H1N1 2009 influenza virus infection during pregnancy in the USA

Studies suggest that pregnant women might be at increased risk for severe illness associated with coronavirus disease 2019 (COVID-19) (1,2). This report provides updated information about symptomatic women of reproductive age (15-44 years) with laboratory-confirmed infection with SARS-CoV-2, the virus that causes COVID-19. During January 22-October 3, CDC received reports through national COVID-19 case surveillance or through the National Notifiable Diseases Surveillance System (NNDSS) of 1,300,938 women aged 15-44 years with laboratory results indicative of acute infection with SARS-CoV-2. Data on pregnancy status were available for 461,825 (35.5%) women with laboratory-confirmed infection, 409,462 (88.7%) of whom were symptomatic. Among symptomatic women, 23,434 (5.7%) were reported to be pregnant. After adjusting for age, race/ethnicity, and underlying medical conditions, pregnant women were significantly more likely than were nonpregnant women to be admitted to an intensive care unit (ICU) (10.5 versus 3.9 per 1,000 cases; adjusted risk ratio [aRR] = 3.0; 95% confidence interval [CI] = 2.6-3.4), receive invasive ventilation (2.9 versus 1.1 per 1,000 cases; aRR = 2.9; 95% CI = 2.2-3.8), receive extracorporeal membrane oxygenation (ECMO) (0.7 versus 0.3 per 1,000 cases; aRR = 2.4; 95% CI = 1.5-4.0), and die (1.5 versus 1.2 per 1,000 cases; aRR = 1.7; 95% CI = 1.2-2.4). Stratifying these analyses by age and race/ethnicity highlighted disparities in risk by subgroup. Although the absolute risks for severe outcomes for women were low, pregnant women were at increased risk for severe COVID-19-associated illness. To reduce the risk for severe illness and death from COVID-19, pregnant women should be counseled about the importance of seeking prompt medical care if they have symptoms and measures to prevent SARS-CoV-2 infection should be strongly emphasized for pregnant women and their families during all medical encounters, including prenatal care visits. Understanding COVID-19-associated risks among pregnant women is important for prevention counseling and clinical care and treatment.

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Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status - United States, January 22-October 3, 2020.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know.

The emergence of a novel coronavirus, termed SARS-CoV-2, and the potentially life-threating respiratory disease that it can produce, COVID-19, has rapidly spread across the globe creating a massive public health problem. Previous epidemics of many emerging viral infections have typically resulted in poor obstetrical outcomes including maternal morbidity and mortality, maternal-fetal transmission of the virus, and perinatal infections and death. This communication reviews the effects of two previous coronavirus infections - severe acute respiratory syndrome (SARS) caused by SARS-CoV and Middle East respiratory syndrome (MERS) caused by MERS-CoV - on pregnancy outcomes. In addition, it analyzes literature describing 38 pregnant women with COVID-19 and their newborns in China to assess the effects of SARS-CoV-2 on the mothers and infants including clinical, laboratory and virologic data, and the transmissibility of the virus from mother to fetus. This analysis reveals that unlike coronavirus infections of pregnant women caused by SARS and MERS, in these 38 pregnant women COVID-19 did not lead to maternal deaths. Importantly, and similar to pregnancies with SARS and MERS, there were no confirmed cases of intrauterine transmission of SARS-CoV-2 from mothers with COVID-19 to their fetuses. All neonatal specimens tested, including in some cases placentas, were negative by rt-PCR for SARS-CoV-2. At this point in the global pandemic of COVID-19 infection there is no evidence that SARS-CoV-2 undergoes intrauterine or transplacental transmission from infected pregnant women to their fetuses. Analysis of additional cases is necessary to determine if this remains true.

An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes.

The comparison of the immunological state of pregnancy to an immunosuppressed host-graft model continues to lead research and clinical practice to ill-defined approaches. This Review discusses recent evidence that supports the idea that immunological responses at the receptive maternal-fetal interface are not simply suppressed but are instead highly dynamic. We discuss the crucial role of trophoblast cells in shaping not only the way in which immune cells respond to the invading blastocyst but also how they collectively react to external stimuli. We also discuss the role of the microbiota in promoting a tolerogenic maternal immune system and highlight how subclinical viral infections can disrupt this status quo, leading to pregnancy complications.

The unique immunological and microbial aspects of pregnancy

Effects of influenza on pregnant women and infants.

Coronavirus Disease 2019 (COVID-19) and Pregnancy: Responding to a Rapidly Evolving Situation.

What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention.

Background: Although biological markers of women's exposure to semen from vaginal intercourse have been developed as surrogates for risk of infection or probability of pregnancy, data on their persistence time and clearance are limited. Study Design: During 2006–2008, 52 couples were enrolled for three 14-day cycles of abstinence from vaginal sex during which women were exposed in the clinic to a specific quantity (10, 100 or 1000 μL) of their partner's semen. Vaginal swabs were collected before and at 1, 6, 12, 24, 48, 72 and 144 h after exposure for testing for prostate-specific antigen (PSA) and Y-chromosome DNA (Yc DNA). Results: Immediately after exposure to 1000 μL of semen, the predicted sensitivity of being PSA positive was 0.96; this decreased to 0.65, 0.44, 0.21 and 0.07 at 6, 12, 24 and 48 h, respectively. Corresponding predicted sensitivity of being Yc DNA positive was 0.72 immediately postexposure; this increased to 0.76 at 1 h postexposure and then decreased to 0.60 (at 6 h), 0.63 (at 12 h), 0.49 (at 24 h), 0.21 (at 48 h), 0.17 (at 72 h) and 0.12 (at 144 h). Conclusions: Overall findings suggest that PSA may be more consistent as a marker of very recent exposure and that Yc DNA is more likely to be detected in the vagina after 12 h postexposure compared to PSA.

Original research article Detection of two biological markers of intercourse: prostate-specific antigen and Y-chromosomal DNA

Since its recognition in China in December 2019, coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread throughout the world and become a pandemic. Although considerable data on COVID-19 are available, much remains to be learned about its effects on pregnant women and newborns. No data are currently available to assess whether pregnant women are more susceptible to COVID-19. Pregnant women are at risk for severe disease associated with other respiratory illnesses (eg, 2009 H1N1 influenza),1 but thus far, pregnant women with COVID-19 do not appear to be at increased risk for severe disease compared with the general population. Data from China showed that among 147 pregnant women, 8% had severe disease and 1% had critical illness, which are lower rates than observed in the nonpregnant population (14% with severe disease and 6% with critical illness).2 Case series from China consisting primarily of women with third-trimester infection have shown that clinical findings in pregnant women are similar to those seen in the general population.1 Conversely, a small Swedish study reported that pregnant and postpartum women with COVID-19 were 5 times more likely to be admitted to an intensive care unit compared with nonpregnant women of similar age.3 Data on pregnant women with COVID-19 in the US are beginning to accumulate. For example, a recent report included 43 pregnant women with COVID-19 who presented for care at 2 hospitals in New York City.4 Although this case series did not include a nonpregnant control group, the proportion of pregnant women with severe disease was similar to that described in nonpregnant adults with COVID-19.4 More information is needed about the effect of pregnancy and comorbidities to understand how they affect clinical outcomes of COVID-19. The US experience might differ from other countries because of the high frequency of comorbidities among pregnant women in the US. The effects of COVID-19 during pregnancy on the neonate are not well understood. Nearly all infections reported from China were during the third or late-second trimester, so whether first-trimester SARSCoV-2 infection might cause birth defects or pregnancy loss is unknown. Some newborns born to mothers with COVID-19 during pregnancy were born preterm or of low birth weight, but whether these outcomes were COVID-19–related is unclear. SARS-CoV-2 transmission from a mother to her newborn could occur prenatally, perinatally, or postnatally. In most newborns tested after birth, results have been negative for SARS-CoV-2.1 However, symptomatic newborns born to mothers with COVID-19 have been reported to have SARSCoV-2 infection at a few days of life5; whether this was due to prenatal, perinatal, or postnatal transmission is unknown. Recently, a probable case of congenital infection was reported in a newborn born to a woman with familial neutropenia who was diagnosed with COVID-19 before delivery. A neonatal nasopharyngeal swab collected on the day of birth prior to skin-to-skin maternal contact was positive.6 The presence of IgM and IgG antibodies in 3 infants born to mothers with COVID-19 during pregnancy was recently reported.7 IgG antibodies freely cross the placenta; however, IgM antibodies do not typically cross the placenta, suggesting the possibility of prenatal transmission of SARS-CoV-2. However, these studies do not provide definitive evidence for intrauterine transmission because cross-reactivity and false-positive IgM test results can occur.7 Whether transmission can occur through breastfeeding is unknown. SARS-CoV-2 RNA has been detected in breastmilk samples from a single woman with COVID19, and her infant tested positive for SARS-CoV-2, but whether the infant was infected through breastfeeding is unclear.8 Given the benefits of breast milk, when feasible, breast milk should be fed to infants regardless of maternal COVID-19 status. Based on experiences with other infections (eg, influenza), adverse effects on the fetus or newborn related to prenatal infection might occur even without intrauterine transmission. For example, severe maternal illness with influenza requiring intensive care unit admission was associated with increased risks for preterm birth, low birth weight, and low Apgar scores.9 Whether an increased risk for adverse outcomes among newborns born to women with COVID-19 will be seen is unknown. Given the limited data, recommendations for caring for women who are planning a pregnancy, pregnant, or have given birth during the COVID-19 pandemic are based on expert opinion. Women planning a pregnancy in the time of COVID-19 might ask whether they should delay pregnancy until after the pandemic. Based on limited data, there does not seem to be a compelling reason to recommend delaying pregnancy. For women who are pregnant, the primary recommendation is to avoid becoming infected with SARS CoV-2 through hygiene and social distancing measures. Early recognition of COVID-19 in a pregnant patient admitted to a labor and delivery unit is necessary so appropriate infection control practices can be instituted. Given that some women with COVID-19 might be asymptomatic or presymptomatic, health care facilities may consider polymerase chain reaction testing for SARS-CoV-2 at the time of admission. Guidelines for the care of pregnant women known or suspected to have COVID-19 admitted for delivery have been developed by the Centers for Disease Control and Prevention (CDC) and several professional organizations (Box). On presentation, a mask should be placed on the woman and she should be isolated in a singlepatient room with the door closed, with an airborne isolation room used for aerosol-generating procedures. Clinical care of a pregnant woman with COVID-19 should be based on illness severity; diagnostic measures and treatments should not be withheld based on pregnancy status. Given the risks of maternal respiratory depression, consideration should be given to limiting the use of magnesium sulfate for seizure prophylaxis and fetal neuroprotection. Given concerns about potential harm from corticosteroid use in patients with COVID19, antenatal corticosteroid use for fetal maturation should be carefully considered and should depend on the gestational age. Early epidural analgesia should be considered to mitigate the risks associated with general anesthesia in the setting of an urgent cesarean delivery. Clinical Review & Education

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Denise J. Jamieson

Papers

Effects of influenza on pregnant women and infants.

Coronavirus Disease 2019 (COVID-19) and Pregnancy: Responding to a Rapidly Evolving Situation.

What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention.

Original research article Detection of two biological markers of intercourse: prostate-specific antigen and Y-chromosomal DNA

Caring for Women Who Are Planning a Pregnancy, Pregnant, or Postpartum During the COVID-19 Pandemic.