOR = 4.57,95% CI: 2.42, 8.62], having ANC follow up [AOR = 2.95, 95% CI: 1.35, 6.46] and adequate knowledge towards COVID-19 [AOR = 1.70, 95% CI: 1.20, 2.41] were significantly associated with good adherence to COVID-19 preventive practice.

Conclusion

In this study, adherence towards COVID-19 preventive practice in pregnant women is low. Hence, it is important to strengthen women’s awareness about COVID-19 through different media and health education. In addition, empowering women to attain ANC and special consideration should be given to women who had no formal education.

Does the Fetus Limit Antibiotic Treatment in Pregnant Patients with COVID-19?

During pregnancy, there is a state of immune tolerance that predisposes them to viral infection, causing maternal-fetal vulnerability to the adverse effects of COVID-19. Bacterial coinfections significantly increase the mortality rate for COVID-19. However, it is known that all drugs, including antibiotics, will enter the fetal circulation in a variable degree despite the role of the placenta as a protective barrier and can cause teratogenesis or other malformations depending on the timing of exposure to the drug. Also, it is important to consider the impact of the indiscriminate use of antibiotics during pregnancy can alter both the maternal and fetal-neonatal microbiota, generating future repercussions in both. In the present study, the literature for treating bacterial coinfections in pregnant women with COVID-19 is reviewed. In turn, we present the findings in 50 pregnant women hospitalized diagnosed with SARS-CoV-2 without previous treatment with antibiotics; moreover, a bacteriological culture of sample types was performed. Seven pregnant women had coinfection with Staphylococcus haemolyticus, Staphylococcus epidermidis, Streptococcus agalactiae, Escherichia coli ESBL +, biotype 1 and 2, Acinetobacter jahnsonii, Enterococcus faecium, and Clostridium difficile. When performing the antibiogram, resistance to multiple drugs was found, such as macrolides, aminoglycosides, sulfa, dihydrofolate reductase inhibitors, beta-lactams, etc. The purpose of this study was to generate more scientific evidence on the better use of antibiotics in these patients. Because of this, it is important to perform an antibiogram to prevent abuse of empirical antibiotic treatment with antibiotics in pregnant women diagnosed with SARS-CoV-2.

The quest for a better fight: How can nanomaterials address the current therapeutic and diagnostic obstacles in the fight against COVID-19?

The inexorable coronavirus disease 2019 (COVID-19) pandemic with around 226 million people diagnosed and approximately 4.6 million deaths, is still moving toward more frightening statistics, calling for the urgent need to explore solutions for the current challenges in therapeutic and diagnostic approaches. The challenges associated with existing therapeutics in COVID-19 include lack of in vivo stability, efficacy, and safety. Nanoparticles (NPs) can offer a handful of tools to tackle these problems by enabling efficacious and safe delivery of both virus- and host-directed therapeutics. Furthermore, they can enable maximized clinical outcome while eliminating the chance of resistance to therapy by tissue-targeting and concomitant delivery of multiple therapeutics. The promising application of NPs as vaccine platforms is reflected by the major advances in developing novel COVID-19 vaccines. Two of the most critical COVID-19 vaccines are mRNA-based vaccines delivered via NPs, making them the first FDA-approved mRNA vaccines. Besides, NPs have been deployed as simple, rapid, and precise tools for point of care disease diagnosis. Not enough said NPs can also be exploited in novel ways to expedite the drug discovery process. In light of the above, this review discusses how NPs can overcome the hurdles associated with therapeutic and diagnostic approaches against COVID-19.

COVID-19 AND UPPER LIMB ANOMALIES IN NEWBORNS: A REASON FOR CONCERN?

The relationship between viral infection in pregnancy and congenital anomalies is reported in the medical literature. The risks for the SARS-CoV-2 virus interfering with implantation, growth, and fetal development are not yet known. Many drugs with potential teratogenic risk are being used for treatment. The studies with the vaccine excluded pregnant women from clinical trials, currently preventing high-quality evidence. We present a review of the most common anomalies in the upper extremities caused by congenital viral infection and the risks of anti-COVID-19 therapy and vaccine during pregnancy. We aim to alert orthopedic and hand surgeons to the possibility of these conditions in the future. Level of evidence V; Narrative review.

Pregnant people's responses to the COVID-19 pandemic: a mixed-methods, descriptive study

BACKGROUND

Given the extent of the COVID-19 pandemic and uncertainty around the timing of its containment, understanding the experiences and responses of the perinatal population is essential for planning responsive maternity care both during and after the pandemic. The aim of this study was to explore the experiences of pregnant people and their responses to the COVID-19 pandemic, and to identify how health care providers can support this population.

METHODS

This was a mixed-methods, descriptive study with cross-sectional and qualitative descriptive components. We conducted the study between Mar. 20 and May 31, 2020, in British Columbia, Canada. Any pregnant person at any gestational age living in BC was eligible to participate. We collected quantitative data using online survey tools, including the Edinburgh Postnatal Depression Scale (EPDS) and the 7-item Generalized Anxiety Disorder questionnaire (GAD-7). We collected qualitative data using open-ended questions to explore people's thoughts, feelings and experiences during the pandemic. Participants were recruited using study posters distributed via prenatal care clinics and classes, LifeLabs and social media across the province. We used thematic and descriptive analyses to analyze the data, and we integrated the qualitative and quantitative findings at the interpretation level.

RESULTS

The study sample included 96 participants with mean (± standard deviation) maternal and gestational ages of 32 ± 3.92 years and 22.73 ± 8.93 weeks, respectively. Most (93%; n = 89) identified as female. Of the participants, 54% (n = 50) and 35% (n = 34) reported anxiety and depressive symptoms, as measured by the GAD-7 and EPDS, respectively. Overarching themes that emerged from the qualitative data included uncertainty about birth plans and setting, added burden to existing health and social disparities, perceived or projected lack of support or limited support, concerns about early development, and struggle over managing multiple demands. Perceived maternity care needs included mental health support, maintaining prenatal care, frequent and proactive check-ins to build rapport, and recommendations specific to the pandemic.

INTERPRETATION

We found that the impact of the COVID-19 pandemic on the pregnant population has been substantial. The findings of this mixed-methods study can be used to help plan informed and evidence-based health care interventions to mitigate adverse effects and support mothers and families.

Pathophysiological and molecular considerations of viral and bacterial infections during maternal-fetal and -neonatal interactions of SARS-CoV-2, Zika, and Mycoplasma infectious diseases

During pregnancy, a series of physiological changes are determined at the molecular, cellular and macroscopic level that make the mother and fetus more susceptible to certain viral and bacterial infections, especially the infections in this and the companion review. Particular situations increase susceptibility to infection in neonates. The enhanced susceptibility to certain infections increases the risk of developing particular diseases that can progress to become morbidly severe. For example, during the current pandemic caused by the SARS-CoV-2 virus, epidemiological studies have established that pregnant women with COVID-19 disease are more likely to be hospitalized. However, the risk for intensive care unit admission and mechanical ventilation is not increased compared with nonpregnant women. Although much remains unknown with this particular infection, the elevated risk of progression during pregnancy towards more severe manifestations of COVID-19 disease is not associated with an increased risk of death. In addition, the epidemiological data available in neonates suggest that their risk of acquiring COVID-19 is low compared with infants (<12 months of age). However, they might be at higher risk for progression to severe COVID-19 disease compared with older children. The data on clinical presentation and disease severity among neonates are limited and based on case reports and small case series. It is well documented the importance of the Zika virus infection as the main cause of several congenital anomalies and birth defects such as microcephaly, and also adverse pregnancy outcomes. Mycoplasma infections also increase adverse pregnancy outcomes. This review will focus on the molecular, pathophysiological and biophysical characteristics of the mother/placental-fetal/neonatal interactions and the possible mechanisms of these pathogens (SARS-CoV-2, ZIKV, and Mycoplasmas) for promoting disease at this level.

Susceptibility to COVID-19 in Pregnancy, Labor, and Postpartum Period: Immune System, Vertical Transmission, and Breastfeeding

The new coronavirus (SARS-Cov-2) was first identified in late 2019 as the new RNA virus in the coronaviridae family responsible for causing COVID-19 in the residents of China's Hubei province. In mid-March 2020 WHO declared the pandemic caused by this virus as a result of thousands of people infected all over the world. Epidemiological evidence obtained from other pandemics, such as influenza and ebola, suggest that pregnant women are more susceptible to serious complications and death from viral infection. Physiological changes in the anatomical structure of the respiratory system as well as in the immune system during the pregnancy-puerperal period seem to contribute to this greater risk. Thus, pregnant women are more susceptible to be infected by the SARS-COV-2 or other viruses and to have serious COVID-19 disease. In fact, COVID-19 can alter immune responses at the maternal-fetal interface, affecting the well-being of both mother and her fetus. There is still no sufficient evidence in the literature to support the occurrence of vertical transmission and through breastfeeding, but the prevalence of prematurity was high among pregnant women infected by SARS-Cov-2. In this review, the changes in the immune system that may increase susceptibility to SARS-Cov-2 are discussed as well as the possible mechanisms involved in the transmission of the virus to the fetus by vertical transmission and during breastfeeding.

Pregnancy and COVID-19 - liver damage

This review examines information from systematic reviews and meta-analyses, research studies, and case reports to present current knowledge about liver damage in pregnant patients having Covid-19 during pregnancy. Problems with diagnosis and differential diagnosis are examined in the context of the need to rule out other causes of liver dysfunction, including pregnancy-related liver disease. In this paper we give an overview of COVID-19 liver problems during pregnancy. Mechanisms of liver involvement in COVID-19 infection are being examined. An overview of the assessment of abnormal liver biological syndromes in pregnant patients is provided. Differential diagnostic algorithms for primary liver damage established in a pregnant woman in the context of the Covid-19 pandemic are presented. Challenges in diagnosis and etiology assessment methods and customized management options are described. The management of pregnant women with hepatic dysfunction onset on the Covid-19 background and subsequently aggravated is discussed. The importance of anticoagulant therapy as an essential measure of symptomatic management of Covid-19 in pregnant women is emphasized, as both pregnancy and COVID-19 are thrombogenic. Hypercoagulability appears to adversely affect the pregnant women liver with Covid-19 and post Covid-19 and anticoagulant therapy has benefits in the management of liver damage associated with Covid-19. The COVID-19 liver problems in a 33-year-old woman who was not vaccinated for Covid-19, without a history of chronic liver disease, was tested positive for Covid-19 at 33 weeks of gestation is discussed. The report of the diagnostics, differential diagnosis, and management questions in the context of liver dysfunction manifested by a significant increase in alanine aminotransferase cytolysis syndrome. The positive effect of anticoagulant therapy in resolving cytolytic syndrome is emphasized. The good maternal and perinatal result is also mentioned.

Pharmacological Treatments against COVID-19 in Pregnant Women

The recent respiratory virus known as SARS-CoV-2 has caused millions of deaths worldwide, causing great uncertainty due to the lack of a specific treatment, which has been mitigated by the use of various drugs traditionally used against other types of pathologies. Pregnancy presents special physiological conditions that expose the pregnant woman and the foetus to greater risk. Pregnant women are often excluded from trials due to possible risk of toxicity or side effects, resulting in a lack of knowledge about the use of drugs and treatments during pregnancy. The main objective of this review was to compile existing knowledge about currently available drug treatments for COVID-19 in pregnant women. The review report met the criteria of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) review protocol and was registered with the registration number CRD42021251036. The electronic databases searched were Scopus, PubMed, CINAHL and SciELO. Finally, 22 articles were included, resulting in an analysis of drugs with an acceptable safety profile in the treatment of pregnant women with COVID-19.

Drug repurposing against coronavirus disease 2019 (COVID-19): A review

Since December 2019, severe acute respiratory syndrome coronavirus 2 has been found to be the culprit in the coronavirus disease 2019 (COVID-19), causing a global pandemic. Despite the existence of many vaccine programs, the number of confirmed cases and fatalities due to COVID-19 is still increasing. Furthermore, a number of variants have been reported. Because of the absence of approved anti-coronavirus drugs, the treatment and management of COVID-19 has become a global challenge. Under these circumstances, drug repurposing is an effective method to identify candidate drugs with a shorter cycle of clinical trials. Here, we summarize the current status of the application of drug repurposing in COVID-19, including drug repurposing based on virtual computer screening, network pharmacology, and bioactivity, which may be a beneficial COVID-19 treatment.

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Mechanism of SARS-CoV-2 infection and drug targets were reviewed.

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Drug repurposing against COVID-19 based on computer virtual screening, network pharmacology, bioactivity were summarized.

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The use of drug repurposing in COVID-19 was addressed.

The expression of hACE2 receptor protein and its involvement in SARS-CoV-2 entry, pathogenesis, and its application as potential therapeutic target

Pneumonia cases of unknown etiology in Wuhan, Hubei province, China were reported to the World Health Organization on 31st of December 2019. Later the pathogen was reported to be a novel coronavirus designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes Corona virus disease 2019 (COVID-19). The disease outspread was followed by WHO declaration of COVID-19 pandemic as a "Public Health Emergency of International Concern". SARS-CoV-2 is a novel pathogenic beta coronavirus that infects humans causing severe respiratory illness. However, multifarious factors can contribute to the susceptibility to COVID-19 related morbidity and mortality such as age, gender, and underlying comorbidities. Infection initiates when viral particles bind to the host cell surface receptors where SARS-CoV-2 spike glycoprotein subunit 1 binds to the Angiotensin Converting Enzyme 2 (ACE2). It is of importance to mention that SARS-CoV and SARS-CoV-2 viruses' mediate entry into the host cells via ACE2 receptor which might be correlated with the structural similarity of spike glycoprotein subunit 1 of both SARS viruses. However, the structural binding differs, whereas ACE2 receptor binding affinity with SARS-CoV-2 is 4 folds higher than that with SARS-CoV. Moreover, amino acids sequence divergence between the two S glycoproteins might be responsible for differential modulations of the specific immune response to both viruses. Identification of different aspects such as binding affinity, differential antigenic profiles of S-glycoproteins, and ACE2 mutations might influence the investigation of potential therapeutic strategies targeting SARS-CoV-2/ACE2 binding interface. In this review, we aim to elaborate on the expression of hACE2 receptor protein and its binding with SARS-CoV-2 S1 subunit, the possible immunogenic sequences of spike protein, effect of ACE 2 polymorphism on viral binding, and infectivity/susceptibility to disease. Furthermore, targeting of hACE2 receptor binding with SARS-CoV-2 S1 subunit via various mechanisms will be discussed to understand its role in therapeutics.

Interactions Between Specific Immune Status of Pregnant Women and SARS-CoV-2 Infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the Coronavirus Disease 2019 (COVID-19) global pandemic. Because it is a new and highly contagious coronavirus, most people, especially pregnant women, lack immunity. It is therefore important to understand the interaction between why pregnant women are susceptible to SARS-CoV-2 and the specific immune systems of pregnant women. Here, we provide an overview of the changes that occur in the immune system during pregnancy, the activation and response of the immune system in pregnant women with COVID-19, adverse pregnancy outcomes in pregnant women with COVID-19, and the treatment and prevention of COVID-19 in this population.

Management of pregnancy-related hypertensive disorders in patients infected with SARS CoV-2: pharmacological and clinical issues

Aims

Coronavirus-19 disease (COVID-19) continues to spread throughout the world. It is known that among patients with hypertension, diabetes, chronic respiratory disease, or cardiovascular diseases, COVID-19 is associated with greater morbidity and mortality compared with patients without these conditions. This correlation is of great importance in pregnant women affected by COVID-19, since it usually leads to the development of a serious clinical complication. In particular, managing hypertensive disorders in pregnancy can be problematic because antihypertensive medications may interact pharmacologically with drugs used to treat COVID-19. This review focuses on the safety of drug treatment for COVID-19 in pregnant women treated with antihypertensive medication.

Methods and results

Several databases were searched to identify relevant literature. A few antihypertensive drugs and antithrombotic treatments are known for having a beneficial effect in the management of hypertension and hypertensive disorders in pregnancy. In this review, we focus on the expected drug–drug interactions with the experimental agents most often used to treat COVID-19.

Conclusions

The current indications for the management of hypertension-related disorders in pregnancy maintain their validity, while the risk of pharmacological interaction with the currently tested anti-SARS-CoV-2 medications is relatively low.

Classical and Counter-Regulatory Renin-Angiotensin System: Potential Key Roles in COVID-19 Pathophysiology

In the current COVID-19 pandemic, severe acute respiratory syndrome coronavirus 2 uses angiotensin-converting enzyme-2 (ACE-2) receptors for cell entry, leading to ACE-2 dysfunction and downregulation, which disturb the balance between the classical and counter-regulatory renin-angiotensin system (RAS) in favor of the classical RAS. RAS dysregulation is one of the major characteristics of several cardiovascular diseases; thus, adjustment of this system is the main therapeutic target. RAS inhibitors-particularly angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II type 1 receptor blockers (ARBs)-are commonly used for treatment of hypertension and cardiovascular disease. Patients with cardiovascular diseases are the group most commonly seen among those with COVID-19 comorbidity. At the beginning of this pandemic, a dilemma occurred regarding the use of ACEIs and ARBs, potentially aggravating cardiovascular and pulmonary dysfunction in COVID-19 patients. Urgent clinical trials from different countries and hospitals reported that there is no association between RAS inhibitor treatment and COVID-19 infection or comorbidity complication. Nevertheless, the disturbance of the RAS that is associated with COVID-19 infection and the potential treatment targeting this area have yet to be resolved. In this review, the link between the dysregulation of classical RAS and counter-regulatory RAS activities in COVID-19 patients with cardiovascular metabolic diseases is investigated. In addition, the latest findings based on ACEI and ARB administration and ACE-2 availability in relation to COVID-19, which may provide a better understanding of the RAS contribution to COVID-19 pathology, are discussed, as they are of the utmost importance amid the current pandemic.

Peripartal anti-SARS-CoV-2-IgA/IgG in asymptomatic pregnant women during regional SARS-CoV-2-outbreak

OBJECTIVES

The Severe Acute Respiratory Distress Corona Virus 2 (SARS-CoV-2) pandemic poses special challenges for the society and especially the medical staff. Even if a rather mild course is assumed among pregnant women the measures to prevent transmission of the infection are of outstanding importance.

METHODS

To screen asymptomatic pregnant women during admission to our university maternal hospital we focused on anti-SARS-CoV-2-specific IgG and IgA antibody responses. Hundred and fifty one women admitted to the hospital for childbirth or caesarean delivery were included. In case of suspicious anti-SARS-CoV-2-antibody levels an RT-PCR was performed to confirm an ongoing infection with SARS-CoV-2.

RESULTS

A total of 89% showed negative results for anti-SARS-CoV-2-IgA antibodies, whereas 3% were borderline and 7% positive (both labeled as suspicious). In only one patient with suspicious serology we detected SARS-CoV-2-RNA in the following RT-PCR. 2% presented anti-SARS-CoV-2-IgG antibodies, all being positive for anti-SARS-CoV-2-IgA. The observed positive rate of our study collective of 10.6% seemed much higher than the expected one (1.3%) based on the reports of the Robert Koch Institute and the specifications given by the test's manufacturer. The expected positive predictive value (PPV) was 4.3-6.7 times higher than the observed one.

CONCLUSIONS

To our knowledge this is the first report of anti-SARS-CoV-2-antibody levels in the peripartum period of asymptomatic women. As the positive anti-SARS-CoV-2 serology poorly correlated with the confirmatory RT-PCR and the fact that mainly the detection of the virus by PCR correlates with the patient's infectiousness we suggest to rather perform a SARS-CoV-2-PCR-based admission screening in perinatal centers to prevent the spread of the disease.

An overview of sex hormones in relation to SARS-CoV-2 infection

Aim: Sex differences in COVID-19 outcomes might be explained from a sex hormones (SexHs) perspective. Materials & methods: PubMed, Scopus, Web of Science, EMBASE and Google Scholar were searched up to March 2021. Results: Based on the literature review, the crosstalk between SexHs (estrogens, progesterone and testosterone), their receptors (estrogen α and β, androgen, and progesterone) and the immune system shaped the sex-related differences in immune responses against COVID-19. Differential production of SexHs over the lifespan (during pregnancy, reproductive years, menopause and andropause) and over different seasons may result in disparities in body response toward COVID-19. Moreover, SexHs-specific differences might affect vaccine efficacy and response to treatment. Conclusion: The roles of SexHs need to be considered in vaccine development and even treatment of COVID-19.

A review on the pharmacokinetic properties and toxicity considerations for chloroquine and hydroxychloroquine to potentially treat coronavirus patients

The SARS-CoV-2 virus, caused a novel emerged coronavirus disease, is growing rapidly worldwide. Few studies have evaluated the efficacy and safety of Chloroquine (CQ), an old antimalarial drug, and Hydroxychloroquine (HCQ) in the treatment of COVID-19 infection. HCQ is derived from CQ by adding a hydroxyl group into it and is a less toxic derivative of CQ for the treatment of COVID-19 infection because it is more soluble. This article summarizes pharmacokinetic properties and toxicity considerations for CQ and HCQ, drug interactions, and their potential efficacy against COVID-19. The authors also look at the biochemistry changes and clinical uses of CQ and HCQ, and supportive treatments following toxicity occurs. It was believed that CQ and HCQ may provide few benefits to COVID-19 patients. A number of factors should be considered to keep the drug safe, such as dose, in vivo animal toxicological findings, and gathering of metabolites in plasma and/or tissues. The main conclusion of this review is that CQ and HCQ with considered to their ADMET properties has major shortcomings and fully irresponsible.

Knowledge, Attitude and Practice Toward Corona virus Infection Among Pregnant Women Attending Antenatal Care at Public Hospitals in Three Wollega Zones, Ethiopia

BACKGROUND

Pregnancy is an immune-suppressed state which makes pregnant women generally more susceptible to COVID-19 infection and severe illness. Extensive precautions have been recommended to avoid exposure to the virus. Knowledge and attitude toward the disease play an integral role in readiness to accept public health measures. This study aimed to assess the knowledge, attitude and practice towards COVID-19 among pregnant women attending antenatal clinics in three Wollega zones, Ethiopia.

METHODS

Institution-based cross-sectional study was employed among 415 pregnant women attending antenatal care at public hospitals in three Wollega zones, Ethiopia from July to August 2020. The data were collected using an interviewer-administered structured questionnaire. The level of knowledge was assessed using 12 multiple choice questions; the score of above or equal to mean was considered as adequate knowledge. Binary logistic regression was performed and the adjusted odds ratio with P-value ≤0.05 at 95% CI was taken as statistically significant.

RESULTS

This study indicates that more than two-thirds (75.4%; 95% CI: 71.1-79.3%) and 43.6% of the pregnant women had adequate knowledge and good practice about the coronavirus pandemic, respectively. The pregnant women who attended secondary school and above and were urban residents were more likely to have good knowledge, AOR = 2.99 (1.7-5.0) and 1.6 (1.2-2.7), respectively. Maternal age ≤ 25 yearsand being an urban resident were the two predictors of good practice of preventive measures, AOR = 1.7 (1.2-2.6) and 2.3 (1.3-4.0), respectively.

CONCLUSIONS AND RECOMMENDATIONS

The target population demonstrated acceptable knowledge and poor practice toward COVID-19. Health-care providers should give more attention to educating pregnant women at any point of contact; legal enforcement should be implemented to improve practice of preventive measures. Special consideration should be given to those who are from rural areas, and to less-educated pregnant women.

SARS-CoV-2 infection during pregnancy and pregnancy-related conditions: Concerns, challenges, management and mitigation strategies-a narrative review

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health problem. The SARS-CoV-2 triggers hyper-activation of inflammatory and immune responses resulting in cytokine storm and increased inflammatory responses on several organs like lungs, kidneys, intestine, and placenta. Although SARS-CoV-2 affects individuals of all age groups and physiological statuses, immune-compromised individuals such as pregnant women are considered as a highly vulnerable group. This review aims to raise the concerns of high risk of infection, morbidity and mortality of COVID-19 in pregnant women and provides critical reviews of pathophysiology and pathobiology of how SARS-CoV-2 infection potentially increases the severity and fatality during pregnancy. This article also provides a discussion of current evidence on vertical transmission of SARS-CoV-2 during pregnancy and breastfeeding. Lastly, guidelines on management, treatment, preventive, and mitigation strategies of SARS-CoV-2 infection during pregnancy and pregnancy-related conditions such as delivery and breastfeeding are discussed.

The Italian Network for Monitoring Medication Use During Pregnancy (MoM-Net): Experience and Perspectives

There is an acute need for research to acquire high-quality information on the use of medicines in pregnancy, both in terms of appropriateness and safety. For this purpose, the Italian Medicines Agency established a Network for Monitoring Medication use in pregnancy (MoM-Net) through the conduction of population-based studies using administrative data available at regional level. This paper aimed to describe the experiences and challenges within the network. MoM-Net currently involves eight regions and several experts from public and academic institutions. The first study conducted aimed to identify drug use before, during and after pregnancy investigating specific therapeutic categories, analysing regional variability and monitoring drug use in specific subpopulations (i.e. foreign women/multiple pregnancies). Aggregated demographic, clinical, and prescription data were analysed using a distributed network approach based on common data model. The study population included all women delivering during 2016–2018 in the participating regions (n = 449,012), and corresponding to 59% of deliveries in Italy. Seventy-three per cent of the cohort had at least one drug prescription during pregnancy, compared to 57% before and 59% after pregnancy. In general, a good adherence to guidelines for pregnant women was found although some drug categories at risk of inappropriateness, such as progestins and antibiotics, were prescribed. A strong variability in the use of drugs among regions and in specific subpopulations was observed. The MoM-Net represents a valuable surveillance system on the use of medicines in pregnancy, available to monitor drug categories at high risk of inappropriateness and to investigate health needs in specific regions or subpopulations.

Adherence to COVID-19 preventive measures and associated factors among pregnant women in Ghana

OBJECTIVE

To assess adherence to COVID-19 preventive measures and its associated factors among pregnant women in Ghana.

METHODS

This was a cross-sectional study conducted in the Nabdam district, Ghana. Data were collected from 527 pregnant women randomly selected from antenatal care clinics from 16 healthcare facilities. Descriptive statistics were used to assess the prevalence of adherence to COVID-19 preventive measures. Multivariable logistic regression was used to estimate the factors associated with COVID-19 preventive measures, whilst adjusting for potential confounders.

RESULTS

The prevalence of wearing a face mask 18.0% (95% CI: 14.73%, 21.32%); of handwashing/hand sanitising 31.7% (95% CI: 27.70%, 35.67%), and of social distancing, 22.0% (95% CI: 18.46%, 25.56%). Multivariable logistic regression analysis revealed that knowledge of COVID-19 symptoms [Adjusted odds ratios (aOR): 2.86, 95% CI: 1.03, 7.89] and knowledge of COVID-19 transmission via contaminated surfaces/objects (aOR: 4.60, 95% CI: 1.23, 17.18) were associated with wearing a face mask. Pregnant women who knew that avoiding the touching of eyes, nose and mouth can prevent COVID-19 (aOR: 2.71, 95% CI: 1.01, 7.28), and knowledge of the virus being transmitted via contaminated objects/surfaces (aOR: 4.08, 95% CI: 1.42, 11.76), were associated with handwashing/hand sanitising. Knowledge of COVID-19 transmission via contaminated surfaces/objects (aOR: 15.27, 95% CI: 1.87, 124.43) was also associated with social distancing.

CONCLUSION

The findings of our study suggest that knowledge of COVID-19 symptoms, transmission and preventive measures may play an important role in the practice of preventive measures against COVID-19 among pregnant women.

Expression of SARS-CoV-2 entry genes ACE2 and TMPRSS2 at single cell resolution in the peripartum decidua

Angiotensin-converting enzyme 2 (ACE2) is the key receptor for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). However, the susceptibility of the decidua to infection during the peripartum period has not been explored, even though this may affect vertical transmission. The objective of this study was to investigate the expression of ACE2 and related genes in the decidua during delivery. Here, single-cell RNA sequencing was used to characterize the transcriptomes of decidual cells before and after the onset of labor. During the peripartum period, ACE2 expression was highly heterogeneous. ACE2 was expressed principally in decidual stromal cells, uterine smooth muscle cells, and extravillous trophoblasts. Comparison of the transcriptomes of ACE2-positive and ACE2-negative cells indicated that ACE2-positive cells exhibited integrin clusters on the cell surface interactions. ACE2-positive cells were compared before and after labor onset. After delivery, the number of ACE2-positive cells was slightly higher than before delivery. Before labor onset, ACE2-positive decidual stromal cells were in the regulation of membrane protein ectodomain proteolysis cluster. After labor onset, the upregulated genes changed to include cell junction assembly genes. The susceptibility of decidual cells to SARS-CoV-2 infection is thus heterogeneous during the peripartum period.

Therapeutic Development in COVID-19

Since the outbreak of coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2, the disease has spread rapidly worldwide and developed into a global pandemic, causing a significant impact on the global health system and economic development. Scientists have been racing to find effective drugs and vaccines for the treatment and prevention of COVID-19. However, due to the diversity of clinical manifestations caused by COVID-19, no standard antiviral regimen beyond supportive therapy has been established. Ongoing clinical trials are underway to evaluate the efficacy of drugs that primarily act on the viral replication cycle or enhanced immunity of patients. This chapter will summarize the currently used antiviral and adjuvant therapies in clinical practice and provide a theoretical basis for the future treatment of COVID-19.

Retrospective Analysis of Clinical Characteristics and Neonatal Outcomes of Pregnant Women with SARS-COV-2 Infection

This retrospective study aimed to investigate the clinical characteristics and neonatal outcomes of pregnant women with SARS-COV-2 in Wuhan Children's Hospital and further suggested a possible management strategy for infected pregnant women under epidemic situation. In this study, 8 pregnant women with SARS-COV-2 who were admitted into Wuhan Children's Hospital, China from February 1, 2020 to March 30, 2020 and the clinical features, laboratory data, maternal and neonatal outcomes were analyzed. The mean age of the women at the time of admission was 30.6 years. The mean gestational age of the women was 37 weeks+4 days, and one woman presented with dichorionic diamniotic (DCDA) twin pregnancy. Except for one woman who was febrile, others had no typical clinical symptoms. For all pregnant women, the count of white blood cells and lymphocytes appeared normal, but 6 had a lower percentage of lymphocytes. C-reactive protein (CRP) levels were normal for all the women. One neonate was tested positive for the coronavirus IgG and IgM antibodies. The clinical symptoms of the pregnant women with SARS-COV-2 were mild, and the laboratory data showed similar characteristics to those of non-infected pregnant women. Since one neonate was tested positive for coronavirus, there is a possibility of vertical transmission of SARS-CoV-2. Prompt and efficient screening, triage, and isolation of pregnant women are effective management strategies to reduce nosocomial infection during the SARS-COV-2 epidemic.