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Impact of COVID-19 on pregnancy and delivery - current knowledge.
Krupa, A, Schmidt, M, Zborowska, K, Jorg, D, Czajkowska, M, Skrzypulec-Plinta, V
Ginekologia polska. 2020;(9):564-568
Abstract
The World Health Organization announced on 12 March 2020 a global pandemic of the new SARS-CoV-2 coronavirus causing COVID-19 disease associated with pneumonia and acute respiratory failure. SARS-CoV-2 has caused so far over 6.66 million recorded cases, of which 393,000 ended in death (as of June 1, 2020). Despite the demographic statistics of incidence, there is no current recording of cases in the group of pregnant or perinatal women. Changes occurring in the female body system during pregnancy also affect and alter the immune system, and as studies based on other viral respiratory infections have shown, the population of pregnant women is at risk of having a severe course of the disease. The aim of the study is to summarize current reports on the course of COVID-19 disease in a group of pregnant women and the possible impact of SARS-CoV-2 on the foetus and vertical transmission, taking into account changes occurring in the woman's immune system during pregnancy. Available advice and recommendations for antenatal and perinatal care of pregnant women during the pandemic period are also included.
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HIV Infection in Pregnant Women: A 2020 Update.
Harris, K, Yudin, MH
Prenatal diagnosis. 2020;(13):1715-1721
Abstract
Acquired immunodeficiency syndrome (AIDS) was first described in 1981, and continues to be one of the worst global health pandemics in recorded history. Concerted international efforts have helped to increase awareness of human immunodeficiency (HIV) status, improve access to treatment and continuation of therapy to achieve viral suppression with a goal of ending the AIDS epidemic by 2030. The clinical outcomes for patients living with HIV on combined antiretroviral therapy are considerably improved with prolonged life expectancy and superior quality of life. Further, perinatal transmission rates have dramatically decreased with elimination of mother to child transmission of HIV in a growing number of countries worldwide. However, there have been significant reductions in the pace of progress in treatment expansion for pregnant women with failure to meet global targets in 2018. In this review, we will highlight recent advances and challenges ahead in 2020 for three areas of perinatal care for women with HIV in developed countries: (a) pregnancy planning considerations, (b) impact of antiviral medications on perinatal outcomes, and (c) infant feeding practices. The promise of a HIV-free generation is on the horizon and continued international efforts in preventing perinatal transmission are an important component of this achievement.
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3.
A review of newborn outcomes during the COVID-19 pandemic.
Kyle, MH, Glassman, ME, Khan, A, Fernández, CR, Hanft, E, Emeruwa, UN, Scripps, T, Walzer, L, Liao, GV, Saslaw, M, et al
Seminars in perinatology. 2020;(7):151286
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Abstract
As the COVID-19 pandemic continues to spread worldwide, it is crucial that we determine populations that are at-risk and develop appropriate clinical care policies to protect them. While several respiratory illnesses are known to seriously impact pregnant women and newborns, preliminary data on the novel SARS-CoV-2 Coronavirus suggest that these groups are no more at-risk than the general population. Here, we review the available literature on newborns born to infected mothers and show that newborns of mothers with positive/suspected SARS-CoV-2 infection rarely acquire the disease or show adverse clinical outcomes. With this evidence in mind, it appears that strict postnatal care policies, including separating mothers and newborns, discouraging breastfeeding, and performing early bathing, may be more likely to adversely impact newborns than they are to reduce the low risk of maternal transmission of SARS-CoV-2 or the even lower risk of severe COVID-19 disease in otherwise healthy newborns.
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Breastfeeding and coronavirus disease-2019: Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies.
Davanzo, R, Moro, G, Sandri, F, Agosti, M, Moretti, C, Mosca, F
Maternal & child nutrition. 2020;(3):e13010
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Abstract
The recent COVID-19 pandemic has spread to Italy with heavy consequences on public health and economics. Besides the possible consequences of COVID-19 infection on a pregnant woman and the fetus, a major concern is related to the potential effect on neonatal outcome, the appropriate management of the mother-newborn dyad, and finally the compatibility of maternal COVID-19 infection with breastfeeding. The Italian Society on Neonatology (SIN) after reviewing the limited scientific knowledge on the compatibility of breastfeeding in the COVID-19 mother and the available statements from Health Care Organizations has issued the following indications that have been endorsed by the Union of European Neonatal & Perinatal Societies (UENPS). If a mother previously identified as COVID-19 positive or under investigation for COVID-19 is asymptomatic or paucisymptomatic at delivery, rooming-in is feasible, and direct breastfeeding is advisable, under strict measures of infection control. On the contrary, when a mother with COVID-19 is too sick to care for the newborn, the neonate will be managed separately and fed fresh expressed breast milk, with no need to pasteurize it, as human milk is not believed to be a vehicle of COVID-19. We recognize that this guidance might be subject to change in the future when further knowledge will be acquired about the COVID-19 pandemic, the perinatal transmission of SARS-CoV-2, and clinical characteristics of cases of neonatal COVID-19.
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Guidance on breastfeeding during the Covid-19 pandemic.
Calil, VMLT, Krebs, VLJ, Carvalho, WB
Revista da Associacao Medica Brasileira (1992). 2020;(4):541-546
Abstract
OBJECTIVE These recommendations aim to provide guidance on breastfeeding for mothers with suspected or confirmed Covid-19. METHODS We performed a review of the recent medical literature on breastfeeding mothers with suspected or confirmed Covid-19, focusing on the neonatal period. RESULTS We analyzed 20 recent publications on breastfeeding, Covid-19, and its transmission through breastmilk. We presented possible options for breastfeeding and their consequences for the mother and the child. CONCLUSION All maternal decisions in relation to breastfeeding are justifiable since the infection by Covid-19 is still poorly known. However, puerperal women and their families must be very well informed to make a conscious choice based on the information available in the literature so far.
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Impact of breastfeeding, maternal antiretroviral treatment and health service factors on 18-month vertical transmission of HIV and HIV-free survival: results from a nationally representative HIV-exposed infant cohort, South Africa.
Goga, AE, Lombard, C, Jackson, D, Ramokolo, V, Ngandu, NK, Sherman, G, Puren, A, Chirinda, W, Bhardwaj, S, Makhari, N, et al
Journal of epidemiology and community health. 2020;(12):1069-1077
Abstract
BACKGROUND We analysed the impact of breastfeeding, antiretroviral drugs and health service factors on cumulative (6 weeks to 18 months) vertical transmission of HIV (MTCT) and 'MTCT-or-death', in South Africa, and compared estimates with global impact criteria to validate MTCT elimination: (1) <5% final MTCT and (2) case rate ≤50 (new paediatric HIV infections/100 000 live births). METHODS 9120 infants aged 6 weeks were enrolled in a nationally representative survey. Of 2811 HIV-exposed uninfected infants (HEU), 2644 enrolled into follow-up (at 3, 6, 9, 12, 15 and 18 months). Using Kaplan-Meier analysis and weighted survey domain-based Cox proportional hazards models, we estimated cumulative risk of MTCT and 'MTCT or death' and risk factors for time-to-event outcomes, adjusting for study design and loss-to-follow-up. RESULTS Cumulative (final) MTCT was 4.3% (95% CI 3.7% to 5.0%); case rate was 1290. Postnatal MTCT (>6 weeks to 18 months) was 1.7% (95% CI 1.2% to 2.4%). Cumulative 'MTCT-or-death' was 6.3% (95% CI 5.5% to 7.3%); 81% and 62% of cumulative MTCT and 'MTCT-or-death', respectively, occurred by 6 months. Postnatal MTCT increased with unknown maternal CD4-cell-count (adjusted HR (aHR 2.66 (1.5-5.6)), undocumented maternal HIV status (aHR 2.21 (1.0-4.7)) and exclusive (aHR 2.3 (1.0-5.2)) or mixed (aHR 3.7 (1.2-11.4)) breastfeeding. Cumulative 'MTCT-or death' increased in households with 'no refrigerator' (aHR 1.7 (1.1-2.9)) and decreased if infants used nevirapine at 6 weeks (aHR 0.4 (0.2-0.9)). CONCLUSIONS While the <5% final MTCT target was met, the case rate was 25-times above target. Systems are needed in the first 6 months post-delivery to optimise HEU health and fast-track ART initiation in newly diagnosed mothers.
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Pharmacokinetics of HIV-Integrase Inhibitors During Pregnancy: Mechanisms, Clinical Implications and Knowledge Gaps.
van der Galiën, R, Ter Heine, R, Greupink, R, Schalkwijk, SJ, van Herwaarden, AE, Colbers, A, Burger, DM
Clinical pharmacokinetics. 2019;(3):309-323
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Abstract
Prevention of mother-to-child transmission of HIV and optimal maternal treatment are the most important goals of antiretroviral therapy in pregnant women with HIV. These goals may be at risk due to possible reduced exposure during pregnancy caused by physiological changes. Limited information is available on the impact of these physiological changes. This is especially true for HIV-integrase inhibitors, a relatively new class of drugs, recommended first-line agents and hence used by a large proportion of HIV-infected patients. Therefore, the objective of this review is to provide a detailed overview of the pharmacokinetics of HIV-integrase inhibitors in pregnancy. Second, this review defines potential causes for the change in pharmacokinetics of HIV-integrase inhibitors during pregnancy. Despite increased clearance, for raltegravir 400 mg twice daily and dolutegravir 50 mg once daily, exposure during pregnancy seems adequate; however, for elvitegravir, the proposed minimal effective concentration is not reached during pregnancy. Lower exposure to these drugs may be caused by increased hormone levels and, subsequently, enhanced drug metabolism during pregnancy. The pharmacokinetics of bictegravir and cabotegravir, which are under development, have not yet been evaluated in pregnant women. New studies need to prospectively assess whether adequate exposure is reached in pregnant women using these new HIV-integrase inhibitors. To further optimize antiretroviral treatment in pregnant women, studies need to unravel the underlying mechanisms behind the changes in the pharmacokinetics of HIV-integrase inhibitors during pregnancy. More knowledge on altered pharmacokinetics during pregnancy and the underlying mechanisms contribute to the development of effective and safe antiretroviral therapy for HIV-infected pregnant women.
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Pre-exposure prophylaxis for HIV prevention during pregnancy and lactation: forget not the women and children.
Horgan, L, Blyth, CC, Bowen, AC, Nolan, DA, McLean-Tooke, AP
The Medical journal of Australia. 2019;(6):281-284
Abstract
Pregnancy is known to be a time of increased susceptibility to acquiring to human immunodeficiency virus (HIV) infection and this increased maternal risk places the unborn child at risk of vertical transmission. Pre-exposure prophylaxis (PrEP) involves the provision of antiretroviral therapy to an HIV-negative individual with ongoing risk of HIV exposure to limit the likelihood of HIV transmission. The inclusion of PrEP as part of a comprehensive strategy is recognised as an effective and safe means of reducing HIV infection in serodiscordant couples, thereby reducing the risk of vertical transmission of HIV. Current data suggest that PrEP is safe to continue during pregnancy and breastfeeding in HIV-negative women who remain vulnerable to acquiring HIV. The recent Pharmaceutical Benefits Scheme subsidisation of PrEP has reduced the financial and practical obstacles of PrEP provision, and a subsequent increase in patient awareness and acceptance of PrEP is expected. The framework for appropriately identifying and managing at-risk pregnant and lactating women requiring PrEP is poorly defined and warrants further clarification to better support clinicians and this patient group. This review discusses the current recommendations highlighting the gaps in the guidelines and makes some recommendations for future guideline development.
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Microbial transmission from mother to child: improving infant intestinal microbiota development by identifying the obstacles.
Van Daele, E, Knol, J, Belzer, C
Critical reviews in microbiology. 2019;(5-6):613-648
Abstract
Industrialisation has introduced several lifestyle changes and medical advancements but their impact on intestinal microbiota acquisition is often overlooked. Even though these consequential changes in the microbiota could contribute to the disease burden that accompanies industrialisation, such as obesity and atopic disease. A healthy intestinal microbiota is acquired early in life but its exact origin is not fully elucidated. The maternal microbiota is a likely source because the infant and mother intestinal microbiota share identical strains. Successfully transmitting microbes from mother to child requires microbes in the maternal donor, contact between the maternal source and the infant, and an acquiring infant recipient. Transmission can be altered by changes to any of those three transmission determinants: (1) maternal microbiota sources are shaped by the mother's genotype, diet, health status and perturbing antimicrobial exposure; (2) maternal contact is reduced through C-section and formula feeding and (3) engraftment in the infant recipient is determined by host habitat filtering, the established microbes and antibiotic disruptions. This review gives an overview of the possible maternal transmission routes, the disruptions thereof, and the missing links that should be addressed in future research to investigate the maternal transmissions that are crucial for obtaining a healthy infant microbiota.
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Management Algorithm for Interrupting Mother-to-Child Transmission of Hepatitis B Virus.
Hou, J, Cui, F, Ding, Y, Dou, X, Duan, Z, Han, G, Jia, J, Mao, Q, Li, J, Li, Z, et al
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2019;(10):1929-1936.e1
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Abstract
In areas where hepatitis B virus (HBV) is endemic, mother-to-child transmission (MTCT) is the major route of infection of children. Blocking MTCT of HBV therefore would reduce its prevalence. The China Foundation of Hepatitis Prevention and Control organized a team of specialists in infectious diseases, hepatology, immunology, obstetrics, and public health to develop an algorithm for interrupting MTCT of HBV, based on the most recent hepatitis B guidelines and latest evidence. This algorithm comprises 10 steps and has been adopted in clinical practice in China. Four aspects (screening, antiviral intervention during pregnancy, immunoprophylaxis, and postvaccination serologic testing) are the core components of preventing MTCT. Although the combination of passive and active immunization in newborns of hepatitis B surface antigen-positive mothers reduces MTCT of HBV, this immunoprophylaxis cannot completely eradicate MTCT. In the past decade, administration of antiviral agents to pregnant women has been shown to be safe and effective in reducing MTCT of HBV in combination with immunoprophylaxis. Aiming to achieve zero MTCT, this algorithm recommends the use of antivirals during pregnancy by women with high viral loads. Preventing MTCT is key to achieving the goal of eliminating HBV as a public health threat by 2030. Implementation and enhancement of the standardized algorithm for pregnant women with chronic HBV infection and their infants is urgently needed to prevent MTCT.