How to deal with covid cases who want to get pregnant and those who already are pregnant : A dllema Vaccine or No vaccine : we will answer this in this talk

1. COVID-19
SARS-CoV-2
2019-nCov
HCoV-19
Disease
Virus Name

2. Outline
• Introduction
• Infertility
• Pregnancy

3. Clinical Course of the disease
severe

4. Patient response to therapy and recovery:
• CRP, IL6, D-Dimer, neutrophils
• TLC, Lymphocytes, Platelet, eosinophils
• Ferritin last parameter to return to normal

5. May, 2021
Viral vector
vaccines

6. South Africa only of the population vaccinated while UK
8.8% 72%
DR in south Africa more than UK although the same number of population.

7. Case Fatality rate
• COVID-19: 0.7 to 3.4% (>5% in Wuhan itself during peak)
• Will be higher without access to healthcare, oxygen and ventilators
• Spanish Influenza 1918: >2.5% Mostly younger people
• Seasonal Influenza: 0.1-0.2%

8. COVID -19 in Egypt, 6 September,2021
• Confirmed 288,441
• Recovered 239,343
• Deaths 16,736
• Fatality Rate 5.8%
• Vaccination 9,341,000 (%)

9. Not STD
• To be (STD), a virus has to be detected in seminal or vaginal fluids
from asymptomatic or symptomatic people and transmitted through
intercourse or insemination.
• 98.0% (293/299) of the seminal fluids, 16/17 testicular biopsies, all
89 prostatic fluids, 98.3% (57/58) of the vaginal fluids, all 35 cervical
smears, and all 16 oocyte samples tested negative for SARS-CoV-2.
• None of the studies confirmed sexual transmission of SARS-CoV-2.

10. Link to Reproduction
• For SARS-CoV-2 cell entry, the angiotensin-converting-enzyme 2
receptor (ACE2) and transmembrane serine protease 2 (TMPRSS2) are
needed.
• The presence of ACE2 receptor and TMPRSS2 in both male and
female reproductive tract cells has raised concerns that the Covid 19
infection may compromise human fertility and pregnancy.

11. Reproduction
Infertility
Pregnancy

12. Outline
• Introduction
• Infertility
• Pregnancy

13. Infertility
• Affect 7-10% of populations
• Even in pandemic as Covid 19, it remains a social problem
• Initially, suspension of infertility services was recommended
• 2021, they are resumed
• Why?

14. Infertility
• In the next few years, we may experience reduced fertilization,
implantation and live birth rates
• Why? SARS virus receptors were found on human gametes and
embryos

15. Risk : real or theory?
• Male fertility
• Female
• IVF outcome
• Cryopreservation

16. Male Fertility
• SARS-CoV-2, through an activation of pathogenic pathways, may
increase sperm DNA fragmentation, which in turn may affect
fertilizing potential.
• Those having severe infection, Male fertility may be temporarily
reduced due to inflammatory responses following infection.

18. Summary of studies

19. Female
• The endometrium is highly susceptible to SARS-CoV-2 cell entry;
however, it remains unclear whether this could alter receptivity and
embryo implantation.

20. IVF outcome : 2021, August
Female IVF treatment parameters were comparable to the pre-Covid-
19 infection cycle performance. Sperm concentration and motility
demonstrated lower mean counts following Covid-19 infection.

21. Cryopreservation?

24. Closed “sealed” cryo system
• Prevent semen suspension to get in contact with liquid nitrogen
• Thus prevent cross contamination
• Apart from sprem washing steps which are common in all centers

25. Consensus : August 2021
• men and women should have access to fertility services, and such
access should be irrespective of the vaccine.
• screening all patients prior to cycle initiation
• Avoid initiating treatment of women with severe comorbidities as
bronchial asthma until the pandemic is under control

26. Special subgroups
• Poor responders
• Fertility preservation
• IVF should be offered without delay

27. COVID-19 vaccines and fertility,
June 2021
• There is no evidence to suggest that COVID-19 vaccines will affect fertility or
fertility treatment
• The RCOG advise there is no plausible mechanism by which current vaccines
could cause any impact on women’s fertility

28. monitoring the outcomes
• to compare them in vaccinated versus non-vaccinated patients.

29. Which type of vaccine
• No information on which type could affect male or female fertility
more
• mRNA COVID-19 vaccines (Comirnaty from Pfizer/BioNTech and
COVID-19 Vaccine Moderna) and viral vector vaccines (COVID-19
Vaccine AstraZeneca, COVID-19 Vaccine Janssen)
• Killed virus vaccines: Sinopharm, sinofak, Sputink

30. Moreover
• no information on the role of vaccination in patients and staff who
have had COVID-19 disease and could have developed immunity

31. To date
• the possible effects of COVID-19 on the ovary or residual ovarian
reserve have not been investigated.
• survivors of COVID-19 should be evaluated for their short- and long-
term ovarian and testicular function

32. Menstrual disorders
•
• The current evidence does not suggest an increased
risk of either menstrual disorders or unexpected
vaginal bleeding following the vaccines

33. COVID-19 vaccination in women who
are planning pregnancy
• Women who are planning pregnancy or in the
immediate postpartum period can be vaccinated
without fear
• The question is : If a woman finds out she is
pregnant after she has started a course of vaccine??
What to do?

34. Medical Staff
• Surgical Mask if no N95 and for
regular exposure
• https://infectioncontrol.ucsfmedi
calcenter.org/covid/donning-and-
doffing-novel-coronavirus-covid-
19-videos

35. Risk Conditions
• Age
• HTN
• Diabetes
• Coronary Heart Disease
• Hep B
• COPD
• Cancer

36. Outline
• Introduction
• Infertility
• Pregnancy

37. Covid 19 & pregnancy
Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
1
2
3
4
5
7
8
Termination
6

38. More dangerous during pregnancy
• hospital admission and severe illness are more common in pregnant women
(compared to those not pregnant
• stillbirth and preterm birth is more likely (2x more) (compared to pregnant
women without COVID-19).
• Pregnant women with underlying medical conditions are at higher risk of severe
illness.
• RCOG, 2021

39. Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
2
3
4
5
7
8
Termination
6
1

40. Admission
Shortness of breath
Oxygen saturation < 94%
cough
Co-morbidities : bronchial
asthma
In labor
obstetric indications
fever
1
2
3
4
5
7
8
CT : typical ground glass
6

41. Warning signs
-
Increased O2 demands by 50% over 1-2h
O2 sat < 94% despite O2 support
>4.0L O2 by facemask
MEOWS: Maternal Early Obstetrical Warning Score
2 yellow or 1 red alert
triggers MD evaluation
Surveillance:
Location depends on the local facility:
special ward with O2 facilities

42. Investigations
Routine labs
Prognostic labs : ferritin, D
dimer
U/S
CRP
Swab
1
2
3
4
5

43. Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
2
3
4
5
7
8
Termination
6
1

44. Clexan 60
- Any pregnant patient admitted to hospital for any indication is at risk for VTE
- In COVID- “hypercoagulable” state
Recommend: VTE prophylaxis for women admitted with moderate to severe disease
- duration depends on clinical scenario
Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic
Jennifer Jury McIntosh, DO, MD DOI https://doi.org/ 10.1055/s-0040-1709684.
- lowest quality of evidence... authors opinion...
- leap from high dose/duration in ICU patient
SUPPORT THE USE OF CELESTONE IF AN
IDENTIFIED RISK FOR PRETERM BIRTH

45. Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
2
3
4
5
7
8
Termination
6
1

46. Corticosteroids
Corticosteroid Guidance for Pregnancy during COVID-19 Pandemic
SUPPORT THE USE OF Corticosteroids IF AN
IDENTIFIED RISK FOR PRETERM BIRTH

47. Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
2
3
4
5
7
8
Termination
6
1

48. Termination
Principles:
a. If < 28w GA & can maintain mechanical ventilation: ….. risk of prematurity > risk of IUFD
b. If <28w GA & can NOT maintain mechanical ventilation…. ? Would delivery improve ventilation status
c. If > 28w GA & can maintain mechanical ventilation …. Consider delivery if signs of non-reassuring fetal status*
d. If >28 w GA & CAN NOT maintain mechanical ventilation: …. Consider delivery to manage ventilation **
** NOT to improve maternal disease process, not to alter fetal/neonatal outcome, but to facilitate the ventilation
*** if delivering < 34w GA, give MgSO4 4g bolus before delivery- over 1 hour to limit maternal respiratory depression
1. COVID-19 infection is NOT a direct indication for delivery
2. Decision to deliver is individualized based on maternal & fetal status, GA

49. Intrapartum Management:
- Regardless of GA: CEFM based on case reports of fetal compromise in women with
COVID-19 diagnosis (8/18 – 44% incidence)
- Maternal vital signs (HR, BP, RR, O2 sat) q 1h. Oxygen to keep O2 sat >94%
- Hourly fluid status to avoid fluid overload (affects ventilation, work of breathing)
- Encourage spinal anesthesia
- No indication for C/S unless to improve maternal resuscitation efforts
- Consideration: shorten the second stage

50. Key Points for Newborn to COVID
1. Based on: No evidence of virus in cord blood
Fetus was exposed to cord blood
Limited evidence of vertical transmission
2. Support breastfeeding*
3. Support skin to skin
* https://www.cps.ca/en/documents/position/breastfeeding-when-mothers-have-suspected-or-proven-covid-19
Mother to wear mask
SUPPPORT DELAYED CORD CLAMPING

51. Postpartum Thromboprophylaxis:
Recommend:
1. OB indications for VTE prophylaxis
2. If no OB indications:
a. mild COVID disease – not required
b. moderate & severe disease- recommend as shown to decrease morbidity & mortality

52. Covid 19 & pregnant woman
Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
1
2
3
4
5
7
8
Termination
6

53. Facts
• Vaccination is effective in preventing COVID-19 mortality
• COVID-19 vaccines do NOT contain live coronavirus
• Other non-live vaccines (whooping cough, influenza) are safe for pregnant
women and their unborn babies.

54. Is there any evidence of safety?
• No studies on Covid 19 vaccine in pregnant women till now
• large trials which showed that these vaccines are safe and effective did not
include pregnant women
• Data from the United States, England and Scotland of more than 200,000
pregnant women vaccinated showed no adverse effects recorded.

55. However,
• no studies yet on the long term effects on babies born to women who
had a COVID-19 vaccine
• Extremely rare but serious side effects involving thrombosis (blood clots) have
been reported for the AstraZeneca vaccine

56. • About two-thirds of women who test positive for COVID-19 in pregnancy have no
symptoms at all
• One in 10 women admitted to hospital with COVID-19 require intensive care.

57. Effect of vaccination
• since 1 February 2021, 99% of pregnant women admitted to hospital with
symptomatic COVID-19 were unvaccinated.
• (Source: https://www.medrxiv.org/content/10.1101/2021.07.22.21261000v1).

58. Delta variant
• One dose of COVID-19 vaccination gives good protection against infection, but
with the most recent (Delta) variant of the virus, two doses are needed to give a
good level of immunity.

59. Breastfeeding and vaccination
• There is no known risk associated with giving non-live vaccines whilst
breastfeeding
• The woman should be informed about the absence of safety data for the
vaccine in breastfeeding women
•Studies are now suggesting the development of passive immunity in the neonate
following maternal COVID-19 infection, with documentation of the presence of SARS-
CoV-2 antibodies in cord blood and breast milk
(https://pubmed.ncbi.nlm.nih.gov/33512440)

60. No vaccine is 100% effective
• practise social distancing
• wear a face mask as necessary
• wash your hands carefully and frequently

61. Nutrition
• There is data that implicates malnutrition as a prognostic factor in
Covid 19 severity.
• Obesity is one end of the malnutrition spectrum and obese patients
frequently are micronutrient depleted.
• supplements such as vitamin C or D, zinc, or melatonin might help in
the fight against COVID-19
• Evidence is lacking? Research is needed.

62. • vitamins are important in maintaining the normal
health of pregnant women.
Fat-soluble vitamins act as immunomodulators
which help minimize the inflammation-induced
damage
yet appropriate dosage and usefulness in COVID-19
are yet to be decided.

63. Can u recommend one?

64. Covid 19 & pregnant woman
Admission
Investigations
anticoagulants
Corticosteroids
Vaccination
Recommendations
Introduction
1
2
3
4
5
7
8
Termination
6

65. Take home Message
Very limited information
- Male fertility can be affected
- Infertility management should continue
- All pregnant women should have the vaccine
- Vitamin supplements are important

66. Useful resources
Green Book COVID-19 chapter 14a https://www.gov.uk/government/publications/covid-19-the-green-book-
chapter-14a
RCOG – COVID-19 information for pregnancy and women’s health https://www.rcog.org.uk/en/guidelines-
research-services/coronavirus-covid-19-pregnancy-and-womens-health/
PHA COVID-19 Vaccination training resources https://www.publichealth.hscni.net/covid-19-
coronavirus/northern-ireland-covid-19-vaccination-programme
https://www.gov.uk/guidance/vaccination-in-pregnancy-vip PHE tracks women who have been immunised
with COVID -19 vaccine who did not know they were pregnant at the time of vaccination. Please
complete the notification and reporting form for all cases
• Coronavirus Yellow Card reporting scheme coronavirusyellowcard.mhra.gov.uk/ or call 0800 731 6789
• https://www.gov.uk/government/news/jcvi-issues-new-advice-on-covid-19-vaccination-for-pregnant-
women