Pregnancy and COVID-19: prevention, vaccination, therapy, and beyond

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has alarmed the world since its first emergence. As pregnancy is characterized by significant changes in cardiovascular, respiratory, endocrine, and immunological systems, there are concerns on issues like the course of disease in pregnant women, safety of medications, route of delivery and risk of obstetric complications. The aim of this review is to summarize the current literature in the management of pregnant women during the COVID-19 pandemic. Although more than 90% of pregnant women with COVID-19 recover without serious morbidity, rapid deterioration of disease and higher rates of obstetric complications may be observed. The risk of vertical transmission has not been clearly revealed yet. Decreasing the number of prenatal visits, shortening the time allocated for the examinations, active use of telemedicine services, limiting the number of persons in healthcare settings, combining prenatal tests in the same visit, restricting visitors during the visits, providing a safe environment in healthcare facilities, strict hygiene control, and providing personal protective equipment during the visits are the main strategies to control the spread of disease according to current guidelines. Although new medication alternatives are being proposed every day for the treatment of COVID-19, our knowledge about the use of most of these drugs in pregnancy is limited. Preliminary results are promising for the administration of SARS-CoV-2 vaccines in the pregnant population. Timing of delivery should be decided based on maternal health condition, accompanying obstetric complications and gestational age. Cesarean delivery should be performed for obstetric indications. Breast feeding should be encouraged as long as necessary precautions for viral transmission are taken. In conclusion, an individualized approach should be provided by a multidisciplinary team for the management of pregnant women with COVID-19 to achieve favorable outcomes.

Antenatal and Postnatal Care.

Optimal care during the antenatal and postnatal phases of the life cycle is a potentially positive determinant of health elsewhere in the continuum. A successful transition from the antenatal to the postnatal period requires early detection, optimal management, and prevention of disease; health promotion; birth preparedness; and complication readiness. Women, their babies, and families need appropriate evidence-based care based on their dignity and human rights before, during, and after birth. In this review, we present an overview of the components of antenatal and postnatal care needed to provide women a culturally sensitive and positive pregnancy and postnatal experience. The challenge of antenatal and postnatal care is determining their core components and underpinning them with evidence without overmedicalizing their practice.

Evaluation of the Pragmatic Implementation of a Digital Health Intervention Promoting Healthy Nutrition, Physical Activity, and Gestational Weight Gain for Women Entering Pregnancy at a High Body Mass Index.

txt4two is a multi-modality intervention promoting healthy pregnancy nutrition, physical activity (PA), and gestational weight gain (GWG), which had been previously evaluated in a pilot randomized controlled trial (RCT). This study aimed to evaluate a pragmatic implementation of an adapted version of txt4two in a public tertiary hospital. Using a consecutive cohort design, txt4two was delivered to women with a pre-pregnancy BMI > 25 kg/m2, between 10 + 0 to 17 + 6 weeks. Control and intervention cohorts (n = 150) were planned, with surveys and weight measures at baseline and 36 weeks. The txt4two cohort received a dietetic goal-setting appointment and program (SMS, website, and videos). The navigation of disparate hospital systems and the COVID-19 pandemic saw adaptation and adoption take two years. The intervention cohort (n = 35; 43% full data) demonstrated significant differences (mean (SD)), compared to the control cohort (n = 97; 45% full data) in vegetable intake (+0.9 (1.2) versus +0.1 (0.7), p = 0.03), fiber-diet quality index (+0.6 (0.8) versus 0.1 (0.5), p = 0.012), and total diet quality index (+0.7 (1.1) versus +0.2 (±0.6), p = 0.008), but not for PA or GWG. Most (85.7%) intervention participants found txt4two extremely or moderately useful, and 92.9% would recommend it. Embedding the program in a non-RCT context raised implementation challenges. Understanding the facilitators and barriers to adaptation and adoption will strengthen the evidence for the refinement of implementation plans.

The association between peritraumatic distress, perceived stress, depression in pregnancy, and NR3C1 DNA methylation among Chinese pregnant women who experienced COVID-19 lockdown.

Prenatal stress can affect pregnant women in an epigenetic way during the critical period of conception of their offspring. The study aims to investigate the relationship between peritraumatic distress, prenatal perceived stress, depression, and glucocorticoid receptor (NR3C1) DNA methylation among pregnant women who experienced COVID-19 lockdown in China. Study data were collected from 30 pregnant women in Wuhan and Huanggang, China. The Peritraumatic Distress Inventory was used to measure peritraumatic distress, the Edinburgh Postnatal Depression Scale was used to measure depressive symptoms, and the Perceived Stress Scale was used to measure perceived stress. DNA methylation in the exon 1F promoter region of NR3C1 gene from the venous blood mononuclear cell genome was characterized by bisulfite sequencing. Correlation and linear regression were used for data analysis. The mean level of peritraumatic distress, perceived stress, and depression was 6.30 (SD = 5.09), 6.50 (SD = 5.41), and 6.60 (SD = 4.85), respectively, with 23.33% of pregnant women being depressed. The mean NR3C1 methylation was 0.65 (SD = 0.22). Prenatal depression was positively correlated with the degree of methylation in venous blood from the mother (r = 0.59, p = 0.001), and depression predicted methylation of NR3C1 gene at the CpG 8 site (ß = 0.05, p = 0.03). No association was found between peritraumatic distress as well as perceived stress and methylation of NR3C1. NR3C1 gene was susceptible to epigenetic modification of DNA methylation in the context of prenatal stress, and maternal depression was associated with increased NR3C1 methylation among women who experienced COVID-19 lockdown.

Antenatal Classes in the Context of Prenatal Anxiety and Depression during the COVID-19 Pandemic.

Perinatal maternal anxiety and depression negatively affect intrauterine fetal development, birth outcome, breastfeeding initiation, duration, and milk composition. Antenatal classes potentially reduce the anxiety of pregnant women and may thus contribute to healthy infant development. The study investigates the relationship between participation in online or in-person antenatal classes and levels of anxiety and depression in Polish women during the COVID-19 pandemic. The study group included 1774 adult, non-smoking pregnant women. We compared the state anxiety (STAI-State) and depression levels (EPDS) in women who (i) attended antenatal classes in-person, (ii) attended online classes, and (iii) did not attend any of them. The statistical analyses included a GLM model and trend analysis, while controlling for maternal trait anxiety, age, pregnancy complications, trimester of pregnancy, previous pregnancies, and COVID-19 infections. We observed statistically significant differences in the level of anxiety (and depression). Women who did attend antenatal classes in person had the lowest levels of anxiety and depression. Considering the importance of maternal mental well-being on fetal development, birth outcome, and breastfeeding, in-person participation in antenatal classes should be recommended to pregnant women.

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.

The Covid 19 outbreak: Maternal Mental Health and Associated Factors.

OBJECTIVE: Evaluation of the mental health of pregnant women during the early and peak stages of the Covid-19 outbreak DESIGN: Online survey PARTICIPANTS: Pregnant women over the age of 18 years with no mental disorder during the pre-pregnancy period (N = 729). MEASUREMENTS AND FINDINGS: Mental disorders were assessed using the "Depression Anxiety Stress Scale" and social support was determined using the "Multidimensional Perceived Social Support Scale." Pregnant women had moderate levels of anxiety and depression and mild levels of stress. Anxiety, depression, and stress of moderate or high severity was reported in 62.2%, 44.6%, and 32.2% of the women, respectively. Pregnant women who lost their jobs during the pandemic period showed a 3-fold increase in the risk of anxiety, a 6-fold increase in the risk of depression, and a 4.8-fold increase in the risk of stress. An increase in the perception of social support has protective effects against all three mental disorders during pregnancy. In pregnant women with at least one obstetric risk, the risk of antenatal anxiety is 2 times higher than that in women with no risk. Similarly, women with a chronic physical illness before pregnancy have a higher risk of anxiety during pregnancy than healthy women. Financial strain has predictive value for anxiety and depression, and advanced age is a predictor for depression. KEY CONCLUSIONS: The incidence of mental disorders in pregnant women during the pandemic period was much higher than that during the pre-pandemic period. The high frequency of antenatal mental disorders can lead to an increase in the frequency of obstetric and maternal complications in the short and long term. IMPLICATIONS FOR PRACTICE: Early detection of inadequate social support and economic difficulties of pregnant women during the pandemic period is recommended for protecting their mental health. Pregnant women should have easy access to psychosocial support, and they should be provided obstetric counseling during the pandemic conditions.

Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality.

The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.

Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study.

BACKGROUND: Pregnancy is a risk factor for coronavirus disease 2019 (COVID-19). Pregnant women suffer from varying levels of pregnancy-related anxiety (PRA) which can negatively affect pregnancy outcomes. The aim of this study was to assess PRA and its associated factors during the COVID-19 pandemic. METHODS: This web-based cross-sectional study was conducted in 2020 on 318 pregnant women purposively recruited from primary healthcare centers in Sari and Amol, Iran. Data were collected using questionnaires (PRAQ, Edinburg, KAP of COVID-19, CDA-Q and Demographic questionnaire), which were provided to participants through the social media or were completed for them over telephone. Data were analyzed with the linear regression and the logistic regression analysis, at the significance level of 0.05 using the SPSS software (v. 21). RESULTS: Around 21% of participants had PRA, 42.1% had depression, and 4.4% had COVID-19 anxiety. The significant predictors of PRA were number of pregnancies (P = 0.008), practice regarding COVID-19 (P < 0.001), COVID-19 anxiety (P < 0.001), depression (P < 0.001), and social support (P = 0.025) which explained 19% of the total variance. Depression and COVID-19 anxiety increased the odds of PRA by respectively four times and 13%, while good practice regarding COVID-19 decreased the odds by 62%. CONCLUSION: Around 21% of pregnant women suffer from PRA during the COVID-19 pandemic and the significant predictors of PRA during the pandemic include number of pregnancies, practice regarding COVID-19, COVID-19 anxiety, depression, and social support. These findings can be used to develop appropriate strategies for the management of mental health problems during pregnancy in the COVID-19 pandemic.

The Effects of opioids on female fertility, pregnancy and the breastfeeding mother-infant dyad: A Review.

Opioids cover a broad class of natural, synthetic and semi-synthetic drugs that act on opioid receptors to produce powerful analgesic effects. Rates of opioid use and opioid agonist maintenance treatment have increased substantially in recent years, particularly among women. Trends and outcomes of opioids use on fertility, pregnancy and breastfeeding, and longer-term child developmental outcomes have not been well-described. Here, we review the existing literature on the health effects of opioid use on female fertility, pregnancy, breastmilk and the exposed infant. We find that the current literature is primarily concentrated on the impact of opioid use in pregnancy and neonatal outcomes, with little exploration of effects on fertility. Studies are limited in number, some with small sample sizes, and many are hampered by methodological challenges related to confounding and other potential biases. Opioid use is becoming more prevalent due to environmental pressures such as COVID-19. More research is needed to better elucidate its effects on reproductive health among younger women and support the development of evidence-based recommendations for safe prescription practices and public health messaging.

Using Helping Mothers Survive to Improve Intrapartum Care.

Data from the past decade have revealed that neonatal mortality represents a growing burden of the under-5 mortality rate. To further reduce these deaths, the focus must expand to include building capacity of the workforce to provide high-quality obstetric and intrapartum care. Obstetric complications, such as hypertensive disorders and obstructed labor, are significant contributors to neonatal morbidity and mortality. A well-prepared workforce with the necessary knowledge, skills, attitudes, and motivation is required to rapidly detect and manage these complications to save both maternal and newborn lives. Traditional off-site, didactic, and lengthy training approaches have not always yielded the desired results. Helping Mothers Survive training was modeled after Helping Babies Breathe and incorporates further evidence-based methodology to deliver training on-site to the entire team of providers, who continue to practice after training with their peers. Research has revealed that significant gains in health outcomes can be reached by using this approach. In the coronavirus disease 2019 era, we must look to translate the best practices of these training programs into a flexible and sustainable model that can be delivered remotely to maintain quality services to women and their newborns.

Pregnancy and birth planning during COVID-19: The effects of tele-education offered to pregnant women on prenatal distress and pregnancy-related anxiety.

AIM: This study aims to examine pregnancy and birth planning during COVID-19 and the effects of a tele-education offered to pregnant women for this planning process on prenatal distress and pregnancy-related anxiety. METHOD: The population of this quasi-experimental study was composed of pregnant women who applied for the antenatal education class of a public hospital in the east of Turkey during their past prenatal follow-ups and wrote their contact details in the registration book to participate in group trainings. The sample of the study consisted of a total of 96 pregnant women, including 48 in the experiment and 48 in the control groups, who were selected using power analysis and non-probability random sampling method. The data were collected between April 22 and May 13, 2020 using a "Personal Information Form", the "Revised Prenatal Distress Questionnaire (NuPDQ)" and the "Pregnancy Related Anxiety Questionnaire-Revised 2 (PRAQ-R2)". An individual tele-education (interactive education and consultancy provided by phone calls, text message and digital education booklet) was provided to the pregnant women in the experiment group for one week. No intervention was administered to those in the control group. The data were statistically analyzed using descriptive statistics (frequency, percentage, mean, standard deviation, min-max values) and t-test in dependent and independent groups. RESULTS: The posttest NuPDQ total mean scores of pregnant women in the experiment and control groups were 8.75±5.10 and 11.50±4.91, respectively, whereby the difference between the groups was statistically significant (t=-2.689, p=0.008). Additionally, the difference between their mean scores on both PRAQ-R2 and its subscales of "fear of giving birth" and "worries of bearing a physically or mentally handicapped child" was statistically significant (p<0.05), where those in the experiment group had lower anxiety, fear of giving birth and worries of bearing a physically or mentally handicapped child. CONCLUSION: The tele-education offered to the pregnant women for pregnancy and birth planning during COVID-19 decreased their prenatal distress and pregnancy-related anxiety.

Stillbirths and the COVID-19 pandemic: Looking beyond SARS-CoV-2 infection.

OBJECTIVE: To study the impact of the COVID-19 outbreak and subsequent lockdown on the incidence, associated causes, and modifiable factors of stillbirth. METHODS: An analytical case-control study was performed comparing stillbirths from March to September 2020 (cases) and March to September 2019 (controls) in a tertiary care center in India. Modifiable factors were observed as level-I, level-II, and level-III delays. RESULTS: A significant difference in the rate of stillbirths was found among cases (37.4/1000) and controls (29.9/1000) (P = 0.045). Abruption in normotensive women was significantly higher in cases compared to controls (P = 0.03). Modifiable factors or preventable causes were noted in 76.1% of cases and 59.6% of controls; the difference was highly significant (P < 0.001, relative risk [RR] 1.8). Level-II delays or delays in reaching the hospital for delivery due to lack of transport were observed in 12.7% of cases compared to none in controls (P < 0.006, RR 47.7). Level-III delays or delays in providing care at the facility were observed in 31.3% of cases and 11.5% of controls (P < 0.001, RR 2.7). CONCLUSION: Although there was no difference in causes of stillbirth between cases and controls, level-II and level-III delays were significantly impacted by the pandemic, leading to a higher rate of preventable stillbirths in pregnant women not infected with COVID-19.

Challenges for Midwives' Healthcare Practice in the Next Decade: COVID-19 - Global Climate Changes - Aging and Pregnancy - Gestational Alcohol Abuse.

Midwives are multifaceted healthcare professionals whose competence spectrum includes a large variety of knowledge and skills going from antenatal care to education and research. The aim of this review is to suggest the future challenges midwives are going to face in the upcoming decade of this Century. COVID-19 and other infections will reasonably impact healthcare workers all over the world. Midwives are frontline healthcare professionals who are constantly at risk of contagion as their job implies close contact with women, physical support and hand touch. Also, menstruation waste plays a large role in the pollution of waters, severely impacting hygiene in the developing countries and fueling climate change. Appropriate disposal of used menstrual material is still insufficient in many countries of the world especially because of lack of sanitary education on girls. As educators, midwives will be more involved into preventing inappropriate disposal of menstrual hygiene devices by educating girls around the world about the green alternatives to the commercial ones. Despite the evidences about the fertility decrement that occurs with aging, women keep postponing reproduction and increasing their chance being childless or suffering complications related to the advanced maternal age. Teen pregnancies are as well an important issue for midwives who will be called to face more age-related issues and use a tailored case to case approach, enhancing their family planning skills. Another crucial role of midwifery regards the information about the risk of drinking alcohol during gestation. Alcohol assumption during pregnancy is responsible for serious damage to the fetus causing a wide range of pathological conditions related to Fetal Alcoholic Spectrum Disorder, leading cause of mental retardation in children of western countries. On the whole, midwives have demonstrated their willingness to expand their practice through continuing professional development, and through specialist and advanced roles especially in preventive and educational positions.