What immunological and hormonal protective factors lower the risk of COVID-19 related deaths in pregnant women?

Genital Dysbiosis and Different Systemic Immune Responses Based on the Trimester of Pregnancy in SARS-CoV-2 Infection

Respiratory infections are common in pregnancy with conflicting evidence supporting their association with neonatal congenital anomalies, especially during the first trimester. We profiled cytokine and chemokine systemic responses in 242 pregnant women and their newborns after SARS-CoV-2 infection, acquired in different trimesters. Also, we tested transplacental IgG passage and maternal vaginal-rectal microbiomes. IgG transplacental passage was evident, especially with infection acquired in the first trimester. G-CSF concentration-involved in immune cell recruitment-decreased in infected women compared to uninfected ones: a beneficial event for the reduction of inflammation but detrimental to ability to fight infections at birth. The later the infection was acquired, the higher the systemic concentration of IL-8, IP-10, and MCP-1, associated with COVID-19 disease severity. All infected women showed dysbiosis of vaginal and rectal microbiomes, compared to uninfected ones. Two newborns tested positive for SARS-CoV-2 within the first 48 h of life. Notably, their mothers had acute infection at delivery. Although respiratory infections in pregnancy are reported to affect babies' health, with SARS-CoV-2 acquired early during gestation this risk seems low because of the maternal immune response. The observed vaginal and rectal dysbiosis could be relevant for neonatal microbiome establishment, although in our series immediate neonatal outcomes were reassuring.

Immunobiology of pregnancy: from basic science to translational medicine

Embryo implantation failure and spontaneous abortions represent the main causes of infertility in developed countries. Unfortunately, incomplete knowledge of the multiple factors involved in implantation and fetal development keeps the success rate of medically assisted procreation techniques relatively low. According to recent literature, cellular and molecular mechanisms of 'immunogenic tolerance' towards the embryo are crucial to establish an 'anti-inflammatory' state permissive of a healthy pregnancy. In this review we dissect the role played by the immune system in the endometrial-embryo crosstalk, with a particular emphasis towards the fork-head-box-p3 (Foxp3+) CD4+CD25+ regulatory T (Treg) cells and discuss the most recent therapeutic advances in the context of early immune-mediated pregnancy loss.

The immunological role of b7-h4 in pregnant women with sars-cov2 infection

Problem

T‐cells are key players in fighting the coronavirus disease 2019 (COVID‐19). The checkpoint molecule B7‐H4, a member of the B7 family, can inhibit T‐cell activation and proliferation by inhibiting NF‐kb expression. We aimed to elucidate the immunological role of soluble B7‐H4 (sB7‐H4) and B7‐H4 in pregnant women suffered from an acute Sars‐Cov2 infection.

Methods

Expression levels of sB7‐H4 and cytokines were detected by enzyme linked immunosorbent assay. B7‐H4 and cytokines mRNA expression was analyzed by qPCR, and B7‐H4 and NF‐κb (p65) protein levels were investigated by western blot and immunofluorescence staining in placenta chorionic villous and decidual basalis tissues of COVID‐19 affected women and healthy controls.

Results

Fibrinoid necrosis in the periphery of placental villi was increased in the COVID‐19‐affected patients. sB7‐H4 protein in maternal and cord blood serum and IL‐6/IL‐10 were increased while leukocytes were decreased during SARS‐CoV‐2 infection. Serum sB7‐H4 level was increased according to the severity of SARS‐Cov‐2 infection. Cytokines (IL‐6, IL‐18, IL‐1β, TNF‐α), B7‐H4 mRNA and protein in the decidual basalis tissues of COVID‐19‐infected pregnant women were significantly increased compared to healthy controls. IL‐18 and IL‐1β were significantly increased in the placenta chorionic villous samples of COVID‐19 affected patients, while NF‐κb (p65) expression was decreased.

Conclusions

The expression of the immunological marker sB7‐H4 correlated with the severity of COVID‐19 disease in pregnant women. sB7‐H4 and B7‐H4 can be used to monitor the progression of COVID‐19 infection during pregnancy, and for evaluating of the maternal immune status.

The percentage of CD39+ monocytes is higher in pregnant COVID-19+ patients than in nonpregnant COVID-19+ patients

Current medical guidelines consider pregnant women with COVID-19 to be a high-risk group. Since physiological gestation downregulates the immunological response to maintain “maternal-fetal tolerance”, SARS-CoV-2 infection may constitute a potentially threatening condition to both the mother and the fetus. To establish the immune profile in pregnant COVID-19+ patients, a cross-sectional study was conducted. Pregnant women with COVID-19 (P-COVID-19+; n = 15) were analyzed and compared with nonpregnant women with COVID-19 (NP-COVID-19+; n = 15) or those with physiological pregnancy (P-COVID-19-; n = 13). Serological cytokine and chemokine concentrations, leucocyte immunophenotypes, and mononuclear leucocyte responses to polyclonal stimuli were analyzed in all groups. Higher concentrations of serological TNF-α, IL-6, MIP1b and IL-4 were observed within the P-COVID-19+ group, while cytokines and chemokines secreted by peripheral leucocytes in response to LPS, IL-6 or PMA-ionomicin were similar among the groups. Immunophenotype analysis showed a lower percentage of HLA-DR+ monocytes in P-COVID-19+ than in P-COVID-19- and a higher percentage of CD39+ monocytes in P-COVID-19+ than in NP-COVID-19+. After whole blood polyclonal stimulation, similar percentages of T cells and TNF+ monocytes between groups were observed. Our results suggest that P-COVID-19+ elicits a strong inflammatory response similar to NP-COVID19+ but also displays an anti-inflammatory response that controls the ATP/adenosine balance and prevents hyperinflammatory damage in COVID-19.

COVID-19 tanısı konmuş gebe kadınlarda proinflamatuar IL-6 ve antiinflamatuar IL-10 sitokinlerinin etkileri

ÖZ Amaç: Çalışmamızda COVID-19 pozitif gebelerde serum interlökin-6 ve interlökin-10 düzeyleri ile hastalığın seyri arasındaki ilişkinin araştırılması amaçlandı. Yöntemler: Çalışmamızda 28 üçüncü trimester COVID-19 pozitif gebe ve 30 üçüncü trimester sağlıklı gebede serum IL-6 ve IL-10 düzeyleri ölçüldü. COVID-19 pozitif vakalar, taşıyıcı veya hasta olarak sınıflandırıldı. Çalışma grubundaki gebelerden 13'ü asemptomatik iken veya hafif hastalık nedeniyle takip edilirken; 7'si yoğun bakımda (YBÜ) olmak üzere toplam 15 hamile kadın hastaneye kaldırılarak tedavi altına alındı. COVID-19 pozitif gebe kadınların IL-6 ve IL-10 testleri ilk uygulama sırasında çalışıldı. Bulgular: COVID-19'lu 7 (%25) hastanın yoğun bakım ünitesine kabul edilmesi gerekti. COVID-19 negatif gebelerde IL-6 düzeyi, COVID-19 taşıyıcısı ve hasta gebelere göre anlamlı derecede düşük bulundu (p=0,01). COVID-19 negatif olan gebelerde IL-10 düzeyi, COVID-19 taşıyıcısı olan gebelere (p=0,002) ve hastalara (p=0,002) göre anlamlı derecede yüksek bulundu. Sonuç: Şüpheli veya doğrulanmış bir COVID-19 teşhisi ile başvuran hamile kadınlarda olumsuz sonuç riskini en aza indirmek için IL-6 ve IL-10 sitokin düzeylerinin yakından izlenmesi önerilir. Bu şekilde hamile kadınlarda orta-hafif COVID-19'u şiddetli COVID-19'dan ayırt etmek mümkün olabilir.

Pregnancy and the Risk of In-Hospital Coronavirus Disease 2019 (COVID-19) Mortality

OBJECTIVE

To evaluate whether pregnancy is an independent risk factor for in-hospital mortality among patients of reproductive age hospitalized with coronavirus disease 2019 (COVID-19) viral pneumonia.

METHODS

We conducted a retrospective cohort study (April 2020-May 2021) of 23,574 female inpatients aged 15-45 years with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code for COVID-19 discharged from 749 U.S. hospitals in the Premier Healthcare Database. We used a viral pneumonia diagnosis to select for patients with symptomatic COVID-19. The associations between pregnancy and in-hospital mortality, intensive care unit (ICU) admission, and mechanical ventilation were analyzed using propensity score-matched conditional logistic regression. Models were matched for age, marital status, race and ethnicity, Elixhauser comorbidity score, payer, hospital number of beds, season of discharge, hospital region, obesity, hypertension, diabetes mellitus, chronic pulmonary disease, deficiency anemias, depression, hypothyroidism, and liver disease.

RESULTS

In-hospital mortality occurred in 1.1% of pregnant patients and 3.5% of nonpregnant patients hospitalized with COVID-19 and viral pneumonia (propensity score-matched odds ratio [OR] 0.39, 95% CI 0.25-0.63). The frequency of ICU admission for pregnant and nonpregnant patients was 22.0% and 17.7%, respectively (OR 1.34, 95% CI 1.15-1.55). Mechanical ventilation was used in 8.7% of both pregnant and nonpregnant patients (OR 1.05, 95% CI 0.86-1.29). Among patients who were admitted to an ICU, mortality was lower for pregnant compared with nonpregnant patients (OR 0.33, 95% CI 0.20-0.57), though mechanical ventilation rates were similar (35.7% vs 38.3%, OR 0.90, 95% CI 0.70-1.16). Among patients with mechanical ventilation, pregnant patients had a reduced risk of in-hospital mortality compared with nonpregnant patients (0.26, 95% CI 0.15-0.46).

CONCLUSION

Despite a higher frequency of ICU admission, in-hospital mortality was lower among pregnant patients compared with nonpregnant patients with COVID-19 viral pneumonia, and these findings persisted after propensity score matching.

COVID-19 and tuberculosis co-infection in pregnancy - A case series and review

Various guidelines are in place for management for COVID-19 and pulmonary tuberculosis (PTB) in pregnancy. However, to the best of our knowledge, there are no significant guidelines for the management of COVID-19 and PTB co-infection in pregnancy. Pregnancy being an altered physiological state, the use of various drugs and their outcomes are altered. Here we present two cases of COVID-19 and PTB co-infection in pregnancy which were managed successfully.

Pregnancy and Birth Outcomes during the Early Months of the COVID-19 Pandemic: The MOACC-19 Cohort

The new coronavirus, SARS-CoV-2, is devastating for specific groups of patients, but currently there is not enough information concerning its effects on pregnant women. The purpose of this study is to identify the impact of SARS-CoV-2 infection on pregnancy and the consequences that it could cause. We studied a cohort of pregnant ladies who were tested for SARS-CoV-2 infection by RT-PCR and classified as infected or not infected. The recruitment was carried out in the HUMV hospital, a third-level hospital located in Santander, northern Spain. It started on 23 March 2020 and ended on 14 October 2020. Data from our cohort were compared to another cohort recruited in 2018 at the same hospital. We found that gestational hypertension, placental abruptio, and home exposure to an infected person, among other variables, could be associated with SARS-CoV-2 infection. In conclusion, we consider pregnant women a high-risk group of patients towards a possible SARS-CoV-2 infection, especially those who present with conditions such as gestational hypertension or obesity; moreover, we think that SARS-CoV-2 infection could increase the possibilities of having an abruptio placentae, although this result was found in only a few women, so it requires further confirmation.

Will prenatal exposure to SARS-CoV-2 define a birth cohort with accelerated aging in the century ahead?

The 1918 Influenza pandemic had long-term impacts on the cohort exposed in utero which experienced earlier adult mortality, and more diabetes, ischemic heart disease, and depression after age 50. It is possible that the Coronavirus Disease 2019 (COVID-19) pandemic will also have long-term impacts on the cohort that was in utero during the pandemic, from exposure to maternal infection and/or the stress of the pandemic environment. We discuss how COVID-19 disease during pregnancy may affect fetal and postnatal development with adverse impacts on health and aging. Severe maternal infections are associated with an exaggerated inflammatory response, thromboembolic events, and placental vascular malperfusion. We also discuss how in utero exposure to the stress of the pandemic, without maternal infection, may impact health and aging. Several recently initiated birth cohort studies are tracking neonatal health following in utero severe acute respiratory syndrome virus 2 (SARS-CoV-2) exposure. We suggest these cohort studies develop plans for longer-term observations of physical, behavioral, and cognitive functions that are markers for accelerated aging, as well as methods to disentangle the effects of maternal infection from stresses of the pandemic environment. In utero exposure to COVID-19 disease could cause developmental difficulties and accelerated aging in the century ahead. This brief review summarizes elements of the developmental origins of health, disease, and ageing and discusses how the COVID-19 pandemic might exacerbate such effects. We conclude with a call for research on the long-term consequences of in utero exposure to maternal infection with COVID-19 and stresses of the pandemic environment.

COVID-19 in Africa: an ovarian victory?

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) mainly attacks the respiratory system and is characterized by pneumonia, cytokine storm, coagulation disorders and severe immune downregulation. Although public health experts predicted worst outcomes in Africa, the incidence, hospitalization and mortality rates have been lower in Africa compared to other continents. Interestingly, lower incidence and mortality rates have been observed in women from Africa compared to their cohorts from other continents. Also, in the US non-Hispanic Black females have lower COVID-19 and death rates compared to their white counterparts. It's unclear why this significant difference exists; however, the ovarian function, genetics and immunological statuses could play a major role. Women of African descent have elevated levels of estrogen compared with Caucasians hence we anticipate that estrogen might offer some protection against the SARS-CoV-2 infections. The racial differences in lifestyle, age and inaccessibility to contraceptive usage might also play a role. Here, we provide insight on how the high levels of estrogen in African women might contribute to the lower cases and fatalities in Africa. Specifically, estrogen might offer protection against COVID-19 by suppressing hyper-production of cytokines, promoting anti-inflammatory cytokines, stimulating antibody production and suppressing endoplasmic reticulum (ER) stress. This will as well provide useful information on how future pandemics could be managed using Africa as a case study.

Immune Response to COVID-19 During Pregnancy

Pregnant women are generally more susceptible to viral infection. Although the impact of SARS-CoV-2 on pregnant women remains to be determined, evidence indicates that risks of adverse clinical outcomes are similar in pregnancy to the general population. Here we analyzed clinical symptoms and outcomes of 20 pregnant and 299 reproductive-aged non-pregnant female COVID-19 patients who were hospitalized during the same period. Laboratory measurements were compared among mild cases and healthy pregnant women. Our study found that pregnant patients showed enhanced innate immune response evident by higher neutrophils and C-reactive protein. Cytokines, chemokines, and growth factors (CCGFs) profiles from 11 pregnant and 4 non-pregnant COVID-19 patients and 10 healthy pregnant female patients, and lymphocyte subsets analysis of 7 pregnant patients and 19 non-pregnant patients, indicate suppressed cytokine storm and potential enhanced CD8+ T cell and NK cell activity in pregnant patients with COVID-19, which may be essential in contributing to the unique anti-SARS-CoV-2 response in pregnancy.

SARS-CoV-2 Infection in Pregnant Women: Neuroimmune-Endocrine Changes at the Maternal-Fetal Interface

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) has devastating effects on the population worldwide. Given this scenario, the extent of the impact of the disease on more vulnerable individuals, such as pregnant women, is of great concern. Although pregnancy may be a risk factor in respiratory virus infections, there are no considerable differences regarding COVID-19 severity observed between pregnant and nonpregnant women. In these circumstances, an emergent concern is the possibility of neurodevelopmental and neuropsychiatric harm for the offspring of infected mothers. Currently, there is no stronger evidence indicating vertical transmission of SARS-CoV-2; however, the exacerbated inflammatory response observed in the disease could lead to several impairments in the offspring's brain. Furthermore, in the face of historical knowledge on possible long-term consequences for the progeny's brain after infection by viruses, we must consider that this might be another deleterious facet of COVID-19. In light of neuroimmune interactions at the maternal-fetal interface, we review here the possible harmful outcomes to the offspring brains of mothers infected by SARS-CoV-2.

Chronic Active Hepatitis B with COVID-19 in Pregnancy: A Case Report

Currently, infection with coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), during pregnancy is a problem worthy of attention, especially in patients with underlying diseases. In this case report, we present a case of chronic active hepatitis B with COVID-19 in pregnancy. A 31-year-old woman at 29 weeks of gestation who had a history of chronic hepatitis B virus infection discontinued antiviral treatment, was admitted to the hospital with chronic active hepatitis B, and tested positive for SARS-CoV-2 infection. In this case, we applied liver protective and antiviral agents, and low-dose dexamethasone therapy to successfully treat the critically ill pregnant woman suffering from chronic active hepatitis B combined with COVID-19.

Sex and COVID-19: A Protective Role for Reproductive Steroids

Evidence shows coronavirus disease 2019 (COVID-19)-induced symptom severity and mortality is more frequent in men than in women, suggesting sex steroids may play a protective role. Female reproductive steroids, estrogen and progesterone, and its metabolite allopregnanolone, are anti-inflammatory, reshape competence of immune cells, stimulate antibody production, and promote proliferation and repair of respiratory epithelial cells, suggesting they may protect against COVID-19 symptoms.

Starting a regional collaborative research group for COVID-19 in pregnancy: the Southern Michigan experience

The outbreak of the SARS-CoV-2 elicited a surge in publications. Obstetric reports were with few exceptions characterized by small sample sizes with potentially limited generalizability. In this review, evidence suggests increased susceptibility to COVID-19 in pregnancy; common pregnancy comorbidities may help explain worse outcomes. While the risk of death is low, pregnancy may be associated with increased need for ventilation. Prematurity rates seem to be increased but may be accounted for in part by higher cesarean rates, to a large degree accounted for by elective decision to shorten the course of the labor. Though fetal/neonatal complication rates may be higher in the presence of COVID-19 infection, survival rates seem unaffected and vertical transmission is rare. As the outbreak continues in the USA with resurgence in many other western countries that achieved initial success in suppressing the virus, much remains to be learned. For example, the question related to the degree to pregnancy modifying symptomatology remains open. Currently, routine polymerase chain reaction testing remains limited by supply shortages possibly delaying diagnosis until later in the course of the disorder and thus altering the symptom complex at presentation. To add to the knowledge base, we initiated a regional COVID-19 in pregnancy collaborative observational study with a coordinating center, standardized data collection and a shared database. This was facilitated by a longstanding tradition of collaboration among regional obstetric services. Over an anticipated two-year study duration, we expect to study 400 documented and suspected COVID-19 pregnancies with time and site of services controls for cohort effect and high power to detect several adverse maternal/infant outcomes. We include a complete listing of variables in our database, which, along with our experience in setting up our regional collaborative, we hope and believe will be of use in other settings.