Importance of Inclusion of Pregnant and Breastfeeding Women in COVID-19 Therapeutic Trials

COVID-19 therapeutics for the pregnant patient

SARS-CoV-2 infection can cause severe disease among pregnant persons. Pregnant persons were not included in initial studies of therapeutics for COVID-19, but cumulative experience demonstrates that most are safe for pregnant persons and the fetus, and effective for prevention or treatment of severe COVID-19.

Remdesivir: treatment of COVID-19 in special populations

Remdesivir (RDV) is the mainstay antiviral therapy for moderate to severe COVID-19. Although remdesivir was the first drug approved for COVID-19, information about its efficacy and safety profile is limited in a significant segment of the population, such as people with underlying diseases, the elderly, children, and pregnant and lactating women. The efficacy and safety profile of RDV in disease progression, renal impairment, liver impairment, immunosuppression, geriatrics, pediatrics, pregnancy, and breastfeeding in COVID-19 patients was evaluated. The databases searched included Embase, Scopus, and PubMed. Only English language studies enrolling specific subpopulations with COVID-19 and treated with RDV were included. Thirty-nine clinical trials, cohorts, cross-sectional studies, and case series/reports were included. Most supported the benefits of RDV therapy for COVID-19 patients, such as lessening the duration of hospitalization, alleviating respiratory complications, and reducing mortality. Adverse effects of RDV, including liver and kidney impairment, were, for the most part, moderate to mild, supporting the safety profile of RDV therapy. RDV therapy was well tolerated, no new safety signals were detected, and liver function test abnormalities were the most common adverse events. Moreover, RDV, for the most part, was effective in managing the complications of COVID-19 and reducing mortality in these patients, except for patients with kidney impairment. Future studies, including RCTs, should include these subpopulations of patients to avoid delays associated with receiving proper medication through compassionate use programs.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

CLINICAL TRIALS

gov # NCT04410562, registered on June 1, 2020.

RESULTS

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

CONCLUSIONS

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

A Mother's Dilemma: The 5-P Model for Vaccine Decision-Making in Pregnancy

Pregnant women are a highly vaccine-resistant population and face unique circumstances that complicate vaccine decision-making. Pregnant women are also at increased risk of adverse maternal and neonatal outcomes to many vaccine-preventable diseases. Several models have been proposed to describe factors informing vaccine hesitancy and acceptance. However, none of these existing models are applicable to the complex decision-making involved with vaccine acceptance during pregnancy. We propose a model for vaccine decision-making in pregnancy that incorporates the following key factors: (1) perceived information sufficiency regarding vaccination risks during pregnancy, (2) harm avoidance to protect the fetus, (3) relationship with a healthcare provider, (4) perceived benefits of vaccination, and (5) perceived disease susceptibility and severity during pregnancy. In addition to these factors, the availability of research on vaccine safety during pregnancy, social determinants of health, structural barriers to vaccine access, prior vaccine acceptance, and trust in the healthcare system play roles in decision-making. As a final step, the pregnant individual must balance the risks and benefits of vaccination for themselves and their fetus, which adds greater complexity to the decision. Our model represents a first step in synthesizing factors informing vaccine decision-making by pregnant women, who represent a highly vaccine-resistant population and who are also at high risk for adverse outcomes for many infectious diseases.

Remdesivir Prescription in Pregnant Women Infected with COVID-19: A Report of Compassionate Use

Background

Coronavirus disease 2019 (COVID-19) is an infectious disease that the physiological changes in pregnancy can make pregnant patients more susceptible to more severe forms of this infection. Hence, the treatment of COVID-19 in pregnant women can be challenging. This study was designed to evaluate the safety and efficacy of Remdesivir in pregnant women with COVID-19.

Materials and Methods

This study was conducted on 150 pregnant women with moderate to severe COVID-19 infection. Remdesivir was prescribed and continued for 5 or 10 days according to the patient's condition. Maternal and pregnancy outcomes and also recovery rates were evaluated. Moreover, additional variables were examined: age, gestational age, symptoms, O2 saturation and laboratory tests at admission, the interval between symptom initiation and admission to hospital and Remdesivir prescription, hospitalization days, and ICU admission.

Results

The mean age was 32.37 years. Cough and dyspnea were the most prevalent symptoms (74% and 68.7%, respectively). At the time of admission, 79 (52.7%) women needed low-flow oxygen support, 67 (44.7%) needed high-flow oxygen support, and 4 (2.7%) were intubated. Fifty-four (36%) patients required ICU care. In patients who died (12 women), Remdesivir was prescribed later than those discharged (P value, 0.04). Patients with favorable pregnancy outcomes received Remdesivir earlier than those with unfavorable pregnancy outcomes (P value: 0.008). The recovery rate was 70% (89.9% in the low-flow oxygen, 50.7% in the NIPPV/high flow oxygen, and 0% in the intubated women).

Conclusion

The results suggest that the early prescription of Remdesivir in pregnant women with moderate COVID-19 can improve the outcomes.

A shared agenda for gender and COVID-19 research: priorities based on broadening engagement in science

While the acute and collective crisis from the pandemic is over, an estimated 2.5 million people died from COVID-19 in 2022, tens of millions suffer from long COVID and national economies still reel from multiple deprivations exacerbated by the pandemic. Sex and gender biases deeply mark these evolving experiences of COVID-19, impacting the quality of science and effectiveness of the responses deployed. To galvanise change by strengthening evidence-informed inclusion of sex and gender in COVID-19 practice, we led a virtual collaboration to articulate and prioritise gender and COVID-19 research needs. In addition to standard prioritisation surveys, feminist principles mindful of intersectional power dynamics underpinned how we reviewed research gaps, framed research questions and discussed emergent findings. The collaborative research agenda-setting exercise engaged over 900 participants primarily from low/middle-income countries in varied activities. The top 21 research questions included the importance of the needs of pregnant and lactating women and information systems that enable sex-disaggregated analysis. Gender and intersectional aspects to improving vaccine uptake, access to health services, measures against gender-based violence and integrating gender in health systems were also prioritised. These priorities are shaped by more inclusive ways of working, which are critical for global health as it faces further uncertainties in the aftermath of COVID-19. It remains imperative to address the basics in gender and health (sex-disaggregated data and sex-specific needs) and also advance transformational goals to advance gender justice across health and social policies, including those related to global research.

Pregnant women's knowledge about and beliefs toward COVID-19 vaccine: a cross-sectional study

Purpose

The aim of this study was to determine the scope of knowledge, attitudes, and behaviors of pregnant women about the coronavirus disease 2019 (COVID-19) vaccine.

Materials and Methods

A total of 886 pregnant women were recruited for the study. A cross-sectional questionnaire was conducted on these selected participants. Data about past infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), SARS-CoV-2 infection of closely related people, and deaths due to COVID-19 among their relatives were questioned.

Results

The rate of vaccination was higher (64.1%) in pregnant women with higher education levels. Informing about the vaccine, especially by health professionals, showed that the rates of vaccination (25%) increased (p<0.001). In addition, a significant increase was observed in vaccination rates with increasing age and financial income (p<0.001).

Conclusion

The main limitation of our study is that the vaccine, which was approved for "emergency use", was just started to be administered to pregnant women during the study. Our findings show that our target audience, low-income, low-education, younger pregnant women should be given more attention than those who apply to the doctor for routine follow-up.

A medication-wide association study (MWAS) on repurposed drugs for COVID-19 with Pre-pandemic prescription medication exposure and pregnancy outcomes

Information on effects of medication therapies during pregnancy is lacking as pregnant patients are often excluded from clinical trials. This retrospective study explores the potential of using electronic health record (EHR) data to inform safety profiles of repurposed COVID medication therapies on pregnancy outcomes using pre-COVID data. We conducted a medication-wide association study (MWAS) on prescription medication exposures during pregnancy and the risk of cesarean section, preterm birth, and stillbirth, using EHR data between 2010-2017 on deliveries at PennMedicine. Repurposed drugs studied for treatment of COVID-19 were extracted from ClinicalTrials.gov (n = 138). We adjusted for known comorbidities diagnosed within 2 years prior to birth. Using previously developed medication mapping and delivery-identification algorithms, we identified medication exposure in 2,830 of a total 63,334 deliveries; from 138 trials, we found 31 medications prescribed and included in our cohort. We found 21 (68%) of the 31 medications were not positively associated with increased risk of the outcomes examined. With caution, these medications warrant potential for inclusion of pregnant individuals in future studies, while drugs found to be associated with pregnancy outcomes require further investigation. MWAS facilitates hypothesis-driven evaluation of drug safety across all prescription medications, revealing potential drug candidates for further research.

Knowledge, attitude, and determinants of exclusive breastfeeding during COVID-19 pandemic among lactating mothers in Mekelle, Tigrai: a cross sectional study

Background

Due to the nutritive and immunologic benefits of breastmilk, children should be exclusively breastfed for the first 6 months of life, even during the corona virus pandemic. However, fear of transmission risk and pandemic-related restrictions could undermine the practice of breastfeeding. This study aimed to assess the knowledge, attitude, and determinants of exclusive breastfeeding (EBF) during COVID-19 among lactating mothers in Mekelle, Tigrai, Ethiopia.

Methods

A community based cross-sectional study was conducted among 621 lactating mothers living in Mekelle city, Tigrai, from April to June, 2021. Data were collected using an adapted form of a standard KAP questionnaire. Binary logistic regression was used to determine the independent determinants of EBF at a statistical significance of p < 0.05. The strength of the association was measured by odds ratio and 95% confidence interval.

Results

Four hundred (64.4%) mothers exclusively breastfed their children. Infants from female-headed households had twice (AOR 2.21; 95% CI 1.31, 3.71) higher odds of EBF. Higher educational status was associated with higher odds of EBF practice. A unit increase in parity was associated with a 23% increase in the odds of EBF. Mothers who received breastfeeding information had a 73% (AOR 1.73; 95% CI 1.17, 2.56) higher odds of EBF. Moreover, mothers with high knowledge score and positive attitude showed a 74% higher (AOR 1.74; 95% CI 1.20, 2.51) and more than double (AOR 2.35; 95% CI 1.50, 3.70) odds of EBF, respectively.

Conclusion

About two-thirds of the mothers practiced EBF. Household head, maternal educational, parity, breastfeeding information, knowledge of breastfeeding, and attitude towards EBF were significant determinants of EBF. Our study findings highlighted that programs that enhance women’s participation in education and decision-making could improve EBF practice. Besides, during the COVID-19 pandemic, providing lactating mothers with adequate and up-to-date breastfeeding information could be significant in improving EBF practice.

SARS-CoV-2 vaccine uptake and reasons for hesitancy among Canadian pregnant people: a prospective cohort study

BACKGROUND

Several vaccines against SARS-CoV-2 have been developed and approved at an unparalleled speed. Given that SARS-CoV-2 vaccines are recommended to pregnant people, our aim was to quantify vaccination uptake, and describe vaccination hesitancy and behavioural attitudes surrounding SARS-CoV-2 vaccination in pregnancy in Canada.

METHODS

The CONCEPTION study is an ongoing international study started in June 2020, evaluating the impact of the COVID-19 pandemic on the health of pregnant people and their children. For this study, pregnant people recruited from Apr. 20, 2021, to Feb. 8, 2022, and residing in Canada were invited to complete a Web-based survey. In addition to all CONCEPTION variables, data on vaccine uptake as well as personal knowledge of COVID-19 severity in pregnancy and of SARS-CoV-2 vaccine safety and efficacy were collected. Marginal risk differences and adjusted odds ratios (ORs) were calculated to assess determinants of SARS-CoV-2 vaccination during pregnancy.

RESULTS

From Apr. 20, 2021, to Feb. 8, 2022, 603 pregnant people were recruited and gave consent, of which 83.7% (n = 505) were vaccinated and 16.3% (n = 98) were not vaccinated against SARS-CoV-2. Uptake of the influenza vaccine in 2020/21 was a significant predictor of being vaccinated against SARS-CoV-2 or intention to be vaccinated (marginal risk difference 3.2%, 95% confidence interval [CI] 3.0% to 3.3%, adjusted OR 4.43, 95% CI 2.32 to 9.25), and being employed (marginal risk difference 11.2%, 95% CI 10.6% to 11.9%, adjusted OR 2.17, 95% CI 1.03 to 4.35) increased the likelihood of being vaccinated against SARS-CoV-2. Self-assessed knowledge of COVID-19 severity and vaccine efficacy was not associated with vaccine uptake.

INTERPRETATION

Among the Canadian pregnant people who responded to this study, vaccine uptake against SARS-CoV-2 was high. However, our results underscore the importance of improving knowledge transfer about the efficacy of SARS-CoV-2 vaccines in pregnancy to guide vaccination efforts.

Effect of IMB Model Combined with Spousal Support Breastfeeding Intervention on PBSES Score and Breastfeeding Rate of Primipara with Chronic Hepatitis B Virus Infection

Objective

To analyze the effects of the info-motivation-behavior skills (IMB) model combined with spousal support breastfeeding intervention on breastfeeding Self-Efficacy Scale (PBSES) scores and breastfeeding rate of primiparas with chronic hepatitis B virus (HBV) infection.

Methods

Seventy-four first-term pregnant women and 74 of their spouses were selected as the traditional control group by the convenience sampling method from July to September 2021 in obstetrics department of Shenzhen Third People's Hospital. 74 pregnant women with their first child and 74 spouses who had their first child checked during October to December 2021 were classified as the IMB model group. The traditional control group was applied with conventional intervention management mode, and the IMB model group was applied with intervention management mode based on IMB theory on the basis of the traditional control group. The self-efficacy scores of breastfeeding before and after intervention during pregnancy and during hospitalization were compared between the two groups, and the self-efficacy scores of paternal support for breastfeeding were compared. The exclusive breastfeeding rate of infants within 6 months and the maternal breastfeeding knowledge level of the two groups were compared, and the correlation between maternal breastfeeding self-efficacy score and feeding knowledge level was analyzed.

Results

After pregnancy intervention, PBSES and FBSES-SF scores were significantly increased in both groups, and scores of scales in the IMB model group increased significantly than the traditional control group (all P < 0.05). The BSES-SF and FBSES-SF scores of the IMB model group increased significantly than the traditional control group at 3 days after delivery and at discharge (P < 0.05), and the scores of each scale at discharge in both groups increased significantly than those at 3 days after delivery (P < 0.05). The rate of exclusive breastfeeding in the IMB model group was 94.59% (70/74), and that in the traditional control group was 78.38% (58/74). There was a significant difference (χ2 = 8.325, P = 0.004). At discharge, the score of maternal breastfeeding knowledge increased significantly in both groups, and the score of the IMB model group increased significantly than that of the traditional control group (all P < 0.05). Pearson correlation coefficient was used to analyze the correlation between PBSES score, FBSES-SF score, and maternal feeding knowledge level, which showed positive correlation (all P < 0.05).

Conclusion

The self-efficacy of prenatal breastfeeding in pregnant women with HBV is low, and the application of the IMB model combined with the intervention mode of spy-supported breastfeeding has positive effects on the improvement of maternal breastfeeding efficiency, breastfeeding health knowledge level, and postpartum breastfeeding rate, which is worthy of clinical promotion and application.

Data-driven commentary on SARS-CoV-2 infection, vaccination, and fertility

A recent study by Wesselink et al. (Am J Epidemiol. 2022 Jan 20;kwac011. doi: 10.1093/aje/kwac011. Online ahead of print) adds to the growing body of research finding that vaccination for coronavirus disease 2019 (COVID-19) is safe for individuals either seeking pregnancy or who are pregnant. The study's authors found no effect of COVID-19 vaccination on fecundity in a population of individuals with no known infertility who were attempting conception. The finding reinforces the messaging of the American Society for Reproductive Medicine COVID-19 Task Force, the aim of which is to provide data-driven recommendations to individuals contemplating pregnancy in the face of the COVID-19 pandemic. As safe and effective COVID-19 vaccines became available, and with an increasing number of studies showing a heightened risk of severe disease during pregnancy, an important role of the Task Force is to encourage vaccination during the preconceptual window and in early pregnancy. The Task Force supports ongoing research to address gaps in knowledge about safe and effective therapies and preventive measures for individuals contemplating pregnancy and during pregnancy. Such research will help optimize care for reproductive-age individuals in the face of current and future health crises.

Data-Driven Commentary on SARS-CoV-2 Infection, Vaccination, and Fertility

A recent study by Wesselink et al. (Am J Epidemiol. 2022;191(8):1383-1395) adds to the growing body of research finding that vaccination for coronavirus disease 2019 (COVID-19) is safe for individuals either seeking pregnancy or who are pregnant. The study's authors found no effect of COVID-19 vaccination on fecundity in a population of individuals with no known infertility who were attempting conception. The finding reinforces the messaging of the American Society for Reproductive Medicine COVID-19 Task Force, the aim of which is to provide data-driven recommendations to individuals contemplating pregnancy in the face of the COVID-19 pandemic. As safe and effective COVID-19 vaccines became available, and with an increasing number of studies showing a heightened risk of severe disease during pregnancy, an important role of the Task Force is to encourage vaccination during the preconceptual window and in early pregnancy. The Task Force supports ongoing research to address gaps in knowledge about safe and effective therapies and preventive measures for individuals contemplating pregnancy and during pregnancy. Such research will help optimize care for reproductive-age individuals in the face of current and future health crises.

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.

COVID-19 and pregnancy: Lessons from 2020

The outbreak and spread of the coronavirus disease 2019 pandemic has led to an unprecedented wealth of literature on the impact of human coronaviruses on pregnancy. The number of case studies and publications alone are several orders of magnitude larger than those published in all previous human coronavirus outbreaks combined, enabling robust conclusions to be drawn from observations for the first time. However, the importance of learning from previous human coronavirus outbreaks cannot be understated. In this narrative review, we describe what we consider to the major learning points arising from the SARS-CoV-2 pandemic in relation to pregnancy, and where these confound what might have been expected from previous coronavirus outbreaks.

Impact of SARS-CoV-2 on pregnancy outcomes (Review)

The impact of the pandemic outbreak associated with coronavirus 2019 disease (COVID-19) on pregnant women is of interest to obstetricians and gynecologists due to the vulnerability of this target group. In pregnant women and their infants, an exceptional clinical management is warranted. Current epidemiological findings provide information regarding the effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on pregnant patients and potential adverse perinatal outcomes. Overall, these findings are a strong indication that an increased antenatal surveillance for pregnant patients infected with COVID-19 is warranted. The aim of the present narrative review was to summarize the data obtained to date regarding the health of women during pregnancy, as well as that of the fetus associated with the risk of severe infection due to COVID-19. The present review aimed to provide further insight into the effects of this pandemic on pregnancy, also providing the experience of the authors on this matter as an example.

Acceptability of Clinical Trials on COVID-19 during Pregnancy among Pregnant Women and Healthcare Providers: A Qualitative Study

Participation of pregnant women in clinical trials entails challenges mainly related to concerns about the risks for fetuses. We undertook a qualitative study from June to October 2020 to assess the acceptability of participating in COVID-19 clinical trials among pregnant women in Spain. Phenomenology and grounded theory were used as methodological approaches. Semi-structured interviews were conducted with 24 pregnant women and six healthcare providers. Women were unsure if pregnancy was a risk factor to acquire the infection or to develop severe disease and expressed the limited information they had received, which led to uncertainties and emotional suffering. They had concerns regarding participation in clinical trials on COVID-19, regardless of the drug under study. Healthcare providers alluded to the importance of involving pregnant women’s relatives at the recruitment visit of the clinical trial. These findings may be useful to facilitate pregnant women’s participation in clinical trials.

Physician experiences in management of COVID-19-associated coagulopathy in pregnancy: Communication from the ISTH SSC Subcommittee on Women's Health Issues in Thrombosis and Haemostasis

BACKGROUND

Coronavirus disease 2019 (COVID-19) occurs following infection with the potentially fatal, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus. Infection can be complicated by coagulopathy, at times featuring thrombocytopenia and thrombosis alongside other coagulation abnormalities, also termed COVID-19-associated coagulopathy (CAC). Data concerning CAC in pregnancy are limited. Better understanding of physician experiences is essential to identify current practice patterns and knowledge gaps.

OBJECTIVES

To determine physician experiences and practice patterns regarding CAC in pregnancy.

METHODS

Self-administered survey using the RedCap online platform; supported by the ISTH Subcommittee on Women's Health Issues in Thrombosis and Hemostasis.

RESULTS

Seventy-five respondents fully or partially completed the survey. Of 1546 reported cases, disease severity was specified in 1298. Sixty-four percent of COVID-19 infections were mild, whereas 4% were severe. Of all cases, 1% developed CAC, with 65% classified as severe. The most frequent abnormalities included thrombocytopenia, elevated C-reactive protein, D-dimer, and lymphopenia. Low molecular weight heparin was the anticoagulant of choice in CAC and was provided by 77% of respondents, with 60% using standard prophylactic dosing. Thrombosis occurred in seven anticoagulated patients who were receiving standard prophylactic (four) or weight-based (three) dosing. Disease severity and additional thrombosis risk factors dictated anticoagulation duration.

CONCLUSION

In the select population reported by our survey, CAC appears to be uncommon in pregnancy. Anticoagulation practices vary and may not reflect current guidelines. Venous thromboembolism was observed in some CAC patients despite prophylactic anticoagulation (including standard and weight-adjusted dosing). Urgent research is required to determine appropriate anticoagulant dosing and duration in pregnant women with COVID-19 infection.

Maternal and Child Symptoms Following COVID-19 Vaccination Among Breastfeeding Mothers

Background: The impact of COVID-19 vaccination on breastfeeding is unknown. The primary aim of this study was to determine whether vaccine-related side effects following COVID-19 vaccination were associated with an adverse impact on breastfeeding. Secondarily, we sought to determine perceived symptoms in breastfed children and maternal opinion about COVID-19 vaccination. Materials and Methods: We conducted a cross-sectional survey of breastfeeding mothers who underwent COVID-19 vaccination >2 days before the survey. Subjects were recruited through social media and websites. Data included sociodemographic information, vaccine history, maternal and child symptoms, and impact on lactation/breastfeeding. Bivariate statistics (chi-square, Wilcoxon rank sum, and t tests) and multivariable logistic regression models examined the association of vaccine side effects with lactation, symptoms in breastfed children, and maternal opinion on vaccination. Results: Analysis included 4,455 breastfeeding mothers. Maternal postvaccination symptoms were more common after the second dose (p < 0.001). Overall, 77 (1.7%) respondents reported a negative impact on breastfeeding postvaccination, and these mothers were more likely to have experienced fatigue, headache, muscle pain, injection site pain, chills, fever, or allergic reactions. After adjusting for confounding variables, higher odds of an adverse impact on lactation were associated with lower breastfeeding intensity, dose of vaccine, and child symptoms. Even among mothers who reported an adverse impact on breastfeeding, maternal opinion about vaccination and confidence in their decision to receive the COVID-19 vaccine were high. Conclusions: COVID-19 vaccination among breastfeeding mothers resulted in minimal disruption of lactation or adverse impact on the breastfed child. These findings may be considered in vaccination decision-making.

Responsible Inclusion of Pregnant Individuals in Eradicating HCV

HCV infections have increased in recent years due to injection drug use and the opioid epidemic. Simultaneously, HCV cure has become a reality, with the advent of direct-acting antivirals (DAAs) and expansion of treatment programs. As a result, HCV screening recommendations now include all adults, including pregnant individuals; and many countries have endorsed widespread DAA access as a strategy to achieve HCV eradication. However, almost universally, pregnant individuals have been systematically excluded from HCV clinical research and treatment programs. This omission runs counter to public health strategies focused on elimination of HCV but is consistent with a historical pattern of exclusion of pregnant individuals from research. Our systematic review of publications on HCV treatment with DAAs in pregnancy revealed only one interventional study, which evaluated sofosbuvir/ledipasvir in 8 pregnant individuals. Given the paucity of research on this issue of great public health importance, we aimed to appraise the current landscape of HCV research/treatment and analyze the ethical considerations for responsibly including pregnant individuals. We propose that pregnancy may be an opportune time to offer HCV treatment given improved access, motivation, and other health care monitoring occurring in the antenatal period. Moreover, treatment of pregnant individuals may support the goal of eliminating perinatal HCV transmission and overcome the established challenges with transitioning care after delivery. The exclusion of pregnant individuals without justification denies them and their offspring access to potential health benefits, raising justice concerns considering growing data on DAA safety and global efforts to promote equitable and comprehensive HCV eradication. Finally, we propose a path forward for research and treatment programs during pregnancy to help advance the goal of HCV elimination.

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.

Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State

BACKGROUND

Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown.

OBJECTIVE

This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality.

STUDY DESIGN

Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery.

RESULTS

The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001).

CONCLUSION

Coronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.

COVID-19 Gender Disparities and Mitigation Recommendations: A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic has rapidly created widespread impacts on global health and the economy. Data suggest that women are less susceptible to severe illness. However, sex-disaggregated data are incomplete, leaving room for misinterpretation, and focusing only on biologic sex underestimates the gendered impact of the pandemic on women. This narrative review summarizes what is known about gender disparities during the COVID-19 pandemic and the economic, domestic, and health burdens along with overlapping vulnerabilities related to the pandemic. In addition, this review outlines recommended strategies that advocacy groups, community leaders, and policymakers should implement to mitigate the widening gender disparities related to COVID-19.

The Impact of Epidemiology on Fertility and Prenatal Care During the COVID-19 Pandemic

The emergence of the novel coronavirus disease 2019 (COVID-19) presented the field of reproductive medicine with many challenges due to an absence of data to guide clinical decision-making and inform patient counseling and management in the early days of the pandemic. Epidemiological studies rapidly filled key gaps in our understanding of the susceptibility of reproductive-aged women to the virus, transmission dynamics during pregnancy and lactation, and the effect of infection during the prenatal, pregnancy, and postpartum periods. This data guided the development of clinical guidelines written by the American Society for Reproductive Medicine as patients and clinicians navigated reproductive decisions during a time of uncertainty. We present a review of epidemiologic studies published between March and December 2020 that have directly informed prenatal and fertility care during the COVID-19 pandemic. Despite a significant increase in our knowledge base over the past year, many questions remain about the impact of COVID-19 on conception, pregnancy, fetal development, and lactation. In the future, a commitment toward inclusion of pregnant persons and those attempting pregnancy in the design of observational and interventional trials is necessary to gain earlier insights about outcomes and assist providers and patients in making data-driven decisions.

The coronavirus disease 2019 vaccine in pregnancy: risks, benefits, and recommendations

The coronavirus disease 2019 has caused over 2 million deaths worldwide, with over 412,000 deaths reported in Unites States. To date, at least 57,786 pregnant women in the United States have been infected, and 71 pregnant women have died. Although pregnant women are at higher risk of severe coronavirus disease 2019-related illness, clinical trials for the available vaccines excluded pregnant and lactating women. The safety and efficacy of the vaccines for pregnant women, the fetus, and the newborn remain unknown. A review of maternal and neonatal coronavirus disease 2019 morbidity and mortality data along with perinatal vaccine safety considerations are presented to assist providers with shared decision-making regarding vaccine administration for this group, including the healthcare worker who is pregnant, lactating, or considering pregnancy. The coronavirus disease 2019 vaccine should be offered to pregnant women after discussing the lack of safety data, with preferential administration for those at highest risk of severe infection, until safety and efficacy of these novel vaccines are validated.

COVID-19 vaccine acceptance in pregnant women

Objective

To determine vaccine acceptance and hesitancy attitudes toward coronavirus disease 2019 (COVID‐19) vaccines in pregnant women.

Methods

Three hundred pregnant women were surveyed face to face with 40 questions. Sociodemographic characteristics, vaccination history, perception of risk for the COVID‐19 pandemic, the impact of the COVID‐19 pandemic, and acceptance of and attitude toward future COVID‐19 vaccination were prospectively evaluated.

Results

Among all participants, 111 (37%) stated their intent to receive the vaccine if it were recommended for pregnant women. Most common refusal reasons were lack of data about COVID‐19 vaccine safety in pregnant populations and possibility of harm to the fetus. There was a weak positive correlation between COVID‐19 vaccine acceptancy and number of school‐age children. Pregnant women in the first trimester expressed higher acceptance of COVID‐19 vaccination than those in the second and third trimesters.

Conclusion

The present study reported low acceptance of COVID‐19 vaccination in a sample of pregnant women. Concern about vaccine safety was the major reason for hesitancy. Identifying attitudes among priority groups will be useful for creating vaccination strategies that increase uptake during the current pandemic.

Identifying attitudes among priority groups like pregnant women will be useful to create vaccination strategies in the prevention and control of COVID‐19.

Pregnant in the United States in the COVID-19 pandemic: A collision of crises we cannot ignore

NO abstract intended, Introduction is listed here The COVID-19 pandemic and call for social justice is occurring when the United States, unlike its peer countries, has already experienced a steady 20-year rise in maternal morbidity and mortality with pregnant women today facing a 50 percent higher risk of mortality than their mothers. 1 Most vulnerable are women of color, black and American Indian/Alaska Native women, who have experienced longstanding disparities in access to and quality of healthcare and may begin pregnancy with hypertension, diabetes, and obesity, complications known to be more common in women enduring segregation. 2–4 Initially, the race-related health disparities and resultant disproportionately higher rates of COVID-19 cases and mortality in indigenous communities and black, latinx, or other communities of color were mistakenly considered innate racial differences. More recently, these higher rates have been attributed to underlying social, structural, and environmental determinants of health including resource inequities, inadequate housing, and occupational and environmental hazards that result in greater exposure to and less protection from COVID-19. 5,6 Augmented by the added physiologic stress of pregnancy, these comorbidities and disparities compound the risk of pregnancy-associated cardiomyopathy, thromboembolism, and hemorrhage, often resulting in lasting physical and mental health consequences.

Remdesivir in a pregnant patient with COVID-19 pneumonia

Remdesivir is an antiviral drug currently being studied as a potential treatment of pneumonia caused by infection with SARS-CoV-2. The Adaptive Covid-19 Treatment Trial (ACTT-1) by NIH and the SIMPLE study by Gilead Sciences are two major trials that showed promising results of Remdesivir in the non-pregnant population. We are presenting the case of a pregnant patient who was diagnosed with COVID-19 pneumonia and successfully treated with Remdesivir.

Clinical characteristics of 46 pregnant women with a severe acute respiratory syndrome coronavirus 2 infection in Washington State

BACKGROUND

The impact of coronavirus disease 2019 on pregnant women is incompletely understood, but early data from case series suggest a variable course of illness from asymptomatic or mild disease to maternal death. It is unclear whether pregnant women manifest enhanced disease similar to influenza viral infection or whether specific risk factors might predispose to severe disease.

OBJECTIVE

To describe maternal disease and obstetrical outcomes associated with coronavirus disease 2019 in pregnancy to rapidly inform clinical care.

STUDY DESIGN

This is a retrospective study of pregnant patients with a laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection from 6 hospital systems in Washington State between Jan. 21, 2020, and April 17, 2020. Demographics, medical and obstetrical history, and coronavirus disease 2019 encounter data were abstracted from medical records.

RESULTS

A total of 46 pregnant patients with a severe acute respiratory syndrome coronavirus 2 infection were identified from hospital systems capturing 40% of births in Washington State. Nearly all pregnant individuals with a severe acute respiratory syndrome coronavirus 2 infection were symptomatic (93.5%, n=43) and the majority were in their second or third trimester (43.5% [n=20] and 50.0% [n=23], respectively). Symptoms resolved in a median of 24 days (interquartile range, 13-37). Notably, 7 women were hospitalized (16%) including 1 admitted to the intensive care unit. A total of 6 cases (15%) were categorized as severe coronavirus disease 2019 with nearly all patients being either overweight or obese before pregnancy or with asthma or other comorbidities. Of the 8 deliveries that occurred during the study period, there was 1 preterm birth at 33 weeks' gestation to improve pulmonary status in a woman with class III obesity, and 1 stillbirth of unknown etiology.

CONCLUSION

Severe coronavirus disease 2019 developed in approximately 15% of pregnant patients and occurred primarily in overweight or obese women with underlying conditions. Obesity and coronavirus disease 2019 may synergistically increase risk for a medically indicated preterm birth to improve maternal pulmonary status in late pregnancy. These findings support categorizing pregnant patients as a higher-risk group, particularly those with chronic comorbidities.

Compassionate Use of Remdesivir in Pregnant Women with Severe Covid-19

Background

Remdesivir is efficacious for severe coronavirus disease 2019 (COVID-19) in adults, but data in pregnant women are limited. We describe outcomes in the first 86 pregnant women with severe COVID-19 who were treated with remdesivir.

Methods

The reported data span 21 March to 16 June 2020 for hospitalized pregnant women with polymerase chain reaction–confirmed severe acute respiratory syndrome coronavirus 2 infection and room air oxygen saturation ≤94% whose clinicians requested remdesivir through the compassionate use program. The intended remdesivir treatment course was 10 days (200 mg on day 1, followed by 100 mg for days 2–10, given intravenously).

Results

Nineteen of 86 women delivered before their first dose and were reclassified as immediate “postpartum” (median postpartum day 1 [range, 0–3]). At baseline, 40% of pregnant women (median gestational age, 28 weeks) required invasive ventilation, in contrast to 95% of postpartum women (median gestational age at delivery 30 weeks). By day 28 of follow-up, the level of oxygen requirement decreased in 96% and 89% of pregnant and postpartum women, respectively. Among pregnant women, 93% of those on mechanical ventilation were extubated, 93% recovered, and 90% were discharged. Among postpartum women, 89% were extubated, 89% recovered, and 84% were discharged. Remdesivir was well tolerated, with a low incidence of serious adverse events (AEs) (16%). Most AEs were related to pregnancy and underlying disease; most laboratory abnormalities were grade 1 or 2. There was 1 maternal death attributed to underlying disease and no neonatal deaths.

Conclusions

Among 86 pregnant and postpartum women with severe COVID-19 who received compassionate-use remdesivir, recovery rates were high, with a low rate of serious AEs.

A Systematic Review of Treatment and Outcomes of Pregnant Women With COVID-19-A Call for Clinical Trials

BACKGROUND

Data pertaining to COVID-19 in pregnancy are limited; to better inform clinicians, we collated data from COVID-19 cases during pregnancy and summarized clinical trials enrolling this population.

METHODS

We performed a systematic literature review of PubMed/MEDLINE to identify cases of COVID-19 in pregnancy or the postpartum period and associated outcomes. We then evaluated the proportion of COVID-19 clinical trials (from ClinicalTrials.gov) excluding pregnant or breastfeeding persons (both through June 29, 2020).

RESULTS

We identified 11 308 published cases of COVID-19 during pregnancy. Of those reporting disease severity, 21% (416/1999) were severe/critical. Maternal and neonatal survival were reassuring (98% [10 437/10 597] and 99% [1155/1163], respectively). Neonatal disease was rare, with only 41 possible cases of infection reported in the literature. Of 2351 ongoing COVID-19 therapeutic clinical trials, 1282 were enrolling persons of reproductive age and 65% (829/1282) excluded pregnant persons. Pregnancy was an exclusion criterion for 69% (75/109) of chloroquine/hydroxychloroquine, 80% (28/35) of lopinavir/ritonavir, and 48% (44/91) of convalescent plasma studies. We identified 48 actively recruiting or completed drug trials reporting inclusion of this population.

CONCLUSIONS

There are limited published reports of COVID-19 in pregnancy despite more than 14 million cases worldwide. To date, clinical outcomes appear reassuring, but data related to important long-term outcomes are missing or not yet reported. The large number of clinical trials excluding pregnant persons, despite interventions with safety data in pregnancy, is concerning. In addition to observational cohort studies, pregnancy-specific adaptive clinical trials could be designed to identify safe and effective treatments.

Clinical update on COVID-19 in pregnancy: A review article

The data pertaining to the COVID-19 pandemic has been rapidly evolving since the first confirmed case in December 2019. This review article presents a comprehensive analysis of the current data in relation to COVID-19 and its effect on pregnant women, including symptoms, disease severity and the risk of vertical transmission. We also review the recommended management of pregnant women with suspected or confirmed COVID-19 and the various pharmacological agents that are being investigated and may have a role in the treatment of this disease. At present, it does not appear that pregnant women are at increased risk of severe infection than the general population, although there are vulnerable groups within both the pregnant and nonpregnant populations, and clinicians should be cognizant of these high-risk groups and manage them accordingly. Approximately 85% of women will experience mild disease, 10% more severe disease and 5% critical disease. The most common reported symptoms are fever, cough, shortness of breath and diarrhea. Neither vaginal delivery nor cesarean section confers additional risks, and there is minimal risk of vertical transmission to the neonate from either mode of delivery. We acknowledge that the true effect of the virus on both maternal and fetal morbidity and mortality will only be evident over time. We also discuss the impact of social isolation can have on the mental health and well-being of both patients and colleagues, and as clinicians, we must be mindful of this and offer support as necessary.

Clinical update on COVID-19 in pregnancy: A review article

The data pertaining to the COVID-19 pandemic has been rapidly evolving since the first confirmed case in December 2019. This review article presents a comprehensive analysis of the current data in relation to COVID-19 and its effect on pregnant women, including symptoms, disease severity and the risk of vertical transmission. We also review the recommended management of pregnant women with suspected or confirmed COVID-19 and the various pharmacological agents that are being investigated and may have a role in the treatment of this disease. At present, it does not appear that pregnant women are at increased risk of severe infection than the general population, although there are vulnerable groups within both the pregnant and nonpregnant populations, and clinicians should be cognizant of these high-risk groups and manage them accordingly. Approximately 85% of women will experience mild disease, 10% more severe disease and 5% critical disease. The most common reported symptoms are fever, cough, shortness of breath and diarrhea. Neither vaginal delivery nor cesarean section confers additional risks, and there is minimal risk of vertical transmission to the neonate from either mode of delivery. We acknowledge that the true effect of the virus on both maternal and fetal morbidity and mortality will only be evident over time. We also discuss the impact of social isolation can have on the mental health and well-being of both patients and colleagues, and as clinicians, we must be mindful of this and offer support as necessary.

Remdesivir: A beacon of hope from Ebola virus disease to COVID-19

Since the emergence of coronavirus disease 2019 (Covid-19), many studies have been performed to characterize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and find the optimum way to combat this virus. After suggestions and assessments of several therapeutic options, remdesivir (GS-5734), a direct-acting antiviral drug previously tested against Ebola virus disease, was found to be moderately effective and probably safe for inhibiting SARS-CoV-2 replication. Finally, on 1 May 2020, remdesivir (GS-5734) was granted emergency use authorization as an investigational drug for the treatment of Covid-19 by the Food and Drug Administration. However, without a doubt, there are challenging days ahead. Here, we provide a review of the latest findings (based on preprints, post-prints, and news releases in scientific websites) related to remdesivir efficacy and safety for the treatment of Covid-19, along with covering remdesivir history from bench-to-bedside, as well as an overview of its mechanism of action. In addition, active clinical trials, as well as challenging issues related to the future of remdesivir in Covid-19, are covered. Up to the date of writing this review (19 May 2020), there is one finished randomized clinical trial and two completed non-randomized studies, in addition to some ongoing studies, including three observational studies, two expanded access studies, and seven active clinical trials registered on the clinicaltrials.gov and isrctn.com websites. Based on these studies, it seems that remdesivir could be an effective and probably safe treatment option for Covid-19. However, more randomized controlled studies are required.

Obstetrics risk Assessment: Evaluation of selection criteria for vaccine research studies in pregnant women

Vaccines designed for use in pregnancy and vaccine trials specifically involving pregnant women are rapidly expanding. One of the key challenges in designing maternal immunization trials is that developing exclusion criteria requires understanding and quantifying the background risk for adverse pregnancy outcomes in the pregnancy being studied, which can occur independent of any intervention and be unrelated to vaccine administration. The Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project has developed and published case definitions and guidelines for data collection, analysis, and evaluation of maternal immunization safety in trials involving pregnant women. Complementing this work, we sought to understand how to best assess obstetric risk of adverse outcomes and differentiate it from the assessment of vaccine safety. Quantification of obstetric risk is based on prior and current obstetric, and maternal medical history. We developed a step-wise approach to evaluate and quantify obstetric and maternal risk factors in pregnancy based on review of published literature and guidelines, and critically assessed these factors in the context of designing inclusion and exclusion criteria for maternal vaccine studies. We anticipate this risk assessment evaluation may assist clinical trialists with study design decisions, including selection of exclusion criteria for vaccine trials involving pregnant women, consideration of sub-group classification, such as high or low risk subjects, or schedule considerations, such as preferred trimester of gestation for an intervention during pregnancy. Additionally, this tool may be utilized in data stratification at time of study analyses.