Vaginal delivery in COVID-19 pregnant women: anorectum as a potential alternative route of SARS-CoV-2 transmission

Investigating the mode of transmission of COVID-19 through genital secretions, semen, the birth canal, and lactation: A systematic review

In a global pandemic, the coronavirus has brought new challenges to reproductive and sexual health. This systematic review has been conducted with the aim of investigating a) the transmission of coronavirus disease 2019 (COVID-19) through female-to-male sexual secretions and vice versa, b) vertical transmission to the fetus, c) transmission to the newborn through the birth canal, and d) transmission through breast milk. In this review study, to find related articles, databases were searched using English and Persian keywords from the beginning of 2019 to the end of 2023. Based on the entry and exit criteria and the qualitative evaluation of the studies based on the STROBE criterion, the final studies were summarized. According to the initial search, 5970 articles were reviewed. After removing duplicate articles and the inappropriateness of the title, the abstract of the article was not related to the objectives of the project, there was no relevant study, and retrospective studies were excluded. Finally, 120 articles were selected as final articles. The general results show that transmission of the virus through the vagina to the blood of the fetus causing septicemia, vertical transmission from the mother to the fetus, transmission through the water bag, genital secretions, and ejaculate fluid are considered rare and ruled out. Transmission through rectal secretions during anal or oral sex requires more extensive studies. It is not possible to transmit the virus through breast milk. The long-term reproductive impact of COVID-19 on the reproductive systems of women and men is unclear.

No infectious SARS-CoV-2 in breast milk from a cohort of 110 lactating women

BACKGROUND

Genomic RNA of severe acute respiratory syndrome-associated coronavirus type 2 (SARS-CoV-2) has been detected in the breast milk of lactating women, but its pathological significance has remained uncertain due to the small size of prior studies.

METHODS

Breast milk from 110 lactating women was analyzed by reverse transcription-polymerase chain reaction (285 samples) and viral culture (160 samples). Those containing SARS-CoV-2 viral RNA (vRNA) were examined for the presence of subgenomic RNA (sgRNA), a putative marker of infectivity.

RESULTS

Sixty-five women had a positive SARS-CoV-2 diagnostic test, 9 had symptoms but negative diagnostic tests, and 36 symptomatic women were not tested. SARS-CoV-2 vRNA was detected in the milk of 7 (6%) women with either a confirmed infection or symptomatic illness, including 6 of 65 (9%) women with a positive SARS-CoV-2 diagnostic test. Infectious virus was not detected in any culture and none had detectable sgRNA. In control experiments, infectious SARS-CoV-2 could be cultured after addition to breastmilk despite several freeze-thaw cycles, as it occurs in the storage and usage of human milk.

CONCLUSIONS

SARS-CoV-2 RNA can be found infrequently in the breastmilk after recent infection, but we found no evidence that breastmilk contains an infectious virus or that breastfeeding represents a risk factor for transmission of infection to infants.

IMPACT

This article goes beyond prior small studies to provide evidence that infectious SARS-CoV-2 is not present in the milk of lactating women with recent infection, even when SARS-CoV-2 RNA is detected. Recent SARS-CoV-2 infection or detection of its RNA in human milk is not a contraindication to breastfeeding.

A Review of the Presence of SARS-CoV-2 in Wastewater: Transmission Risks in Mexico

The appearance of SARS-CoV-2 represented a new health threat to humanity and affected millions of people; the transmission of this virus occurs through different routes, and one of them recently under debate in the international community is its possible incorporation and spread by sewage. Therefore, the present work's research objectives are to review the presence of SARS-CoV-2 in wastewater throughout the world and to analyze the coverage of wastewater treatment in Mexico to determine if there is a correlation between the positive cases of COVID-19 and the percentages of treated wastewater in Mexico as well as to investigate the evidence of possible transmission by aerosol sand untreated wastewater. Methodologically, a quick search of scientific literature was performed to identify evidence the presence of SARS-CoV-2 RNA (ribonucleic acid) in wastewater in four international databases. The statistical information of the positive cases of COVID-19 was obtained from data from the Health Secretary of the Mexican Government and the Johns Hopkins Coronavirus Resource Center. The information from the wastewater treatment plants in Mexico was obtained from official information of the National Water Commission of Mexico. The results showed sufficient evidence that SARS-CoV-2 remains alive in municipal wastewater in Mexico. Our analysis indicates that there is a low but significant correlation between the percentage of treated water and positive cases of coronavirus r = -0.385, with IC (95%) = (-0.647, -0.042) and p = 0.030; this result should be taken with caution because wastewater is not a transmission mechanism, but this finding is useful to highlight the need to increase the percentage of treated wastewater and to do it efficiently. In conclusions, the virus is present in untreated wastewater, and the early detection of SAR-CoV-2 could serve as a bioindicator method of the presence of the virus. This could be of great help to establish surveillance measures by zones to take preventive actions, which to date have not been considered by the Mexican health authorities. Unfortunately, wastewater treatment systems in Mexico are very fragile, and coverage is limited to urban areas and non-existent in rural areas. Furthermore, although the probability of contagion is relatively low, it can be a risk for wastewater treatment plant workers and people who are close to them.

Is There a Role for SARS-CoV-2/COVID-19 on the Female Reproductive System?

Coronavirus disease (COVID-19) has emerged as a very serious pandemic caused by the rapidly evolving transmission of the coronavirus SARS-CoV-2. Since its outbreak in 2020, the SARS CoV-2 has represented an important challenge for the physicians due to its well known respiratory sequelae. To date, the role of SARS-CoV-2 infection on organs and systems other than lungs and respiratory tract remains less clear. In particular, it remains to be investigated whether the reproductive system can be affected by the SARS-CoV-2 in the long term-period or, in alternative, drugs used to treat COVID-19 might impact the reproductive systems and, in turn, fertility. What is known is that SARS-Cov-2 binds to target cells of host through different receptors including angiotensin-converting enzyme 2 (ACE2), neuropilin-1, AXL and antibody-FcɣR complexes. ACE2 physiologically regulates both the expression of angiotensin II (Ang II) as well as Ang-(1-7) to exerts its physiological functions. The reproductive system abundantly expresses ACE2 and produces Ang-(1-7), starting from precursors which are locally generated or derived from systemic circulation. Ang-(1-7) plays an important role of stimulus to the growth and maturation of ovarian follicle as well as to ovulation. Also human endometrium expresses Ang-(1-7), mainly during the post-ovulatory phase. Animal and human observational studies demonstrated that Ang-(1-7) is involved in the maternal immune response to pregnancy and its deficiency is associated with a defective placenta development. In our manuscript, we review the current knowledge about whether SARS-CoV-2 may impact the female reproductive system. We further explain the possible molecular mechanism by which SARS-CoV-2 might affect ovarian, endometrial and female genital tract cells.

Obstetric and neonatal outcomes after SARS-CoV-2 infection in the first trimester of pregnancy: A prospective comparative study

OBJECTIVE(S)

This prospective observational cohort study aimed to evaluate whether women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the first trimester of pregnancy are at higher risk of adverse obstetric and neonatal outcomes compared to negative patients.

STUDY DESIGN

Seromolecular testing for SARS-CoV-2 was performed at 12, 16, 21 weeks, and at delivery; the cohort was then subdivided into a first-trimester SARS-CoV-2-positive (case) group and a SARS-CoV-2-negative (control) group. The primary outcome was a composite adverse obstetric outcome, defined as the presence of either abortion, preterm delivery, preterm prelabor rupture of membranes, preeclampsia, intrauterine growth restriction, stillbirth; and a composite measure of adverse neonatal events, including either 1- and 5-min Apgar score ≤ 7, neonatal intensive care unit admission and congenital birth defects. Maternal symptoms and antibody titer were secondarily assessed.

RESULTS

A total of 17 of 164 women tested positive for SARS-CoV-2 (10.3%) in the first trimester. One SARS-CoV-2-positive patient who gave birth at another hospital was excluded. Composite adverse obstetric outcome was observed in 6.2% (1/16) SARS-CoV-2-positive and 10.5% (11/105) SARS-CoV-2-negative women; composite adverse neonatal outcome in 12.5% (2/16) and 7.6% (8/105), respectively. In the newborns of women who had developed IgG antibodies, the same antibodies were detected in arterial cord blood and the nasopharyngeal swab tested negative for SARS-CoV-2. No maternal pneumonia or hospital admission due to coronavirus disease-19 were recorded.

CONCLUSION

Asymptomatic or mildly symptomatic women during the first trimester of pregnancy did not experience significantly more adverse events than SARS-CoV-2-negative women.

Placenta histopathology in SARS-CoV-2 infection: analysis of a consecutive series and comparison with control cohorts

Infection by SARS-CoV-2 has been shown to involve a wide range of organs and tissues, leading to a kaleidoscope of clinical conditions. Within this spectrum, an involvement of the fetal-maternal unit could be expected, but, so far, the histopathological evaluation of placentas delivered by women with SARS-CoV-2 infection did not show distinct hallmarks. A consecutive series of 11 placentas, delivered by 10 women with COVID-19 admitted to our Obstetrics and Gynecology clinic have been investigated and compared to a control cohort of 58 pre-COVID-19 placentas and 28 placentas delivered by women who had a previous cesarean section. Four out of eleven placentas showed changes consistent with chronic villitis/villitis of unknown etiology (VUE), while in one case, chronic histiocytic intervillositis was diagnosed. Thrombo-hemorrhagic alterations were observed in a subset of cases. Compared to the control cohort, chronic villitis/VUE (p < 0.001), chronic deciduitis (p = 0.023), microvascular thrombosis (p = 0.003), presence of infarction areas (p = 0.047) and of accelerated villous maturation (p = 0.005) showed higher frequencies in placentas delivered by women with COVID-19. Chronic villitis/VUE (p = 0.003) and accelerated villous maturation (p = 0.019) remained statistically significant by restricting the analysis to placentas delivered after a previous cesarean section. The observed differences in terms of pathological findings could be consistent with SARS-CoV-2 pathogenesis, but just a subset of alterations remained statistically significant after adjusting for a previous cesarean section. A careful consideration of potential confounders is warranted in future studies exploring the relationship between COVID-19 and pregnancy.

A critical review on SARS-CoV-2 infectivity in water and wastewater. What do we know?

The COVID-19 outbreak circulating the world is far from being controlled, and possible contamination routes are still being studied. There are no confirmed cases yet, but little is known about the infection possibility via contact with sewage or contaminated water as well as with aerosols generated during the pumping and treatment of these aqueous matrices. Therefore, this article presents a literature review on the detection of SARS-CoV-2 in human excreta and its pathways through the sewer system and wastewater treatment plants until it reaches the water bodies, highlighting their occurrence and infectivity in sewage and natural water. Research lines are still indicated, which we believe are important for improving the detection, quantification, and mainly the infectivity analyzes of SARS-CoV-2 and other enveloped viruses in sewage and natural water. In fact, up till now, no case of transmission via contact with sewage or contaminated water has been reported and the few studies conducted with these aqueous matrices have not detected infectious viruses. On the other hand, studies are showing that SARS-CoV-2 can remain viable, i.e., infectious, for up to 4.3 and 6 days in sewage and water, respectively, and that other species of coronavirus may remain viable in these aqueous matrices for more than one year, depending on the sample conditions. These are strong pieces of evidence that the contamination mediated by contact with sewage or contaminated water cannot be ruled out, even because other more resistant and infectious mutations of SARS-CoV-2 may appear.

No Evidence of Infectious SARS-CoV-2 in Human Milk: Analysis of a Cohort of 110 Lactating Women

BACKGROUND

SARS-CoV-2 infections of infants and toddlers are usually mild but can result in life-threatening disease. SARS-CoV-2 RNA been detected in the breast milk of lactating women, but the potential role of breastfeeding in transmission to infants has remained uncertain.

METHODS

Breast milk specimens were examined for the presence of the virus by RT-PCR and/or culture. Specimens that contained viral RNA (vRNA) were examined for the presence of subgenomic coronavirus RNA (sgRNA), a putative marker of infectivity. Culture methods were used to determine the thermal stability of SARS-CoV-2 in human milk.

RESULTS

Breast milk samples from 110 women (65 confirmed with a SARS-CoV-2 diagnostic test, 36 with symptoms but without tests, and 9 with symptoms but a negative SARS-CoV-2 diagnostic test) were tested by RT-PCR (285 samples) and/or viral culture (160 samples). Although vRNA of SARS-CoV-2 was detected in the milk of 7 of 110 (6%) women with either a confirmed infection or symptomatic illness, and in 6 of 65 (9%) of women with a positive SARS-CoV-2 diagnostic test, virus was not detected in any culture. None of the 7 milk specimens with detectable vRNA contained sgRNA. Notably, when artificially added to human milk in control experiments, infectious SARS-CoV-2 could be cultured despite several freeze-thaw cycles, as occurs in the storage and usage of human milk.

CONCLUSIONS

SARS-CoV-2 RNA can be found infrequently in the breastmilk of women with recent infection, but we found no evidence that breastmilk contains infectious virus or that breastfeeding represents a risk factor for transmission of infection to infants.

KEY POINTS

Question: SARS-CoV-2 RNA has been detected in a small number of human milk samples collected from recently infected women. The role of breastfeeding in transmission of the virus to infants has remained uncertain due to the small number of specimens analyzed in any study published thus far.Findings: In a total study group of 110 women, SARS-CoV-2 RNA was detected in milk from 6 of 65 women (9.2%) with recent confirmed infection. Neither infectious virus nor subgenomic RNA (a marker of virus infectivity) were detected in any of the samples.Meaning: We found no evidence that infectious SARS-CoV-2 is present milk from recently infected women, even if SARS-CoV-2 PCR tests are positive, providing reassurance of the safety of breastfeeding.

Coronavirus disease 2019 and first-trimester spontaneous abortion: a case-control study of 225 pregnant patients

Background

The disease caused by the severe acute respiratory syndrome coronavirus 2 was named coronavirus disease 2019 and classified as a global public health emergency. The evidence related to the impact of coronavirus disease 2019 on pregnancy is limited to the second and third trimester of pregnancy, whereas data on the first trimester are scant. Many viral infections can be harmful to the fetus during the first trimester of pregnancy, and whether severe acute respiratory syndrome coronavirus 2 is one of them is still unknown.

Objective

With this study, we evaluated severe acute respiratory syndrome coronavirus 2 infection as a risk factor for early pregnancy loss in the first trimester of pregnancy. Furthermore, coronavirus disease 2019 course in the first trimester was assessed.

Study Design

Between February 22 and May 21, 2020, we conducted a case-control study at S. Anna Hospital, Turin, among pregnant women in their first trimester, paired for last menstruation. The cumulative incidence of coronavirus disease 2019 was compared between women with spontaneous abortion (case group, n=100) and those with ongoing pregnancy (control group, n=125). Current or past infection was determined by the detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swab and severe acute respiratory syndrome coronavirus 2 immunoglobulin G and immunoglobulin M antibodies in a blood sample. Patient demographics, coronavirus disease 2019–related symptoms, and the main risk factors for abortion were collected.

Results

Of 225 women, 23 (10.2%) had a positive test result for coronavirus disease 2019. There was no difference in the cumulative incidence of coronavirus disease 2019 between the cases (11/100, 11%) and the controls (12/125, 9.6%) (P=.73). Logistic regression analysis confirmed that coronavirus disease 2019 was not an independent predictor of early pregnancy loss (odds ratio, 1.28; confidence interval, 0.53–3.08). Coronavirus disease 2019–related symptoms in the first trimester were fever, anosmia, ageusia, cough, arthralgia, and diarrhea; no cases of pneumonia or hospital admission owing to coronavirus disease 2019–related symptoms were recorded. No difference in the incidence of symptoms was noted between the 2 groups.

Conclusion

Severe acute respiratory syndrome coronavirus 2 infection during the first trimester of pregnancy does not seem to predispose to early pregnancy loss; its cumulative incidence did not differ between women with spontaneous abortion and women with ongoing pregnancy. Coronavirus disease 2019 appears to have a favorable maternal course at the beginning of pregnancy, consistent with what has been observed during the second and third trimesters.

Prenatal Biochemical and Ultrasound Markers in COVID-19 Pregnant Patients: A Prospective Case-Control Study

This prospective observational study aimed to evaluate whether women with SARS-CoV-2 infection during the first trimester of pregnancy are at higher risk of noninvasive prenatal screening test alterations and/or of congenital fetal anomalies at the second-trimester fetal anatomy scan. Maternal symptoms were secondly investigated. The study was carried out on 12-week pregnant women admitted for noninvasive prenatal testing (16 April and 22 June 2020). The cohort had seromolecular tests for SARS-CoV-2, after which they were divided into a positive case group and a negative control group. Both groups had 20-week ultrasound screening. Seventeen out of the 164 women tested positive for SARS-CoV-2 (10.3%). There were no significant differences in mean nuchal translucency thickness or biochemical markers (pregnancy-associated plasma protein A, alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol) between cases and controls (p = 0.77, 0.63, 0.30, 0.40, 0.28) or in the fetal incidence of structural anomalies at the second-trimester fetal anatomy scan (p = 0.21). No pneumonia or hospital admission due to COVID-19-related symptoms were observed. Asymptomatic or mildly symptomatic SARS-CoV-2 infection during the first trimester of pregnancy did not predispose affected women to more fetal anomalies than unaffected women. COVID-19 had a favorable maternal course at the beginning of pregnancy in our healthy cohort.

Healthy Aging in the Time of Corona Pandemic

BACKGROUND

The key considerations for healthy aging are diversity and inequity. Diversity means that there is no typical older person. Policy should be framed to improve the functional ability of all older people, whether they are robust, care dependent or in between.

OBJECTIVE

The aim of this article is to describe negative influence of Corona pandemic (COVID-19) for realization of the WHO project about Healthy Aging global strategy proposed in the targets "Health for all".

METHODS

Authors used descriptive model for this cross-sectional study based on facts in analyzed scientific literature deposited in on-line databases about healthy aging concept of the prevention and treatment of the people who will come or already came to the "third trimester of the life".

RESULTS AND DISCUSSION

Some 80-year-olds have levels of physical and mental capacity that compare favorably with 30-year-olds. Others of the same age may require extensive care and support for basic activities like dressing and eating. Policy should be framed to improve the functional ability of all older people, whether they are robust, care dependent or in between. Inequity reflects a large proportion (approximately 75%) of the diversity in capacity and circumstance observed in older age is the result of the cumulative impact of advantage and disadvantage across people's lives. Importantly, the relationships we have with our environments are shaped by factors such as the family we were born into, our sex, ethnicity, level of education and financial resources.

CONCLUSION

COVID-19 pandemic "celebrated" one year of existing in almost all countries in the world with very difficult consequences for whole population. But in the first risk group are old people who have in average 6 to 7 co-morbidities. WHO recommended some measures to improve prevention and treatment this category of population, but COVID-19 pandemic stopped full realization of Decade of Healthy Aging project.

Why Not Lose Faith in Science in the Fight Against Coronavirus

BACKGROUND

One of the most vulnerable group to cope with the consequences of COVID-19 pandemic are women, particularly pregnant ones.

OBJECTIVE

The aim of this article was to make review of the scientific literature to show clearly that pandemic is not so dangerous neither for mother nor her unborn and newborn children.

RESULTS AND DISCUSSION

It should be stated that most of the scientific papers on COVID-19 are currently being conducted in a way that would probably be completely unacceptable to serious science in any other circumstances. Taking into account everything we have learned about the SARS-CoV-2 virus so far it comes as a surprise that there has not been a more intense scientific debate on whether the blind lockdown model, implemented by most national governments, was truly an appropriate response to the challenges posed by the pandemic.

CONCLUSION

Deep analysis what science in perinatal medicine did assess and what it recommended to perinatal world it may be followed by principles that the research of the members of the Academy will not be the first to be published, but we certainly aim that the scientific evidence published by Academy is fast, reliable and implementable.

Maternal and Perinatal Outcomes in Patients with Suspected COVID-19 and Their Relationship with a Negative RT-PCR Result

This study was designed to examine maternal-perinatal outcomes in pregnant women with suspected coronavirus disease 2019 (COVID-19) according to the result of a real-time reverse transcription polymerase chain reaction (RT-PCR) test and to investigate possible variables that could be useful for predicting a negative RT-PCR result. Participants of this retrospective cohort study were obstetrics patients with suspected COVID-19 who underwent an RT-PCR test in a tertiary hospital in Madrid, Spain. Maternal-perinatal features were analysed according to the results of this test. Clinical, radiological and analytical characteristics that could be associated with a negative result were also explored. In a final subgroup analysis, patients were included if they had pneumonia and a negative test result for the virus. Out of the 111 obstetric patients with suspected COVID-19 that were enrolled, 38.7% returned a negative result. In this RT-PCR-negative group, we recorded lower rates of pneumonia (21.4% vs. 45.6%, p = 0.009), severe or critical clinical features (4.7% vs. 11.8% and 0.0% vs. 5.9%, p = 0.02, respectively), lower lactate dehydrogenase (LDH) levels (168 UI/L vs. 224.5 UI/L, p = 0.003), a greater need for maternal treatment (60.3% vs 24.4%, p < 0.001), a reduced need for oxygen therapy (2.4% vs 28.8%, p < 0.001) and a lower rate of intensive care unit admission (0.0% vs. 3.7%, p = 0.046) than the RT-PCR-positive group. While no differences were found in other variables, the monocyte count was higher (946.2/μL vs. 518.8/μL, p = 0.022) in this group. The predictive model for a negative test result included the monocyte count, LDH level and no need for oxygen therapy. This model was able to identify 73.5% of patients with a negative RT-PCR result. Only 11% of the patients with pneumonia testing negative for the virus had IgG antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The proportion of pregnant women with suspected COVID-19 and a negative RT-PCR result was nearly 39%. In these patients, the symptoms were mild and the systemic severity of the disease was lower. The monocyte count, LDH level and no need for oxygen therapy were the factors that were more related to a negative test result in this group. These variables could be used to guide the management of patients with suspected COVID-19, mainly while waiting for RT-PCR results or in settings where this test is not available.