Incidence of SARS-CoV-2 vertical transmission: a meta-analysis

Perinatal outcomes of pregnancies affected by COVID-19 in Singapore: A cohort study

Pregnant women and infants were not spared from the coronavirus disease 2019 (COVID-19) after it was first identified in December 2019.1,2 In the beginning of the pandemic, a lack of data on transmission risks and outcomes of pregnancies affected by SARS-CoV-2, impacted perinatal clinical decision-making.1,3 We report the perinatal outcomes of pregnancies affected by COVID-19 in Singapore, covering the period from initial virus identification to the emergence of the Omicron variant in late 2021. We investigated the impact of COVID-19 vaccination and the Omicron variant on the perinatal outcomes of infected pregnant women and their newborns.

Impact of COVID-19 on pregnant women's health: Consequences in obstetrics two years after the pandemic

The pandemic linked to SARS-CoV-2 has profoundly disrupted the health systems and many studies have led to a better understanding of this virus, which is responsible for severe disease, particularly during pregnancy. Pregnancy is a risk factor for severe COVID-19. Term of pregnancy and vaccination status is the main risk factor in addition to classic comorbidities like general population. COVID-19 during pregnancy is responsible for more maternal death, stillbirth, pre-eclampsia spontaneous and induced prematurity. Vaccination is therefore strongly recommended for pregnant patients. In addition, the COVID-19 pandemic has highlighted a psychological and social dimension that should not be neglected in the management of a pregnant patient. Correlation between immunological changes and clinical impact are described in this review. Many conclusions can now be made and are summarized in this article in order to discuss possible future research.

SINE RNA of the imprinted miRNA clusters mediates constitutive type III interferon expression and antiviral protection in hemochorial placentas

Hemochorial placentas have evolved defense mechanisms to prevent the vertical transmission of viruses to the immunologically underdeveloped fetus. Unlike somatic cells that require pathogen-associated molecular patterns to stimulate interferon production, placental trophoblasts constitutively produce type III interferons (IFNL) through an unknown mechanism. We demonstrate that transcripts of short interspersed nuclear elements (SINEs) embedded in miRNA clusters within the placenta trigger a viral mimicry response that induces IFNL and confers antiviral protection. Alu SINEs within primate-specific chromosome 19 (C19MC) and B1 SINEs within rodent-specific microRNA cluster on chromosome 2 (C2MC) produce dsRNAs that activate RIG-I-like receptors (RLRs) and downstream IFNL production. Homozygous C2MC knockout mouse trophoblast stem (mTS) cells and placentas lose intrinsic IFN expression and antiviral protection, whereas B1 RNA overexpression restores C2MCΔ/Δ mTS cell viral resistance. Our results uncover a convergently evolved mechanism whereby SINE RNAs drive antiviral resistance in hemochorial placentas, placing SINEs as integral players in innate immunity.

SARS-CoV-2 variant-related abnormalities detected by prenatal MRI: a prospective case-control study

Background

There are known complications for fetuses after infection with SARS-CoV-2 during pregnancy. However, previous studies of SARS-CoV-2 in pregnancy have largely been limited to histopathologic studies of placentas and prenatal studies on the effects of different SARS-CoV-2 variants are scarce to date. To examine the effects of SARS-CoV-2 variants on the placenta and fetus, we investigated fetal and extra-fetal structures using prenatal MRI.

Methods

For this prospective case-control study, two obstetric centers consecutively referred pregnant women for prenatal MRI after confirmed SARS-CoV-2 infection. Thirty-eight prenatal MRI examinations were included after confirmed infection with SARS-CoV-2 and matched 1:1 with 38 control cases with respect to sex, MRI field strength, and gestational age (average deviation 1.76 ± 1.65, median 1.5 days). Where available, the pathohistological examination and vaccination status of the placenta was included in the analysis. In prenatal MRI, the shape and thickness of the placenta, possible lobulation, and vascular lesions were quantified. Fetuses were scanned for organ or brain abnormalities.

Findings

Of the 38 included cases after SARS-CoV-2 infection, 20/38 (52.6%) were infected with pre-Omicron variants and 18/38 (47.4%) with Omicron. Prenatal MRIs were performed on an average of 83 days (±42.9, median 80) days after the first positive PCR test. Both pre-Omicron (P = .008) and Omicron (P = .016) groups showed abnormalities in form of a globular placenta compared to control cases. In addition, placentas in the pre-Omicron group were significantly thickened (6.35, 95% CI .02-12.65, P = .048), and showed significantly more frequent lobules (P = .046), and hemorrhages (P = .002). Fetal growth restriction (FGR) was observed in 25% (n = 5/20, P = .017) in the pre-Omicron group.

Interpretation

SARS-CoV-2 infections in pregnancy can lead to placental lesions based on vascular events, which can be well visualized on prenatal MRI. Pre-Omicron variants cause greater damage than Omicron sub-lineages in this regard.

Funding

Vienna Science and Technology Fund.

COVID-19 via intrauterine transmission in a critically ill preterm infant: A case report

A preterm infant was born emergently at 29 weeks gestation to a mother with active coronavirus disease 2019 (COVID-19). Clinical presentation and evaluation were consistent with in utero transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The neonate experienced progressive, refractory respiratory failure and catastrophic intracranial hemorrhage which ultimately led to limitation of care.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India

Introduction

The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months.

Materials and methods

We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research.

Results

Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers.

Conclusion

The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

Clinical Overview in Pregnancy with COVID-19 at prof. Dr. I.G.N.G. Ngoerah Hospital Period of April 2020-March 2021

BACKGROUND: Pregnant women are one of the populations that are susceptible to coronavirus disease 2019 (COVID-19) infection due to physiological changes during pregnancy that is an adaptive response to pregnancy such as diaphragmatic elevation, increased oxygen consumption, and airway mucosal edema which can also make pregnant women more intolerant of hypoxia. In addition to being vulnerable, COVID-19 in pregnant women may have a different clinical course from the general population. AIM: This study aims to determine the demographic and clinical characteristics in pregnancy with COVID-19 at Prof. Dr. I.G.N.G. Ngoerah Hospital, Bali, Indonesia. METHODS: This study was a cross-sectional descriptive study using secondary data derived from patient medical records and carried out in the delivery room and medical record installation at Prof. Dr. I.G.N.G. Ngoerah Hospital, Bali, Indonesia, for the period of April 1, 2020–March 31, 2021. RESULTS: Of the 275 patients, most were in the age range of 26–30 years (46.55%), in the third trimester (81.45%), and patients came alone (54.18%). Most of the patients came without symptoms with reactive rapid antibody results (60.97%). Of the 197 patients who delivered, 84.77% had CS and 66.55% without oxygen therapy. About 69.69% of patients experienced complications and the mortality rate was 1.09%. The highest birth weight was >2500 g by 76.8%, with the good neonatal outcome (82.92%) and negative swab results (89.45%). Inflammatory markers tend to increase as symptoms increase. Neutrophil-to-lymphocyte ratio, procalcitonin, and ferritin were markedly increased from moderate symptoms to severe-critical symptoms. The same was true for ferritin levels, where there was a sharp rise in significant symptoms. Meanwhile, procalcitonin levels have started to increase quite strikingly from moderate symptoms to the highest in severe symptoms. CONCLUSION: It is hoped that this demographic and clinical picture would further our understanding of COVID-19 and help us develop methods to lessen the disease’s severity and spread to enhance maternal and newborn outcomes.

A short-term follow-up study on breastfeeding practices, growth parameters and immunization practices among babies born to COVID-19 positive mothers in a tertiary care hospital

We aimed to study the impact of the COVID-19 pandemic on exclusive breastfeeding (EBF) rate and routine follow-up practices including immunization. A total of 62 neonates born to COVID-19 positive mothers and an equal number of neonates born to COVID-19 negative mothers were prospectively evaluated for EBF rate and routine neonatal follow-up practices including delay (>7 days) in routine immunization at 3 months follow-up. We further tried to compare the results across two epochs (epoch 1, March-June 2020 and epoch 2, July-November 2020). There was significantly lesser number of babies born to COVID-19 positive mothers on EBF at 3 months of age when compared with the control group (45.1% vs. 96.7%, p = 0.00) as well it was significantly lesser in epoch 1 when compared with epoch 2 (16% vs. 74%, p = 0.00). Further, a significantly higher number of babies born to COVID-19 positive mothers had their routine immunization delayed with no significant difference across the epochs. There was no significant difference in growth parameters between babies born to COVID-19 positive mother when compared with the control group as well as across the epochs. The COVID-19 pandemic has significantly disrupted the EBF rates as well as hampered the routine immunization practices among babies born to COVID-19 positive mothers. Although such practices got improved after the implementation of evidence-based national guidelines, but it is still much below when compared with those born to COVID-19 negative mother.

COVID-19 vaccination in pregnancy: A review of maternal and infant benefits

Pregnant women with COVID-19 are more likely to be admitted to the intensive care unit and their babies born prematurely. Clinical trials excluded pregnant women from the vaccine and safety data were limited. However, an increasing number of studies have demonstrated the safety and immunogenicity of the COVID-19 vaccines for pregnant women and their babies including evidence of maternal transfer of antibodies. In addition to these benefits, the vaccines are proved to be effective for both the pregnant women and infants. The current evidence supports the safety, immunogenicity of the COVID-19 vaccine and its effectiveness in reducing the theoretical risk of the infection among pregnant women and their infants. This review summarizes the recent data on the beneficial effects of COVID-19 immunization on both the pregnant mother and infant.

Unexpected Vertical Transmission of SARS-CoV-2: Discordant Clinical Course and Transmission from Mother to Newborn

Mother-to-newborn COVID-19 transmission is mainly postnatal, but single-case reports and small case series have also described SARS-CoV-2 transplacental transmission. Unfortunately, studies regarding vertical transmission of SARS-CoV-2 lack systematic approaches to diagnosis and classification. So far, scientific evidence seems to suggest that the severity of maternal infection increases the risk of vertical transmission. We report two neonates born from COVID-19-positive mothers, of which one of the newborns had a vertical infection. The placental involvement, and consequent intrauterine transmission of SARS-CoV-2, were inversely related to the severity of the maternal disease. The description of cases divergent from current evidence on this topic could provide new insights to better understand SARS-CoV-2 vertical transmission.

Knowledge and Expectations of Perinatal Care Among Pregnant Women During the COVID-19 Pandemic

Introduction

This study aimed to investigate the knowledge and expectations of pregnant women on perinatal care during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

A cross-sectional survey was conducted among pregnant women ≥21 years, without a history of confirmed COVID-19, attending antenatal clinics between August and September 2020 via a secure online platform. The survey consisted of 10 questions which evaluated the knowledge and expectations on perinatal and neonatal care during the current pandemic.

Results

A total of 313 pregnant women completed the survey. The mean age of the participants was 30 years (SD 4; range 22–43 years). The median gestational age was 25 weeks (range 4–40 weeks). The participants were predominantly multiparous (54%) and almost all (98%) had completed secondary level education. Majority of participants were aware of the spread of COVID-19 by respiratory secretions and contact (90%), and the importance of prevention strategies (94%). Up to 72% agreed or strongly agreed that in-utero transmission of SARS-CoV-2 was possible. Most were unsure of the optimal mode of delivery (77%) and only 22% believed that breastfeeding was safe in a pregnant woman with active COVID-19. Although 46% were concerned about increased transmission risk with antenatal clinic visits, only 37% were agreeable to teleconferencing of clinic appointments. Maternal age >35 years was significantly associated with agreement with separation of mother-infant after birth [AOR 1.89 (95% CI 1.05, 3.39)], restrictions of visitors during the postnatal period [1.92 (1.05, 3.49)] and having their confinement practices were affected [2.3 (1.26, 4.17)]. Pregnant women who were multiparous disagreed that breastfeeding was safe in women with active COVID-19 [0.42 (0.23, 0.75)].

Conclusions

There was significant uncertainty about the optimal delivery method and safety of breastfeeding with COVID-19 among expectant mothers, along with variable agreement with alterations to routine perinatal care.

Neurological effects of COVID-19 in infants and children

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are becoming increasingly apparent as the coronavirus disease (COVID-19) pandemic continues. While children manifest relatively milder features of the disease, accumulating evidence warrants concern that COVID-19 exacts both acute- and long-term effects on the developing central and peripheral nervous systems. This review focuses on the relatively underinvestigated topic of the effects of SARS-CoV-2 on the brain in infancy and childhood, concluding that clinicians should be attentive to both the acute effects and long-term consequences of COVID-19 from a neurological perspective.

Clinical Profile of SARS-CoV-2-Infected Neonates

Background

There are conflicting data on the mother-to-child transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and few studies have described the clinical course of neonates infected with SARS-CoV-2.

Objectives

This study investigates the mother-to-child transmission rate and clinical profile of SARS-CoV-2-infected newborns.

Methods

Data on 304 newborns of 301 mothers with coronavirus disease 2019 (COVID-19) were prospectively collected and analyzed. Reverse transcription-polymerase chain reaction (RT-PCR) determined the presence of SARS-CoV-2 in the placenta, umbilical cord stump, and nasopharyngeal swabs collected within 24h of birth. Clinical and laboratory data of SARS-CoV-2-infected newborns was entered in a structured proforma.

Results

A total of 20 neonates (6.5%) were positive for SARS-CoV-2, of which 12 were positive only in the nasopharyngeal swab, four cases had the umbilical stump positive, three were positive in the placenta, and one case was positive in all the three specimens collected. Six of the 20 SARS-CoV-2-positive neonates developed severe symptoms. The SARS-CoV-2-positive symptomatic neonates required a more extended stay in hospital compared to their non-symptomatic infected counterparts.

Conclusions

A proportion of the babies born to SARS-CoV2-infected mothers tested positive and some of these newborns had severe symptoms.

Stillbirth due to SARS-CoV-2 placentitis without evidence of intrauterine transmission to fetus: association with maternal risk factors

OBJECTIVES

To describe the placental pathology, fetal autopsy findings and clinical characteristics of pregnancies that resulted in stillbirth owing to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) placentitis, and to identify potential risk factors.

METHODS

This was a prospective multicenter study of non-vaccinated pregnant women affected by coronavirus disease 2019 (COVID-19) in Greece from April 2020 to August 2021. A total of 165 placentas were examined histologically and six cases of stillbirth associated with SARS-CoV-2 placentitis were retrieved. Complete fetal autopsy was performed in three of these cases. Gross, histopathological, immunohistochemical, molecular and electron microscopy examinations were carried out in the stillbirth placentas and fetal organs. The histological findings of cases with SARS-CoV-2 placentitis were compared with those in 159 cases with maternal COVID-19 which resulted in a live birth. Regression analysis was used to identify predisposing risk factors for SARS-CoV-2 placentitis.

RESULTS

The placentas of all six stillborn cases showed severe and extensive histological changes typical of SARS-CoV-2 placentitis, characterized by a combination of marked intervillositis with a mixed inflammatory infiltrate and massive perivillous fibrinoid deposition with trophoblast damage, associated with intensely positive immunostaining for SARS-CoV-2 spike protein, the presence of virions on electron microscopy and positive reverse-transcription polymerase chain reaction test of placental tissues. The histological lesions obliterated over 75% of the maternal intervillous space, accounting for intrauterine fetal death. Similar histological lesions affecting less than 25% of the placenta were observed in seven liveborn neonates, while the remaining 152 placentas of COVID-19-affected pregnancies with a live birth did not show these findings. Complete fetal autopsy showed evidence of an asphyctic mode of death without evidence of viral transmission to the fetus. The mothers had mild clinical symptoms or were asymptomatic, and the interval between maternal COVID-19 diagnosis and fetal death ranged from 3 to 15 days. Statistically significant predisposing factors for SARS-CoV-2 placentitis included thrombophilia and prenatally diagnosed fetal growth restriction (FGR). Multiple sclerosis was seen in one case.

CONCLUSIONS

SARS-CoV-2 placentitis occurred uncommonly in COVID-19-affected pregnancies of non-vaccinated mothers and, when extensive, caused fetal demise, with no evidence of transplacental fetal infection. Thrombophilia and prenatally detected FGR emerged as independent predisposing factors for the potentially lethal SARS-CoV-2 placentitis. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Characteristics and outcome of infants born to mothers with SARS-CoV-2 infection during the first three waves of COVID-19 pandemic in northern Iran: A prospective cross-sectional study

Background

Despite the rapid increase in knowledge about coronavirus disease 2019 (COVID-19), there is limited data on vertical transmission, viral loads in mother-neonate pairs, and health outcomes. We aimed to describe the characteristics, viral loads, and short-and mid-term outcomes of neonates born to mothers with confirmed COVID-19 infection in northern Iran.

Materials and methods

In a cross-sectional study, we prospectively collected and analyzed the clinical features, reverse transcription-polymerase chain reaction (RT-PCR) results, viral loads, and outcomes of 60 neonates delivered by 58 SARS-CoV-2 infected pregnant women in maternity hospitals of Mazandaran University of Medical Sciences (northern Iran) during first three waves of the pandemic from March 1 to December 31, 2020. We assessed neonates' short and mid-term outcomes up to 24 months after the pandemic. We also described the timing of mother-to-infant transmission based on the classification presented by the World Health Organization.

Results

Of the 17767 deliveries, 58 mothers had confirmed and probable COVID-19 infection. Twenty (33.3%) neonates were positive for SARS-CoV-2, two of whom had possible in utero transmission. Twenty-five (41.2%) neonates were preterm, most of whom were born during the first and second waves in which mothers were critically ill. 19 (31.7%) patients needed resuscitation in the delivery room. 34 (56.7%) neonates were isolated in the neonatal intensive care unit. We observed a significant relationship between the maternal and neonatal viral load (correlation coefficient = 0.983, P = 0.00). No neonatal death was observed and all babies had a good outcome.

Conclusions

The results showed that vertical transmission of SARS-CoV-2 is possible but rare. Regional factors and severity of mother's disease may influence the clinical course of neonates. With increasing experience, proper observance of health precautions, and rapid development of evidence-based response systems for regional and global disasters, the transmission rate of SARS-CoV-2 from mother to newborn is reduced.

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Data describing the effect of SARS-CoV-2 in newborns are scarce.

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The mid-term and long-term outcomes of neonates exposed to SARS-CoV-2 infection are still unknown.

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We described characteristics and outcomes of SARS-CoV-2 infection in neonates who were born to infected mothers.

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Vertical transmission is rare but possible.

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Neonatal short-term and mid-term outcome is good.

SARS-CoV-2 Infection and Possible Neonatal Neurological Outcomes: A Literature Review

The virus responsible for COVID-19 is designated "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), a highly transmissible and pathogenic coronavirus. Although people of all ages are susceptible to SARS-CoV-2 infection, clinical manifestations may vary with age. The response of neonates to SARS-CoV-2 infection or exposure differs from that of children and adults. Encephalitis due to viral infections in the central nervous system (CNS) and childhood multisystem inflammatory syndrome (MIS-C) are some of the possible neonatal consequences of SARS-CoV-2 infection. This review aims to verify possible neonatal neurological outcomes after SARS-CoV-2 infection. Overall, the cellular and molecular basis of the neurological sequelae of SARS-CoV-2 in neonates remains unclear, and attempts to elucidate the pathophysiology of COVID-19 involve a comparison with the mechanism of other viral diseases. There are a considerable number of case reports in the literature exploring neurological outcomes in the neonatal period. In this review, we present possible effects of SARS-CoV-2 in neonates, emphasizing the importance of monitoring this group. The mechanisms of SARS-CoV-2 entry into the CNS have not yet been fully elucidated, and the potential severity of SARS-CoV-2 infection in neonates, as well as the possible short- and long-term neurological sequelae, remain unclear.

A SARS-CoV-2 Delta Variant Case Manifesting as Extensive Placental Infection and Fetal Transmission

INTRODUCTION

Studies indicate a very low rate of SARS-CoV-2 detection in the placenta or occasionally a low rate of vertical transmission in COVID-19 pregnancy. SARS-CoV-2 Delta variant has become a dominant strain over the world and possesses higher infectivity due to mutations in its spike receptor-binding motif.

CASE PRESENTATION

To determine whether SARS-CoV-2 Delta variant has increased potential for placenta infection and vertical transmission, we analyzed SARS-CoV-2 infection in the placenta, umbilical cord, and fetal membrane from a case where an unvaccinated mother and her neonate were COVID-19 positive. A 35-year-old primigravida with COVID-19 underwent an emergent cesarean delivery due to placental abruption in the setting of premature rupture of membranes. The neonate tested positive for SARS-CoV-2 within the first 24 h, and then again on days of life 2, 6, 13, and 21. The placenta exhibited intervillositis, increased fibrin deposition, and syncytiotrophoblast necrosis. Sequencing of viral RNA from fixed placental tissue revealed SAR-CoV-2 B.1.167.2 (Delta) variant. Both spike protein and viral RNA were abundantly present in syncytiotrophoblasts, cytotrophoblasts, umbilical cord vascular endothelium, and fetal membranes.

CONCLUSION

We report with strong probability the first SARS-CoV-2 Delta variant transplacental transmission. Placental cells exhibited extensive apoptosis, senescence, and ferroptosis after SARS-CoV-2 Delta infection.

Physical Health, Media Use, Stress, and Mental Health in Pregnant Women during the COVID-19 Pandemic

Background: The COVID-19 pandemic has led to significant changes in the care of pregnant women and their fetuses. Emerging data show elevated depression and anxiety symptoms among pregnant women. Aims: The purpose of this article is to investigate the psychological and behavioral impact of the COVID-19 pandemic on pregnant women in Greece during the first national lockdown. Methods: We used a cross-sectional, anonymous survey to collect data in two fetal medicine clinics in the largest urban centers of Greece during the months of April and May 2020. The questionnaire was largely based on the CoRonavIruS Health Impact Survey (CRISIS), and assessed sociodemographic characteristics, general health and obstetric data and COVID-19-related worries and life changes. Mood symptoms, substance use and lifestyle behaviors were assessed at two time points (3 months prior to the pandemic and the 2 weeks before taking the survey), while perceived stress was measured with the perceived stress scale (PSS-14). Results: A total of 308 pregnant women (Mage = 34.72), with a mean gestation of 21.19 weeks participated in the study. Over one-third of the women found COVID-19 restrictions stressful, and their highest COVID-19-related worry was having to be isolated from their baby. Mean PSS-14 score was 21.94, suggesting moderate stress. The strongest predictors of stress were physical and mental health status before COVID-19 and having experienced a stressful life event during their pregnancy. Compared to 3 months before the pandemic, women reported higher scores on mood symptoms (p < 0.001), TV use (p = 0.01) and social media use (p = 0.031) in the last 2 weeks before taking the survey. Conclusion: Our study provides important preliminary evidence of the negative impact of the COVID-19 pandemic and the lockdown on pregnant women’s well-being and functioning.

Severe COVID-19 in Cardiopath Young Pregnant Patient without Vertical Transmission

The new betacoronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the cause of COVID-19, and has spread rapidly around the world, reaching more than 200 countries, around 364 million people and causing more than 5 million deaths according to the World Health Organization, so this paper reports a fatal case of SARS-CoV-2 infection in a young pregnant woman with heart disease, without vertical transmission. A 26 years old patient at 28th week of pregnancy with regular prenatal care, presented dry cough, high fever, and severe respiratory distress. Due to her clinical symptoms, she sought medical care at a cardiology hospital in Northern Brazil. The medical conditions she presented were heart disease, rheumatic fever history and had no recent record of national or international travel. She was hospitalized and after clinical stabilization, she was referred for an emergency cesarean intervention. The young mother and the newborn were transferred to the intensive care unit after surgery, where diagnostic tests for respiratory viral infections, including SARS-CoV-2, were performed. The mother tested positive, while her newborn was negative for SARS-CoV-2 demonstrating no vertical transmission of SARS-CoV-2 in this severe case. This study reveals that despite the mother’s initially mild symptoms, she progressed to severe clinical conditions resulting in death, although no vertical transmission was observed. This report highlights the relevance of comorbidities for the unfavorable clinical course of COVID-19.

Perinatal outcomes of pregnant women with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO): a case series and literature review

Purpose

Pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a higher risk of hospitalization, admission to intensive care unit (ICU) and invasive ventilation, and of acute respiratory distress syndrome (ARDS). In case of ARDS and critical severe coronavirus disease 2019 (COVID-19), the use of extracorporeal membrane oxygenation (ECMO) is recommended when other respiratory support strategies (oxygen insufflation, non-invasive ventilation [NIV], invasive ventilation through an endotracheal tube) are insufficient. However, available data on ECMO in pregnant and postpartum women with critical COVID-19 are very limited.

Methods

A case series of three critically ill pregnant women who required ECMO support for COVID-19 in pregnancy and/or in the postpartum period.

Results

The first patient tested positive for COVID-19 during the second trimester, she developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a cesarean-section [CS] at term was performed for obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation. During ECMO, she experienced a precipitous vaginal delivery at 31 weeks and 6 days of gestation. She was discharged 1 month later in good general conditions. The third patient, an obese 43-year-old woman, tested positive at 38 weeks and 2 days of gestation. Because of the worsening of clinical condition, a CS was performed, and she underwent ECMO. 143 days after the CS, she died because of sepsis and multiple organ failure (MOF). Thrombosis, hemorrhage and infections were the main complications among our patients. Neonatal outcomes have been positive.

Conclusion

ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19.

Titres and neutralising capacity of SARS-CoV-2-specific antibodies in human milk: a systematic review

OBJECTIVE

Synthesise evidence on production of SARS-CoV-2 antibodies in human milk of individuals who had COVID-19, and antibodies' ability to neutralise SARS-CoV-2 infectivity.

DESIGN

A systematic review of studies published from 1 December 2019 to 16 February 2021 without study design restrictions.

SETTING

Data were sourced from PubMed, MEDLINE, Embase, CNKI, CINAHL and WHO COVID-19 database. Search was also performed through reviewing references of selected articles, Google Scholar and preprint servers. Studies that tested human milk for antibodies to SARS-CoV-2 were included.

PATIENTS

Individuals with COVID-19 infection and human milk tested for anti-SARS-CoV-2 neutralising antibodies.

MAIN OUTCOME MEASURES

The presence of neutralising antibodies in milk samples provided by individuals with COVID-19 infection.

RESULTS

Individual participant data from 161 persons (14 studies) were extracted and re-pooled. Milk from 133 (82.6%) individuals demonstrated the presence of anti-SARS-CoV-2 immunoglobulin A (IgA), IgM and/or IgG. Illness severity data were available in 146 individuals; 5 (3.4%) had severe disease, 128 (87.7%) had mild disease, while 13 (8.9%) were asymptomatic. Presence of neutralising antibodies in milk from 20 (41.7%) of 48 individuals neutralised SARS-CoV-2 infectivity in vitro. Neutralising capacity of antibodies was lost after Holder pasteurisation but preserved after high-pressure pasteurisation.

CONCLUSION

Human milk of lactating individuals after COVID-19 infection contains anti-SARS-CoV-2-specific IgG, IgM and/or IgA, even after mild or asymptomatic infection. Current evidence demonstrates that these antibodies can neutralise SARS-CoV-2 virus in vitro. Holder pasteurisation deactivates SARS-CoV-2-specific IgA, while high-pressure pasteurisation preserves the SARS-CoV-2-specific IgA function.

Effect of in utero exposure to SARS-CoV-2 infection on pregnancy outcomes and growth and development of infants: protocol for a multicentre ambispective cohort study in India

INTRODUCTION

Poor pregnancy and neonatal outcomes in infants born to COVID-19 positive mothers have been reported, but there is insufficient evidence regarding subsequent growth and development of these children. Our study aims to explore the effect of in-utero exposure to SARS-CoV-2 on pregnancy outcomes and growth and development of infants.

METHODS AND ANALYSIS

A multicentric ambispective cohort study with comparison group (1:1) will be conducted at six sites. A total of 2400 participants (exposure cohort, n=1200; comparison cohort, n=1200), ie, 400 participants from each site (200 retrospectively; 200 prospectively) will be included. Exposure cohort will be infants born to women with documented COVID-19 infection anytime during pregnancy and comparison cohort will be infants born to women who did not test positive for SARS-CoV-2 anytime during pregnancy. All infants will be followed up till 1 year of age. Anthropometric measurement, age of attainment of developmental milestones and clinical examination findings will be recorded at each follow-up. Data regarding possible cofactors affecting the outcomes will be collected from both groups and adjusted for during analysis. The two groups will be compared for prevalence of every variable considered in the study. Relative risk, attributable and population attributable risks will be calculated. All risk factors with p<0.1 on bivariate analysis will be subjected to multiple logistic regression analysis. A final multivariable model will be developed by including the statistically significant risk factors.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of IIHMR Delhi (IRB/2021-2022/006) and will be required to be approved at all participating study sites. The study is scheduled from September 2021 to August 2023. Data from retrospective cohort will be reported by August 2022. All participants will provide written informed consent. We plan to publish our results in a peer-reviewed journal and present findings at academic conferences.

Evidence of vertical transmission of SARS-CoV-2 and interstitial pneumonia in second trimester twin stillbirth in asymptomatic woman. Case report and review of the literature

Data on the vertical transmission rate of COVID-19 in pregnancy are limited, although data reporting mother-fetal transmission in the second trimester of pregnancy are controversial.

We described a case of second-trimester twin stillbirth in a woman with SARS-CoV-2 infection in which placental and fetal markers of infection were detected, despite the absence of respiratory syndrome. The patient developed clinical chorioamnionitis and spontaneously delivered 2 stillborn infants. Placental histology and immunohistochemistry demonstrated SARS-CoV-2 infection mostly within the syncytiotrophoblast, and fetal autopsy showed the development of interstitial pneumonia.

Our findings demonstrated that in utero vertical transmission is possible in asymptomatic pregnant women with SARS-CoV-2 infection and that infection can lead to severe morbidity in the second trimester of pregnancy.

Clinical Profile and Short-Term Outcome of SARS-CoV-2-Infected Neonates from a Government Medical College in West Bengal, India

INTRODUCTION

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has led to a terrifying global pandemic. The presentations in neonates are varied with less case severity compared to adults.

AIM

To describe the clinical and laboratory features and outcomes of neonates admitted with SARS-CoV-2 infection during the second surge of COVID-19 pandemic in a Government Medical College, West Bengal, India.

MATERIALS AND METHODS

It is a hospital-based observational cross-sectional study conducted in the newborn unit of Burdwan Medical College and Hospital between 1 April 2021 and 31 July 2021 including all SARS-CoV-2 Real time RT-PCR (Reverse transcriptase polymerase chain reaction) positive neonates. The demographic, clinical and laboratory characteristics of all the neonates and their outcomes were documented and analysed.

RESULTS

Twenty-two neonates were found to be SARS-CoV-2 RT-PCR positive out of which 9 (40.9%) were found to be asymptomatic and 6 (27.27%) required neonatal intensive care unit admissions. Among the symptomatic neonates, most common presentations were respiratory distress (40.9%) and gastrointestinal manifestations (40.9%). Eight (36.36%) neonates required respiratory support. Three (13.6%) neonates had pneumonia of which one had right middle lobe collapse. Laboratory parameters were nonspecific except for the two (9%) cases of multisystem inflammatory syndrome in neonates. High-resolution computed tomography findings in two cases were suggestive of SARS-CoV-2 infection-induced changes. Two (9%) neonates died of which one was likely due to SARS-CoV-2 infection.

CONCLUSION

Neonates with SARS-CoV-2 infection are mostly asymptomatic. However, clinicians must be vigilant as atypical presentations such as consolidation, collapse, meningitis or multisystem inflammatory syndrome may occur.

Updating Clinical Practices to Promote and Protect Human Milk and Breastfeeding in a COVID-19 Era

The COVID-19 pandemic has impacted breastfeeding and lactation globally, with clinical practices implemented early in the pandemic being mostly anti-breastfeeding, e.g., separation of mothers from their infants, and not evidence based. As the pandemic has progressed, evidence has emerged reconfirming the value of human milk and the importance of protecting and supporting breastfeeding, especially the initiation of lactation. However, it is clear that COVID-19 has changed the clinical care paradigm around breastfeeding and lactation support and, as such, it is imperative that practices adapt and evolve to maintain the emphasis on lactation support. We participated in a round table conference aiming to rescue and develop protocols and practices that support breastfeeding during the COVID-19 pandemic. One key area to target will be to maximize the use of the antenatal period. The early identification of lactation risk factors together with the development of person-centered methods to deliver breastfeeding information and education to parents-to-be will be critical. In addition, the establishment of a hospital culture that values breastfeeding and prioritizes the use of human milk will be integral for the motivation of health care professionals. That culture will also support active management of the initiation of lactation and the development of a 'back-up plan' toolkit to support the mother experiencing lactation difficulties. Post-discharge support will also be crucial with the development of both in-person and virtual lactation support programs, in particular for the immediate post-discharge period to benefit mothers who experience an early discharge process. These measures will allow for a new, adapted framework of practice that acknowledges the current COVID-19 paradigm and maintains the emphasis on the need to protect and support breastfeeding and the use of human milk.

COVID-19 and vertical transmission: assessing the expression of ACE2/TMPRSS2 in the human fetus and placenta to assess the risk of SARS-CoV-2 infection

BACKGROUND

Pregnant women have been identified as a potentially at-risk group concerning COVID-19 infection, but little is known regarding the susceptibility of the fetus to infection. Co-expression of ACE2 and TMPRSS2 has been identified as a prerequisite for infection, and expression across different tissues is known to vary between children and adults. However, the expression of these proteins in the fetus is unknown.

METHODS

We performed a retrospective analysis of a single cell data repository. The data were then validated at both gene and protein level by performing RT-qPCR and two-colour immunohistochemistry on a library of second-trimester human fetal tissues.

FINDINGS

TMPRSS2 is present at both gene and protein level in the predominantly epithelial fetal tissues analysed. ACE2 is present at significant levels only in the fetal intestine and kidney, and is not expressed in the fetal lung. The placenta also does not co-express the two proteins across the second trimester or at term.

INTERPRETATION

This dataset indicates that the lungs are unlikely to be a viable route of SARS-CoV2 fetal infection. The fetal kidney, despite presenting both the proteins required for the infection, is anatomically protected from the exposure to the virus. However, the gastrointestinal tract is likely to be susceptible to infection due to its high co-expression of both proteins, as well as its exposure to potentially infected amniotic fluid.

TWEETABLE ABSTRACT

This work provides detailed mechanistic insight into the relative protection & vulnerabilities of the fetus & placenta to SARS-CoV-2 infection by scRNAseq & protein expression analysis for ACE2 & TMPRSS2. The findings help to explain the low rate of vertical transmission.

Outcome of Neonates Born to COVID-Positive Women at 6 Months of Age

Objective

Methods

Results

Conclusions

One Year on: An Overview of Singapore's Response to COVID-19-What We Did, How We Fared, How We Can Move Forward

Background—One year has passed since the first COVID-19 case in Singapore. This scoping review commemorates Singaporean researchers that have expanded the knowledge on this novel virus. We aim to provide an overview of healthcare-related articles published in peer-reviewed journals, authored by the Singapore research community about COVID-19 during the first year of the pandemic. Methods—This was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol. It included healthcare-related articles about COVID-19 published between 23 January 2020 and 22 January 2021 with a Singapore-affiliated author. MEDLINE, Embase, Scopus, Web of Science, CINAHL, PsycINFO, Google Scholar, and local journals were searched. The articles were screened independently by two reviewers. Results—The review included 504 articles. Most of the articles narrated the changes to hospital practice (210), while articles on COVID-19 pathology (94) formed most of the non-narrative papers. Publications on public health (61) and the indirect impacts to clinical outcomes (45) were other major themes explored by the research community. The remaining articles detailed the psychological impact of the pandemic (35), adaptations of medical education (30), and narratives of events (14). Conclusion—Amidst a resurgence of community cases involving variant COVID-19 strains, the resources from the research community will provide valuable guidance to navigate these uncertain times.

A reasoned approach towards administering COVID-19 vaccines to pregnant women

There are over 50 SARS-CoV-2 candidate vaccines undergoing Phase II and III clinical trials. Several vaccines have been approved by regulatory authorities and rolled out for use in different countries. Due to concerns of potential teratogenicity or adverse effect on maternal physiology, pregnancy has been a specific exclusion criterion for most vaccine trials with only two trials not excluding pregnant women. Thus, other than limited animal studies, gradually emerging development and reproductive toxicity data, and observational data from vaccine registries, there is a paucity of reliable information to guide recommendations for the safe vaccination of pregnant women. Pregnancy is a risk factor for severe COVID-19, especially in women with comorbidities, resulting in increased rates of preterm birth and maternal morbidity. We discuss the major SARS-CoV-2 vaccines, their mechanisms of action, efficacy, safety profile and possible benefits to the maternal-fetal dyad to create a rational approach towards maternal vaccination while anticipating and mitigating vaccine-related complications. Pregnant women with high exposure risks or co-morbidities predisposing to severe COVID-19 infection should be prioritised for vaccination. Those with risk factors for adverse effects should be counselled accordingly. It is essential to support patient autonomy by shared decision-making involving a risk-benefit discussion with the pregnant woman.

COVID-19 and pregnancy: An umbrella review of clinical presentation, vertical transmission, and maternal and perinatal outcomes

BACKGROUND

We conducted an overview of systematic reviews (SRs) summarizing the best evidence regarding the effect of COVID-19 on maternal and child health following Cochrane methods and PRISMA statement for reporting (PROSPERO-CRD42020208783).

METHODS

We searched literature databases and COVID-19 research websites from January to October 2020. We selected relevant SRs reporting adequate search strategy, data synthesis, risk of bias assessment, and/or individual description of included studies describing COVID-19 and pregnancy outcomes. Pair of reviewers independently selected studies through COVIDENCE web-software, performed the data extraction, and assessed its quality through the AMSTAR-2 tool. Discrepancies were resolved by consensus. Each SR's results were synthesized and for the most recent, relevant, comprehensive, and with the highest quality, by predefined criteria, we presented GRADE evidence tables.

RESULTS

We included 66 SRs of observational studies out of 608 references retrieved and most (61/66) had "critically low" overall quality. We found a relatively low degree of primary study overlap across SRs. The most frequent COVID-19 clinical findings during pregnancy were fever (28-100%), mild respiratory symptoms (20-79%), raised C-reactive protein (28-96%), lymphopenia (34-80%), and pneumonia signs in diagnostic imaging (7-99%). The most frequent maternal outcomes were C-section (23-96%) and preterm delivery (14-64%). Most of their babies were asymptomatic (16-93%) or presented fever (0-50%), low birth weight (5-43%) or preterm delivery (2-69%). The odds ratio (OR) of receiving invasive ventilation for COVID-19 versus non-COVID-19 pregnant women was 1.88 (95% Confidence Interval [CI] 1.36-2.60) and the OR that their babies were admitted to neonatal intensive care unit was 3.13 (95%CI 2.05-4.78). The risk of congenital transmission or via breast milk was estimated to be low, but close contacts may carry risks.

CONCLUSION

This comprehensive overview supports that pregnant women with COVID-19 may be at increased risk of adverse pregnancy and birth outcomes and low risk of congenital transmission.

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.

Fetal and Perinatal Outcome Following First and Second Trimester COVID-19 Infection: Evidence from a Prospective Cohort Study

A novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new strain of coronavirus causing coronavirus disease 2019 (COVID-19) disease, which emerged as a global pandemic. Data regarding the implications of COVID-19 disease at early gestation on fetal and obstetric outcomes is scarce. Thus, our aim was to investigate the effect of first and second trimester maternal COVID-19 disease on fetal and perinatal outcomes. This was a prospective cohort study of pregnant women with a laboratory-proven SARS-COV-2 infection contracted prior to 26 weeks gestation. Women were followed at a single tertiary medical center by serial sonographic examinations every 4-6 weeks to assess fetal well-being, growth, placental function, anatomic evaluation and signs of fetal infection. Amniocentesis was offered to assess amniotic fluid SARS-COV-2-PCR (polymerase chain reaction) and fetal brain magnetic resonance imaging (MRI) was offered at 30-32 weeks gestation. Demographic, obstetric and neonatal data were collected from history intake, medical charts or by telephone survey. Perinatal outcomes were compared between women infected at first vs. second trimester. 55 women with documented COVID-19 disease at early gestation were included and followed at our center. The mean maternal age was 29.6 ± 6.2 years and the mean gestational age at viral infection was 14.2 ± 6.7 weeks with 28 (51%) women infected at the first trimester and 27 (49%) at the second trimester. All patients but one experienced asymptomatic to mild symptoms. Of 22 patients who underwent amniocentesis, none had evidence of vertical transmission. None of the fetuses exhibited signs of central nervous system (CNS) disease, growth restriction and placental dysfunction on serial ultrasound examinations and fetal MRI. Pregnancies resulted in perinatal survival of 100% to date with mean gestational age at delivery of 38.6 ± 3.0 weeks and preterm birth <37 weeks rate of 3.4%. The mean birthweight was 3260 ± 411 g with no cases of small for gestational age infants. The obstetric and neonatal outcomes were similar among first vs. second trimester infection groups. We conclude SARS-CoV-2 infection at early gestation was not associated with vertical transmission and resulted in favorable obstetric and neonatal outcomes.

EBCOG position statement on COVID-19 vaccination for pregnant and breastfeeding women

Covid 19 pandemic has led to significant mortality and long term morbidity globally. Pregnant women are at increased risk of severe illness from COVID 19 infection. There is an urgent need for all health authorities and Governments to offer vaccination to all pregnant women especially those with high risk pregnancy.

Clinical course, radiological findings and late outcome in preterm infant with suspected vertical transmission born to a mother with severe COVID-19 pneumonia: a case report

BACKGROUND

Vertical transmission of coronavirus disease 2019 (COVID-19) from mother to newborn infant is doubtful, and very little is known about disease severity and neonatal outcome.

CASE PRESENTATION

We present a preterm Iranian infant born to a Persian mother with severe COVID-19 pneumonia. The mother underwent cesarean delivery, and amniotic fluid yielded a positive result for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by real-time reverse transcription polymerase chain reaction (RT-PCR). The newborn infant showed early-onset infection with SARS-CoV-2 confirmed on pharyngeal swabs by RT-PCR assay within 24 hours after birth, suggesting vertical transmission. Unfortunately, the mother died 14 days after delivery. We describe the clinical course and outcome of the infant up to 7 months of age.

CONCLUSION

COVID-19 infection in pregnant women may increase maternal morbidity, mortality and possibly vertical transmission in severe cases. However, it does not seem to progress to serious early or late neonatal complications.

Current Resources for Evidence-Based Practice, May 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of the prenatal prediction of fetal macrosomia and commentaries on reviews focused on the effects of date palm and dill seed on labor outcomes and the current research available on SARS-CoV-2 and pregnancy outcomes.

Perinatal Maternal-Fetal/Neonatal Transmission of COVID-19: A Guide to Safe Maternal and Neonatal Care in the Era of COVID-19 and Physical Distancing

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), is highly contagious and can cause serious respiratory illness and other clinical manifestations. The aim of this review is to summarize the clinical presentation, diagnosis, and outcomes of COVID-19 in pregnant women and neonates, who may be especially vulnerable to the effects of COVID-19, and to discuss what is known about potential maternal-fetal and maternal-neonatal transmission of SARS-CoV-2.

Breastfeeding in COVID-19: A Pragmatic Approach

The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in changes to perinatal and neonatal care, concentrating on minimizing risks of transmission to the newborn and health care staff while ensuring medical care is not compromised for both mother and infant. Current recommendations on infant care and feeding when mother has COVID-19 ranges from mother-infant separation and avoidance of human milk feeding, to initiation of early skin-to-skin contact and direct breastfeeding. Health care providers fearing risks of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) maternal-infant transmission may veer toward restricted breastfeeding practices. We reviewed guidelines and published literature and propose three options for infant feeding depending on various scenarios. Option A involves direct breastfeeding with the infant being cared for by the mother or caregiver. In option B, the infant is cared for by another caregiver and receives mother's expressed milk. In the third option, the infant is not breastfed directly and does not receive mother's expressed milk. We recommend joint decision making by parents and the health care team. This decision is also flexible as situation changes. We also provide a framework for counseling mothers on these options using a visual aid and a corresponding structured training program for health care providers. Future research questions are also proposed. We conclude that evidence and knowledge about COVID-19 and breastfeeding are still evolving. Our options can provide a quick and flexible reference guide that can be adapted to local needs. KEY POINTS: · SARS-CoV-2 is unlikely transmitted via human milk.. · A shared decision making on infant feeding is the preferred approach.. · Mothers can safely breastfeed with appropriate infection control measures..

Transmission of SARS-CoV-2 to premature twins from an asymptomatic mother

Objectives

The incidence of vertically transmitted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be higher than published. We feel that cases of SARS-CoV-2 vertical transmission are under-reported.

Case presentation

We report a case of SARS-CoV-2 in premature monochorionic monoamniotic twins born by caesarean section to an asymptomatic SARS-CoV-2 positive mother.

Conclusions

This case supports the potential for intrauterine transmission of SARS-CoV-2 as previously reported. The incidence of SARS-CoV-2 vertical transmission from reported cases is low; however this may be due to the difficulty disproving horizontal transmission or under-reporting of cases.