Pregnant with COVID-19 and Rubella: Impact in the Maternal and Newborn Health

  

    
Parameter
    
Stantard Value
    
Day
  
  

    
05-08-2020
    
05-13-2020
  
  

    
Bilirubin(mg/dL)
    
< 0,8
    
-
    
125
  
  

    
Phenylalanine (mg/dL)
    
< 2,2
    
-
    
08
  
  

    
Neonatal hemoglobinplasty
    
Normal
    
-
    
Normal
  
  

    
TSH (mcU/mL)
    
< 15
    
-
    
141
  
  

    
17 alpha hydroxyprogesterone

      (ng/mL)
    
< 15
    
-
    
13
  
  

    
Trypsin (mg/mL)
    
< 90
    
-
    
152
  
  

    
T4 (mcg/dL)
    
6-22,1
    
-
    
69
  
  

    
Biotinidase
    
Normal
    
-
    
Normal
  
  

    
G6PD deficiency (U/g Hb)
    
> 2,4
    
-
    
45
  
  

    
SARS-CoV-2 nucleicacids
    
No Detected
    
No Detected
    
-
  
  

    
Amino acid chromatography
    
Normal
    
-
    
Normal
  
  

    
Galactose (mg/dL)
    
< 9,0
    
-
    
12
  
  

    
Anti-HIVantibodies
    
NR
    
NR
    
-
  
  

    
IgM Toxoplasmosis
    
NR
    
-
    
NR
  
  

    
IgG COVID-19
    
NR
    
Reactive
    
-
  
  

    
IgM COVID-19
    
NR
    
NR
    
-
  
  

    
Syphilis test
    
-
    
-
    
-
  
  

    
IgG Rubella
    
NR
    
Reactive
    
-
  
  

    
IgM Rubella
    
NR
    
NR
    
-
  

Table 1B: Laboratory data of the newborn.

This pregnant woman is not a healthcare professional, nonalcoholic and non-smoking. She does not have diabetes, upper respiratory tract disease, autoimmune disease and high blood pressure. She used polyvitamins and did not use anticoagulant. After COVID-19 diagnostic, she did not use any medication, such as chloroquine or hydroxychloroquine. According to the anthropometric measurements she may be categorized as eutrophic (weight 63 kg/height 167 cm). At term, she gave birth by vaginal delivery. The newborn did not present clinical alterations, except jaundice.

Discussion

With the world widespread of COVID-19, concerns have been raised on the impact of pandemics on pregnant women and motherfetal vertical intrauterine transmission [2,3]. It should be noted that the physiologic and immunologic changes that occur as a normal component of pregnancy may have systemic effects which may increase the risk for complications of respiratory infections [4]. Limited data is available about COVID-19 during pregnancy [5], however information about the disease should be reported in order to understand the impact on pregnant women and newborns.

Coronaviruses are single-stranded RNA, nonsegmented, enveloped viruses, that measure about 50–200 nm in diameter, which cause illness ranging in severity from the common cold to severe and fatal illness. The virus viewed by electron microscopy display a crown-like fringe typically referred to as spikes. The new coronavirus SARS-CoV-2 is transmitted through respiratory droplets, physical contact, and aerosols [3,4].

The rapid diagnosis of COVID-19 is an important strategy for preventing the spread of viruses. RT-qPCR is widely deployed in diagnostic virology and represents the gold standard method for confirmation of COVID-19 [1,6]. The RT-qPCR test performed on the mother’s nasopharyngeal swab during pregnancy was positive for new coronavirus. In relation to clinical manifestations, the common symptoms of these pregnant women at the onset of COVID-19 were fever and cough, and the less common symptoms were diarrhea and shortness of breath. Laboratory tests showed that absolute lymphocyte counts were reduced, C-reactive protein, erythrocyte sedimentation rate and D-dimer were increased, and leucocytes were normal in most of the seven pregnant patients. It is reported that SARS-CoV-2 may cause a decrease in peripheral white blood cell and lymphocyte counts in the early stages of the disease [7], however some patients did not showed laboratorial alterations. Comorbidities such as diabetes, obesity and high blood pressure have been identified as a risk factor in the pathogenesis of COVID-19 [8]. The pregnant woman in this study did not present hyperglycemia, did not report hypertension and is not obese.

The RT-qPCR test performed on the neonatal´s nasopharyngeal swab was negative in the first hours of life, suggesting no vertical transmission of coronavirus. Along with molecular RT-qPCR testing, IgM and IgG screening are relevant and figure out as alternative diagnostic methods [9]. In this report, virus-specific antibodies (IgG) were detected in neonatal serum, suggesting transplacental transmission of coronavirus antibodies, ensuring immediate immunity to newborn, once questions are being raised on the length of COVID-19 immunity. IgG is passively transferred across the placenta, beginning at the end of the second trimester [9]. Anti-coronavirus IgM was not detected, what is expected once IgM is not transferrable between mother and fetus due to its large macromolecular structure [9]. Data from a case reports published earlier in this year described SARS-CoV-2 infected women with no laboratory evidence of vertical mother-fetal intrauterine transmission [4,5,10,11]. According to these reports, some newborn were symptomatic but throat swab testing of all retrieved negative results for SARS-CoV-2, suggesting that these neonatal complications could not be related to intrauterine transmission.

Rubella is a mild viral disease that typically occurs in childhood. Rubella infection during pregnancy causes congenital rubella syndrome, including the classic triad of ocular and cardiac abnormalities and sensorineural deafness. Highly effective vaccines have been developed since 1969, and vaccination campaigns have been established in many countries, including Brazil. Although there has been progress, the prevention and diagnosis of rubella remain problematic [12]. The consequences of rubella infection in the first 20 weeks of pregnancy, and the relationship between gestational week of exposure and likelihood of fetal loss or features of congenital rubella syndrome have been related [13]. The rubella virus belongs to the Togaviridae family and is an enveloped, positive single-stranded RNA virus, with a 9.8-kb nucleotide length.

Humans are the only known reservoir of infection, and the rubella virus is transmitted through direct inter-human contact through the aerosol route. After being inhaled, the virus replicates in the respiratory mucosa and cervical lymph nodes, before reaching the target organs via systemic circulation. The infectious period extends approximately 8 days before to 8 days after the rash onset. Viremia is transient and is detected during the week before the rash. Rubella is less contagious than measles or influenza; because many rubella cases are asymptomatic, the true attack rate is uncertain [12]. In this case report, Anti-rubellaVirus IgG antibody was detected in the neonatal serum, indicating transplacental transmission of antibodies, ensuring immunity to neonatal. Anti-rubella Virus IgM antibody was not detected, indicating that there was not vertical transmission of virus.

In an epidemic situation, special care should be taken in pregnancy management and in making decisions on termination of pregnancy and handling of the neonate in order to minimize the risk of subsequent health consequences [14].

SARS-CoV-2 nucleic acid was not detected in the newborn nasopharyngeal swabs, which strongly suggest that there was not vertical transmission of virus. However, laboratory analysis revealed Anti-SARS-CoV-2 IgG antibody and Anti-rubella Virus IgG antibody in the newborn serum. This case reveals evidence of transplacental transmission of coronavirus and rubella antibodies, ensuring immunity against these pathogens to newborn.

Acknowledgement

The authors thank the pregnant woman for participating in this work.

Ethical Conduct of Research Statement

The case report was carried out through consultation and consent of the participant, according to a project approved by the Research Ethics Committee of UFJF, with number 4.057.992, CAAE 31527720.3.0000.5147.

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