COVID-19 vaccine response in pregnant and lactating women: a cohort study

Association of BNT162b2 SARS-CoV-2 vaccination during pregnancy with postnatal outcomes in premature infants

AIM

The effect of COVID-19 vaccine given during pregnancy on premature infants is unknown. This study aims to determine the association between maternal COVID-19 vaccine with postnatal outcome in premature infants.

METHODS

This is a single-centre retrospective case-control study of infants born before 35 weeks gestation to mothers who received SARS-CoV-2 vaccine during pregnancy compared with infant born to non-vaccinated mothers.

RESULTS

A total of 78 infants in each group were included. Infants in the vaccinated group had less respiratory distress syndrome (RDS) (p = 0.02) and less need for respiratory support (p = 0.002), and maternal vaccine had a protective effect on RDS [adjustable OR 0.38 (0.17-0.85)]. Vaccination during the first compared to the second trimester was associated with earlier gestational age (32.3 ± 2.1 vs. 33.3 ± 1.1 weeks, p = 0.03).

CONCLUSION

We demonstrated that maternal SARS-CoV-2 vaccine is not associated with postnatal adverse effect in premature infants and potentially has a protective effect on RDS. Earlier gestational age among the infants born to mothers who received COVID-19 vaccine during the first trimester did not translate to higher rate of postnatal complications. These findings might suggest that COVID-19 vaccine is safe in high-risk pregnancies, but timing of administration should be considered. Further studies are needed to confirm our findings and the biological mechanism.

IgG antibody levels against the SARS-CoV-2 spike protein in mother-child dyads after COVID-19 vaccination

PURPOSE

We aimed to assess IgG antibodies against the SARS-CoV-2 spike protein (anti-SARS-CoV-2 S IgG) in vaccinated mothers and their infants at delivery and 2-3 months of age.

METHODS

We conducted a prospective study on mothers who received at least one dose of the COVID-19 vaccine (Pfizer-BNT162b2, Moderna mRNA-1273, or Oxford-AstraZeneca ChAdOx1-S) during pregnancy and on their infants. The baseline was at the time of delivery (n = 93), and the end of follow-up was 2 to 3 months post-partum (n = 53). Serum anti-SARS-CoV-2 S IgG titers and ACE2 binding inhibition levels were quantified by immunoassays.

RESULTS

Mothers and infants had high anti-SARS-CoV-2 S IgG titers against the B.1 lineage at birth. However, while antibody titers were maintained at 2-3 months post-partum in mothers, they decreased significantly in infants (p < 0.001). Positive and significant correlations were found between anti-SARS-CoV-2 S IgG titers and ACE2-binding inhibition levels in mothers and infants at birth and 2-3 months post-partum (r > 0.8, p < 0.001). Anti-S antibodies were also quantified for the Omicron variant at 2-3 months post-partum. The antibody titers against Omicron were significantly lower in mothers and infants than those against B.1 (p < 0.001). Again, a positive correlation was observed for Omicron between IgG titers and ACE2-binding inhibition both in mothers (r = 0.818, p < 0.001) and infants (r = 0.386, p < 0.005). Previous SARS-CoV-2 infection and COVID-19 vaccination near delivery positively impacted anti-SARS-CoV-2 S IgG levels.

CONCLUSIONS

COVID-19 mRNA vaccines induce high anti-SARS-CoV-2 S titers in pregnant women, which can inhibit the binding of ACE2 to protein S and are efficiently transferred to the fetus. However, there was a rapid decrease in antibody levels at 2 to 3 months post-partum, particularly in infants.

Covid-19 vaccination and pregnancy: a systematic review of maternal and neonatal outcomes

OBJECTIVES

Although the vaccination against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS Cov-2) is considered safe during pregnancy, vaccine hesitancy among pregnant women is high. The results of published observational studies addressing the issue of Covid-19 vaccination's efficacy and safety during pregnancy need to be summarized.

CONTENT

This systematic review compares the incidence of major maternal and neonatal outcomes between SARS Cov-2 vaccinated and unvaccinated pregnant women. The included studies enrolled pregnant women of any age and any trimester. Medline-Pubmed, Scopus, Cochrane Library, and grey literature were searched until the 28th of May 2022, and 2,947 studies were found.

SUMMARY

Seven observational cohort studies, enrolling 67,274 pregnant women, were selected. When comparing vaccinated and unvaccinated pregnant women, SARS Cov-2 vaccines were not associated with major maternal and neonatal adverse events. The rate of SARS Cov-2 infections among vaccinated pregnant women compared to unvaccinated is significantly reduced by 43%.

OUTLOOK

SARS Cov-2 vaccination in pregnant women is effective and safe. The results are promising, but caution is advised due to some limitations: only observational studies addressing this issue were found. Parallelly, the enrolled populations and the intervention (vaccination type and the number of doses) were not homogeneous.

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

Introduction

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

Study Design

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

Results

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

Conclusion

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

Anti-Severe Acute Respiratory Syndrome Coronavirus 2 IgG Is Present in the Amniotic Fluid of both Infected and Vaccinated Women at Second Trimester of Pregnancy: A Cohort Study

INTRODUCTION

Pregnant women are protected from the complications of COVID-19 infection, thanks to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. The benefit of this vaccination to prevent morbidity and mortality in the fetus has not yet been completely elucidated. Our aim was to test the presence of anti-SARS-CoV-2 antibodies in the amniotic fluid during the second trimester of pregnancy and then to compare them to the antibody levels in maternal serum to evaluate their correlation and to improve amniotic fluid immunological characteristics knowledge.

METHODS

This cohort study took place at the Policlinico G. Martino of Messina from September 2021 to February 2022; 22 pregnant women had amniocentesis: we analyzed serum and amniotic fluid samples of women who contracted the SARS-CoV-2 infection or vaccinated against the same virus within 1 year, and women never infected or vaccinated against it. Amniotic fluids and peripheral blood were collected to evaluate IgG anti-SARS-CoV-2 nucleocapsid and spike S1 protein antibodies.

RESULTS

Patients vaccinated had higher S1 receptor-binding domain antibody levels both in amniotic fluid (p < 0.006; mean 68.70; standard deviation [SD] 85.46) and maternal blood (p < 0.005; mean 1,989.86; SD 3,777.15) than unvaccinated women. Anti-nucleocapsid antibodies were present in women who developed COVID infection both in amniotic fluid and maternal blood but not in unvaccinated women. There was a high correlation between the concentrations of anti-spike antibody levels in serum and amniotic fluid of vaccinated women (p < 0.001; R = 1.0) and of anti-nucleocapsid antibody levels in serum and amniotic fluid of women who developed COVID infection (p < 0.001; R = 0.93).

CONCLUSION

Recent studies have shown that SARS-CoV-2 vaccination during pregnancy is safe. Moreover, we can assume that there is an early transplacental antibody transfer after anti-SARS-CoV-2 immunization to protect the fetus, and there is also a high correlation between levels of anti-nucleocapsid antibodies in blood and amniotic fluid of pregnant women previously infected.

Detection of SARS-CoV-2 IgA and IgG in human milk and breastfeeding infant stool 6 months after maternal COVID-19 vaccination

OBJECTIVE

Assess presence, durability, and neutralization capacity of SARS-CoV-2-specific antibodies in breastfeeding infants' stool, mother's plasma and milk following maternal vaccination.

DESIGN

Thirty-seven mothers and 25 infants were enrolled between December 2020 and November 2021 for this prospective observational study. All mothers were vaccinated during lactation except three, which were vaccinated during pregnancy. Milk, maternal plasma, and infants' stool was collected pre-vaccination and at periods up to 6 months following COVID-19 vaccine series initiation/completion. SARS-CoV-2 antibody levels and their neutralization capacities were assessed.

RESULTS

SARS-CoV-2-specific IgA and IgG levels were higher in infant stool post-maternal vaccination amongst milk-fed compared to controls. Maternal SARS-CoV-2-specific IgA and IgG concentrations decreased over 6 months post-vaccination but remained higher than pre-vaccination levels. We observed improved neutralization capacity in milk and plasma after COVID-19 vaccination.

CONCLUSIONS

The presence of SARS-CoV-2-specific antibodies in infant stool following maternal vaccination offers further evidence of the lasting transfer of these antibodies through breastfeeding.

Anti-SARS-CoV-2 Immunoglobulins in Human Milk after Coronavirus Disease or Vaccination-Time Frame and Duration of Detection in Human Milk and Factors That Affect Their Titers: A Systematic Review

Human milk (HM) of mothers infected with or vaccinated against SARS-CoV-2 contains specific immunoglobulins, which may protect their offspring against infection or severe disease. The time frame and duration after infection or vaccination, during which these immunoglobulins are detected in HM, as well as the major factors that influence their levels, have not been fully elucidated. This systematic review aimed to collect the existing literature and describe the immune response, specifically regarding the immunoglobulins in HM after COVID-19 disease or vaccination in non-immune women. We conducted a systematic search of PubMed and Scopus databases to identify studies published up until 19 March 2023. In total, 975 articles were screened, and out of which 75 were identified as being relevant and were finally included in this review. Infection by SARS-CoV-2 virus primarily induces an IgA immune response in HM, while vaccination predominantly elevates IgG levels. These immunoglobulins give HM a neutralizing capacity against SARS-CoV-2, highlighting the importance of breastfeeding during the pandemic. The mode of immune acquisition (infection or vaccination) and immunoglobulin levels in maternal serum are factors that seem to influence immunoglobulin levels in HM. Further studies are required to determine the impact of other factors, such as infection severity, lactation period, parity, maternal age and BMI on immunoglobulin level in HM.

COVID-19 Pharmacotherapy in Pregnancy: A Literature Review of Current Therapeutic Choices

The clinical management of COVID-19 in pregnant women, who are considered a vulnerable population, remains uncertain even as the pandemic subsides. SARS-CoV-2 affects pregnant individuals in multiple ways and has been associated with severe maternal morbidity and mortality, as well as neonatal complications. The unique anatomy and physiology of gestation make managing COVID-19 in this population a complex and challenging task, emphasizing the importance of spreading knowledge and expertise in this area. Therapeutic interventions require distinct clinical consideration, taking into account differences in pharmacokinetics, vertical transmission, drug toxicities, and postnatal care. Currently, there is limited data on antiviral and immunomodulating COVID-19 pharmacotherapy in pregnancy. Some medication has been shown to be safe and well tolerated among pregnant women with COVID-19; however, the lack of randomized clinical trials and studies in this patient population is evident. Available vaccines are considered safe and effective, with no evidence of harm to the fetus, embryo development, or short-term postnatal development. Pregnant women should be counseled about the risks of SARS-CoV-2 infection and informed of available ways to protect themselves and their families. Effective treatments for COVID-19 should not be withheld from pregnant individuals, and more research is needed to ensure the best outcomes.

Factors Associated with Anti-SARS-CoV-2 Vaccine Acceptance among Pregnant Women: Data from Outpatient Women Experiencing High-Risk Pregnancy

Pregnant women are at higher risk of severe Coronavirus disease 2019 (COVID-19) complications than non-pregnant women. The initial exclusion of pregnant women from anti-SARS-CoV-2 vaccines clinical trials has caused a lack of conclusive data about safety and efficacy for this vulnerable population. This cross-sectional study aims to define the factors related to vaccination adherence in a sample of women experiencing high-risk pregnancies. The recruited women completed a questionnaire based on the Health Belief Model. Data were analyzed to evaluate the associations between socio-demographic variables and vaccination acceptance through descriptive, univariate and multivariate logistic analyses. Among the 233 women enrolled, 65.2% (n = 152) declared that they would accept the anti-SARS-CoV-2 vaccine. Multivariate analysis showed that vaccination acceptance was associated with a high educational level (aOR = 4.52, p = 0.001), a low perception of barriers to vaccination (aOR = 1.58, p = 0.005) and the gynecologist's advice (aOR = 3.18, p = 0.01). About a third of pregnant women are still hesitant about the anti-SARS-CoV-2 vaccine, probably because of the conflicting information received from media, friends, acquaintances and health institutions. Determining factors linked to vaccine hesitancy among pregnant women is useful for creating vaccination strategies that increase vaccination uptake.

Detection of SARS-CoV-2 Neutralizing Antibodies in Vaccinated Pregnant Women and Neonates by Using a Lateral Flow Immunoassay Coupled with a Spectrum-Based Reader

The focus of this study was to investigate the detection of neutralizing antibodies (Nabs) in maternal serum and cord blood as the targeted samples by employing a lateral flow immunoassay combined with a spectrum reader (LFI-SR) and the correlation of Nab protection against different types of SARS-CoV-2. We enrolled 20 pregnant women who were vaccinated with the Moderna (mRNA-1273) vaccine during pregnancy and collected 40 samples during delivery. We used an LFI-SR for the level of spike protein receptor binding domain antibody (SRBD IgG) as Nabs and examined the correlation of the SRBD IgG concentration and Nab inhibition rates (NabIR) via enzyme-linked immunosorbent assays (ELISA). The LFI-SR had high confidence for the SRBD IgG level (p < 0.0001). Better NabIR were found in wild-type SARS-CoV-2 (WT) compared to Delta-type (DT) and Omicron-type (OT). Women with two-dose vaccinations demonstrated greater NabIR than those with a single dose. The cut-off value of the SRBD IgG level by the LFI-SR for NabIR to DT (≥30%; ≥70%) was 60.15 and 150.21 ng/mL for mothers (both p = 0.005), and 156.31 (p = 0.011) and 230.20 ng/mL (p = 0.006) for babies, respectively. An additional vaccine booster may be considered for those mothers with SRBD IgG levels < 60.15 ng/mL, and close protection should be given for those neonates with SRBD IgG levels < 150.21 ng/mL, since there is no available vaccine for them.

Menstrual changes after COVID-19 vaccination and/or SARS-CoV-2 infection and their demographic, mood, and lifestyle determinants in Arab women of childbearing age, 2021

Background

By September 2, 2021, over 30,000 COVID-19-vaccinated females had reported menstrual changes to the MHRA's Yellow Card surveillance system. As a result, the National Institutes of Health (NIH) is urging researchers to investigate the COVID-19 vaccine's effects on menstruation. Therefore, this study was conducted to explore the menstrual changes after COVID-19 vaccination and/or SARS-CoV-2 infection and their interrelations with demographic, mood, and lifestyle factors in Arab women of childbearing age (CBA).

Methodology

A cross-sectional study was conducted during October 2021 using an Arabic validated and self-administrated questionnaire. In total, 1,254 Women of CBA in the Arabic Population (15–50 y) with regular menstrual cycles were randomly selected from five countries (Saudi Arabia, Egypt, Syria, Libya, and Sudan).

Results

The mean (SD) age of the 1,254 studied females was 29.6 (8.5) years old. In total, 634 (50%) were married, 1,104 (88.0%) had a University education or above, 1,064 (84.4%) lived in urban areas, and 573 (45.7%) had normal body weight. Moreover, 524 (41.8%) were COVID-19 cases and 98 women (18.7%) reported menstrual changes (MCs). The 1,044 (83.5%) vaccinated females reported 418 (38.5%) MCs after being vaccinated, and these MCs resolved in 194 women (55.1%) after more than 9 months. Statistically significant relationships were observed between the reported MCs and the following variables: age, marital status, level of education, nationality, residence, and BMI. MCs were reported at 293(80.6) after the 2nd dose, and were mainly reported after 482 (46.1) Pfizer, 254 (24.3) Astrazenica, and 92 (8.8) Senopharm.

Conclusion

MCs among women of CBA after COVID-19 infection and vaccination are prevalent and complex problems, and had many determinates.

Assessment of Anti m-RNA SARS-CoV-2 (BNT162b2) Antibody Titres in Mother and Child Pairs of Breastfeeding Women Vaccinated Post-Delivery

The global response to the COVID-19 pandemic has been successfully driven by efforts to ramp up access to vaccines. Pregnant or breastfeeding women and their children have not benefited from the vaccines despite their susceptibility to the virus. We investigated whether women who were offered vaccination after delivery passively transferred protective antibodies to their infants via breast milk. Serum was collected from breast feeding mother–infant pairs and analysed for levels of antibodies to the SARS-CoV-2 spike protein using the CLIA chemiluminescence technique. Data were analysed for the significance of the differences using the Mann–Whitney U test and the Spearman’s rank correlation coefficient to determine the strength of the correlation. A total of 13 mothers, mean age 34.86 (95%CI = 33.21–36.48) years and their infants, mean age 15.77 (95%CI = 11.24–20.29) months were enrolled. The mothers had completed their courses of the mRNA BNT162b2 SARS-CoV-2 vaccine during breastfeeding, 8.3 (95%CI = 7.24–9.36) months before the study. All 13 mothers had detectable antibodies to the SARS-CoV-2 spike protein, mean 1252, (95%CI = 736–1769) BAU/mL. Antibodies were detected in 3/13 (23%) breast-fed infants mean 322, (95%CI = 252–897) BAU/mL. There was no correlation between the maternal and infant IgG antibody titres. The time-lag since full vaccination did not correlate to the presence of antibodies in infant sera. Maternal or infant ages did not correlate to the presence of antibodies. Although some children (23%) had anti-SARS-CoV-2 antibodies, there was no association between vaccine-induced COVID-19 spike protein specific maternal IgG antibody titres and the presence of antibodies in the breastfed infants. The data show that the transfer of passive immunity to infants following post-partum vaccination with the mRNA BNT162b2 SARS-CoV-2 vaccine may be infrequent in this population.

Milk of Cow and Goat, Immunized by Recombinant Protein Vaccine ZF-UZ-VAC2001(Zifivax), Contains Neutralizing Antibodies Against SARS-CoV-2 and Remains Active After Standard Milk Pasteurization

Here, we present the first experimental validation of the possibility for obtaining immune milk with neutralizing antibodies against SARS-CoV-2 from vaccinated cows and goat using approved recombinant protein human coronavirus vaccine, ZF-UZ-VAC2001, in the Republic of Uzbekistan. In the period of 2 weeks after first vaccination, we detected the neutralizing antibodies against coronavirus in the blood serum of vaccinated animals. The neutralizing activity, in its peak on the 21st day after receiving the third dose (77th day from first dose), was effective in neutralization test using a live SARS-CoV-2 in Vero E6 cells, even after 120-fold serum titration. In cows receiving three dose of human vaccine, the MAGLUMI® SARS-CoV-2 neutralizing antibody competitive chemiluminescence immunoassay revealed that colostrum of the first day after calving had a greater activity to neutralize the SARS-CoV-2 compared to colostrum of subsequent three days (4.080 μg/ml vs 2.106, 1.960 and 1.126 μg/ml). In comparison, the neutralizing activity for goat and cow milk was 1.486 μg/ml and 0.222 μg/ml, respectively. We observed a positive correlation of receptor-binding domain (RBD)-specific IgG antibodies between the serum of actively immunized cow and milk-feeding calf during the entire course of vaccination (r = 0.95, p = 0.05). We showed an optimal regime for immune milk pasteurization at 62.5°C for 30 min, which retained specific neutralizing activity to SARS-CoV-2, potentially useful for passive immunization against coronavirus infection threats as an additive approach to the vaccination. This strategy, as a supportive approach to the vaccination, could also be applicable for directly reducing the effect of COVID-19 infection in gastrointestinal tract, supporting mucosal immunity.

The impact of COVID-19 on pregnancy and therapeutic drug development

Emerging data show that pregnant women with COVID-19 are at significantly higher risk of severe outcomes compared with non-pregnant women of similar age. This review discusses the invaluable insight revealed from vaccine clinical trials in women who were vaccinated and inadvertently became pregnant during the trial period. It further explores a number of clinical avenues in their management and proposes a drug development strategy in line with clinical trials for vaccines and drug treatments for the drug development community. Little is known of the long-term effects of COVID-19 on the mother and the baby. Our hypothesis that COVID-19 predisposes pregnant women to pre-eclampsia or hypertensive disorders during pregnancy is supported by a clinical study, and this may also adversely impact a woman's cardiovascular disease risk later in life. It may also increase a woman's risk of pre-eclampsia in subsequent pregnancy. This is an ever-evolving landscape, and early knowledge for healthcare providers and drug innovators is offered to ensure benefits outweigh the risks. COVID-19 mRNA vaccines appear to generate robust humoral immunity in pregnant and lactating women. This novel approach to vaccination also offers new ways to therapeutically tackle disorders of many unmet medical needs. LINKED ARTICLES: This article is part of a themed issue on The second wave: are we any closer to efficacious pharmacotherapy for COVID 19? (BJP 75th Anniversary). To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v179.10/issuetoc.

SARS-CoV-2 infection and COVID-19 vaccination in pregnancy

SARS-CoV-2 infection poses increased risks of poor outcomes during pregnancy, including preterm birth and stillbirth. There is also developing concern over the effects of SARS-CoV-2 infection on the placenta, and these effects seem to vary between different viral variants. Despite these risks, many pregnant individuals have been reluctant to be vaccinated against the virus owing to safety concerns. We now have extensive data confirming the safety and effectiveness of COVID-19 vaccination during pregnancy, although it will also be necessary to determine the effectiveness of these vaccines specifically against newly emerging viral variants, including Omicron. In this Progress article, I cover recent developments in our understanding of the risks of SARS-CoV-2 infection in pregnancy, and how vaccination can reduce these.

Seroprevalence of SARS-CoV-2 in German secondary schools from October 2020 to July 2021: a longitudinal study

Purpose

To quantify the number of SARS-CoV-2 infections in students and teachers in 14 Secondary schools in eastern Saxony, Germany. Seroprevalence of SARS-CoV-2 antibodies in study population. Number of undetected cases.

Methods

Serial seroprevalence study.

Results

The role of educational settings in the SARS-CoV-2 Pandemic is still controversial. Seroprevalence increases from 0.8 to 5.9% from October to December when schools remained open and to 12.2% in March/April during a strict lockdown with closed schools. The ratio of undetected to detected cases decreased from 0.76 to 0.44 during the study period.

Conclusion

During the second and third wave of the pandemic in Germany, students and teachers are not overrepresented in SARS-CoV-2 infections. The percentage of undetected cases is moderate and decreases over time. The risk of contracting SARS-CoV-2 within the household is higher than contracting it in educational settings making school closures rather ineffective in terms of pandemic control measures or individual risk reduction in children and adolescents.

Trial registration

DRKS00022455 (July 23rd, 2020).

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01824-9.

Comprehensive Overview of Vaccination during Pregnancy in Europe

Vaccinations during pregnancy can protect the mother from several infections, thus blocking vertical transmission. Furthermore, through passive antibody transfer, the newborn can be protected against some infections in the first months of life until their own vaccination regimen is initiated and completed at the appropriate age. Pregnancy can be considered a high-risk condition that increases vulnerability to infectious diseases with potentially unfavorable evolution. We present the current knowledge on vaccination during pregnancy in Europe as a useful information source for different health workers involved in prenatal care. Many European countries implement vaccination policies specifically designed for pregnant women, but there is great heterogeneity among programs. Recommendations on vaccination during pregnancy must be based on current high-quality scientific data. The decisions must be made for each individual case, depending on the associated conditions or special circumstances, with a concomitant assessment of the potential benefits and risks to both the pregnant patient and the fetus. Many vaccines are well-tolerated in pregnant women, with no clinically meaningful injection site reactions, systemic symptoms, or vaccine-related serious adverse events.

[Vaccines against COVID-19]

The ongoing COVID-19 pandemic represents an emergency situation of devastating proportions. To mitigate its effects, several safe and effective vaccines have been developed in a very short period of time. Currently, four vaccines have been approved by the European Medicines Agency (EMA) and are in use in Germany. These include two mRNA vaccines and two vector-based vaccines. They all show very good protective efficacy, especially against severe courses of disease and can significantly contain the pandemic by reducing viral transmission. This article focuses on the development and mechanism of action of the vaccines, their safety and efficacy profile as well as indications for vaccination and current recommendations for the use of vaccines in special groups of people, such as convalescent, immunosuppressed and pregnant patients. Finally, currently open scientific questions are addressed.

Focusing Treatment on Pregnant Women With COVID Disease

Since the emergence of a novel coronavirus in China at the end of December 2019, its infection - COVID-19 - has been associated with high morbidity and mortality and has left healthcare systems wrestling with the optimal management strategy, especially for vulnerable populations, such as pregnant women. At this moment, few resources exist to guide the multi-disciplinary team through decisions regarding optimal maternal-fetal treatment and delivery timing. In this article, we present the drugs and vaccines under investigation as potential treatments and prevention for COVID-19 infection. Based on a comprehensive evaluation, we prioritized these possible treatments, and provide dose-response and dose-toxicity information on each drug. Currently, there is limited but very increasing reassuring information concerning vaccines to prevent SARS-CoV-2 during pregnancy, and in this review, we also emphasize the results (mostly positive) provided by the few small trials evaluating COVID-19 vaccines in pregnant patients.

Safety, Immunogenicity, Efficacy and Effectiveness of Inactivated Influenza Vaccines in Healthy Pregnant Women and Children Under 5 Years: An Evidence-Based Clinical Review

Annual influenza vaccination is often recommended for pregnant women and young children to reduce the risk of severe influenza. However, most studies investigating the safety, immunogenicity, and efficacy or effectiveness of influenza vaccines are conducted in healthy adults. In this evidence-based clinical review, we provide an update on the safety profile, immunogenicity, and efficacy/effectiveness of inactivated influenza vaccines (IIVs) in healthy pregnant women and children <5 years old. Six electronic databases were searched until May 27, 2021. We identified 3,731 articles, of which 93 met the eligibility criteria and were included. The IIVs were generally well tolerated in pregnant women and young children, with low frequencies of adverse events following IIV administration; however, continuous vaccine safety monitoring systems are necessary to detect rare adverse events. IIVs generated good antibody responses, and the seroprotection rates after IIVs were moderate to high in pregnant women (range = 65%-96%) and young children (range = 50%-100%), varying between the different influenza types/subtypes and seasons. Studies show vaccine efficacy/effectiveness values of 50%-70% in pregnant women and 20%-90% in young children against lab-confirmed influenza, although the efficacy/effectiveness depended on the study design, host factors, vaccine type, manufacturing practices, and the antigenic match/mismatch between the influenza vaccine strains and the circulating strains. Current evidence suggests that the benefits of IIVs far outweigh the potential risks and that IIVs should be recommended for pregnant women and young children.

COVID-19 Vaccine Perceptions and Differences by Sex, Age, and Education in 1,367 Community Adults in Ontario

Background: COVID-19 is a global pandemic and vaccination efforts may be impeded by vaccine hesitancy. The present study examined willingness to receive a COVID-19 vaccine, the associated reasons for willingness/unwillingness, and vaccine safety perceptions in a cross-sectional assessment of community adults in Ontario. Methods: One thousand three hundred sixty seven individuals (60.6% female, mean age = 37.5%) participated in this study between January 15, 2021 and February 15, 2021. Perceptions of vaccine safety and reasons for willingness/unwillingness to receive the COVID-19 vaccine were investigated using an online assessment. Perceptions were investigated in general and by age, sex and education using analysis of variance. Results: Overall, 82.8% of the sample reported they were willing to receive a COVID-19 vaccine and 17.2% reported they were unwilling. The three most common reasons for unwillingness were long-term side effects (65.5%), immediate side effects (60.5%), and lack of trust in the vaccine (55.2%). Vaccine willingness significantly differed by sex and education level, with female participants and those with less than a bachelor's degree being more likely to report unwillingness. Perception of COVID-19 vaccine safety was significantly lower (-10.3%) than vaccines in general and differed by age, sex and education, with females, older adults, and individuals with less than a bachelor's degree reporting lower perceived COVID-19 vaccine safety. Conclusion: In this sample of community adults, the COVID-19 vaccine hesitancy rate was less than one in five individuals, but with higher rates in population subgroups. Targeting public health messaging to females and individuals with less than bachelor's degree, and addressing concerns about long-term and immediate side effects may increase vaccine uptake.

Maternal and Child Outcomes Reported by Breastfeeding Women Following Messenger RNA COVID-19 Vaccination

Background: In December 2020, two novel messenger RNA (mRNA) vaccines for severe acute respiratory syndrome coronavirus-2 received emergency use authorization from the U.S. Food and Drug Administration; however, the early trials excluded lactating women. Methods: Breastfeeding women residing in the United States who received either of the two mRNA vaccines were enrolled into the Mommy's Milk Human Milk Research Biorepository at the University of California, San Diego. From December 14, 2020 to February 1, 2021, 180 women who received two doses of either mRNA vaccine were recruited into the study. Results: Similar proportions of women reported any one or more symptoms following vaccination with either mRNA vaccine. In addition, the frequency by specific type of symptom did not differ by brand. However, following the second dose of vaccine, women who received the Moderna brand were significantly more likely to report symptoms. A small proportion of women following the first dose of either vaccine brand reported a reduction in milk supply, and significantly, more women reported a reduction in milk supply following the second dose of Moderna. Few infant events were reported for either vaccine brand following either dose, and no serious adverse events were reported. Conclusions: These data are reassuring regarding the safety of vaccination in breastfeeding women and their breastfed children with either of the mRNA COVID-19 vaccines.

A Literature Review on the Vaccination of COVID-19 in Pregnant and Breastfeeding Women: Effectiveness and Safety

Background: Pregnant women and breastfeeding women who are infected with the COVID-19 virus have a high risk, but pregnant women and women who breastfeed are not included in the initial vaccine trial for coronavirus 19 (COVID-19). There are currently no clinical data on the use of the COVID-19 mRNA vaccine in pregnant and lactating women. Aim: This study aims to get a picture about nurse’s knowledge, attitude and supervision, and its relationship to the implementation of pain reassessment. Methods: The method used in this paper is the Literature Review study. The data based used in the source search were Google Scholar, PubMed, JAMA, and AJOG which aimed to collect themes regarding the discussion of COVID-19 Vaccination in Pregnant and Breastfeeding Women. The COVID-19 mRNA vaccine creates immunity in pregnant and lactating women. Results: IgG immunoglobulin after vaccination in pregnant, lactating and non-pregnant women increased significantly and was stronger than pregnant women who were previously infected with SARS-CoV-2 Conclusion: Pregnant and lactating women have a stronger immune response after being vaccinated than pregnant women who were previously infected with SARS-CoV-2. Immune transfer to neonates occurs through placenta and breast milk, antibodies are formed after vaccination in the third trimester of pregnancy. Immunogenicity and reactogenicity reactions after the vaccine are the same as for nonpregnant women. Therefore, education is needed by health workers to patients about the risks and benefits of vaccines for pregnant and lactating women.

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

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

Newborns at risk of Covid-19 - lessons from the last year

After more than 1 year of the SARS-CoV-2 pandemic, a great deal of knowledge on how this virus affects pregnant women, the fetus and the newborn has accumulated. The gap between different guidelines how to handle newborn infants during this pandemic has been minimized, and the American Academy of Pediatrics (AAP)'s recommendations are now more in accordance with those of the World Health Organization (WHO). In this article we summarize present knowledge regarding transmission from mother to the fetus/newborn. Although both vertical and horizontal transmission are rare, SARS-CoV-2 positivity is associated with an increased risk of premature delivery and higher neonatal mortality and morbidity. Mode of delivery and cord clamping routines should not be affected by the mother's SARS-CoV-2 status. Skin to skin contact, rooming in and breastfeeding are recommended with necessary hygiene precautions. Antibodies of infected or vaccinated women seem to cross both the placenta and into breast milk and likely provide protection for the newborn.

Investigating the Links Between Vaccination Against COVID-19 and Public Attitudes Toward Protective Countermeasures: Implications for Public Health

The COVID-19 pandemic caused by the novel coronavirus, SARS-CoV-2, is spreading globally at an unprecedented rate. To protect the world against this devastating catastrophe, vaccines for SARS-CoV-2 have been produced following consistent clinical trials. However, the durability of a protective immune response due to vaccination has not been confirmed. Moreover, COVID-19 vaccination against SARS-CoV-2 is not 100% guaranteed, as new variants arise due to mutations. Consequently, health officials are pleading with the public to take extra precautions against the virus and continue wearing masks, wash hands, and observe physical distancing even after vaccination. The current research collected data from 4,540 participants (1,825 vaccinated and 2,715 not vaccinated) in China to analyze this phenomenon empirically. The propensity score matching (PSM) model is employed to analyze the impact of vaccination against COVID-19 on participants' attitudes toward protective countermeasures. The findings showed that gender, age, education level, occupation risk, individual health risk perception, public health risk perception, social responsibility, peer effect, and government supervision are the main drivers for participants to be vaccinated with COVID-19's vaccines. The results further show that vaccination lessened participants' frequency of hand washing by 1.75 times and their compliance frequency intensity of observing physical distancing by 1.24 times. However, the rate of mask-wearing did not reduce significantly, implying that China's main countermeasure of effective mask-wearing effectively controls COVID-19. Moreover, the findings indicate that a reduction in the frequency of hand washing and observing physical distance could cause a resurgence of COVID-19. In conclusion, factors leading to the eradication of SARS-CoV-2 from the world are complex to be achieved, so the exploration of COVID-19 vaccination and people's attitude toward protective countermeasures may provide insights for policymakers to encourage vaccinated people to follow protective health measures and help in completely defeating the COVID-19 from the globe.

Efficient maternal to neonatal transfer of antibodies against SARS-CoV-2 and BNT162b2 mRNA COVID-19 vaccine

BACKGROUNDThe significant risks posed to mothers and fetuses by COVID-19 in pregnancy have sparked a worldwide debate surrounding the pros and cons of antenatal SARS-CoV-2 inoculation, as we lack sufficient evidence regarding vaccine effectiveness in pregnant women and their offspring. We aimed to provide substantial evidence for the effect of the BNT162b2 mRNA vaccine versus native infection on maternal humoral, as well as transplacentally acquired fetal immune response, potentially providing newborn protection.METHODSA multicenter study where parturients presenting for delivery were recruited at 8 medical centers across Israel and assigned to 3 study groups: vaccinated (n = 86); PCR-confirmed SARS-CoV-2 infected during pregnancy (n = 65), and unvaccinated noninfected controls (n = 62). Maternal and fetal blood samples were collected from parturients prior to delivery and from the umbilical cord following delivery, respectively. Sera IgG and IgM titers were measured using the Milliplex MAP SARS-CoV-2 Antigen Panel (for S1, S2, RBD, and N).RESULTSThe BNT162b2 mRNA vaccine elicits strong maternal humoral IgG response (anti-S and RBD) that crosses the placenta barrier and approaches maternal titers in the fetus within 15 days following the first dose. Maternal to neonatal anti-COVID-19 antibodies ratio did not differ when comparing sensitization (vaccine vs. infection). IgG transfer ratio at birth was significantly lower for third-trimester as compared with second trimester infection. Lastly, fetal IgM response was detected in 5 neonates, all in the infected group.CONCLUSIONAntenatal BNT162b2 mRNA vaccination induces a robust maternal humoral response that effectively transfers to the fetus, supporting the role of vaccination during pregnancy.FUNDINGIsrael Science Foundation and the Weizmann Institute Fondazione Henry Krenter.

COVID-19 vaccination in pregnancy and postpartum

Pregnant women were excluded from the initial phase 3 clinical trials of COVID-19 vaccines resulting in limited data on their efficacy and safety during pregnancy and postpartum. As a result, since December 2020, there has been conflicting advice from public health, governmental, and professional authorities on this matter. From the end of 2020 up to now, some consensus guidance has been published with a prevalent precautionary approach on the administration of vaccines in pregnant women, in breastfeeding ones, or for those who are planning a pregnancy (either spontaneously or with assisted technologies). After the first few months of vaccine administration in some countries, more permissiveness seems to prevail, although with inconsistencies. Some little indicative advice, their inconsistency around the world and their changes in a short time have probably disoriented both women and their health care providers and placed the burden of decision making upon women and their health care providers without information to assist in making an informed choice. We reviewed the COVID-19 vaccination guidance for pregnant and breastfeeding women published to date and evidence from cases of unplanned pregnancy during the course of vaccine trials, preclinical experimental and observational clinical studies, and discuss their implications. In this way, we have tried to identify the safety of COVID-19 vaccines for pregnant or breastfeeding women, and their offspring.

Coronavirus disease and vaccination during pregnancy and childbirth: a review of the Israeli perspective and experience

Purpose of the study: To discuss selected aspects of our local and national experience in treating and vaccinating pregnant women with SARS-CoV-2 infection and COVID-19 disease.Materials and methods: A comprehensive, retrospective review of COVID-19 parturients in our center as well as a detailed literature review of several aspects from the groundbreaking research done in Israel to investigate the direct obstetrical impact of COVID-19, indirect effect of the lockdown measures and the vaccination effort among pregnant women.Results: The study shows our local and national experience in treating COVID-19 in pregnancy and the maternal and neonatal impact of vaccination in nationwide scale. We treated our first COVID-19 pregnant patient on April 4th, 2020 reaching a total of 193 pregnant women, with PCR-positive SARS-CoV-2 by 8th March 2021. Several studies from Israel have evaluated pregnancy-related outcomes of COVID-19, be it maternal, obstetrical or neonatal complications. We suggest that only in a small subset of severely ill mothers, intubated and otherwise respiratory or hemodynamically unstable, an emergency cesarean delivery should be considered, factoring gestational age, in order to assist maternal ventilation and circulation, as well as to avoid possible secondary fetal compromise due the maternal deterioration.In addition, there is conflicting evidence as to the price of lockdown on obstetrical outcomes, i.e., not the direct medical impact of the virus, but rather the impact of the measures to contain its spread - mainly lockdowns, which has been a major tool in Israel to combat COVID-19.Finally, we demonstrate to overall safety and efficacy of vaccination pregnant women and the beneficial impact on pregnancy outcome and neonatal gain of protecting antibodies.Conclusion: The data emerging from Israel is overall reassuring, as for the association of COVID-19 with adverse pregnancy outcome and the possible protective effect of the vaccinations. Further, long term studies, should be conducted to answer the long-term maternal outcomes, as well and neonatal prognosis.

Safety of COVID-19 vaccines, their components or their platforms for pregnant women: A rapid review

BACKGROUND

Pregnant women with COVID-19 are at an increased risk of severe COVID-19 illness as well as adverse pregnancy and birth outcomes. Many countries are vaccinating or considering vaccinating pregnant women with limited available data about the safety of this strategy. Early identification of safety concerns of COVID-19 vaccines, including their components, or their technological platforms is therefore urgently needed.

METHODS

We conducted a rapid systematic review, as the first phase of an ongoing full systematic review, to evaluate the safety of COVID-19 vaccines in pregnant women, including their components, and their technological platforms (whole virus, protein, viral vector or nucleic acid) used in other vaccines, following the Cochrane methods and the PRISMA statement for reporting (PROSPERO-CRD42021234185).We searched literature databases, COVID-19 and pregnancy registries from inception February 2021 without time or language restriction and explored the reference lists of relevant systematic reviews retrieved. We selected studies of any methodological design that included at least 50 pregnant women or pregnant animals exposed to the vaccines that were selected for review by the COVAX MIWG in August 2020 or their components or platforms included in the COVID-19 vaccines, and evaluated adverse events during pregnancy and the neonatal period.Pairs of reviewers independently selected studies through the COVIDENCE web software and performed the data extraction through a previously piloted online extraction form. Discrepancies were resolved by consensus.

RESULTS

We identified 6768 records, 256 potentially eligible studies were assessed by full-text, and 37 clinical and non-clinical studies (38 reports, involving 2,397,715 pregnant women and 56 pregnant animals) and 12 pregnancy registries were included.Most studies (89%) were conducted in high-income countries. The most frequent study design was cohort studies (n=21), followed by surveillance studies, randomized controlled trials, and registry analyses. Most studies (76%) allowed comparisons between vaccinated and unvaccinated pregnant women (n=25) or animals (n=3) and reported exposures during the three trimesters of pregnancy.The most frequent exposure was to AS03 adjuvant in the context of A/H1N1 pandemic influenza vaccines (n=24), followed by aluminum-based adjuvants (n=11). Aluminum phosphate was used in Respiratory Syncytial Virus Fusion candidate vaccines (n=3) and Tdap vaccines (n=3). Different aluminum-based adjuvants were used in hepatitis vaccines. The replication-deficient simian adenovirus ChAdOx1 was used for a Rift Valley fever vaccine. Only one study reported exposure to messenger RNA (mRNA) COVID-19 vaccines that also used lipid nanoparticles. Except for one preliminary report about A/H1N1 influenza vaccination (adjuvant AS03) - corrected by the authors in a more thorough analysis, all studies concluded that there were no safety concerns.

CONCLUSION

This rapid review found no evidence of pregnancy-associated safety concerns of COVID-19 vaccines that were selected for review by the COVAX MIWG or of their components or platforms when used in other vaccines. However, the need for further data on several vaccine platforms and components is warranted given their novelty. Our findings support current WHO guidelines recommending that pregnant women may consider receiving COVID-19 vaccines, particularly if they are at high risk of exposure or have comorbidities that enhance the risk of severe disease.

COVID-19 vaccination in pregnancy and postpartum

AIM

To identify whether COVID-19 vaccines should be administered in pregnant and breastfeeding women by reviewing the guidance and other evidence.

METHODS

We reviewed the COVID-19 vaccination guidance for pregnant and breastfeeding women published to date and evidence from preclinical experimental and observational clinical studies, and discuss their implications.

RESULTS

Pregnant women were excluded from the initial phase 3 clinical trials of COVID-19 vaccines resulting in limited data on their efficacy and safety during pregnancy and postpartum. As a result, since December 2020, there has been conflicting advice from public health, governmental, and professional authorities on this matter. From the end of 2020 up to now, some consensus guidance has been published with a prevalent precautionary approach on the administration of vaccines in pregnant women, in breastfeeding ones, or for those who are planning a pregnancy (either spontaneously or with assisted technologies). After the first few months of vaccine administration in some countries, more permissiveness seems to prevail, although with inconsistencies. At the moment, the results obtained by preclinical experimental and observational clinical studies suggest that the risks of the maternal COVID-19 outweigh the undocumented and hypothetical risks of the COVID-19 vaccines in pregnancy. Also, until two viral vector COVID-19 vaccines were associated with very rare thromboembolic events, all guidance had agreed that all approved COVID-19 vaccines could be administered in pregnancy. Actually, some concern has been expressed.

CONCLUSION

COVID-19 vaccines administered in pregnancy can reduce the risk of severe COVID-19 and their serious consequences for mothers and their offspring. However, many aspects remain to be clarified.

Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a zoonotic coronavirus that crossed species to infect humans, causing coronavirus disease 2019 (COVID-19). Despite a potentially higher risk of pregnant women acquiring SARS-CoV-2 infection compared with the non-pregnant population (particularly in some ethnic minorities), no additional specific recommendations to avoid exposure are needed in pregnancy. The most common clinical symptoms and laboratory signs of SARS-CoV-2 infection in pregnancy are fever, cough, lymphopenia and elevated C-reactive protein levels. Pregnancy is associated with a higher risk of severe SARS-CoV-2 infection compared with the non-pregnant population, including pneumonia, admission to the intensive care unit and death, even after adjusting for potential risk factors for severe outcomes. The risk of miscarriage does not appear to be increased in women with SARS-CoV-2 infection. Evidence with regards to preterm birth and perinatal mortality is conflicting, but these risks are generally higher only in symptomatic, hospitalized women. The risk of vertical transmission, defined as the transmission of SARS-CoV-2 from the mother to the fetus or the newborn, is generally low. Fetal invasive procedures are considered to be generally safe in pregnant women with SARS-CoV-2 infection, although the evidence is still limited. In pregnant women with COVID-19, use of steroids should not be avoided if clinically indicated; the preferred regimen is a 2-day course of dexamethasone followed by an 8-day course of methylprednisolone. Non-steroidal anti-inflammatory drugs may be used if there are no contraindications. Hospitalized pregnant women with severe COVID-19 should undergo thromboprophylaxis throughout the duration of hospitalization and at least until discharge, preferably with low molecular weight heparin. Hospitalized women who have recovered from a period of serious or critical illness with COVID-19 should be offered a fetal growth scan about 14 days after recovery from their illness. In asymptomatic or mildly symptomatic women who have tested positive for SARS-CoV-2 infection at full term (i.e. ≥ 39 weeks of gestation), induction of labor might be reasonable. To date, there is no clear consensus on the optimal timing of delivery for critically ill women. In women with no or few symptoms, management of labor should follow routine evidence-based guidelines. Regardless of COVID-19 status, mothers and their infants should remain together and breastfeeding, skin-to-skin contact, kangaroo mother care and rooming-in throughout the day and night should be practiced, while applying necessary infection prevention and control measures. Many pregnant women have already undergone vaccination, mostly in the USA where the first reports show no significant difference in pregnancy outcomes in pregnant women receiving SARS-CoV-2 vaccination during pregnancy compared with the background risk. Vaccine-generated antibodies were present in the umbilical cord blood and breast milk samples of pregnant and lactating women who received the mRNA COVID-19 vaccine. Based on the available limited data on the safety of the COVID-19 vaccine in pregnancy, it seems reasonable to offer the option of vaccination to pregnant women after accurate counseling on the potential risk of a severe course of the disease and the unknown risk of fetal exposure to the vaccine. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

COVID-19 and Pregnancy: Risk, Symptoms, Diagnosis, and Treatment

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel virus responsible for causing an infection known as COVID-19. Several pulmonary and systemic manifestations of the illness have been described since the discovery of this virus. However, there have been higher-risk populations in which this infection has not been well studied nor documented. One of these populations includes the pregnant cohort. The purpose of this article is to describe the clinical manifestations of COVID-19 infection in the pregnant population and review the implications and sequelae of the infection throughout pregnancy and outcomes of live births. Also, we summarize the understanding and safety of current treatments and vaccination in pregnancy. This comprehensive review article comprises several case reports, case series, cohort studies, retrospective studies, and randomized clinical trials. Findings regarding maternal morbidity included an increased risk of acquiring severe COVID-19 infection requiring a higher level of inpatient hospital care along with an increased risk of preterm labor and cesarean delivery. Neonatal COVID-19 vertical transmission was shown to have conflicting data as there was a presence of transmission in certain retrospective studies and absence in others. There was also no evidence of teratogenicity from maternal COVID-19 infection. In conclusion, in part due to the unique physiologic state of pregnancy and part due to unknown factors, pregnant patients are at increased risk for negative outcomes of COVID-19 infection and must be classified as a high-risk population.

COVID-19 Information Sources and Health Behaviors During Pregnancy: Results From a Prenatal App-Embedded Survey

BACKGROUND

Pregnancy is a time of heightened COVID-19 risk. Pregnant individuals' choice of specific protective health behaviors during pregnancy may be affected by information sources.

OBJECTIVE

This study examined the association between COVID-19 information sources and engagement in protective health behaviors among a pregnant population in a large academic medical system.

METHODS

Pregnant patients completed an app-based questionnaire about their sources of COVID-19 information and engagement in protective health behaviors. The voluntary questionnaire was made available to patients using a pregnancy app as part of their routine prenatal care between April 21 and November 27, 2020.

RESULTS

In total, 637 pregnant responders routinely accessed a median of 5 sources for COVID-19 information. The most cited source (79%) was the Centers for Disease Control and Prevention (CDC). Self-reporting evidence-based protective actions was relatively common, although 14% self-reported potentially harmful behaviors to avoid COVID-19 infection. The CDC and other sources were positively associated with engaging in protective behaviors while others (eg, US president Donald Trump) were negatively associated with protective behaviors. Participation in protective behaviors was not associated with refraining from potentially harmful behaviors (P=.93). Moreover, participation in protective behaviors decreased (P=.03) and participation in potentially harmful actions increased (P=.001) over the course of the pandemic.

CONCLUSIONS

Pregnant patients were highly engaged in COVID-19-related information-seeking and health behaviors. Clear, targeted, and regular communication from commonly accessed health organizations about which actions may be harmful, in addition to which actions offer protection, may offer needed support to the pregnant population.