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Covid-19 Characteristics, Susceptibility and Outcomes during Pregnancy
Sultan Kheir, medicine studies, Georgia.

Abstract
Since pregnant women experience alterations in their bodies, they might be highly affected by COVID-19. Therefore it is of great importance that they take precautions to stay safe. Susceptibility in pregnant women is much higher than others and this is anticipated due to certain anatomic and physiologic adaptations. According to studies, the major clinical manifestations in infected women range between low-grade fever, cough, diarrhea, myalgia, and sore throat. Besides, studies indicated that previous corona viruses caused higher rates of severe symptoms, morbidity, and mortality in pregnant women compared to COVID-19. Fortunately, COVID-19 congenital infection (vertical transmission) turned out to be infrequent and usually asymptomatic. For the safety of women, a high degree of hygiene, awareness, disinfection, and quarantine protocols shall be implemented, especially in case of breastfeeding. And according to the latest studies, there is no proof of COVID-19 in the breastmilk of infected mothers, yet COVID-19 may be transmitted via droplets and direct contact. Therefore, physiologically, pregnant woman shall be monitored, protected and safe; and psychologically, they shall be encouraged to interact with family and friends in order to avoid loneliness, tackle their concerns and ultimately have a positive pregnancy experience and a long psycho-social wellbeing.

Introduction
The World Health Organization has declared COVID-19 as a global pandemic on March 11, 2020. (Qiancheng et al., 2020). The said pandemic has been designated as a major public health crisis that is affecting health, movement and well-being of people worldwide and impacting the global economy as well (Tandan et al., 2021). The whole world came together to combat this pandemic and respond to this global outbreak. The outpouring of global support and solidarity was extraordinary and scientists around the world competed in order to develop treatments and vaccines. Yet, several questions are raised on the efficiency of the vaccines and its availability.

During this situation, a specific group requires special care, namely, pregnant women. Therefore the aim of this essay is to shed light on pregnant women who concern each and every one of us, to provide guidance to them, show them the solidarity spirit and help them out through a number of recommendations, since pregnant women experience alterations in their bodies and immune systems, so they might be highly affected by respiratory infections. For a pregnant mom, it is an extraordinary experience to feel a new life growing inside her body, despite the fact that she may not always be at her best along the way, knowing that infections during pregnancy can harm the mother and the baby. Thankfully, both the pregnant woman and her family can improve the chances that the fetus have a safe and healthy delivery by adopting a few extra measures and precautions and taking only healthy choices. Likewise, every member of the society bears an equal responsibility, so we shall all have collective consciousness in order to implement suitable measures. The said measures are decisive in controlling this new infection and protecting pregnant women.

Acknowledgment of COVID-19 and its consequences on pregnancy grows day by day. The indirect effects of the pandemic on mothers-to-be could be fundamental. Social distancing and preventive measures have modified the way of giving care to pregnant women, namely, expansion of telehealth usage, decreased in-person appointments, and restriction of number of support people during peri-partum stage (Atmuri et al., 2021). Thus, due to the experience gained from previous pathogen outbreaks, medical staff and health care providers now do have a deeper knowledge on preserving the wellbeing of pregnant women during infections.

During the H1N1 influenza pandemic for example in 2009, pregnancy resulted in an elevated risk of severe pneumonia, assisted ventilation, and sometimes death when compared to non-pregnancy cases. Yet, according to several studies, during the current pandemic outbreak, pregnant women are likely to have less harmful events to the mother and the newborn than the ones caused by SARS and MERS (Qiancheng et al., 2020).

Pregnancy is a stage of massive challenge in terms of maternal immunity. Physiological changes happen for the sake of adjusting to this new thing “the fetus,” meanwhile, preserving the ability to combat viruses and infections. Pregnancy immunological adaptations happen to be convenient for the growth of the fetus throughout the gestation. Meaning, there is a transformation from the implantation and placentation stage (pro-inflammatory), to an anti-inflammatory state in the second trimester (the growth of the fetus) and finally to the third trimester (being ready for delivery) (Malinowski et al., 2020).

In addition to the said immune alterations, physiologic pregnancy changes impact different organ systems, particularly the respiratory tract due to elevated amounts of estrogen and progesterone and modified amounts of other steroids, not to mention the restriction in the expansion of the lungs, increasing the risk of respiratory diseases infection in pregnant women and consequently, serious disease course (Malinowski et al., 2020). Thus, it is very important to include pregnant people in observations, evaluations and clinical trials and therapies in order to guarantee their health and safety.

During the early stages of the pandemic, pregnant women experienced mysterious risks linked to COVID-19 infection. Now, the infection during pregnancy causes a range of asymptomatic to serious maternal illnesses. Novel data indicate that in some cases, infected pregnant women are more likely susceptible to hospitalization, admission to intensive care unit, assisted ventilation, and sometimes preterm birth (Lokken et al., 2021). Pregnant women are very susceptible to COVID-19 due to the emerging immune adaptations and respiratory conditions, leading to mild compilations accordingly, and thus requiring familial and medical support.

Susceptible Condition of Pregnant Women
To protect ourselves and ultimately, all pregnant women out there, we have to be aware of the transmission of the pathogen and the relevant protective measures. The main cause for COVID-19 transmission is respiratory spit or exposure to others bare-faced, knowing that it is still not confirmed if this virus passes through the digestive tract. One novel study indicated that the COVID-19 average incubation duration is 3 to 24 days and that confirmed infected people were the major origin of infection (Malinowski et al., 2020). So, knowing the virus is super contagious, it is necessary to observe the infection during early stages for the purpose of controlling the virus in pregnant women. It is a top priority that we be aware of women's symptoms and reflect on their surrounding environment.

Certain measures are necessary to avoid nosocomial infections and keep patients safe. Nosocomial infections postpone the recovery of patients, and contribute to spreading infection. A new survey has showed that the medical staff are responsible for some 30 percent to 50 percent of nosocomial cases (Liu et al., 2021). Therefore, we must firmly manage every aspect of maternal care to decrease the rate of nosocomial infection and pave the way for patients’ recovery.

Besides, susceptibility in pregnant women is much higher and this is anticipated due to certain anatomic and physiologic adaptations, namely, increase in oxygen demand as a result of a 15 % rise in metabolic average, 20 % more oxygen consuming, as well as limited lung expansion especially in late pregnancy due to the diaphragmatic elevation (Malinowski et al., 2020). We conclude that pregnant women are more vulnerable to respiratory pathogens and therefore more likely to have clinical complications, knowing that their body is now being shared with a new creature.

According to the majority of studies, it has been obvious that the major clinical manifestations in infected women range between low-grade fever, cough, diarrhea, myalgia, and sore throat. Some symptoms happen to be severe sequela after delivery. During these studies, women were strictly monitored, with regular observation of major signs, such as oxygen levels, temperature, and gastrointestinal signs. Moreover, women were asked to track any changes in bowel movements and in fetal movements, and to monitor vaginal bleeding and respiratory symptoms: dyspnea. Each change in the health condition of women shall be immediately reported to the medical staff (Liu et al., 2021). We can hence conclude that pregnant women often share the same symptoms with non-pregnant ones.

On the other hand, quick deterioration in respiratory system would be examined in pregnant women who advance to serious illness. What is even more challenging, the need of major interventions, such as airway management and ventilation (Malinowski et al., 2020). Therefore, it is obligatory to observe the fetal heart, drug efficiency and side effects and supply women with oxygen when needed in order to prevent any risky consequences.

Pregnant women’s susceptibility to viral infections would be triggered as well by the unique immunologic condition. Therefore, the body during pregnancy is witnessing a shift from the dominant T-helper 1 (Th1) system (where there are pro-inflammatory cytokines), all the way to Th2 system (where there are anti-inflammatory cytokines) (Malinowski et al., 2020). Therefore, this shift that takes place in order to protect the fetus, causes maternal susceptibility to a serious infection that is more controlled in the Th1 system.

Pregnancy Implications during COVID-19, SARS and MERS
Reports issued by the Centers for Disease Control and Prevention indicated that some 26,364 pregnant women were diagnosed with Cov-2 in the United States in the period extending between January 22 and October 13, 2020. 72 % thereof were 25 to 44 years old, ranging between 27 % hospitalized, 4 % entered the Intensive Care Unit, while 2 % required assisted ventilation. As for mortality, 45 cases (0.17 %) were reported. Moreover, recent data about 2,567 pregnancies with COVID-19, have shown that 7 % required ICU admission and 3.4 % required intubation (Malinowski et al., 2020). We can conclude from the results of the mentioned study that the implications of COVID-19 during pregnancy are mainly mild and do not require hospitalization or intensive care.

According to other studies, 60 % of pregnant women entered the ICU with Severe Acute Respiratory Syndrome (SARS) and 64 % with Middle East Respiratory Syndrome (MERS); while the percentage for COVID-19 was only 4. Likewise with the fatality rate, during SARS was 15 % and MERS 27 %, but now with COVID-19 it stands at 0.1%. The said divergence in pregnancy cases between SARS, MERS and COVID-19, is attributed to respective cytokine profiles. At the time that SARS and MERS activate the Th1 immune system, it has been obvious that COVID-19 activate both Th1 and Th2, causing IL-4 and IL-10 propagation (Malinowski et al., 2020). Therefore, we can conclude that unlike previous corona viruses that caused high morbidity and mortality rates, the course of most pregnant women who have been infected with COVID-19 recently was mild if compared to the other people.

Thus, COVID-19 in pregnant women has proved to be serious in 13 %, where 3 % used assisted ventilation and 0.4 % needed extra oxygenation. The most common relevant symptoms are fever and cough, severe disease factors were limited to pregnant women over 39 years, who already suffer from hypertension, diabetes and pre-eclampsia. The inflammation caused by COVID-19 has been attributed to fluctuating levels of cytokine, the most serious is called cytokine-storm and known with high plasma levels of interleukins (IL-2, IL-7, IL-10) (Malinowski et al., 2020). Thus, we can notice that the age also plays a role in the severity of the pathogen in pregnant women.

Possibility of Vertical Transmission
Vertical transmission, the passage of the pathogen from the mother to her neonate, raises lots of concerns, in the latest outbreak. For the sake of addressing this major topic, a number of specific studies were carried out, testing amniotic fluid, throat swab, and cord blood and other samples upon delivery to investigate the possibility of intrauterine vertical infection (Chen et al., 2020).

The fetus may be directly affected by viral infection due to vertical transmission or indirectly through infection of the placenta. Indeed, the placenta makes a biological and immunologic border between the mother and her unborn baby, protecting the fetus from viruses and infections, and simultaneously simplifying the transfer of food and waste (Anteby et al., 2021). We can therefore notice that the biological protective barrier between the mother and her baby is much stronger than the virus, preventing any fetal infection in this regard.

There are several innate immune mechanisms that keep the fetus protected and safe. Indeed, immune cells are 30% of total cells present in the decidua, and a huge number thereof are classified as natural killer cells. Syncytiotrophoblasts, that create the outer surface of the chorionic villi and directly linked to the maternal blood, produces microRNAs, cytokines and antimicrobial molecules that limit infections. Large amounts of IFN-λ, the type III interferon, secreted by syncytiotrophoblasts is a major feature of the placental defense. Further experimental studies are required to explain if the placenta facilitates COVID-19 replication (Moore & Suthar, 2021). Thus, the placental defense has a major role in stopping the vertical transmission and preventing fetal infection.

The presence of COVID-19 in the human placenta has been detected via several laboratory techniques, example: PCR, immunohistochemistry, positive strand and transmission electron microscopy. Mainly, these procedures have been taken in the chorionic villi’s syncytiotrophoblast layer. Many studies were carried out on the placenta susceptibility for COVID-19, through examining expression of major cellular machinery for COVID-19, citing viral data on single cell RNA sequencing. In COVID-19 cases, human angiotensin-converting enzyme 2 (ACE2) is classified as the cellular entry’s canonical receptor. Besides, TMPRSS2 and ACE2 antigens are recognized in the layers of cytotrophoblast and syncytiotrophoblast of the chorionic villi through immunohistochemistry. If compared to other virus receptors that commonly infected the placenta, case in point cytomegalovirus (CMV) and Zika virus (ZIKV), reported expression of TMPRSS2 and ACE2 is basically lower (Moore & Suthar, 2021). Despite all the aforementioned details, further studies are required to solve the complication of placental inflammation rate and its connection to gestational age and infection severity.

Several debates were conducted on congenital transmission in case of COVID-19. Interestingly, according to a new revision of 49 studies that covered 666 neonates, only 3 % of babies born naturally and 5 % born by C-section were positive for COVID-19. As a conclusion, the congenital infection is infrequent and usually asymptomatic and be it vaginally or C-section delivery, maintenance of breastfeeding, or direct contact between the mother and the neonate, the incidence of infection is so similar (Malinowski et al., 2020). Therefore, we can see that COVID-19 can have some bright sides despite all its darkness, where it can be rarely transmitted vertically.

Notably, for further clarification, several studies were carried out at the operating rooms of Zhongnan Hospital in China, following caesarean sections, where all gathered samples were protected away from any contamination. The relevant results indicated that the COVID-19 test marked negative in all of the mentioned samples, indicating that no vertical transmission has taken place due to the COVID-19 infection at the pregnancy late stages. It is worth mentioning that previous studies on SARS infection have already shown that there is no vertical transmission among babies who were born to infected mothers during the SARS infection (Chen et al., 2020). Hence, we can notice that according to the aforementioned studies, respiratory pathogens do not cause fetal infection and this might soothe all infected mothers out there.

All women covered by the said study were in the third trimester. So the impact of the virus on the fetus in the first two trimesters is yet to be explained and clarified. Second, the suggestion that vaginal delivery shall raise the risk of intrapartum transmission shall be further discussed. Third, the infection risk during pregnancy and the impacts of the delivery time or process were not estimated. Fourth, it is important to further examine the impact of COVID-19 on the placenta, if it might damage it and this has a direct connection to vertical transmission (Chen et al., 2020). Therefore, we do need further investigations on these topics and additional studies on COVID-19 infection during pregnancy for the sake of ascertaining the wellbeing and safety of mothers and neonates.

Prenatal Recommendations
As we can see, this virus is new and additional relevant studies are required. Yet, we cannot ignore the fact that technology has paved the way for rapid researches that do compress timeframes in order to provide findings in shorter periods of time. So, in accordance with the latest researches, the COVID-19 symptoms during pregnancy were diverse, mainly fever and cough and interestingly, no proof for vertical transmission was reported (Chen et al., 2020). These findings and results are highly important for understanding the clinical features of this disease and the potential of its vertical transmission.

Knowing that not all infected pregnant women had fever or other symptoms, it is so important to preserve a high level of hygiene, awareness, disinfection, and quarantine protocols to protect women (Liu et al., 2021). Thus, in order to avoid virus transmission, it is very important to isolate pregnant women who have COVID-19 infection, whether confirmed or suspected.

During hospitalization, suspected or confirmed infected pregnancy cases shall be put in single rooms. Surgical masks shall be used by the woman and her family members as they shall be aware of cough etiquette. Infected women's urine, feces, and vomit shall be subject to certain rules. Furthermore, main attention shall be given to the respiratory condition of infected women, including cough frequency, dyspnea signs and sputum characteristics. (Liu et al., 2021) Therefore, it is of high importance that symptoms be monitored by both the medical staff and the woman herself in order to avoid any complications and failures.

Similarly, obstetricians, nurses, and midwives shall persuade mothers to do deep breathing, assist them to turn, and make frequent chest percussion sessions to unbend lung congestion and raise the ability to clear spit. Women with serious disease shall receive suctioning and oral expectorants, when necessary, given that medical staff shall use high-level protection (Liu et al., 2021). Therefore, it is not a matter of choice, it is a matter of life, awareness and responsibility and every one of us shall fulfill their duties towards all the vulnerable categories in the society during this wave in order to maintain their health and wellbeing, and ultimately, ours as well.

Regarding the psychological health of pregnant women, a COVID-19 study carried out in Italy, based on stress and anxiety-related evaluations in pregnant women, said that more than half of the number of women have self-rated the psychological effect of the disease as harsh and two thirds more worried than normal. New studies from different countries such as China, Italy, and North America, have proved the said results and indicated that, compared to the pre-pandemic stage, pregnant women are enduring remarkably high rates of depression and stress disorders. The psychological impacts are highly impacting pregnant women with health problems, social vulnerabilities, and those who belong to minority groups (Atmuri et al., 2021). We can therefore notice that there is limited awareness and acknowledgment of the conditions and demands of pregnant women during the current COVID-19 wave due to the novelty of the pandemic.

Furthermore, pregnant women are not only impacted by pregnancy, rather by environmental effects that may impact their situations during the COVID-19 pandemic, case in point: physical interaction restrictions. The said influences may impact how women behave and act towards the challenges or accustom to situations (Atmuri et al., 2021). We can thus conclude that pregnant women’s behavior may shape their self-perception of health and wellbeing and their surroundings.

As part of the solution, some people support a “trauma-informed approach” to maternal care amidst this Covid-19 wave, in order to encourage with the supporting medical staff, while maintaining a shared-decision making strategy and addressing the pregnancy journey. Healthcare organizations shall evaluate the mental health condition of their pregnant women in order to provide the suitable care. New methods are being created, such as COVID-ASSESS that integrate already existing mental health equipment (Atmuri et al., 2021). Therefore, luckily, we can anticipate that these efforts may help maternity care providers guarantee modifications to the provision of health care while preserving a positive pregnancy experience for all mothers out there.

Postnatal Complications and Management
Studies and guidance to the present date advise that pregnant women shall be quarantined for 14 days, whether suspected or infected. It is of high importance to provide effective support, since postpartum physiological breast engorgement may potentially raise the anxiety levels for women. This shall give data on the correct way of latching the baby to start breastfeeding and to determine possible sequelae, along with delaying breastfeeding. Mothers who choose to breastfeed after being treated should know how to preserve lactation by hand or pumps (Liu et al., 2021). Therefore, medical staff, whether obstetricians, nurses or midwives need to monitor postpartum complications, provide care and keep the mother’s skin dry in order to provide a safe postnatal journey to both, the mommy and the baby.

Breastmilk is the ideal nutrition for infants. And according to the latest studies, there is no proof of COVID-19 in the breastmilk of infected mothers, yet COVID-19 may be transmitted via droplets and direct contact. Thus, mothers who are using breast milk banks shall strictly implement hygiene and use medical masks when collecting milk. This milk shall be sterilized via high-pressure sterilization, ultraviolet disinfection, etc.. Finally, breast milk shall be sealed and put in the freezer after sterilization (Liu et al., 2021). So despite the pandemic, breastfeeding is still possible under certain instructions.

As for the woman's temperature, respiration rate, and uterine involution, they shall be regularly monitored as well. Any signs of acute respiratory distress or acidosis must be immediately communicated. Alongside COVID-19 psychological stress, pregnant women are subject to anxiety and worry of the risk of infection to their babies. This could be linked to postpartum depression symptoms (Liu et al., 2021). Therefore, it is recommended that women's psychological health be observed during the postpartum stage.

Besides, moms shall be given information on COVID-19 updates, including recent progress and treatments, breastfeeding, isolation protocols, and quarantine procedures. This could encourage them to collaborate with the staff and overcome psychological stress caused by the protective gear; then spread positive vibes, i.e. discuss the delivery experience and updates on her neonate, to help her comprehend the whole process and treatment of the virus, get rid of fear, and boost confidence (Liu et al., 2021). Therefore, we conclude that communication with mothers shall be promoted to encourage them to interact with family and friends in order to avoid loneliness, help them reach psychological counseling herself and her family, do more indoor activities, eat more and have enough sleep.

Women shall be reminded of the necessity for ongoing quarantine and treatment following their discharge and shall be informed how to access mental health support. As for self-quarantine, women shall stay indoors, and their families also. They must use a mask when leaving the house, wash their hands often, and leave windows open for 30 minutes two times a day at least for the sake of ventilation. Family members must head to the nearest hospital right away after they develop any of COVID-19 symptoms, such as fatigue, fever, and a dry cough (Liu et al., 2021). Hence, women needs for support to fulfill a positive experience during their pregnancy, delivery and post-partum. And especially during COVID-19, supportive people are considered a major protective factor against anxiety.

Due to this pandemic, some women were obliged to choose between the spouse and the doula, who complements family support. Some women favored home birth because it is a source of additional assistant during the period of pandemic. It is worth noting that support provided by in-house accredited doulas may relieve women’s anxiety (Atmuri et al., 2021). All in all, the findings herein may guide health care providers and give them some information on the social and emotional perspectives of pregnant women and their reaction to such pandemics in order for them to help women have a positive and safe pregnancy and delivery experience.

Disruption to childcare worsens psychological ordeal; new mothers during this pandemic have been reported to be at a higher risk for having clinically-relevant fear and stress. Women do need the support from their surroundings and their own mothers in order to maintain confidence, re-assurance and parenting abilities (Atmuri et al., 2021). Therefore, supportive groups and programs can provide group spirit, reduce fear, isolation, and sadness and elevate maternal positive vibes, emotions, and calmness.

Discussion
In normal circumstances, pregnancy is known to be a time of joyous anticipation and excitement for the mother, the father and their families. However, due to this emerging virus (COVID-19), many concerns were raised. COVID-19 is new, and thus no herd immunity has yet been developed, so everyone is susceptible to infection and therefore, we must be responsible. And according to the results of the studies mentioned herein, we can notice that age is a key concept in severe pregnancy conditions, so our responsibility should multiply with older groups in particular.

As for the implications of the pathogen on pregnant women, they appeared to be mild, compared to previous SARS viruses. This fact helps us reassure pregnant women and support them psychologically in case of infection and ultimately relieve their anxiety, because in fact, recognizing the experience of people in general is a hard mission. It needs an understanding of people’s perception of a specific situation, their reaction during that situation and the impact of environmental and external influences. How come if this is the case with pregnant women, who are already experiencing hormonal changes.

On a brighter note, as shown in this essay and citing several trustworthy articles and studies, vertical transmission is infrequent in COVID-19, and this should further alleviate all pregnant women out there, yet they shall continue to follow the recommendations of the medical staff and the isolation protocols in order to stay safe and overcome the physical and psychological pressure.

Finally, knowing that pregnant women have a high susceptibility to COVID-19 due to their new immune adaptations and respiratory conditions, we shall all support them and be aware of this critical period. Awareness may help maternity care providers in particular preserve a positive pregnancy experience for mothers while implementing the required changes to health care. Moreover, addressing mother’s perspectives in official health debates may enhance connections between maternity staff and pregnant women. The COVID-19 infection has shaped women’s pregnancy due to external community influences and hospital-level laws. However, pregnant women are still pro-active and self-regulating. So, as the world grapples with the COVID-19 pandemic, the aforementioned recommendations shall be implemented by organizations to provide mother-centered care, to help women out there tackle their concerns and ultimately have a positive attitude on their pregnancy journey and boost long-run psycho-social health and wellbeing.