Impact of SARS-CoV-2 Infection on Unvaccinated Pregnant Women: Non-Reassuring Fetal Heart Rate Tracing Because of Placentitis.

In 2020, a new coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in China. SARS-CoV-2 infection has been shown to be highly morbid in pregnant women, being a risk factor for several obstetric conditions leading to increased maternal and neonatal mortality. A few studies since 2020 have shown SARS-CoV-2 maternal-fetal transmission and noted placental abnormalities grouped under the term placentitis. We hypothesized that these placental lesions could be responsible for abnormalities in placental exchange and therefore abnormalities in cardiotocographic monitoring, leading to premature fetal extraction. The objective is to identify the clinical, biochemical, and histological determinants associated with the occurrence of non-reassuring fetal heart rate (NRFHR) outside labor in fetuses of SARS-CoV-2-infected mothers. We conducted a retrospective multicenter case series of the natural history of maternal SARS-CoV-2 infections resulting in fetal delivery outside labor due to NRFHR. Collaboration was sought with the maternity hospitals in the CEGORIF, the APHP and Brussels hospitals. The investigators were contacted by e-mail on three successive occasions over a period of one year. Data from 17 mothers and 17 fetuses were analyzed. Most women had a mild SARS-CoV-2 infection; only two women presented severe infection. No woman was vaccinated. We found a substantial proportion of maternal coagulopathy at birth: elevation of APTT ratio (62%), thrombocytopenia (41%) and liver cytolysis (58.3%). Iatrogenic prematurity was noted in 15 of 17 fetuses, and 100% were born by cesarean delivery due to emergency criteria. One male neonate died on the day of birth due to peripartum asphyxia. Three cases of maternal-fetal transmission were recorded following WHO criteria. Placental analysis in 15 cases revealed eight cases of SARS-CoV-2 placentitis, causing placental insufficiency. In total, 100% of the placentas analyzed showed at least one lesion suggestive of placentitis. SARS-CoV-2 maternal infection during pregnancy is likely to generate neonatal morbidity in relation to placental damage resulting in placental insufficiency. This morbidity may be the consequence of induced prematurity as well as acidosis in the most severe situations. Placental damage occurred in unvaccinated women and in women with no identified risk factor, in contrast to severe maternal clinical forms.

Nasopharyngeal SARS-CoV-2 load and perinatal outcomes after maternal infection diagnosed close to delivery.

BACKGROUND: The occurrence of COVID-19 during the pregnancy can cause several negative maternal and neonatal outcomes. Nasopharyngeal viral load is associated with inflammatory markers and might influence the disease severity in non-pregnant patients, but there are no data about the relationship between viral load and perinatal outcomes in pregnant patients. OBJECTIVE: To investigate the hypothesis that nasopharyngeal SARS-CoV-2 load (estimated with real-time polymerase chain reaction delta cycle (ΔCt), measured in hospital clinical laboratories) is associated with perinatal outcomes, when COVID-19 is diagnosed in the third trimester of pregnancy. STUDY DESIGN: International, retrospective, observational, multi-center, cohort study enrolling 390 women (393 neonates, three pairs of twins), analyzed with multivariate generalized linear models with skewed distributions (gamma) and identity link. The analyses were conducted for the whole population and then followed by a subgroup analysis according to the clinical severity of maternal COVID-19. RESULTS: The estimated viral load in maternal nasopharynx is not significantly associated with gestational age at birth (adjusted B: -0.008 (95%CI: -0.04; 0.02); p = 0.889), birth weight (adjusted B: 4.29 (95%CI: -25; 35); p = 0.889), weight Z-score (adjusted B: -0.01 (95%CI: -0.03; 1); p = 0.336), 5' Apgar scores (adjusted B: -0. -9.8e-4 (95%CI: -0.01; 0.01); p = 0.889), prematurity (adjusted OR: -0.97 (95%CI: 0.93; 1.03); p = 0.766) and the small for gestational age status (adjusted OR: 1.03 (95%CI: 0.99; 1.07); p = 0.351). Similar results were obtained in subgroup analyses according to COVID-19 clinical severity. CONCLUSIONS: The estimated maternal nasopharyngeal viral load in pregnant women affected by COVID-19 during the third trimester is not associated with main perinatal outcomes.

The experience of women who delivered during the first wave of COVID-19 pandemic in Belgium: a retrospective study.

BACKGROUND: The lockdown caused by the COVID-19 pandemic has imposed some restrictions on hospital activities, requiring medical staff to find efficient alternatives to ensure adequate medical care for patients. OBJECTIVE: This study aimed to investigate the experience of pregnant women who delivered during the first wave of COVID-19, and to evaluate the impact of COVID-19-related restrictions. STUDY DESIGN: This was a retrospective multicenter study. All pregnant women who delivered a live infant between March 20, 2020 and June 20, 2020 were evaluated using a 35-item survey at 1 year following delivery. Each patient was contacted via 3 modalities. Patients who reported that their prenatal follow-up was interrupted were compared with those who reported that their prenatal follow-up was unchanged. Among 1096 patients who delivered a live infant across the 3 participating centers during the study period, 389 responses were needed for an estimated margin of error of 4%. RESULTS: A total of 469 of 1096 (42.8%) patients answered the survey, of whom 151 (32.2%) reported that the follow-up of their pregnancy was interrupted (exposed group) and 318 (67.8%) reported that their follow-up was maintained as normal (unexposed group). The rate of presentation to the emergency department was higher in the exposed group than in the unexposed group (P=.001). The level of dissatisfaction was also higher in the exposed group, and patients in this group would have postponed their pregnancy if they had known about the pandemic in advance (P<.001 and P=.001, respectively). CONCLUSION: Interruption and modification of antenatal follow-up in pregnant women is associated with patient dissatisfaction and increased presentation to the emergency department.

Effectiveness and acceptability of "at home" versus "at hospital" early medical abortion - A lesson from the COVID-19 pandemic: A retrospective cohort study.

BACKGROUND: Since the lockdown caused by the COVID-19 pandemic, restrictions on hospitals' activity forced healthcare practitioners to innovate in order to provide continuity of care to patients. The aim of this study was to evaluate the efficiency of a newly established protocol for medical abortion and to measure the level of satisfaction of the patients who experienced abortion at home. METHODS: This retrospective study compared all the patients who had an early medical abortion at up to 9 weeks of gestation during the two drastically different periods between December 2018 and March 2021 ("hospital" and "home" groups). We evaluated the expulsion of the gestational sac as a primary outcome. The rates of infection, hemorrhage, retained trophoblastic material and need for surgical management were also assessed. A survey was also used to measure the satisfaction and acceptability of the method. RESULTS: The rate of expulsion of pregnancy was not significantly different between the two groups: 92.9% in hospital versus 99% at home. Early retained trophoblastic material and surgical interventions were higher in the hospital group. No significant difference was observed for the remaining outcomes. Moreover, the level of acceptability was similar in both groups, though patients felt safer in the "hospital" group. CONCLUSION: Switching an early medical abortion protocol from expulsion of pregnancy in hospital to expulsion of pregnancy at home is effective and acceptable to women, and may be associated with decreased rate of retained trophoblastic material. Further larger studies are needed to test the long-term result of this protocol.

Severe Acute Respiratory Syndrome Coronavirus 2 and Pregnancy Outcomes According to Gestational Age at Time of Infection.

We conducted an international multicenter retrospective cohort study, PregOuTCOV, to examine the effect of gestational age at time of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on obstetric and neonatal outcomes. We included all singleton pregnancies with a live fetus at 10 weeks' gestation in which pregnancy outcomes were known. The exposed group consisted of patients infected with SARS-CoV-2, whereas the unexposed group consisted of all remaining patients during the same period. Primary outcomes were defined as composite adverse obstetric outcomes and composite adverse neonatal outcomes. Of 10,925 pregnant women, 393 (3.60%) were infected with SARS-CoV-2 (exposed group). After matching for possible confounders, we identified statistically significant increases in the exposed group of composite adverse obstetric outcomes at >20 weeks' gestation and of composite adverse neonatal outcomes at >26 weeks' gestation (p<0.001). Vaccination programs should target women early in pregnancy or before conception, if possible.