COVID-19 in pregnancy

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COVID-19 in pregnancy
3d illustration of coronavius.png
Virtual model of coronavirus
Risk factors Severe infection
PreventionCovering cough, avoid interacting with sick people, cleaning hands with soap and water or sanitizer

COVID-19 infection in pregnancy is associated with several pregnancy complications. [1] However, pregnancy does not appear to increase the susceptibility of becoming infected by COVID-19. [1] Recommendations for the prevention of COVID-19 include the same measures as non-pregnant people. [2]

Contents

Effect of COVID-19 in pregnancy

COVID-19 in pregnancy [1]
Complication Odds ratio 95% confidence interval
Pre-eclampsia 1.331.03 to 1.73
Preterm birth 1.821.38 to 2.39
Stillbirth 2.111.14 to 3.90

According to a systematic review and meta-analysis in 2021, COVID-19 is associated with stillbirth, pre-eclampsia and preterm birth. [1] According to the same review, compared with mild COVID-19, severe COVID-19 is strongly associated with preeclampsia, preterm birth, gestational diabetes and low birth weight. [1]

A review in 2022 suggests that pregnant women are at increased risk of severe COVID-19 disease, with an increased rate of being hospitalized to the intensive care unit and requiring ventilation death, but was not associated with a statistically significant increase in mortality. [3]

A systematic review update in 2022 demonstrated that pregnant women are at increased risk of severe COVID-19. It also found that risk factors for severe COVID-19 in pregnant people included high body mass index, being of an older age, being of non-white ethnic origin, having pre-existing comorbidities, having pre-eclampsia or gestational diabetes. [4] [5]

A 2023 meta-analysis concluded that COVID-19 infection at any time during a pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. [6] Unlike earlier reviews, this study did not find a link between COVID-19 infection during pregnancy and increased risk of stillbirth at or beyond 28 weeks' gestation. [6] This study used the first large set of pregnancy cohort data from sub-Saharan Africa. [6]

A marked increase in cases of situs inversus was observed several months after the lifting of the zero-COVID-19 policy in China, which coincided with a rise in infections. This rare clinical evidence suggests a possible link between infection during pregnancy and the development of this condition in the fetus, specifically during gestational weeks 4–6, the critical period for organ positioning. [7]

Effect of SARS-CoV-2 on Fetal Neurodevelopment

Maternal infection increases the chance of neurodevelopmental disorders. The underlying mechanisms that cause this have not yet been elucidated. [8] A 2024 study found impaired cardiac function in babies whose mothers contracted COVID in the second trimester. [9]

In two systematic reviews [10] [11] concluded that covid-19 could potentially disrupt the neurodevelopment of the fetus as a consequence of the hyperinflammatory host response elicited by the viral infection through various possible mechanisms. However, it is still a controversial subject due to the complex nature of investigating an unaccounted unforeseen epidemic on already pregnant women or postpartum patients.

Vertical transmission of SARS-CoV-2 directly

It is uncertain if there is a direct route of SARS-CoV-2 from the mother to the fetus, but based on some studies, [12] [13] SARS-CoV-2 was present in the placental samples, amniotic fluid, or infant nasopharyngeal swabs of neonatal shows in utero infection. In a case report, it was confirmed through observing that the placental syncytiotrophoblastic cells and nasopharyngeal samples containing SARS-CoV-2 nucleocapsid proteins along with some viral substrates. [14] However, in a systematic review of systematic reviews, it is sought as a rare event. [15]

Host-virus interactions

The pro-inflammatory state could disrupt the placental development, which, in turn, results in preterm birth, preeclampsia, and restricted intrauterine growth. [16]

The Neurodevelopmental invaded by SARS-CoV-2

The exact mechanism of how it disrupts the normal neurogenesis had brought up different hypotheses:

The direct route of transplacental transmission. Like SARS-CoV, SARS-CoV-2 might create its entry point into the brain through the ACE2 receptor. As a result of viremia, the virus binds to the endothelial ACE2 receptors of the blood brain barrier (BBB) and this way it makes its entry point into the central nervous system (CNS). This was strongly explained in a study where post-mortem brain biopsies were analyzed on electron micrography, and viral particles were evident in the frontal cortex of SARS-CoV-2 infected adults. [17] In addition, the violation of the sophisticated maternal-fetal interface by the virus could potentiate the exaggerated release of cytokines and the penetration of immune cells into the placenta and eventually to the fetus, hindering normal neurogenesis. [16]

Cholinergic Anti-inflammatory Pathway (CAP). It is suspected that the virus disrupts CAP in suppressing the release of proinflammatory cytokines, either of fetus or the mother, which triggers the hyperinflammatory state and increase risk of neurodevelopmental disorders. [16]

DNA methylation. Viral infection could alter DNA methylation patterns in genes involved with neurodevelopment. [10]

Immune system—Itself. Infected immune cells that could express the ACE2 receptor might have a role in their dissemination to the brain through different portals: vasculatures, choroid plexus, and meninges. [18]

Olfactory transport of infection. It is assumed that during laboring the offspring, neonatal infection could be acquired via direct contact with vaginal secretions or physical or airborne route. The virus binding to ACE2 receptors of the olfactory epithelium and through this channel, the virus could be able to pave its way to the CNS. [18]

Retrograde axonal transport. The gut neurons might have transported the viruses into the nervous system. [19]

Recommendations

Prevention

The World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) of the United States advises pregnant women to do the same things as the general public to avoid infection, such as covering cough, avoid interacting with sick people, cleaning hands with soap and water or sanitizer. [2] [20]

Vaccination against COVID-19 was not associated with an increase in miscarriage or reduction in live birth. [21] Meta-analysis has not identified any pregnancy-specific safety concerns with vaccines. [22]

The data overwhelming support maternal vaccination as being effective at reducing the risk for infection and severe illness. [22]

Studies seem to show that completion of a two dose mRNA vaccination during pregnancy reduces hospital admissions for COVID-19 among infants under 6 months, but there is insufficient evidence for how long protection continues for an infant after birth. [22]

The WHO states that pregnant women can receive covid-19 vaccines and, if not already vaccinated, should have access to WHO Emergency Use Listing-approved vaccines, as the benefits of vaccination during pregnancy outweigh potential risks. [22] The Royal College of Obstetricians and Gynaecologists in the UK strongly recommend vaccination in pregnancy and prefers that the Pfizer-BioNTech or Moderna mRNA vaccines are offered where available due to greater amounts of data on that vaccine type. In America, the CDC, the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine encourage pregnant women to get COVID-19 vaccines. [22] The Federation of Obstetric and Gynaecological Societies of India recommend vaccination, though it is not currently recommended by the Government of India. [22] More than 80 countries do not currently recommend that all pregnant and lactating women should be vaccinated. [6]

Treatment

A state of the art review published in 2022 stated that the basic principles of diagnosing and managing COVID-19 should be the same for pregnant patients as for non-pregnant patients. It recommnended that treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids and that Il-6 inhibitors and monoclonal antibodies could be used, as could specific antiviral therapies. [23]

Pregnancy is not a contraindication for therapies including respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position, intubation and ventilation, and extracorporeal membrane oxygenation. [23]

See also

Related Research Articles

<span class="mw-page-title-main">Fifth disease</span> Red rash due to infection with parvovirus B19

Fifth disease, also known as erythema infectiosum and slapped cheek syndrome, is a common and contagious disease caused by infection with parvovirus B19. This virus was discovered in 1975 and can cause other diseases besides fifth disease. Fifth disease typically presents as a rash and is most common in children. While parvovirus B19 can affect people of all ages, only two out of ten individuals will present with symptoms.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

Tocolytics are medications used to suppress premature labor. Preterm birth accounts for 70% of neonatal deaths. Therefore, tocolytic therapy is provided when delivery would result in premature birth, postponing delivery long enough for the administration of glucocorticoids, which accelerate fetal lung maturity but may require one to two days to take effect.

<span class="mw-page-title-main">Low birth weight</span> Birth weight of an infant of 2,499 g (5 lb 8.1 oz) or less

Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an infant of 2,499 g or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal intensive care unit (NICU). They are also at increased risk for long-term health conditions which require follow-up over time.

<span class="mw-page-title-main">Birth weight</span> Weight of a human baby at birth

Birth weight is the body weight of a baby at their birth. The average birth weight in babies of European and African descent is 3.5 kilograms (7.7 lb), with the normative range between 2.5 and 4.0 kilograms. On average, babies of Asian descent weigh about 3.25 kilograms (7.2 lb). The prevalence of low birth weight has changed over time. Trends show a slight decrease from 7.9% (1970) to 6.8% (1980), then a slight increase to 8.3% (2006), to the current levels of 8.2% (2016). The prevalence of low birth weights has trended slightly upward from 2012 to the present.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

<span class="mw-page-title-main">Vertically transmitted infection</span> Infection caused by pathogens that use mother-to-children transmission

A vertically transmitted infection is an infection caused by pathogenic bacteria or viruses that use mother-to-child transmission, that is, transmission directly from the mother to an embryo, fetus, or baby during pregnancy or childbirth. It can occur when the mother has a pre-existing disease or becomes infected during pregnancy. Nutritional deficiencies may exacerbate the risks of perinatal infections. Vertical transmission is important for the mathematical modelling of infectious diseases, especially for diseases of animals with large litter sizes, as it causes a wave of new infectious individuals.

<span class="mw-page-title-main">Angiotensin-converting enzyme 2</span> Exopeptidase enzyme that acts on angiotensin I and II

Angiotensin-converting enzyme 2 (ACE2) is an enzyme that can be found either attached to the membrane of cells (mACE2) in the intestines, kidney, testis, gallbladder, and heart or in a soluble form (sACE2). Both membrane bound and soluble ACE2 are integral parts of the renin–angiotensin–aldosterone system (RAAS) that exists to keep the body's blood pressure in check. mACE2 is cleaved by the enzyme ADAM17 in a process regulated by substrate presentation. ADAM17 cleavage releases the extracellular domain creating soluble ACE2 (sACE2). ACE2 enzyme activity opposes the classical arm of the RAAS by lowering blood pressure through catalyzing the hydrolysis of angiotensin II into angiotensin (1–7). Angiotensin (1-7) in turns binds to MasR receptors creating localized vasodilation and hence decreasing blood pressure. This decrease in blood pressure makes the entire process a promising drug target for treating cardiovascular diseases.

<span class="mw-page-title-main">Nutrition and pregnancy</span> Nutrient intake and dietary planning undertaken before, during and after pregnancy

Nutrition and pregnancy refers to the nutrient intake, and dietary planning that is undertaken before, during and after pregnancy. Nutrition of the fetus begins at conception. For this reason, the nutrition of the mother is important from before conception as well as throughout pregnancy and breastfeeding. An ever-increasing number of studies have shown that the nutrition of the mother will have an effect on the child, up to and including the risk for cancer, cardiovascular disease, hypertension and diabetes throughout life.

A breakthrough infection is a case of illness in which a vaccinated individual becomes infected with the illness, because the vaccine has failed to provide complete immunity against the pathogen. Breakthrough infections have been identified in individuals immunized against a variety of diseases including mumps, varicella (Chickenpox), influenza, and COVID-19. The characteristics of the breakthrough infection are dependent on the virus itself. Often, infection of the vaccinated individual results in milder symptoms and shorter duration than if the infection were contracted naturally.

<span class="mw-page-title-main">Immunization during pregnancy</span>

Immunization during pregnancy is the administration of a vaccine to a pregnant individual. This may be done either to protect the individual from disease or to induce an antibody response, such that the antibodies cross the placenta and provide passive immunity to the infant after birth. In many countries, including the US, Canada, UK, Australia and New Zealand, vaccination against influenza, COVID-19 and whooping cough is routinely offered during pregnancy.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is a pregnancy where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy. A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

<span class="mw-page-title-main">Neonatal infection</span> Human disease

Neonatal infections are infections of the neonate (newborn) acquired during prenatal development or within the first four weeks of life. Neonatal infections may be contracted by mother to child transmission, in the birth canal during childbirth, or after birth. Neonatal infections may present soon after delivery, or take several weeks to show symptoms. Some neonatal infections such as HIV, hepatitis B, and malaria do not become apparent until much later. Signs and symptoms of infection may include respiratory distress, temperature instability, irritability, poor feeding, failure to thrive, persistent crying and skin rashes.

<span class="mw-page-title-main">COVID-19</span> Contagious disease caused by SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the coronavirus SARS-CoV-2. The disease spread worldwide, resulting in the COVID-19 pandemic.

A respiratory syncytial virus vaccine, or RSV vaccine, is a vaccine that protects against respiratory syncytial virus. RSV affects an estimated 64 million people and causes 160,000 deaths worldwide each year.

<span class="mw-page-title-main">Gendered impact of the COVID-19 pandemic</span> Aspect of viral outbreak

COVID-19 affects men and women differently both in terms of the outcome of infection and the effect of the disease upon society. The mortality due to COVID-19 is higher in men. Slightly more men than women contract COVID with a ratio of 10:9.

<span class="mw-page-title-main">Transmission of COVID-19</span> Mechanisms that spread coronavirus disease 2019

The transmission of COVID-19 is the passing of coronavirus disease 2019 from person to person. COVID-19 is mainly transmitted when people breathe in air contaminated by droplets/aerosols and small airborne particles containing the virus. Infected people exhale those particles as they breathe, talk, cough, sneeze, or sing. Transmission is more likely the closer people are. However, infection can occur over longer distances, particularly indoors.

Long COVID or long-haul COVID is a group of health problems persisting or developing after an initial period of COVID-19 infection. Symptoms can last weeks, months or years and are often debilitating. The World Health Organization defines long COVID as starting three months after the initial COVID-19 infection, but other agencies define it as starting at four weeks after the initial infection.

<span class="mw-page-title-main">Shabir Madhi</span> South African physician and professor

Shabir Ahmed Madhi, is a South African physician who is professor of vaccinology and director of the South African Medical Research Council Respiratory and Meningeal Pathogens Research Unit at the University of the Witwatersrand, and National Research Foundation/Department of Science and Technology Research Chair in Vaccine Preventable Diseases. In January 2021, he was appointed Dean of the Faculty of Health Sciences at the University of the Witwatersrand.

References

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  2. 1 2 "Coronavirus Disease 2019 (COVID-19)". Centers for Disease Control and Prevention. 11 February 2020. Retrieved 19 March 2020.
  3. ↑ Wang H, Li N, Sun C, Guo X, Su W, Song Q; et al. (2022). "The association between pregnancy and COVID-19: A systematic review and meta-analysis". Am J Emerg Med. 56: 188–195. doi:10.1016/j.ajem.2022.03.060. PMC   8986277 . PMID   35413655.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ↑ "Update to living systematic review on covid-19 in pregnancy". BMJ. 377: o1205. 2022-05-30. doi:10.1136/bmj.o1205. ISSN   1756-1833. PMID   35636775.
  5. ↑ Allotey, John; Fernandez, Silvia; Bonet, Mercedes; Stallings, Elena; Yap, Magnus; Kew, Tania; Zhou, Dengyi; Coomar, Dyuti; Sheikh, Jameela; Lawson, Heidi; Ansari, Kehkashan; Attarde, Shruti; Littmoden, Megan; Banjoko, Adeolu; Barry, Kathryn (2020-09-01). "Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis". BMJ. 370: m3320. doi:10.1136/bmj.m3320. ISSN   1756-1833. PMC   7459193 . PMID   32873575.
  6. 1 2 3 4 Smith, Emily R.; Oakley, Erin; Grandner, Gargi Wable; Ferguson, Kacey; Farooq, Fouzia; Afshar, Yalda; Ahlberg, Mia; Ahmadzia, Homa; Akelo, Victor; Aldrovandi, Grace; Barr, Beth A. Tippett; Bevilacqua, Elisa; Brandt, Justin S.; Broutet, Nathalie; Buhigas, Irene Fernández (2023-01-01). "Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis". BMJ Global Health. 8 (1): e009495. doi:10.1136/bmjgh-2022-009495. hdl: 10044/1/104684 . ISSN   2059-7908. PMC   9895919 . PMID   36646475.
  7. ↑ Guo, Zhenming; Luo, Yingchun; Bi, Yan; Liu, Liangjie; Qi, Yuan (November 2024). "Association between situs inversus and maternal SARS-CoV-2 infection at gestational age 4–6 weeks". Med. 5 (11): 1433–1441.e3. doi:10.1016/j.medj.2024.07.009. PMID   39094582.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ↑ Duan, Lian; Yin, Huamin; Liu, Jiaxin; Wang, Wenhang; Huang, Peijun; Liu, Li; Shen, Jingling; Wang, Zhendong (2024-11-09). "Maternal COVID-19 infection associated with offspring neurodevelopmental disorders". Molecular Psychiatry: 1–11. doi:10.1038/s41380-024-02822-z. ISSN   1476-5578. PMID   39521839.
  9. ↑ Şahan, Yasemin Özdemir; Sakcak, Bedri; Göncü Ayhan, Şule; Tanaçan, Atakan; Kibar Gül, Ayşe Esin; Şahin, Dilek; İlker Çetin, İbrahim (2024-01-17). "The influence of maternal COVID-19 on cardiac functions: From fetal life to infancy". Echocardiography. 41 (1): e15736. doi:10.1111/echo.15736. ISSN   0742-2822. PMID   38284669.
  10. 1 2 Hill, Rachel A.; Gibbons, Andrew; Han, Uni; Suwakulsiri, Wittaya; Taseska, Angela; Hammet, Fleur; Southey, Melissa; Malhotra, Atul; Fahey, Michael; Palmer, Kirsten R.; Hunt, Rod W.; Lim, Izaak; Newman-Morris, Vesna; Sundram, Suresh (February 2023). "Maternal SARS-CoV-2 exposure alters infant DNA methylation". Brain, Behavior, & Immunity - Health. 27: 100572. doi:10.1016/j.bbih.2022.100572. ISSN   2666-3546. PMC   9758784 . PMID   36570792.
  11. ↑ Yates, Emma F.; Mulkey, Sarah B. (July 2024). "Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned". Pediatric Research. 96 (1): 64–72. doi:10.1038/s41390-024-03145-z. ISSN   0031-3998. PMC  11257821. PMID   38509227.
  12. ↑ Patanè, Luisa; Morotti, Denise; Giunta, Monica Rosaria; Sigismondi, Cristina; Piccoli, Maria Giovanna; Frigerio, Luigi; Mangili, Giovanna; Arosio, Marco; Cornolti, Giorgio (August 2020). "Vertical transmission of coronavirus disease 2019: severe acute respiratory syndrome coronavirus 2 RNA on the fetal side of the placenta in pregnancies with coronavirus disease 2019–positive mothers and neonates at birth". American Journal of Obstetrics & Gynecology MFM. 2 (3): 100145. doi:10.1016/j.ajogmf.2020.100145. ISSN   2589-9333. PMC   7233206 . PMID   32427221.
  13. ↑ Sisman, Julide; Jaleel, Mambarambath A.; Moreno, Wilmer; Rajaram, Veena; Collins, Rebecca R.J.; Savani, Rashmin C.; Rakheja, Dinesh; Evans, Amanda S. (2020-07-10). "Intrauterine Transmission of SARS-COV-2 Infection in a Preterm Infant". Pediatric Infectious Disease Journal. 39 (9): e265–e267. doi:10.1097/inf.0000000000002815. ISSN   0891-3668. PMID   32658097.
  14. ↑ Sisman, Julide; Jaleel, Mambarambath A.; Moreno, Wilmer; Rajaram, Veena; Collins, Rebecca R.J.; Savani, Rashmin C.; Rakheja, Dinesh; Evans, Amanda S. (September 2020). "Intrauterine Transmission of SARS-COV-2 Infection in a Preterm Infant". Pediatric Infectious Disease Journal. 39 (9): e265–e267. doi:10.1097/INF.0000000000002815. ISSN   0891-3668. PMID   32658097.
  15. ↑ Musa, Salihu S.; Bello, Umar M.; Zhao, Shi; Abdullahi, Zainab U.; Lawan, Muhammad A.; He, Daihai (2021-09-20). "Vertical Transmission of SARS-CoV-2: A Systematic Review of Systematic Reviews". Viruses. 13 (9): 1877. doi: 10.3390/v13091877 . ISSN   1999-4915. PMC   8471858 . PMID   34578458.
  16. 1 2 3 Yates, Emma F.; Mulkey, Sarah B. (2024-03-20). "Viral infections in pregnancy and impact on offspring neurodevelopment: mechanisms and lessons learned". Pediatric Research. 96 (1): 64–72. doi:10.1038/s41390-024-03145-z. ISSN   0031-3998. PMC  11257821. PMID   38509227.
  17. ↑ Paniz-Mondolfi, Alberto; Bryce, Clare; Grimes, Zachary; Gordon, Ronald E.; Reidy, Jason; Lednicky, John; Sordillo, Emilia Mia; Fowkes, Mary (2020-06-09). "Central nervous system involvement by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)". Journal of Medical Virology. 92 (7): 699–702. doi:10.1002/jmv.25915. ISSN   0146-6615. PMC   7264598 . PMID   32314810.
  18. 1 2 Iadecola, Costantino; Anrather, Josef; Kamel, Hooman (October 2020). "Effects of COVID-19 on the Nervous System". Cell. 183 (1): 16–27.e1. doi:10.1016/j.cell.2020.08.028. ISSN   0092-8674. PMC   7437501 . PMID   32882182.
  19. ↑ Esposito, Giuseppe; Pesce, Marcella; Seguella, Luisa; Sanseverino, Walter; Lu, Jie; Sarnelli, Giovanni (July 2020). "Can the enteric nervous system be an alternative entrance door in SARS-CoV2 neuroinvasion?". Brain, Behavior, and Immunity. 87: 93–94. doi:10.1016/j.bbi.2020.04.060. ISSN   0889-1591. PMC   7179488 . PMID   32335192.
  20. ↑ "Q&A on COVID-19, pregnancy, childbirth and breastfeeding". www.who.int. Retrieved 6 April 2020.
  21. ↑ Michael P Rimmer, Jhia J Teh, Scott C Mackenzie, Bassel H Al Wattar, The risk of miscarriage following COVID-19 vaccination: a systematic review and meta-analysis, Human Reproduction, 2023 https://academic.oup.com/humrep/advance-article/doi/10.1093/humrep/dead036/7043098?login=false
  22. 1 2 3 4 5 6 Badell, Martina L.; Dude, Carolynn M.; Rasmussen, Sonja A.; Jamieson, Denise J. (2022-08-10). "Covid-19 vaccination in pregnancy". BMJ. 378: e069741. doi:10.1136/bmj-2021-069741. ISSN   1756-1833. PMC   9363819 . PMID   35948352.
  23. 1 2 Nana, Melanie; Hodson, Kenneth; Lucas, Nuala; Camporota, Luigi; Knight, Marian; Nelson-Piercy, Cathy (2022-04-26). "Diagnosis and management of covid-19 in pregnancy". BMJ. 377: e069739. doi:10.1136/bmj-2021-069739. ISSN   1756-1833. PMID   35473709.
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