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Special Medical Information

 

Special Medical Information (Pregnancy, Infants and Young Children)

Each day, Infant Mental Health (IMH) professionals are facing complex medical questions from families with young children about COVID-19. Similarly, every day, pregnant women and their families are seeking medical information concerning how to keep themselves and their baby safe. Pregnancy, and caring for newborns, at the best of times, is a time of heightened awareness of health and safety issues. WAIMH acknowledges every pregnant woman, her partner and family during this time. WAIMH acknowledges every IMH professional who is also seeking answers to these questions. The resources listed here are designed to provide some information from reputable sources with high quality information. This page will be updated to keep pace with new data as it becomes available.  

 

COVID 19 and a call for surveillance and research during pregnancy: A summary of Buekens et al., 2020

By Kai von Klitzing

Recently an international group of renowned epidemiologists and public health researchers have called for coordinated worldwide surveillance and research during pregnancy. The researchers fear that the almost exclusive emphasis on high-risk populations could obscure the specific risk and needs of pregnant women and their unborn and/or newborn babies:

During pregnancy, women experience immunological and physiological changes that might make them more susceptible to viral respiratory infections, such as influenza, and adverse pregnancy outcomes have been observed from severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). Beyond the virus-specific risks, illnesses with high fevers early in pregnancy are associated with specific birth defects, such as neural tube defects. (Buekens et al., 2020, p. 1)

There is a paucity of available data on the effect of SARS-CoV-2 infection and COVID-19 in pregnancy:

Published studies to date seem to be reassuring that pregnant women with COVID-19 might not be at increased risk for severe complications or adverse reproductive health outcomes. However, studies have been limited to case series and case reports and lack sufficient numbers to discern infrequent risks attributable to COVID-19 infection. Reports have also been conflicting and inconclusive as to whether vertical transmission of SARS-CoV-2 can occur. (Buekens et al., 2020, p. 1)

Based on this analysis the researchers suggest cooperation between countries to address the gaps in knowledge about COVID-19 and its effect on pregnant women and their babies. They point to the importance of transparency of reporting to guarantee the accuracy of data. Key surveillance and research studies should help to inform clinical recommendations and public health guidance tailored to local contacts.

Reference

Buekens, Pierre; Alger, Jackeline; Bréart, Gérard; Cafferata, Maria Luisa; Harville, Emily; Tomasso, Giselle: A call for action for COVID-19 surveillance and research during pregnancy. In: The Lancet Global Health. DOI: 10.1016/S2214-109X(20)30206-0.

Recommended web resource:
Coronavirus (COVID-19) Infection in Pregnancy
Information for healthcare professionals Version 8: Published Friday 17 April 2020
The Royal College of Midwives; Royal College of Obstretricians & Gynaecologists

 

Medical update

Kai von Klitzing

What do we know about Corona infections in infants and pregnant women?

According to the WHO and data from China, pregnant women do not seem to have an increased risk of a severe course of the illness. Based on a few case records and studies on immune reaction of newborns, a transmission to the unborn child in the maternal body cannot be excluded. In most cases, children of Covid positive mothers do not show symptoms after delivery. Only a few cases of newborn illness as a possible sequela of an infection in the mother’s body have been reported. A postnatal transmission to the newborn child is possible because of the close contact via droplet infection. To date there is no evidence for the existence of the SARS-CoV-2 virus in the breast milk. The data and experiences are so far not sufficient to answer all open questions about COVID-19 during pregnancy with enough certainty. 

According to our current state of knowledge, the symptoms of Covid19 are markedly less severe in children as compared to adults. Because of the high contagiosity and the usually close contact among children and adolescents, it seems plausible that the virus can infect children and that children can transmit the infection. 

Based on Robert Koch Institute, Germany, April 13, 2020.

Summaries of the most recently published studies

Pregnancy

Pérez-López et al. (2020) published the most recent overview on possible influence of an infection with SARS-CoV 2 on the pregnant woman. “Pregnant women can be infected by SARS-CoV (1 and 2) or MERS; however, COVID-19 disease seems less aggressive than the other viral infections. Despite this, available data linking COVID-19 disease with adverse maternal and perinatal outcomes are limited; however, infected pregnants do not appear to be more susceptible than individuals of the general population and fetal involvement will depend, to a great extent, on maternal well-being. (…) Based on the available evidence the authors estimate that the infection does not directly lead to an unfavorable outcome of the pregnancy. But: The problem in pregnant women may, however, depend on the general complications related per se to the infection. Nevertheless, most pregnancy cases are expected to be mild or moderate although COVID-19 pneumonia pregnancy cases have been reported.” The authors come to the conclusion that “fatality rate among pregnants seems to be similar to that of non-pregnants.”  They point to the fact that outcomes worldwide will differ which will probably be related to organization/clinical services, quality of care and the available resources of each country.” The authors recommend that “women should be encouraged to delay becoming pregnant until more evidence related to risks associated to COVID-19 infection during pregnancy is available.” 

Rasmussen und Jamieson (2020) recommend that prenatal clinics should ensure all pregnant women and their visitors are screened for fever and respiratory symptoms, and symptomatic women should be isolated from well women and required to wear a mask.
Infection of the fetus and neonate (first data from Wuhan) 
Chen et al. (2020) reported four full-term, singleton infants who were born to pregnant women who tested positive for COVID-19 in the city of Wuhan, Of the three infants, for who consent to be diagnostically tested was provided, none tested positive for the virus. None of the infants developed serious clinical symptoms such as fever, cough, diarrhea, or abnormal radiologic or hematologic evidence, and all four infants were alive at the time of hospital discharge. Two infants had rashes of unknown etiology at birth, and one had facial ulcerations. One infant had tachypnea and was supported by non-invasive mechanical ventilation for 3 days. One had rashes at birth but was discharged without parental consent for a diagnostic test.”
 
Zeng et al. (2020a) reported “among 6 mothers with confirmed COVID-19, SARS-CoV-19 was not detected in the serum or throat swab by RT-PCR in any of their newborns. However, virus-specific antibodies were detected in neonatal blood sera samples. The IgG concentrations were elevated in 5 infants. IgG is passively transferred across the placenta from mother to fetus beginning at the end of the second trimester and reaches high levels at the time of birth. However, IgM, which was detected in 2 infants, is not usually transferred from mother to fetus because of its larger macromolecular structure. Alternatively, IgM could have been produced by the infant if the virus crossed the placenta. This study is limited by the small sample size, lack of cord blood, amniotic fluid, and breast milk and by incomplete information on the outcome of the infants.”
 
Also Dong et al. (2020) reported the case of a neonate born to a mother with COVID-19 who had elevated antibody levels and abnormal cytokine test results 2 hours after birth. The elevated IgM antibody level suggests that the neonate was infected in utero. IgM antibodies are not transferred to the fetus via the placenta. The infant potentially could have been exposed for 23 days from the time of the mother’s diagnosis of COVID-19 to delivery. The laboratory results displaying inflammation and liver injury indirectly support the possibility of mother to fetus transmission.
 
Zeng et al. (2020b) reported the data of 33 neonates with or at risk of COVID-19. Consistent with previous studies, the clinical symptoms were mild and outcomes were favorable. “Of the 3 neonates with symptomatic COVID-19, the most seriously ill neonate may have been symptomatic from prematurity, asphyxia, and sepsis, rather than SARS-CoV-2 infection. In this cohort, 3 of 33 infants (9%) presented with early-onset SARS-CoV-2 infection. Because strict infection control and prevention procedures were implemented during the delivery, it is likely that the sources of SARS-CoV-2 in the neonates’ upper respiratory tracts or anuses were maternal in origin. Although recent studies have shown that there were no clinical findings or investigations suggestive of COVID-19 in neonates born to affected mothers, and all samples, including amniotic fluid, cord blood, and breast milk, were negative for SARS-CoV-2, the vertical maternal-fetal transmission cannot be ruled out in the current cohort.” The authors therefor recommend to screen pregnant women and implement strict infection control measures, quarantine of infected mothers, and close monitoring of neonates at risk of COVID-19. 
 
Zhang et al. (2020) identified “4 infections in newborn babies in China as of March 13. The age range was 30 h to 17 days old. Three were male. Two newborn babies had fever, 1 had shortness of breath, 1 had cough and 1 had no syndromes. Supportive treatment was provided for all 4 newborn babies. None required intensive unit care or mechanical ventilation. None had any severe complications. (…) All 4 mothers were infected by SARS-CoV-2, 3 showing symptoms before and 1 after delivery. Cesarean section was used for all 4 mothers. Three newborn babies were separated from mothers right after being born and were not breastfed.”  The authors conclude that newborn babies are susceptible to SARS-CoV-2 infection. The symptoms in newborn babies were milder and outcomes were less severe as compared to adults.”
Infection of young children

Choi et al. (2020) concluded from their systematic review of epidemiological data and clinical reports in China that children take up an only small fraction of COVID-19 cases, and symptoms in pediatric patients are often mild. “However, some pediatric cases may progress to severe disease, and initial atypical presentations may delay the diagnosis of COVID-19, leading to unfavorable outcome.” Newborns are susceptible to this disease and viruses are detected from them for a prolonged period, therefore newborns might play a role in community transmission. 

References

Chen, Yan; Peng, Hua; Wang, Lin; Zhao, Yin; Zeng, Lingkong; Gao, Hui; Liu, Yalan (2020): Infants Born to Mothers With a New Coronavirus (COVID-19). In: Front Pediatr 8, S. 104. DOI: 10.3389/fped.2020.00104.

Choi, Soo-Han; Kim, Han Wool; Kang, Ji-Man; Kim, Dong Hyun; Cho, Eun Young (2020): Epidemiology and Clinical Features of Coronavirus disease 2019 in Children. In: J Korean Pediatr Soc 0 (0), S. 0. DOI: 10.3345/cep.2020.00535.

Dong, Lan; Tian, Jinhua; He, Songming; Zhu, Chuchao; Wang, Jian; Liu, Chen; Yang, Jing (2020): Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. In: JAMA. DOI: 10.1001/jama.2020.4621.

Pérez-López, Faustino R.; Savirón-Cornudella, Ricardo; Chedraui, Peter; Genazzani, Andrea R. (2020): Severe acute respiratory syndrome coronavirus 19 and human pregnancy. In: Gynecological Endocrinology 36 (4), S. 277–278. DOI: 10.1080/09513590.2020.1747426.

Rasmussen, Sonja A.; Jamieson, Denise J. (2020): Coronavirus Disease 2019 (COVID-19) and Pregnancy: Responding to a Rapidly Evolving Situation. In: Obstetrics and gynecology. DOI: 10.1097/AOG.0000000000003873.

Zeng, Hui; Xu, Chen; Fan, Junli; Tang, Yueting; Deng, Qiaoling; Zhang, Wei; Long, Xinghua (2020a): Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. In: JAMA. DOI: 10.1001/jama.2020.4861.

Zeng, Lingkong; Xia, Shiwen; Yuan, Wenhao; Yan, Kai; Xiao, Feifan; Shao, Jianbo; Zhou, Wenhao (2020b): Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. In: JAMA pediatrics. DOI: 10.1001/jamapediatrics.2020.0878.

Zhang, Zhi-Jiang; Yu, Xue-Jie; Fu, Tao; Liu, Yu; Jiang, Yan; Yang, Bing Xiang; Bi, Yongyi (2020): Novel Coronavirus Infection in Newborn Babies Under 28 Days in China. In: The European respiratory journal. DOI: 10.1183/13993003.00697-2020.

  

Links to other recources

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Pregnancy

"At this time, there is no evidence that infection with COVID-19 in pregnant women is different from that in the general population. Because there is not yet much data available about pregnant women and their children, the NVOG, KNOV, NVK and RIVM have decided to follow the RCOG guideline."

Dutch gynaecologists, paediatricians and obstetricians Link to the current guideline
Government of the Netherlands