Treatment of Viral Infections During Pregnancy

Vertical Transmission of SARS-CoV-2 Infection and Miscarriage in the Second Trimester: Report of an Immunohistochemically Proven Case

It is an acknowledged fact that SARS-CoV-2 exhibits tropism for the human placenta. A possible mechanism of SARS-CoV-2 entry into host cells is via angiotensin-converting enzyme 2 (ACE2) receptors, which are expressed in trophoblasts, endothelial cells, and macrophages. The present study describes a case of spontaneous miscarriage in the 20th gestational week after maternal SARS-CoV-2 infection. The placenta and various fetal organs were examined for structural alterations and expression of the viral nucleocapsid protein and several immune cell markers via immunohistochemistry (IHC). Histopathological examination of the placenta revealed acute chorioamnionitis, acute subamnionic placentitis, multiple intervillous thrombi, increased fibrinoid deposition, and necrotic changes of the chorionic villi. Immunohistochemistry confirmed the presence of SARS-CoV-2 nucleocapsid protein regions predominantly in the syncytiotrophoblast. Staining of the placental tissue for different markers helped elucidate the distribution of immune cells. Pathomorphological examination of the fetal organs demonstrated changes in microcirculation with the presence of sludge phenomenon and diapedesis haemorrhages, mostly in the lungs, brain, and myocardium. IHC staining of fetal organs revealed expression of SARS-CoV-2 nucleocapsid protein, which was detected to the highest extent in the brain, lungs, and liver. The findings of the present report support the hypothesis of possible vertical transmission of SARS-CoV-2 from mother to fetus.

Hepatitis C Virus Infection in Pregnancy and Children: Its Implications and Treatment Considerations with Directly Acting Antivirals: A Review

Hepatitis C virus infection (HCV) is a global health problem affecting >71 million people worldwide with chronic hepatitis C, 40% reproductive age group, and 8% pregnant women. Intravenous drug abuse, multi-transfusions are major risk factors in adults, while vertical transmission in pediatric population. It commonly presents as a chronic liver disease, has higher risk of liver cirrhosis and even progression to hepatocellular carcinoma. Therefore, proper screening of high-risk populations including pregnancy is recommended. All diagnosed chronic hepatitis C cases should be treated with directly acting anti-virals (DAAs) including pre-conception which has a cure rate of >95%. This would reduce the disease burden, vertical transmission, and disability associated. However, no DAAs regimens recommendation till date due to lack of evidence on adverse fetal outcomes and are concerned about the pharmacokinetic effect regarding physiological changes during pregnancy. Therefore, in this review, we have tried to explore the possible use of DAAs regimens and their safety issues during pregnancy, and possible consideration of few pan-genotypic regimens in the late 2nd and early 3rd trimester. This would not only prevent vertical transmission and decrease disease burden but also help to meet the WHO 2030 target of HCV elimination as a major public health problem.

Guideline No. 409: Intrauterine Fetal Diagnostic Testing in Women with Chronic Viral Infections

OBJECTIVE

This revised guideline provides updated information for the care of women with chronic viral infections who require intrauterine fetal diagnostic testing.

TARGET POPULATION

Women with chronic viral infections who are pregnant or planning a pregnancy.

OPTIONS

Non-invasive screening tests for diagnosis: maternal serum placental analytes with or without nuchal translucency, sonography, maternal serum cell-free placental DNA; and intrauterine fetal diagnostic testing: amniocentesis, chorionic villus sampling, cordocentesis.

OUTCOMES

The recommendations in this guideline have the potential to decrease or eliminate morbidity and mortality in women with chronic viral infections and their infants, which is associated with significant health and economic outcomes.

EVIDENCE

Published literature was retrieved through searches of PubMed, guidelines of national societies (Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, other international societies), and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) and keywords (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus). Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials (if available), and observational case-control studies or case series from 2012 to 2019 published in English or French. Studies from 1966 to 2002 were previously reviewed in the SOGC guideline No. 123: Amniocentesis and Women with Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus, and those from 2002 to 2012 were previously reviewed in the SOGC guideline No. 309: Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or Human Immunodeficiency Virus Infections. Updated literature searches were completed regularly through August 2019 and were incorporated into this guideline.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

The intended users are maternity care providers and women with chronic viral infections. This guideline provides information to educate and counsel these women, and to offer them reproductive options. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Directive clinique no 409 : Tests diagnostiques fœtaux intra-utérins en cas d'infection virale chronique maternelle

OBJECTIF

La présente directive clinique révisée met à jour les renseignements sur la prestation de soins aux femmes atteintes d'une infection virale chronique devant se soumettre à un test diagnostique fœtal intra-utérin.

POPULATION CIBLE

Femmes atteintes d'une infection virale chronique qui sont enceintes ou prévoient le devenir.

OPTIONS

Tests de dépistage non invasifs à des fins diagnostiques : marqueurs placentaires sériques maternels avec ou sans mesure de la clarté nucale, échographie, ADN fœtal libre circulant dans le sang maternel; et tests diagnostiques fœtaux intra-utérins : amniocentèse, biopsie choriale (choriocentèse), cordocentèse.

ISSUES

Les recommandations de la présente directive clinique pourraient réduire ou éliminer la morbi-mortalité chez les femmes atteintes d'une infection virale chronique et leurs nourrissons, ce qui est associé à d'importantes conséquences sur les plans de la santé et de l'économie. DONNéES PROBANTES: La littérature publiée a été recueillie au moyen de recherches dans les bases de données PubMed et Cochrane Library ainsi que dans les directives cliniques de sociétés médicales nationales et internationales (Société des obstétriciens et gynécologues du Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine et d'autres sociétés internationales) en utilisant un vocabulaire (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) et des mots clés (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus) contrôlés et appropriés. Les résultats retenus se limitent aux revues systématiques, aux essais cliniques randomisés ou aux essais cliniques comparatifs (si disponibles) et aux études cas-témoins observationnelles ou études de série de cas publiées entre 2012 et 2019 en anglais ou en français. Les études publiées entre 1966 et 2002 ont déjà été examinées dans la directive clinique de la SOGC n^o 123, L'amniocentèse chez les femmes infectées par l'hépatite B, l'hépatite C ou le virus de l'immunodéficience humaine; les études publiées entre 2002 et 2012 ont quant à elles été examinées dans la directive clinique de la SOGC n^o 309, Interventions effractives prénatales chez les femmes qui présentent des infections par le virus de l'hépatite B, le virus de l'hépatite C et/ou le virus de l'immunodéficience humaine. De nouvelles recherches ont été effectuées dans la littérature jusqu'en août 2019, puis ont été intégrées à la présente directive clinique. MéTHODES DE VALIDATION: L'auteur a évalué la qualité des données probantes et la solidité des recommandations au moyen du cadre méthodologique GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Consulter l'annexe A en ligne (le tableau A1 pour les définitions et le tableau A2 pour les interprétations des recommandations fortes et faibles). PUBLIC VISé: Les utilisateurs prévus sont des fournisseurs de soins de maternité et les femmes atteintes d'une infection virale chronique. Cette directive fournit des renseignements pour renseigner et conseiller ces femmes et leur offrir des options de procréation. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

COVID-19 in pregnancy: the foetal perspective-a systematic review

OBJECTIVE

We aimed to conduct a systematic review of the available literature to determine the effects of confirmed cases of COVID-19 in pregnant women from the foetal perspective by estimation of mother to child transmission, perinatal outcome and possible teratogenicity.

METHODS

Data sources: eligible studies between 1 November 2019 and 10 August 2020 were retrieved from PubMed, Embase, LitCovid, Google Scholar, EBSCO MEDLINE, CENTRAL, CINAHL, MedRXiv, BioRXiv and Scopus collection databases. English language case reports, case series and cohort studies of SARS-CoV-2 confirmed pregnant women with data on perinatal outcome, congenital anomalies and mother to child transmission were analysed.

RESULTS

38 case reports, 34 cohort and case series describing 1408 neonates were included for evidence acquisition of mother to child transmission. 29 case reports and 31 case series and cohort studies describing 1318 foetuses were included for the evaluation of perinatal outcome and congenital anomalies. A pooled proportion of 3.67% neonates had positive SARS-CoV-2 viral RNA nasopharyngeal swab results and 7.1% had positive cord blood samples. 11.7% of the placenta, 6.8% of amniotic fluid, 9.6% of faecal and rectal swabs and none of the urine samples were positive. The rate of preterm labour was 26.4% (OR=1.45, 95% CI 1.03 to 2.03 with p=0.03) and caesarean delivery (CS) was 59.9% (OR=1.54, 95% CI 1.17 to 2.03 with p=0.002). The most common neonatal symptom was breathing difficulty (1.79%). Stillbirth rate was 9.9 per 1000 total births in babies born to COVID-19 mothers.

CONCLUSION

Chances of mother to child transmission of the SARS-CoV-2 virus is low. The perinatal outcome for the foetus is favourable. There is increased chances of CS but not preterm delivery. The stillbirth and neonatal death rates are low. There are no reported congenital anomalies in babies born to SARS CoV-2 positive mothers.

Innate Immune Responses to Acute Viral Infection During Pregnancy

Immunological adaptations in pregnancy allow maternal tolerance of the semi-allogeneic fetus but also increase maternal susceptibility to infection. At implantation, the endometrial stroma, glands, arteries and immune cells undergo anatomical and functional transformation to create the decidua, the specialized secretory endometrium of pregnancy. The maternal decidua and the invading fetal trophoblast constitute a dynamic junction that facilitates a complex immunological dialogue between the two. The decidual and peripheral immune systems together assume a pivotal role in regulating the critical balance between tolerance and defense against infection. Throughout pregnancy, this equilibrium is repeatedly subjected to microbial challenge. Acute viral infection in pregnancy is associated with a wide spectrum of adverse consequences for both mother and fetus. Vertical transmission from mother to fetus can cause developmental anomalies, growth restriction, preterm birth and stillbirth, while the mother is predisposed to heightened morbidity and maternal death. A rapid, effective response to invasive pathogens is therefore essential in order to avoid overwhelming maternal infection and consequent fetal compromise. This sentinel response is mediated by the innate immune system: a heritable, highly evolutionarily conserved system comprising physical barriers, antimicrobial peptides (AMP) and a variety of immune cells—principally neutrophils, macrophages, dendritic cells, and natural killer cells—which express pattern-receptors that detect invariant molecular signatures unique to pathogenic micro-organisms. Recognition of these signatures during acute infection triggers signaling cascades that enhance antimicrobial properties such as phagocytosis, secretion of pro-inflammatory cytokines and activation of the complement system. As well as coordinating the initial immune response, macrophages and dendritic cells present microbial antigens to lymphocytes, initiating and influencing the development of specific, long-lasting adaptive immunity. Despite extensive progress in unraveling the immunological adaptations of pregnancy, pregnant women remain particularly susceptible to certain acute viral infections and continue to experience mortality rates equivalent to those observed in pandemics several decades ago. Here, we focus specifically on the pregnancy-induced vulnerabilities in innate immunity that contribute to the disproportionately high maternal mortality observed in the following acute viral infections: Lassa fever, Ebola virus disease (EVD), dengue fever, hepatitis E, influenza, and novel coronavirus infections.

Vertical transmission of SARS-CoV-2 infection and preterm birth

Viral infections are common complications of pregnancy, with a wide range of obstetric and neonatal sequelae. Currently, there are limited data on whether SARS-CoV-2 is vertically transmitted in pregnant women tested positive for the virus. Here we describe a case of a known SARS-CoV-2-positive woman giving preterm birth to two fetuses with SARS-CoV-2 positive testing in placental tissue and amniotic fluid. The placental histological examinations showed chronic intervillositis and extensive intervillous fibrin depositions with ischemic necrosis of the surrounding villi.

Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection

Objective

To provide clinical management guidelines for novel coronavirus (COVID‐19) in pregnancy.

Methods

On February 5, 2020, a multidisciplinary teleconference comprising Chinese physicians and researchers was held and medical management strategies of COVID‐19 infection in pregnancy were discussed.

Results

Ten key recommendations were provided for the management of COVID‐19 infections in pregnancy.

Conclusion

Currently, there is no clear evidence regarding optimal delivery timing, the safety of vaginal delivery, or whether cesarean delivery prevents vertical transmission at the time of delivery; therefore, route of delivery and delivery timing should be individualized based on obstetrical indications and maternal–fetal status.

Currently, there is no clear evidence regarding optimal delivery timing or route of delivery for pregnant women with COVID‐19 infection; these should be individualized based on obstetrical indications and maternal–fetal status.

Overview of infection causing hepatitis other than non-A to E hepatitis virus during pregnancy

Abnormal liver function tests during pregnancy are common. While hepatic injury during pregnancy mostly has minimal adverse influence on maternal and fetal outcomes, severe maternal and fetal morbidities, and even death, sometimes occur. Here, we review the epidemiology, clinical features, diagnosis, and management of hepatitis during pregnancy caused by the less common pathogens, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex viruses (HSVs), dengue fever, malaria, leptospirosis, Q fever, typhoid fever, and other occasional infections, as well as the implications on breastfeeding of the infants. Hepatitis during pregnancy with fever and systemic clinical presentations, which are not attributable to the common infectious agents, should raise the suspicion of infection with above-mentioned pathogens, and appropriate laboratory tests are required. Early recognition of severe hepatitis or acute liver failure is critical in initiating appropriate and specific therapy, together with systemic supportive care, to reduce maternal and fetal mortality and long-term sequelae.