Pregnancy, Viral Infection, and COVID-19

Impact of COVID-19 on pregnancy outcomes during delivery admissions: a nationwide analysis with clinical implications

Background

The available literature indicates a link between SARS-CoV-2 infection during pregnancy and a heightened probability of experiencing negative outcomes for both the pregnant patient and the developing fetus. We compared clinical outcomes of pregnant patients with or without COVID-19 hospitalized during delivery.

Methods

Multivariate logistic regression analysis was used to compare outcomes and was adjusted for patient-related, hospital-related, and illness severity indicators.

Results

We identified a total of 3,447,771 pregnant patients admitted between January 1, 2020 and December 31, 2020; 1.3% (n = 46,050) had COVID-19. COVID-19-positive patients had higher rates of in-hospital mortality (0.15% vs 0.05%, adjusted odds ratio [aOR] 5.97, 95% confidence interval [CI] 2.5-14.25, P < 0.001), mechanical ventilation (0.9% vs 0.05%, aOR 14.2, 95% CI 10.7-18.76, P < 0.001), vasopressor use (0.26% vs 0.14%, aOR 1.47, 95% CI 1.07-2.02, P = 0.01), and perinatal maternal complications like preeclampsia (9.66% vs 7.04%, aOR 1.29, 95% CI 1.2-1.39, P < 0.001) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (0.53% vs 0.26%, aOR 1.93, 95% CI 1.43-2.61, P < 0.001) than COVID-19-negative patients.

Discussion

Clinicians should be aware of the heightened risk of complications in pregnant patients with COVID-19 and consider strategies to mitigate them.

Implications of perceived empathy from spouses during pregnancy for health-related quality of life among pregnant women: a cross-sectional study in Anhui, China

BACKGROUND

Empathy is a critical component of nursing care, impacting both nurses' and patients' outcomes. However, perceived empathy from spouses during pregnancy and its impact on health-related quality of life (HRQoL) are unclear. This study aimed to examine pregnant women's perceived empathy from their spouses and assess the relation of perceived empathy on HRQoL.

METHODS

This cross-sectional study, performed in the obstetric clinics or wards of four well-known hospitals in Anhui Province, China, included 349 pregnant women in the second or third trimester; participants were recruited by convenience sampling and enrolled from October to December 2021. A general information questionnaire, the Interpersonal Reactivity Index (IRI), a purpose-designed empathy questionnaire and the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) were used to evaluate the pregnant women's general information, perceptions of empathy and HRQoL. Data were analysed using SPSS 22 at a threshold of P < 0.05. Descriptive analysis, Pearson correlation analysis, Student's t test, ANOVA, and multiple regression analysis were used for analysis.

RESULTS

The pregnant women's total empathy, physical component summary (PCS) and mental component summary (MCS) scores were 41.6 ± 9.0, 41.6 ± 7.6, and 47.7 ± 9.1, respectively. Correlation analysis revealed that the purpose-designed empathy questionnaire items were significantly positively correlated with perspective taking and empathic concern but were not correlated with the personal distress dimension and were only partially correlated with the fantasy dimension. Maternal physical condition during pregnancy, planned pregnancy, and occupational stress were predictors of the PCS score (β = 0.281, P < 0.01; β = 0.132, P = 0.02; β = -0.128, P = 0.02). The behavioural empathy item of our purpose-designed empathy questionnaire and empathic concern were important predictors of the MCS score (β = 0.127, P = 0.02; β = 0.158, P < 0.01), as well as other demographic and obstetric information, explaining 22.0% of the variance in MCS scores totally (F = 12.228, P < 0.01).

CONCLUSIONS

Pregnant women perceived lower empathy from their spouses and reported lower HRQoL. Perceived empathy, particularly behavioural empathy, may significantly impact pregnant women's MCS scores but has no effect on their PCS scores. Strategies that foster perceived empathy from spouses among pregnant women are essential for facilitating healthy pregnancies and potentially improving maternal and child health.

Association between COVID-19 Infection and Miscarriages, What We Really Know?

BACKGROUND

COVID-19 is a modern worldwide pandemic that affected and continues to affect millions of people around the world. Since the discovery that angiotensin-converting enzyme 2 (ACE2) is the binding site for COVID-19 to achieve cell entry, there has been a continuous debate about the effect of COVID-19 infection in first and second trimester abortions. The aim of this review is to investigate the impact of COVID-19 infection on the incidence of miscarriage. Furthermore, we seek to identify potential pathophysiological mechanisms of early pregnancy loss present in infected women.

METHODS

A literature review was conducted on different databases, including PubMed, Google Scholar, Ovid, Science Direct, Scopus, and Cochrane library, between 1 January 2020 and 31 August 2023. A total of 364 articles were identified and 32 articles were ultimately included in the review.

RESULTS

There are several case studies that provide evidence that early pregnancy loss is associated with COVID-19 infection. These findings are not further confirmed by the majority of systematic reviews and meta-analyses, which demonstrate that the total number of miscarriages do not differ significantly between infected and non-infected groups. Furthermore, there are also case reports that associate COVID-19 infection with late second trimester abortions.

CONCLUSIONS

Given that the virus persists globally, it is important to gain a better understanding of its associated risks in the reproductive process, and larger, more homogeneous, and controlled studies are required to obtain more robust data that can be meta-analyzed to obtain an overview of this potential relationship.

Impact of COVID-19 on Pregnancy Outcomes across Trimesters in the United States

BACKGROUND

Current knowledge regarding the association between trimester-specific changes during pregnancy and COVID-19 infection is limited. We utilized the National Inpatient Sample (NIS) database to investigate trimester-specific outcomes among hospitalized pregnant women diagnosed with COVID-19.

RESULTS

Out of 3,447,771 pregnant women identified, those with COVID-19 exhibited higher in-hospital mortality rates in their third trimester compared with those without the virus. Notably, rates of mechanical ventilation, acute kidney injury, renal replacement therapy, and perinatal complications (preeclampsia, HELLP syndrome, and preterm birth) were significantly elevated across all trimesters for COVID-19 patients. COVID-19 was found to be more prevalent among low-income, Hispanic pregnant women.

CONCLUSIONS

Our findings suggest that COVID-19 during pregnancy is associated with increased risk of maternal mortality and complications, particularly in the third trimester. Furthermore, we observed significant racial and socioeconomic disparities in both COVID-19 prevalence and pregnancy outcomes. These findings emphasize the need for equitable healthcare strategies to improve care for diverse and socioeconomically marginalized groups, ultimately aiming to reduce adverse COVID-19-associated maternal and fetal outcomes.

Adverse outcomes in SARS-CoV-2-infected pregnant mice are gestational age-dependent and resolve with antiviral treatment

SARS-CoV-2 infection during pregnancy is associated with severe COVID-19 and adverse fetal outcomes, but the underlying mechanisms remain poorly understood. Moreover, clinical studies assessing therapeutics against SARS-CoV-2 in pregnancy are limited. To address these gaps, we developed a mouse model of SARS-CoV-2 infection during pregnancy. Outbred CD1 mice were infected at E6, E10, or E16 with a mouse-adapted SARS-CoV-2 (maSCV2) virus. Outcomes were gestational age-dependent, with greater morbidity, reduced antiviral immunity, greater viral titers, and impaired fetal growth and neurodevelopment occurring with infection at E16 (third trimester equivalent) than with infection at either E6 (first trimester equivalent) or E10 (second trimester equivalent). To assess the efficacy of ritonavir-boosted nirmatrelvir, which is recommended for individuals who are pregnant with COVID-19, we treated E16-infected dams with mouse-equivalent doses of nirmatrelvir and ritonavir. Treatment reduced pulmonary viral titers, decreased maternal morbidity, and prevented offspring growth restriction and neurodevelopmental impairments. Our results highlight that severe COVID-19 during pregnancy and fetal growth restriction is associated with heightened virus replication in maternal lungs. Ritonavir-boosted nirmatrelvir mitigated maternal morbidity along with fetal growth and neurodevelopment restriction after SARS-CoV-2 infection. These findings prompt the need for further consideration of pregnancy in preclinical and clinical studies of therapeutics against viral infections.

Unraveling Immunological Dynamics: HPV Infection in Women-Insights from Pregnancy

During pregnancy, hormonal and immune adaptations are vital for supporting the genetically distinct fetus during elevated infection risks. The global prevalence of HPV necessitates its consideration during pregnancy. Despite a seemingly mild immune response, historical gestational viral infections underscore its significance. Acknowledging the established HPV infection risks during pregnancy, our review explores the unfolding immunological changes in pregnant women with HPV. Our analysis aims to uncover strategies for safely modulating the immune system, mitigating adverse pregnancy consequences, and enhancing maternal and child health. This comprehensive narrative review delves into the existing knowledge and studies on this topic.

Neonatal Outcome of Mothers With COVID-19 in King Salman Armed Forces Hospital, Tabuk, Kingdom of Saudi Arabia

OBJECTIVES

This study was conducted to assess the neonatal outcome of mothers with COVID-19 in King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

METHODS

This was a hospital record-based, retrospective cohort study. The case group included neonates born to mothers who were positive for the COVID-19 virus during pregnancy, whereas the control group included neonates born to mothers who were not infected with the COVID-19 virus during pregnancy. The data were collected from the records and were analyzed using the Statistical Package for the Social Sciences software (IBM Corp., Armonk, NY, USA).

RESULTS

This study covered the hospital records of 342 women (114 cases and 228 control). The rates of cesarean sections and small for gestational age were significantly higher among the cases compared to the controls (71.1% versus 43.4%, p < 0.001 and 24.6% versus 11.8%, p = 0.003; respectively). The mean birth weight was significantly lower among the cases group (3.0 ± 0.6 versus 3.3 ± 0.6 kg, p = 0.022). Only the case group reported the occurrence of neonatal COVID-19 infection (7.9%, p < 0.001). The study reported only a single case of intrauterine fetal death and one stillbirth in the cases group, but no neonatal deaths (p > 0.05).

CONCLUSIONS

Maternal COVID-19 may be associated with undesirable neonatal outcomes. There is a possibility of vertical transmission of COVID-19 from the mother to the neonate, but this cannot be confirmed.

Sex and gender in infection and immunity: addressing the bottlenecks from basic science to public health and clinical applications

Although sex and gender are recognized as major determinants of health and immunity, their role is rarely considered in clinical practice and public health. We identified six bottlenecks preventing the inclusion of sex and gender considerations from basic science to clinical practice, precision medicine and public health policies. (i) A terminology-related bottleneck, linked to the definitions of sex and gender themselves, and the lack of consensus on how to evaluate gender. (ii) A data-related bottleneck, due to gaps in sex-disaggregated data, data on trans/non-binary people and gender identity. (iii) A translational bottleneck, limited by animal models and the underrepresentation of gender minorities in biomedical studies. (iv) A statistical bottleneck, with inappropriate statistical analyses and results interpretation. (v) An ethical bottleneck posed by the underrepresentation of pregnant people and gender minorities in clinical studies. (vi) A structural bottleneck, as systemic bias and discriminations affect not only academic research but also decision makers. We specify guidelines for researchers, scientific journals, funding agencies and academic institutions to address these bottlenecks. Following such guidelines will support the development of more efficient and equitable care strategies for all.

Adverse outcomes in SARS-CoV-2 infected pregnant mice are gestational age-dependent and resolve with antiviral treatment

SARS-CoV-2 infection during pregnancy is associated with severe COVID-19 and adverse fetal outcomes, but the underlying mechanisms remain poorly understood. Moreover, clinical studies assessing therapeutics against SARS-CoV-2 in pregnancy are limited. To address these gaps, we developed a mouse model of SARS-CoV-2 infection during pregnancy. Outbred CD1 mice were infected at embryonic day (E) 6, E10, or E16 with a mouse adapted SARS-CoV-2 (maSCV2) virus. Outcomes were gestational age-dependent, with greater morbidity, reduced anti-viral immunity, greater viral titers, and more adverse fetal outcomes occurring with infection at E16 (3rd trimester-equivalent) than with infection at either E6 (1st trimester-equivalent) or E10 (2nd trimester-equivalent). To assess the efficacy of ritonavir-boosted nirmatrelvir (recommended for pregnant individuals with COVID-19), we treated E16-infected dams with mouse equivalent doses of nirmatrelvir and ritonavir. Treatment reduced pulmonary viral titers, decreased maternal morbidity, and prevented adverse offspring outcomes. Our results highlight that severe COVID-19 during pregnancy and adverse fetal outcomes are associated with heightened virus replication in maternal lungs. Ritonavir-boosted nirmatrelvir mitigated adverse maternal and fetal outcomes of SARS-CoV-2 infection. These findings prompt the need for further consideration of pregnancy in preclinical and clinical studies of therapeutics against viral infections.

Maternal COVID-19 infection and the fetus: Immunological and neurological perspectives

Immunoneuropsychiatry is an emerging field about the interaction between the immune and nervous systems. Infection and infection-related inflammation (in addition to genetics and environmental factors) can act as the etiopathogenesis of neuropsychiatric disorders (NPDs). Exposure to COVID-19 in utero may be a risk factor for developing NPDs in offspring in the future. Maternal immune activation (MIA) and subsequent inflammation can affect fetal brain development. Inflammatory mediators, cytokines, and autoantibodies can pass through the placenta and the compromised blood-brain barrier after MIA, leading to neuroinflammation. Neuroinflammation also affects multiple neurobiological pathways; for example, it decreases the production of the neurotransmitter serotonin. Fetal sex may affect the mother's immune response. Pregnant women with male fetuses have been reported to have decreased maternal and placental humoral responses. This suggests that in pregnancies with a male fetus, fewer antibodies may be transferred to the fetus and contribute to males' increased susceptibility/vulnerability to infectious diseases compared to female infants. Here, we want to discuss maternal COVID-19 infection and its consequences for the fetus, particularly the neurological outcomes and the interaction between fetal sex and possible changes in maternal immune responses.

Addressing Chronic Gynecological Diseases in the SARS-CoV-2 Pandemic

Introduction: the COVID-19 pandemic has had a considerable impact on healthcare systems worldwide. Since the actual influence of the pandemic on gynecological care is still unclear, we aim to evaluate the effect of the SARS-CoV-2 pandemic on gynecological procedures compared to the pre-pandemic period in Romania. Materials and Methods: this is a single-center retrospective observational study, involving patients hospitalized in the year before the SARS-CoV-2 pandemic (PP), in the first year of the pandemic (P1), and in the second year of the pandemic until February 2022 (P2). The percentages of interventions were analyzed globally but also according to the type of surgery applied on the female genital organs. Results: during pandemic, the number of gynecological surgeries dropped considerably, by more than 50% in some cases, or even decreased by up to 100%, having a major impact on women's health, especially in the first year of the pandemic (P1), before slightly increasing in the post-vaccination period (PV). Surgically treated cancer cases dropped by over 80% during the pandemic, and the consequences of this will be seen in the future. Conclusions: the COVID-19 pandemic played an important part in gynecological care management in the Romanian public health care system, and the effect will have to be investigated in the future.

Analysis of pregnant women with critically severe COVID-19 in Republic of Korea from February 2020 and December 2021

OBJECTIVES

This study aimed to describe the characteristics and risk factors for severe disease in pregnant women infected with coronavirus disease 2019 (COVID-19) from the early days of the COVID-19 epidemic in Korea to the predominant period of the Delta variant.

METHODS

A retrospective cohort study was conducted among pregnant women diagnosed with COVID-19 between February 2020 and December 2021. Logistic regression analysis was performed to compare severe and mild cases after adjusting for pregnant women's age, nationality, infection route, outbreak area, infection period, symptoms, underlying disease, smoking status, trimester, and COVID-19 vaccination status.

RESULTS

In total, 2,233 pregnant women were diagnosed with COVID-19 by December 2021. Among these, 96.7% had mild symptoms, 3.3% had severe symptoms, and 0.04% died. The risk factors for severe disease in pregnant women with confirmed COVID-19 were being in the age group of 35 to 45 years, having hyperlipidemia, being in the second or third trimester of pregnancy at the time of COVID-19 diagnosis, being infected during the Delta-predominant period, and having a fever (≥38 °C) at diagnosis. Furthermore, 47.1% of patients in the mild group and 84.9% of patients in the severe group had 3 or more risk factors.

CONCLUSION

Pregnant women with COVID-19 mainly experienced mild symptoms, but those with risk factors were at a higher risk of developing severe symptoms. Therefore, treatment and follow-up management should be thoroughly implemented.

Roles of TGF-β1 in Viral Infection during Pregnancy: Research Update and Perspectives

Transforming growth factor-beta 1 (TGF-β1) is a pleiotropic growth factor playing various roles in the human body including cell growth and development. More functions of TGF-β1 have been discovered, especially its roles in viral infection. TGF-β1 is abundant at the maternal-fetal interface during pregnancy and plays an important function in immune tolerance, an essential key factor for pregnancy success. It plays some critical roles in viral infection in pregnancy, such as its effects on the infection and replication of human cytomegalovirus in syncytiotrophoblasts. Interestingly, its role in the enhancement of Zika virus (ZIKV) infection and replication in first-trimester trophoblasts has recently been reported. The above up-to-date findings have opened one of the promising approaches to studying the mechanisms of viral infection during pregnancy with links to corresponding congenital syndromes. In this article, we review our current and recent advances in understanding the roles of TGF-β1 in viral infection. Our discussion focuses on viral infection during pregnancy, especially in the first trimester. We highlight the mutual roles of viral infection and TGF-β1 in specific contexts and possible functions of the Smad pathway in viral infection, with a special note on ZIKV infection. In addition, we discuss promising approaches to performing further studies on this topic.

Knowledge and attitudes of pregnant women on maternal immunization against COVID-19 in Croatia

OBJECTIVES

The aim of this study was to assess pregnant women's knowledge and attitudes regarding maternal COVID-19 immunization during pregnancy.

METHODS

A cross-sectional study was performed in two teaching hospitals between May and October 2021 in Zagreb, Croatia. During antenatal clinic visit pregnant women were approached and asked to fill out a predesigned questionnaire about their knowledge and attitudes towards COVID-19 vaccination. Collected data was later analyzed.

RESULTS

A total of 430 women participated in the study. Only 16% of women expressed their willingness to be vaccinated against COVID-19 if offered, despite that 71% of them believe that COVID-19 might be a serious illness in pregnant women. The most important obstacle in having better acceptance of the vaccines is in the assumption that the vaccines are not safe for pregnant women (73%) or the fetus (75%), or that the vaccines are not effective (41%). The relationship exists between acceptance of vaccination in general and willingness to get other vaccines in pregnancy and readiness to be vaccinated against COVID-19 in pregnancy. Only one out of 55 women who were not adherent to the current vaccination recommendations in Croatia would accept the COVID-19 vaccine during pregnancy if offered. 21 (5%) women stated that vaccination against influenza and pertussis during pregnancy is necessary and 13 (62%) of them would get vaccinated against COVID-19 if offered.

CONCLUSIONS

This study showed that the crucial reasons for refusing vaccination against COVID-19 among pregnant women in Croatia are the concerns about the vaccines' effectiveness and safety. All healthcare providers should put more effort into education of pregnant women on risks of COVID-19, as well as on the benefits and safety of the vaccines.

The impact of the COVID-19 pandemic on the mental health of new mothers in China: A qualitative study of mothers with infants aged 0–1 year old

Background

China has implemented a strict epidemic control policy (ECP) for 3 years during the COVID-19 pandemic. New mothers are under great psychological pressure to protect themselves against the virus, following the ECP, as well as taking on the main responsibility of raising their children. However, the mental health of this group has been neglected by the public. This article aims to understand the mental health of new mothers during the COVID-19 pandemic.

Method

Qualitative research methods were adopted in this study. From 1 October to 1 November 2022, we conducted in-depth interviews with 36 new mothers in Guiyang, Guizhou, China, and used thematic analysis to examine their emotional status, as well as the origins of their negative and positive emotions.

Results

(1) New mothers are chronically depressed, feeling anxious, and upset. (2) Negative emotions are caused either by the virus or by the ECP. (3) New mothers are mainly anxious about their children's physical health, feeding options, childcare, and family income. (4) Positive emotions are reflected by tight parent–child bonds, a better understanding of childcare, and an increased ability to perceive risks.

Conclusion

The anxiety of new mothers has revealed the shortcomings of the Chinese health system in the emergency management of the mother and child. At the same time, the outbreak is an opportunity to improve the response management capacity of the health system in order to prevent the recurrence of similar problems for mothers and infants.

Gestational exposure to unmethylated CpG oligonucleotides dysregulates placental molecular clock network and fetoplacental growth dynamics, and disrupts maternal blood pressure circadian rhythms in rats

Bacterial infections and impaired mitochondrial DNA dynamics are associated with adverse pregnancy outcomes. Unmethylated cytosine-guanine dinucleotide (CpG) motifs are common in bacterial and mitochondrial DNA and act as potent immunostimulators. Here, we tested the hypothesis that exposure to CpG oligonucleotides (ODN) during pregnancy would disrupt blood pressure circadian rhythms and the placental molecular clock machinery, mediating aberrant fetoplacental growth dynamics. Rats were repeatedly treated with CpG ODN in the 3 ^rd trimester (gestational day, GD, 14, 16, 18) and euthanized on GD20 (near term) or with a single dose of CpG ODN and euthanized 4 hours after treatment on GD14. Hemodynamic circadian rhythms were analyzed via Lomb-Scargle periodogram analysis on 24-h raw data collected continuously via radiotelemetry. A p -value ≥ 0.05 indicates the absence of a circadian rhythm. Following the first treatment with CpG ODN, maternal systolic and diastolic blood pressure circadian rhythms were lost ( p ≥ 0.05). Blood pressure circadian rhythm was restored by GD16 and remained unaffected after the second treatment with CpG ODN ( p < 0.0001). Diastolic blood pressure circadian rhythm was again lost after the last treatment on GD18 ( p ≥ 0.05). CpG ODN increased placental expression of Per2 and Per3 and Tnfα ( p ≤ 0.05) and affected fetoplacental growth dynamics, such as reduced fetal and placental weights were disproportionately associated with increases in the number of resorptions in ODN-treated dams compared to controls. In conclusion, gestational exposure to unmethylated CpG DNA dysregulates placental molecular clock network and fetoplacental growth dynamics and disrupts blood pressure circadian rhythms.

SARS-CoV-2 infection induces activation of ferroptosis in human placenta

Ferroptosis, a regulated non-apoptotic form of cell death, has been implicated in the response to varied types of infectious agents including virus. In this study, we sought to determine whether SARS-CoV-2 infection can induce activation of ferroptosis in the human placenta. We collected placentas from 23 pregnant females with laboratory-confirmed SARS-CoV-2 following delivery and then used RNA in situ hybridization assay for detection of viral positive-sense strand (PSS) to confirm that these placentas have been infected. We also used immunohistochemistry assay to assess expression levels of acyl-CoA synthetase long-chain family member 4 (ACSL4), an essential executioner of ferroptosis in the same specimens. Our results showed that ACSL4 expression was significantly increased in the group with positive positive-sense strand staining compared to their negative counterparts (p = 0.00022). Furthermore, we found that there was a positive trend for increased PSS staining along with increased ACSL4 expression. Our study supports that ferroptosis is activated in the response to SARS-CoV-2 infection in the human placenta, highlighting a molecular mechanism potentially linking this coronavirus infection and pathogenesis of adverse pregnancy outcomes.

COVID-19 Vaccine Hesitancy among Pregnant Women Attending Antenatal Clinics in Pakistan: A Multicentric, Prospective, Survey-Based Study

This study aimed to assess the vaccination status and factors contributing to vaccine hesitancy among pregnant women in the largest province of Pakistan. A multicentric, prospective, survey-based study using an interviewer-administered tool was conducted among pregnant women attending antenatal clinics between 1 December 2021 through 30 January 2022 across seven hospitals in Pakistan. The healthcare professionals providing care at the participating hospitals administered the survey. Four hundred and five pregnant women fully consented and completed the study. The majority of the study participants (70.6%, n = 286) were aged between 25 and 34 and had a previous successful pregnancy history. More than half of the study participants (56.0%, n = 227) did not receive COVID-19 vaccination at the time of data collection despite their family members (93.9%, n = 372) had already received at least one dose of COVID-19 vaccine. Among those who received COVID-19 vaccination (n = 173), vaccine efficacy, protection for the foetus, and risk of COVID-19-associated hospitalisation were the main driving factors for vaccine hesitancy. The majority of the unvaccinated women (77.8%, n = 182) had no intention of receiving the vaccine. However, more than two-thirds (85.7%, n = 342) consulted the doctor about COVID-19 vaccines, and most were recommended to receive COVID-19 vaccines by the doctors (80.7%, n = 280). Women were significantly more likely to be vaccinated if they had employment (odds ratio [OR] 4.47, 95% confidence interval [CI]: 2.31-8.64) compared with their counterparts who were homemakers, consulted their doctors (OR 0.12, 95% CI: 0.04-0.35), and if they did not have pregnancy-related issues (OR 6.02, 95% CI: 2.36-15.33). In this study, vaccine hesitancy was prevalent, and vaccine uptake was low among pregnant women. Education and employment did impact COVID vaccination uptake, emphasising the need for more targeted efforts to enhance the trust in vaccines.

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

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

Dysregulated Exosomes Result in Suppression of the Immune Response of Pregnant COVID-19 Convalescent Women

A successful pregnancy outcome is dependent on a delicate balance between inflammatory and anti-inflammatory processes throughout the different trimesters. Interruption in this balance can lead to an adverse outcome resulting in pregnancy loss. Since late 2019, the emergence of the new SARS-CoV-2 virus has affected lives worldwide, including pregnant women; therefore, there is an urgent need to address different approaches in relation to prevention, diagnostics, and therapeutics. Early pregnancy is affected by SARS-CoV-2 infection leading to fetal demise. Available evidence also suggests that 90% of pregnant women infected with the SARS-CoV-2 virus seem to be asymptomatic. Nonetheless, it is still unclear how COVID-19 affects exosome production in pregnant women recovered from COVID-19 and how these exosomes regulate the adaptive immune response. In this study, we found several exosomes including CD9, CD31, CD40, CD45, CD41b, CD42a, CD62P, CD69, CD81, CD105, and HLA-DRDPDQ in the plasma of COVID-19-recovered pregnant women were significantly less abundant than the control group. Furthermore, to understand how these exosomes affect the adaptive immune response, we co-cultured the peripheral blood mononuclear cells (PBMCs) from healthy control (HC) pregnant women with exosomes of either Preg-HC or Preg-recovered COVID-19 women. We identified that Preg-recovered COVID-19 women have reduced capacity for the inflammatory cytokine TNF-α from cytotoxic CD8⁺ T cells. In summary, our study highlights that pregnant recovered COVID-19 women have reduced production of several exosomes and possess fewer immunogenic properties. Our study implicates that exosomes can control inflammation and antigen presentation capacity of immune cells, thus limiting the infection in pregnant women.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection Versus Vaccination in Pregnancy: Implications for Maternal and Infant Immunity

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with adverse maternal and neonatal outcomes, yet uptake of SARS-CoV-2 vaccines during pregnancy and lactation has been slow. As a result, millions of pregnant and lactating women and their infants remain susceptible to the virus.

METHODS

We measured spike-specific immunoglobulin G (anti-S IgG) and immunoglobulin A (anti-S IgA) in serum and breastmilk (BM) samples from 3 prospective mother-infant cohorts recruited in 2 academic medical centers. The primary aim was to determine the impact of maternal SARS-CoV-2 immunization vs infection and their timing on systemic and mucosal immunity.

RESULTS

The study included 28 mothers infected with SARS-CoV-2 in late pregnancy (INF), 11 uninfected mothers who received 2 doses of the BNT162b2 vaccine in the latter half of pregnancy (VAX-P), and 12 uninfected mothers who received 2 doses of BNT162b2 during lactation. VAX dyads had significantly higher serum anti-S IgG compared to INF dyads (P < .0001), whereas INF mothers had higher BM:serum anti-S IgA ratios compared to VAX mothers (P = .0001). Median IgG placental transfer ratios were significantly higher in VAX-P compared to INF mothers (P < .0001). There was a significant positive correlation between maternal and neonatal serum anti-S IgG after vaccination (r = 0.68, P = .013), but not infection.

CONCLUSIONS

BNT161b2 vaccination in late pregnancy or lactation enhances systemic immunity through serum anti-S immunoglobulin, while SARS-CoV-2 infection induces mucosal over systemic immunity more efficiently through BM immunoglobulin production. Next-generation vaccines boosting mucosal immunity could provide additional protection to the mother-infant dyad. Future studies should focus on identifying the optimal timing of primary and/or booster maternal vaccination for maximal benefit.

Assessment of Neonatal Cord Blood SARS-CoV-2 Antibodies after COVID-19 Vaccination in Pregnancy: A Prospective Cohort Study

Introduction Maternally derived antibodies are a key element of neonatal immunity. So far, limited data has shown transplacental transmission of antibodies after coronavirus disease 2019 (COVID-19) vaccination with BNT162b2 in the third trimester. Our aim was to detect vertically transferred immunity after COVID-19 vaccination with BNT162b2 (Comirnaty, BioNTech-Pfizer) or mRNA-1273 (Spikevax, Moderna) in the first, second or third trimester of pregnancy, and investigate the impact of maternal characteristics on umbilical cord antibody titre in newborns after delivery.

Study Design Women who gave birth in our department and were vaccinated against COVID-19 during pregnancy were enrolled in CRONOS Satellite, a subproject of the German COVID-19-Related Obstetric and Neonatal Outcome Study. The titre of immunoglobulin G (IgG) antibodies to the receptor-binding domain of the SARS-CoV-2 spike protein was quantified in umbilical cord blood using the SARS-CoV-2 IgG II Quant immunoassay. Correlations between antibody titre and variables, including week of pregnancy when vaccinated, interval between vaccination and delivery, age and body mass index (BMI) were assessed with Spearmanʼs rank correlation. A follow-up was conducted by phone interview 4 – 6 weeks after delivery.

Results The study cohort consisted of 70 women and their 74 newborns. Vaccine-generated antibodies were present in all samples, irrespective of the vaccination type or time of vaccination. None of the parameters of interest showed a meaningful correlation with cord blood antibody concentrations (rho values < 0.5). No adverse outcomes (including foetal malformation) were reported, even after vaccination in the first trimester.

Conclusions Transplacental passage of SARS-CoV-2 antibodies from mother to child was demonstrated in all cases in the present study. It can therefore be assumed that the newborns of mothers vaccinated at any time during pregnancy receive antibodies via the placenta which potentially provide them with protection against COVID-19. This is an additional argument when counselling pregnant women about vaccination in pregnancy.

Pregnant Women's Knowledge of and Attitudes towards Influenza Vaccination during the COVID-19 Pandemic in Poland

Pregnant women are more susceptible to influenza virus infections due to the immunological and physiological changes in the course of pregnancy. Vaccination during pregnancy is a safe and effective method for protecting both the mothers and the infants from influenza and its complications. This study was conducted in order to determine the knowledge and attitudes of Polish pregnant women towards influenza vaccination during the COVID-19 pandemic. A questionnaire-based and self-administered study was carried out fully online and a total of 515 women participated. A total of 52% (n = 268) of surveyed women answered that vaccination against influenza during pregnancy was safe. However, only 21% (n = 108) were vaccinated against influenza during their current pregnancy and 17.5% (n = 90) intended to be vaccinated. The participants indicated many concerns about getting vaccinated during pregnancy, but also many benefits that come with the vaccination. General knowledge about influenza, its complications, and vaccination was quite high in the study group.

The 'new normal' includes online prenatal exercise: exploring pregnant women's experiences during the pandemic and the role of virtual group fitness on maternal mental health

BACKGROUND

Prenatal anxiety and depressive symptoms have significantly increased since the onset of the coronavirus (COVID-19) pandemic In addition, home confinement regulations have caused a drastic increase in time spent sedentary. Online group fitness classes may be an effective strategy that can increase maternal physical activity levels and improve mental health outcomes by providing an opportunity for social connectedness. The present study explores the experiences of pregnant women who participated in an online group exercise program during the pandemic and identifies relationships with maternal mental health and well-being. In addition, we present person-informed recommendations on how to improve the delivery of future online prenatal exercise programs.

METHODS

Semi-structured interviews were conducted with pregnant women (8-39 weeks of pregnancy) who participated in an online group exercise program, from March to October 2020 in Spain. A phenomenological approach was taken, and open-ended questions were asked to understand women's experiences throughout the pandemic and the role the online exercise classes may have had on their physical activity levels, mental health, and other health behaviours such as diet. A thematic analysis was performed to evaluate data. In addition, women completed the State-Trait Anxiety Inventory and these data supplemented qualitative findings.

RESULTS

Twenty-four women were interviewed, and the anxiety scores were on average 32.23 ± 9.31, ranging from low to moderate levels. Thematic analysis revealed that women felt safe exercising from home, an increased availability of time to schedule a structured exercise class, and consequently an improvement in their adherence to the program and other behaviours (i.e., healthier diet). Women emphasized feeling connected to other pregnant women when they exercised online together, and overall, this had a positive effect on their mental well-being. Women suggested that future online exercise programs should include flexible options, detailed instructions and facilitation by a qualified exercise professional.

CONCLUSION

Pregnant women are receptive to online group exercise classes and expressed that they are an accessible option to accommodating physical activity during the pandemic. In addition, the online group environment provides an important sense of connectivity among pregnant women exercising together and this may mitigate the detrimental effect of COVID-19 on maternal mental health.

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.

Does the Fetus Limit Antibiotic Treatment in Pregnant Patients with COVID-19?

During pregnancy, there is a state of immune tolerance that predisposes them to viral infection, causing maternal-fetal vulnerability to the adverse effects of COVID-19. Bacterial coinfections significantly increase the mortality rate for COVID-19. However, it is known that all drugs, including antibiotics, will enter the fetal circulation in a variable degree despite the role of the placenta as a protective barrier and can cause teratogenesis or other malformations depending on the timing of exposure to the drug. Also, it is important to consider the impact of the indiscriminate use of antibiotics during pregnancy can alter both the maternal and fetal-neonatal microbiota, generating future repercussions in both. In the present study, the literature for treating bacterial coinfections in pregnant women with COVID-19 is reviewed. In turn, we present the findings in 50 pregnant women hospitalized diagnosed with SARS-CoV-2 without previous treatment with antibiotics; moreover, a bacteriological culture of sample types was performed. Seven pregnant women had coinfection with Staphylococcus haemolyticus, Staphylococcus epidermidis, Streptococcus agalactiae, Escherichia coli ESBL +, biotype 1 and 2, Acinetobacter jahnsonii, Enterococcus faecium, and Clostridium difficile. When performing the antibiogram, resistance to multiple drugs was found, such as macrolides, aminoglycosides, sulfa, dihydrofolate reductase inhibitors, beta-lactams, etc. The purpose of this study was to generate more scientific evidence on the better use of antibiotics in these patients. Because of this, it is important to perform an antibiogram to prevent abuse of empirical antibiotic treatment with antibiotics in pregnant women diagnosed with SARS-CoV-2.

Cord Blood SARS-CoV-2 IgG Antibodies and Their Association With Maternal Immunity and Neonatal Outcomes

Passive transplacental immunity is crucial for neonatal protection from infections. Data on the correlation between neonatal immunity to SARS-CoV-2 and protection from adverse outcomes is scarce. This work aimed to describe neonatal seropositivity in the context of maternal SARS-CoV-2 infection, seropositivity, and neonatal outcomes. This retrospective nested case-control study enrolled high-risk pregnant women with a SARS-CoV-2 RT-PCR positive test who gave birth at the Instituto Nacional de Perinatología in Mexico City and their term neonates. Anti-SARS-CoV-2 IgG antibodies in maternal and cord blood samples were detected using a chemiluminescent assay. In total, 63 mother-neonate dyads (mean gestational age 38.4 weeks) were included. Transplacental transfer of SARS-CoV-2 IgG occurred in 76% of neonates from seropositive mothers. A positive association between maternal IgG levels and Cycle threshold (Ct) values of RT-qPCR test for SARS-CoV-2 with neonatal IgG levels was observed. Regarding neonatal outcomes, most seropositive neonates did not require any mechanical ventilation, and none developed any respiratory morbidity (either in the COVID-19 positive or negative groups) compared to 7 seronegative neonates. Furthermore, the odds of neonatal respiratory morbidity exhibited a tendency to decrease when neonatal IgG levels increase. These results add further evidence suggesting passive IgG transfer importance.

SARS-CoV-2 and the Immune Response in Pregnancy with Delta Variant Considerations

As of September 2021, there has been a total of 123,633 confirmed cases of pregnant women with SARS-CoV-2 infection in the US according to the CDC, with maternal death being 2.85 times more likely, pre-eclampsia 1.33 times more likely, preterm birth 1.47 times more likely, still birth 2.84 times more likely, and NICU admission 4.89 times more likely when compared to pregnant women without COVID-19 infection. In our literature review, we have identified eight key changes in the immunological functioning of the pregnant body that may predispose the pregnant patient to both a greater susceptibility to SARS-CoV-2, as well as a more severe disease course. Factors that may impede immune clearance of SARS-CoV-2 include decreased levels of natural killer (NK) cells, Th1 CD4+ T cells, plasmacytoid dendritic cells (pDC), a decreased phagocytic index of neutrophil granulocytes and monocytes, as well as the immunomodulatory properties of progesterone, which is elevated in pregnancy. Factors that may exacerbate SARS-CoV-2 morbidity through hyperinflammatory states include increases in the complement system, which are linked to greater lung injury, as well as increases in TLR-1 and TLR-7, which are known to bind to the virus, leading to increased proinflammatory cytokines such as IL-6 and TNF-α, which are already elevated in normal pregnant physiology. Other considerations include an increase in angiotensin converting enzyme 2 (ACE2) in the maternal circulation, leading to increased viral binding on the host cell, as well as increased IL-6 and decreased regulatory T cells in pre-eclampsia. We also focus on how the Delta variant has had a concerning impact on SARS-CoV-2 cases in pregnancy, with an increased case volume and proportion of ICU admissions among the infected expecting mothers. We propose that the effects of the Delta variant are due to a combination of (1) the Delta variant itself being more transmissible, contagious, and efficient at infecting host cells, (2) initial evidence pointing to the Delta variant causing a significantly greater viral load that accumulates more rapidly in the respiratory system, (3) the pregnancy state being more susceptible to SARS-CoV-2 infection, as discussed in-depth, and (4) the lower rates of vaccination in pregnant women compared to the general population. In the face of continually evolving strains and the relatively low awareness of COVID-19 vaccination for pregnant women, it is imperative that we continue to push for global vaccine equity.

Maternal Outcomes and Clinical Characteristics of COVID-19 in Korean Pregnant Women during the Early Period of the Pandemic

The present study aimed to compare the clinical characteristics and outcomes between pregnant women and non-pregnant women of childbearing age (20-49 years old) diagnosed with coronavirus disease 2019 (COVID-19) during the initial stage of the COVID-19 pandemic in the Republic of Korea. This nationwide observational study included the information of COVID-19 patients collected by the Korea Disease Control and Prevention Agency from January 2020 to April 2021. Among 5,647 COVID-19 patients, 2,444 (43.3%) were women of childbearing age and 19 were pregnant. None of the pregnant women died. However, 4 deaths occurred among non-pregnant women aged 20-49 years. None of the 19 pregnant women with COVID-19 were admitted to the intensive care unit: they were admitted to the general ward, and none of them required supplemental oxygen. In conclusion, none of the pregnant women with COVID-19 experienced severe infection or death, unlike non-pregnant women of childbearing age.

The Impact of SARS-CoV-2 Infection on Fertility and Female and Male Reproductive Systems

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains a huge challenge for contemporary healthcare systems. Apart from widely reported acute respiratory distress syndrome (ARDS), the virus affects many other systems inducing a vast number of symptoms such as gastrointestinal, neurological, dermatological, cardiovascular, and many more. Currently it has also been hypothesized that the virus might affect female and male reproductive systems; SARS-CoV-2 infection could also have a role in potential disturbances to human fertility. In this article, we aimed to review the latest literature regarding the potential effects of SARS-CoV-2 infection on female and male reproductive systems as well as fertility, in general.

Platelet-Based Biomarkers for Diagnosis and Prognosis in COVID-19 Patients

Coronavirus disease 2019 (COVID-19) caused millions of deaths worldwide. COVID-19’s clinical manifestations range from no symptoms to a severe acute respiratory syndrome, which can result in multiple organ failure, sepsis, and death. Severe COVID-19 patients develop pulmonary and extrapulmonary infections, with a hypercoagulable state. Several inflammatory or coagulatory biomarkers are currently used with predictive values for COVID-19 severity and prognosis. In this manuscript, we investigate if a combination of coagulatory and inflammatory biomarkers could provide a better biomarker with predictive value for COVID-19 patients, being able to distinguish between patients that would develop a moderate or severe COVID-19 and predict the disease outcome. We investigated 306 patients with COVID-19, confirmed by severe acute respiratory syndrome coronavirus 2 RNA detected in the nasopharyngeal swab, and retrospectively analyzed the laboratory data from the first day of hospitalization. In our cohort, biomarkers such as neutrophil count and neutrophil-to-lymphocyte ratio from the day of hospitalization could predict if the patient would need to be transferred to the intensive care unit but failed to identify the patients´ outcomes. The ratio between platelets and inflammatory markers such as creatinine, C-reactive protein, and urea levels is associated with patient outcomes. Finally, the platelet/neutrophil-to-lymphocyte ratio on the first day of hospitalization can be used with predictive value as a novel severity and lethality biomarker in COVID-19. These new biomarkers with predictive value could be used routinely to stratify the risk in COVID-19 patients since the first day of hospitalization.

COVID-19 Infection in Pregnancy: PCR Cycle Thresholds, Placental Pathology, and Perinatal Outcomes

(1) This study aimed to evaluate characteristics, perinatal outcomes, and placental pathology of pregnant women with or without SARS-CoV-2 infection in the context of maternal PCR cycle threshold (C_T) values. (2) This was a retrospective case-control study in a third-level health center in Mexico City with universal screening by RT-qPCR. The association of COVID-19 manifestations, preeclampsia, and preterm birth with maternal variables and C_T values were assessed by logistic regression models and decision trees. (3) Accordingly, 828 and 298 women had a negative and positive test, respectively. Of those positive, only 2.6% of them presented mild to moderate symptoms. Clinical characteristics between both groups of women were similar. No associations between C_T values were found for maternal features, such as pre-gestational BMI, age, and symptomatology. A significantly higher percentage of placental fibrinoid was seen with women with low C_Ts (<25; p < 0.01). Regarding perinatal outcomes, preeclampsia was found to be significantly associated with symptomatology but not with risk factors or C_T values (p < 0.01, aOR = 14.72). Moreover, 88.9% of women diagnosed with COVID-19 at <35 gestational weeks and symptomatic developed preeclampsia. (4) The data support strong guidance for pregnancies with SARS-CoV-2 infection, in particular preeclampsia and placental pathology, which need further investigation.

COVID-19 Vaccination in Pregnancy and Lactation: Current Research and Gaps in Understanding

The COVID-19 pandemic has demonstrated the urgent need to develop vaccine strategies optimized for pregnant people and their newborns, as both populations are at risk of developing severe disease. Although not included in COVID-19 vaccine development trials, pregnant people have had access to these vaccines since their initial release in the US and abroad. The rapid development and distribution of novel COVID-19 vaccines to people at risk, including those who are pregnant and lactating, presents an unprecedented opportunity to further our understanding of vaccine-induced immunity in these populations. In this review, we aim to summarize the literature to date on COVID-19 vaccination in pregnancy and lactation and highlight opportunities for investigation that may inform future maternal vaccine development and implementation strategies.

Perspectives on administration of COVID-19 vaccine to pregnant and lactating women: a challenge for low- and middle-income countries

Women who are in the pregnancy-puerperal cycle or are lactating have been deliberately excluded from participating in COVID-19 vaccine clinical trials that aimed to evaluate either the efficacy of the vaccines in inducing the formation of neutralizing antibodies or the investigational products' safety profile. The exclusion of pregnant and lactating women from such studies certainly and inequitably denies these women access to COVID-19 vaccines, since these products have become increasingly available to nonpregnant people and even to those who are pregnant and are in high-income settings. In this clinical opinion article, we discuss some aspects of the prolonged pandemic, the emergence of viral variants, the risks of severe complications of COVID-19 in pregnant women, and the disproportionate impact of the above on low- and middle-income countries. We argue that the decision to receive the COVID-19 vaccine should be a joint decision between the pregnant or lactating women and the healthcare providers, while considering the available data on vaccine efficacy, safety, the risks of SARS-CoV-2 infection in pregnant women, and the women's individual risks for infection and serious illness. The various types of vaccines that are already in use and their safety, effectiveness, and the potential risks and benefits of their administration to pregnant or lactating women are also reviewed.

DERMATOLOGY IN A MULTIDISCIPLINARY APPROACH WITH INFECTIOUS DISEASE AND OBSTETRIC MEDICINE AGAINST COVID-19

The care for patients infected with COVID-19 requires a team approach, and dermatologists may collaborate with other specialties, especially infectious disease (ID) medicine and obstetrics and gynecology (ObGyn), at every stage of the infection process. A broad spectrum of cutaneous manifestations may occur early in COVID-19 infection, making appropriate dermatologic identification critical for an early diagnosis. There is prognostic value in appropriately identifying different types of COVID-19–associated skin manifestations, which have been linked to disease severity. Such observations emanated from dermatology research, especially large series and international registries of cutaneous manifestations relating to COVID-19, and impact COVID-19 care provided by most health care providers. Also, research based on international registries of skin reactions from the COVID-19 vaccines has an impact across disciplines. An increased risk for severe illness from COVID-19 is encountered during pregnancy, and dermatologists’ role is to urge ObGyn and other clinicians to monitor and educate pregnant patients about the potential for eruptions as a manifestation of COVID-19. ID and ObGyn experts indicate that teledermatology enhanced the interaction among health care providers and improved COVID-19 care. More than 40% of all dermatology consultations at a tertiary care hospital were done via teledermatology. Future collaborative research involving dermatology and specialties, such as ID and ObGyn, could help delineate guidelines for dermatology consultations in patients infected with COVID-19 and determine cases appropriate for teledermatology.

Association Between BNT162b2 Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women

IMPORTANCE

Data on BNT162b2 messenger RNA (mRNA) vaccine (Pfizer-BioNTech) effectiveness and safety in pregnancy are currently lacking because pregnant women were excluded from the phase 3 trial.

OBJECTIVE

To assess the association between receipt of BNT162b2 mRNA vaccine and risk of SARS-CoV-2 infection among pregnant women.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study within the pregnancy registry of a large state-mandated health care organization in Israel. Pregnant women vaccinated with a first dose from December 19, 2020, through February 28, 2021, were 1:1 matched to unvaccinated women by age, gestational age, residential area, population subgroup, parity, and influenza immunization status. Follow-up ended on April 11, 2021.

EXPOSURES

Exposure was defined by receipt of the BNT162b2 mRNA vaccine. To maintain comparability, nonexposed women who were subsequently vaccinated were censored 10 days after their exposure, along with their matched pair.

MAIN OUTCOMES AND MEASURES

The primary outcome was polymerase chain reaction-validated SARS-CoV-2 infection at 28 days or more after the first vaccine dose.

RESULTS

The cohort included 7530 vaccinated and 7530 matched unvaccinated women, 46% and 33% in the second and third trimester, respectively, with a mean age of 31.1 years (SD, 4.9 years). The median follow-up for the primary outcome was 37 days (interquartile range, 21-54 days; range, 0-70). There were 118 SARS-CoV-2 infections in the vaccinated group and 202 in the unvaccinated group. Among infected women, 88 of 105 (83.8%) were symptomatic in the vaccinated group vs 149 of 179 (83.2%) in the unvaccinated group (P ≥ .99). During 28 to 70 days of follow-up, there were 10 infections in the vaccinated group and 46 in the unvaccinated group. The hazards of infection were 0.33% vs 1.64% in the vaccinated and unvaccinated groups, respectively, representing an absolute difference of 1.31% (95% CI, 0.89%-1.74%), with an adjusted hazard ratio of 0.22 (95% CI, 0.11-0.43). Vaccine-related adverse events were reported by 68 patients; none was severe. The most commonly reported symptoms were headache (n = 10, 0.1%), general weakness (n = 8, 0.1%), nonspecified pain (n = 6, <0.1%), and stomachache (n = 5, <0.1%).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study of pregnant women, BNT162b2 mRNA vaccination compared with no vaccination was associated with a significantly lower risk of SARS-CoV-2 infection. Interpretation of study findings is limited by the observational design.

COVID-19 and cause of pregnancy loss during the pandemic: A systematic review

Introduction

The association between Coronavirus Disease 2019 (COVID-19) and abortion has been debated since the beginning of the COVID-19 pandemic. We aimed to conduct this systematic review to understand better the potential effects of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) on fetal loss in infected mothers presented with abortion following this infection.

Methods

We included articles published in PubMed/Medline, Web of Science, clinicaltrials.gov, and Embase databases in 2019 and 2020 through a comprehensive search via appropriate keywords, including COVID-19 and abortion synonyms. All studies with the abortion data in COVID-19 confirmed pregnant females were collected.

Results

Out of 208 potentially relevant articles, 11 articles were eligible to include in the systematic review. The included reports were published because of the following reasons: (1) First-trimester miscarriage; (2) Late miscarriage; (3) complication of COVID-19 infection in pregnancy; (4) COVID-19 disease in artificial pregnancy. First-trimester abortion was found in 5 studies, and second-trimester abortion in 7 studies. Two patients acquired infection during the hospital stay while they were referred for abortion. Reports related to abortion in pregnant females with COVID-19 show that most miscarriages due to COVID-19 in the first trimester were due to placental insufficiency.

Conclusions

There is an increased risk of abortion in mothers with a positive test result of SARS-CoV-2, which several case reports and case series have identified during the pandemic. Placental inflammation during the viral infection may result in fetal growth retardation and induce abortion. There has not been any consistent evidence of vertical transmission of the virus from mother to fetus, which requires further investigation.

Impact of maternal nutrition in viral infections during pregnancy

Other than being a physiological process, pregnancy is a condition characterized by major adaptations of maternal endocrine and metabolic homeostasis that are necessary to accommodate the fetoplacental unit. Unfortunately, all these systemic, cellular, and molecular changes in maternal physiology also make the mother and the fetus more prone to adverse outcomes, including numerous alterations arising from viral infections. Common infections during pregnancy that have long been recognized as congenitally and perinatally transmissible to newborns include toxoplasmosis, rubella, cytomegalovirus, and herpes simplex viruses (originally coined as ToRCH infections). In addition, enterovirus, parvovirus B19, hepatitis virus, varicella-zoster virus, human immunodeficiency virus, Zika and Dengue virus, and, more recently, coronavirus infections including Middle Eastern respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) infections (especially the novel SARS-CoV-2 responsible for the ongoing COVID-19 pandemic), constitute relevant targets for current research on maternal-fetal interactions in viral infections during pregnancy. Appropriate maternal education from preconception to the early postnatal period is crucial to promote healthy pregnancies in general and to prevent and/or reduce the impact of viral infections in particular. Specifically, an adequate lifestyle based on proper nutrition plans and feeding interventions, whenever possible, might be crucial to reduce the risk of virus-related gestational diseases and accompanying complications in later life. Here we aim to provide an overview of the emerging literature addressing the impact of nutrition in the context of potentially harmful viral infections during pregnancy.

Cord blood antibody following maternal SARS-CoV-2 inactive vaccine (CoronaVac) administration during the pregnancy

Maternal vaccination with SARS-CoV-2 vaccines has not been well studied yet in terms of safety and efficacy for protecting the newborn by the placental passage of antibodies. We reported 34 years of old health care worker (HCW) without any known SARS-CoV-2 infection. She had the first dose of SARS-CoV-2 inactivated virus vaccine (CoronaVac, Sinovac Life Science Co, Ltd, Beijing, China) at a gestational age of 28 weeks. The second dose of vaccine was given four weeks later at a gestational age of 32 weeks. HCW did not report any vaccine-related adverse events after either the first or second dose of the vaccine. Three weeks after the second dose of the vaccine, her anti-receptor-binding domain (RBD) of SARS-CoV-2 spike protein antibody was 779 arbitrary units (AU) per ml. She gave a birth of 38 weeks three days gestation age of healthy, full-term girl with a birth weight of 2770 gr. The mother’s anti-RBD antibody was 734 AU/ml, the infant’s cord blood anti-RBD antibody level was 764 AU/ml, respectively, cord sera/maternal sera transfer ratio was 1,04. This infant is the first identified case of SARS-CoV-2 IgG antibodies detectable in cord blood after maternal vaccination with CoronaVac.

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.

Drug development research in pregnant and lactating women

Pregnant and lactating women are considered "therapeutic orphans" because they generally have been excluded from clinical drug research and the drug development process owing to legal, ethical, and safety concerns. Most medications prescribed for pregnant and lactating women are used "off-label" because most of the clinical approved medications do not have appropriate drug labeling information for pregnant and lactating women. Medications that lack human safety data on use during pregnancy and lactation may pose potential risks for adverse effects in pregnant and lactating women as well as risks of teratogenic effects to their unborn and newborn babies. Federal policy requiring the inclusion of women in clinical research and trials led to considerable changes in research design and practice. Despite more women being included in clinical research and trials, the inclusion of pregnant and lactating women in drug research and clinical trials remains limited. A recent revision to the "Common Rule" that removed pregnant women from the classification as a "vulnerable" population may change the culture of drug research and drug development in pregnant and lactating women. This review article provides an overview of medications studied by the Obstetric-Fetal Pharmacology Research Units Network and Centers and describes the challenges in current obstetrical pharmacology research and alternative strategies for future research in precision therapeutics in pregnant and lactating women. Implementation of the recommendations of the Task Force on Research Specific to Pregnant Women and Lactating Women can provide legislative requirements and opportunities for research focused on pregnant and lactating women.

COVID-19 and pregnant women - An overview on diagnosis, treatment approach with limitation, and clinical management

Coronavirus disease or more popularly called COVID-19 is known to be caused by a novel coronavirus 2. The COVID-19 has been identified to be originated from Wuhan, Hubei, China. This pandemic started in December 2019, and since then it has spread across the world within a short period. The health and family welfare ministry of the Government of India reported 227,546 active, 9,997,272 discharged cases, and 150,114 deaths due to COVID-19 as of 06 January 2021. Indian Council of Medical Research (ICMR) reports that the cumulative testing status of SARS-CoV-2 (COVID-19) was 931,408 up to November 03, 2020. Currently, no specific anti-viral drug for COVID-19 management is recommended in the current scenario. Vulnerable populations such as pregnant women affected by COVID-19 infection need to be recognized and followed up for effective handling concerning morbidity and mortality. At present, very few case reports on COVID-19 infected pregnant women have been published in India and there is no proven exclusive treatment protocol. This article summarizes a review of signs and symptoms, etiopathogenesis, risk factors, diagnosis, and possible management of COVID-19 infection in pregnant women. This overview may be useful for health care providers for practical approach and limitation of drugs used in the current management and considers the choice of drugs with their special attention given to adverse effects to improvise maternal health, pregnancy, and birth outcomes.

The Immunological Role of the Placenta in SARS-CoV-2 Infection-Viral Transmission, Immune Regulation, and Lactoferrin Activity

A pandemic of acute respiratory infections, due to a new type of coronavirus, can cause Severe Acute Respiratory Syndrome 2 (SARS-CoV-2) and has created the need for a better understanding of the clinical, epidemiological, and pathological features of COVID-19, especially in high-risk groups, such as pregnant women. Viral infections in pregnant women may have a much more severe course, and result in an increase in the rate of complications, including spontaneous abortion, stillbirth, and premature birth-which may cause long-term consequences in the offspring. In this review, we focus on the mother-fetal-placenta interface and its role in the potential transmission of SARS-CoV-2, including expression of viral receptors and proteases, placental pathology, and the presence of the virus in neonatal tissues and fluids. This review summarizes the current knowledge on the anti-viral activity of lactoferrin during viral infection in pregnant women, analyzes its role in the pathogenicity of pandemic virus particles, and describes the potential evidence for placental blocking/limiting of the transmission of the virus.

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

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

Coronavirus disease–2019 and the intestinal tract: An overview

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection can progress to a severe respiratory and systemic disease named coronavirus disease–2019 (COVID-19). The most common symptoms are fever and respiratory discomfort. Nevertheless, gastrointestinal infections have been reported, with symptoms such as diarrhea, nausea, vomiting, abdominal pain, and lack of appetite. Importantly, SARS-CoV-2 can remain positive in fecal samples after nasopharyngeal clearance. After gastrointestinal SARS-CoV-2 infection and other viral gastrointestinal infections, some patients may develop alterations in the gastrointestinal microbiota. In addition, some COVID-19 patients may receive antibiotics, which may also disturb gastrointestinal homeostasis. In summary, the gastrointestinal system, gut microbiome, and gut-lung axis may represent an important role in the development, severity, and treatment of COVID-19. Therefore, in this review, we explore the current pieces of evidence of COVID-19 gastrointestinal manifestations, possible implications, and interventions.