The Interaction between Pregnancy and COVID-19: Comparison
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Please note this is a comparison between Version 2 by Alfred Zheng and Version 1 by Victor Ngozi Chilaka.

Pregnancy does not increase susceptibility to SARS-CoV-2 infection but appears to worsen the clinical course of COVID-19 (e.g., increased risks of intensive care unit [ICU] admission, need for mechanical ventilation and ventilatory support, and death) compared with non-pregnant females of the same age, especially in those who are symptomatic.  The risk of an exacerbation is greatest in the third trimester. Other risk factors associated with being infected and hospitalised with COVID-19 include Black and Asian minority ethnic backgrounds, living in socioeconomically deprived areas, and working in healthcare or other public-facing occupations

  • COVID-19
  • pregnancy
  • labour

1. Introduction

In December 2019, the world learned of the first case of a patient infected with atypical pneumonia caused by the 2019 novel coronal virus (severe acute respiratory syndrome coronavirus-2 or SARS-CoV-2) in Wuhan, China [1]. The infection spread rapidly, and by mid-March 2020, more than 190 countries had reported cases prompting the WHO to declare it a pandemic. In February 2020, the World Health Organization designated the disease as COVID-19, which stands for coronavirus disease 2019 [1,2][1][2]. Over half a billion COVID-19 infections worldwide and over 6 million deaths have so far been reported [2].
As is typical with viruses in this genre, mutations frequently lead to the emergence of new strains. There are currently five strains of the SARS-CoV-2 virus that are of concern: the Alpha, Beta, Gamma, Delta and Omicron variants [3]. These variants have specific traits, including increased transmissibility and a tendency to cause more severe disease for some. While the Delta and Alpha variants seem to be associated with more severe disease, the Omicron variant is associated with less severe illness but is more infectious. Globally as of May 2023, WHO is currently monitoring two variants of interest (VOIs), XBB.1.5 and XBB.1.16, along with seven variants under monitoring (VUMs) and their descendent lineages [4]. Currently, available information does not suggest that XBB.1.5 has additional public health risks relative to the other presently circulating Omicron descendent lineages [5].
The rapidity of the spread of the virus and the relatively high mortality of the initial variants threatened to overwhelm health systems worldwide. It impacted maternal health significantly with minimal experience to draw from. Because of this, various nations applied untested drugs, techniques and means to control the spread, including lockdowns, which resulted in isolation and poor attendance and, sometimes, neglected ante-natal care. Using some untested but supposedly life-saving medications on pregnant and labouring women severely challenged the ethics and principles of the medical profession.
Experience has since been growing, and the unique needs of pregnant and labouring women with COVID-19 are becoming more evident. They must be considered while making treatment policies and preparing response plans to COVID-19.
The impact of vaccination and the emergence of supposedly less virulent strains has undoubtedly affected the course of COVID-19. However, it is still likely to continue to cause adverse maternal and neonatal outcomes, especially in those who are unvaccinated [3].

2. COVID and Pregnancy

Current evidence suggests that pregnancy does not increase susceptibility to SARS-CoV-2 infection but appears to worsen the clinical course of COVID-19 (e.g., increased risks of intensive care unit [ICU] admission, need for mechanical ventilation and ventilatory support, and death) compared with non-pregnant females of the same age, especially in those who are symptomatic [6,7,8,9][6][7][8][9]. The risk of an exacerbation is greatest in the third trimester. Risk factors for severe disease and death in pregnancy include older age (especially ≥35 years), obesity, pre-existing medical co-morbidities (particularly hypertension, diabetes, or more than one co-morbidity), and being unvaccinated [9,10,11,12][9][10][11][12]. Other risk factors associated with being infected and hospitalised with COVID-19 include Black and Asian minority ethnic backgrounds, living in socioeconomically deprived areas, and working in healthcare or other public-facing occupations [10]. Recent evidence suggests that pregnancy-related risks can be reasonably minimised or mitigated by standard preventive measures, including vaccination [10].

3. Effects of COVID on Pregnancy and Labour

One of the most important reports on the effect of COVID-19 infection in pregnancy was that by Villar et al. (2021) [13]. They undertook a case-controlled retrospective study of 706 pregnant women diagnosed with COVID-19 and 1424 pregnant women without COVID-19 [13]. The women with COVID-19 diagnosis had a higher risk for preeclampsia/eclampsia (relative risk [RR], 1.76; 95% CI, 1.27–2.43), severe infections (RR, 3.38; 95% CI, 1.63–7.01), intensive care unit admission (RR, 5.04; 95% CI, 3.13–8.10), maternal mortality (RR, 22.3; 95% CI, 2.88–172), preterm birth (RR, 1.59; 95% CI, 1.30–1.94) and medically indicated preterm birth (RR, 1.97; 95% CI, 1.56–2.51). It was also notable that fever and shortness of breath for any duration were associated with an increased risk of severe maternal complications. However, asymptomatic women with COVID-19 remained at higher risk for maternal morbidity (RR, 1.24; 95% CI, 1.00–1.54) and preeclampsia (RR, 1.63; 95% CI, 1.01–2.63). In-utero transmission of COVID-19 is rare, and there is no evidence of an increase in spontaneous miscarriage, fetal congenital structural anomalies or adverse perinatal outcomes. However, the risk of spontaneous and iatrogenic preterm birth is increased [9,14][9][14].

4. Effects of Pregnancy and Labour on COVID

A lot of factors determine the severity of COVID-19 disease in pregnancy, and one of these factors may be the hyperinflammatory immune response which may be responsible for multi-organ damage. It has been noted that ferritin and IL-6 levels were lower in a survivor compared to a non-survivor group, as was the finding of higher neutrophil-lymphocyte ratio, lower percentages of basophils, eosinophils, and monocytes in severely-ill subjects [15].

4.1. Breathing Problems

Although the predominant features of SARS-CoV-2 infection, whether in pregnancy or not, are respiratory, it should be remembered that normal respiratory changes in pregnancy may mimic these symptoms. Constantly monitoring oxygen saturation is an essential aspect of care for the COVID-19 patient during pregnancy and labour.

4.2. Pushing

Women with a cough or breathing difficulties, or those who feel unwell, should be closely monitored for their oxygen saturation and other vital signs, more so when they are in labour. There should be a low threshold for supplementary oxygen [16]. The Valsalva manoeuvre in the second stage of labour is an aerosol-generating event, and healthcare providers must take measures to protect themselves and their birthing partners. Parturient women with worsening respiratory symptoms or exhibiting exhaustion with the bearing down efforts should be offered assisted delivery [16,17][16][17].

4.3. Temperature Swings

It was initially believed that fever is the most frequently reported manifestation of COVID-19. It was, therefore, a critical element of screening for COVID-19. However, it now appears more common in patients with severe or progressive disease [17]. In the report of the first 1000 SARS-CoV-2 patients managed in New York in 2020 [18], fever was almost as common as cough amongst the presenting symptoms (728/1000 vs. 732/1000), respectively. Control of temperature swings is thus essential in managing labour in these patients.

References

  1. Platto, S.; Wang, Y.; Zhou, J.; Carafoli, E. History of the COVID-19 pandemic: Origin, explosion, worldwide spreading. Biochem. Biophys. Res. Commun. 2021, 538, 14–23.
  2. Zhu, N.; Zhang, D.; Wang, W.; Li, X.; Yang, B.; Song, J.; Zhao, X.; Huang, B.; Shi, W.; Lu, R.; et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N. Engl. J. Med. 2020, 382, 727–733.
  3. Vousden, N.; Ramakrishnan, R.; Bunch, K.; Morris, E.; Simpson, N.A.B.; Gale, C.; O’Brien, P.; Quigley, M.; Brocklehurst, P.; Kurinczuk, J.J.; et al. Open access Original research Severity of maternal infection and perinatal outcomes during periods of SARS-CoV-2 wildtype, alpha, and delta variant dominance in the UK: Prospective cohort study. BMJ Med. 2022, 1, e000053.
  4. WHO. Weekly Epidemiological Update on COVID-19—18 May 2023 Edition 143. Available online: https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---18-may-2023 (accessed on 5 May 2023).
  5. Pung, R.; Kong, X.P.; Lin, C.; Chae, S.R.; Chen, M.I.; Lee, V.; Ho, Z.J. Severity of SARS-CoV-2 Omicron XBB subvariants in Singapore. medRxiv 2023.
  6. Allotey, J.; Stallings, E.; Bonet, M.; Yap, M.; Chatterjee, S.; Kew, T.; Debenham, L.; Llavall, A.C.; Dixit, A.; Zhou, D.; et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis. BMJ 2020, 370, m3320.
  7. Zambrano, L.D.; Ellington, S.; Strid, P.; Galang, R.R.; Oduyebo, T.; Tong, V.T.; Woodworth, K.R.; Nahabedian, J.F.; Azziz-Baumgartner, E.; Gilboa, S.M.; et al. Update: Characteristics of Symptomatic Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status—United States, 22 January–3 October 2020. MMWR Morb. Mortal. Wkly. Rep. 2020, 69, 1641–1647.
  8. Badr, D.A.; Mattern, J.; Carlin, A.; Cordier, A.-G.; Maillart, E.; El Hachem, L.; El Kenz, H.; Andronikof, M.; De Bels, D.; Damoisel, C.; et al. Are clinical outcomes worse for pregnant women at ≥20 weeks’ gestation infected with coronavirus disease 2019? A multicenter case-control study with propensity score matching. Am. J. Obstet. Gynecol. 2020, 223, 764–768.
  9. Metz, T.D.; Clifton, R.G.; Hughes, B.L.; Sandoval, G.M.; Saade, G.R.; Grobman, W.A.M.; Manuck, T.A.; Miodovnik, M.; Sowles, A.B.; Clark, K.B.; et al. Disease Severity and Perinatal Outcomes of Pregnant Patients with Coronavirus Disease 2019 (COVID-19). Obstet. Gynecol. 2021, 137, 571.
  10. Kasehagen, L.; Byers, P.; Taylor, K.; Kittle, T.; Roberts, C.; Collier, C.; Rust, B.; Ricaldi, J.N.; Green, J.; Zapata, L.B.; et al. COVID-19–Associated Deaths After SARS-CoV-2 Infection During Pregnancy—Mississippi, 1 March 2020–6 October 2021. MMWR Morb. Mortal. Wkly. Rep. 2021, 70, 1646–1648.
  11. Karimi, L.; Makvandi, S.; Vahedian-Azimi, A.; Sathyapalan, T.; Sahebkar, A. Effect of COVID-19 on Mortality of Pregnant and Postpartum Women: A Systematic Review and Meta-Analysis. J. Pregnancy 2021, 2021, 8870129.
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  13. Villar, J.; Ariff, S.; Gunier, R.B.; Thiruvengadam, R.; Rauch, S.; Kholin, A.; Roggero, P.; Prefumo, F.; Vale, M.S.D.; Cardona-Perez, J.A.; et al. Maternal and Neonatal Morbidity and Mortality Among Pregnant Women with and without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr. 2021, 175, 817–826.
  14. Piekos, S.N.; Roper, R.T.; Hwang, Y.M.; Sorensen, T.; Price, N.D.; Hood, L.; Hadlock, J.J. The effect of maternal SARS-CoV-2 infection timing on birth outcomes: A retrospective multicentre cohort study. Lancet Digit. Health 2022, 4, e95–e104.
  15. Zaim, S.; Chong, J.H.; Sankaranarayanan, V.; Harky, A. COVID-19 and Multiorgan Response. Curr. Probl. Cardiol. 2020, 45, 100618.
  16. Jain, K.; Bhatia, N.; Grewal, A.; Pandya, S.; Gupta, S.; Bagga, R.; Trikha, A. Management of pregnant laboring women during COVID-19 pandemic. J. Anaesthesiol. Clin. Pharmacol. 2020, 36, S91.
  17. Benski, C.; Di Filippo, D.; Taraschi, G.; Reich, M.R. Guidelines for Pregnancy Management During the COVID-19 Pandemic: A Public Health Conundrum. Int. J. Environ. Res. Public Health 2020, 17, 8277.
  18. Argenziano, M.G.; Bruce, S.L.; Slater, C.L.; Tiao, J.R.; Baldwin, M.R.; Barr, R.G.; Chang, B.P.; Chau, K.H.; Choi, J.J.; Gavin, N.; et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: Retrospective case series. BMJ 2020, 369, m1996.
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