In this webinar, Dr Anna Galindo Trias, Medical Director at Gravida International Center of Assisted Human Reproduction of Barcelona, explains COVID-19 and pregnancy topics.
Dr Anna Galindo, Medical Director at Gravida Barcelona, begins the session by explaining COVID-19 stands for coronavirus disease 2019, and it’s an acute respiratory syndrome, but the cause of this syndrome is a beta-type of coronavirus which is called SARS-CoV-2. Dr clarifies this type of coronavirus has been known for a long time. This family of viruses has the shape of a round capsular with little spikes that look like a corona. When this pandemic started, professionals looked back and tried to learn from other epidemics of similar viruses to learn about and face this new sickness.
These previous episodes were caused by another coronavirus that creates a mild respiratory syndrome. According to Dr Galindo, SARS-2002 is the virus that is more similar to the current COVID-19. It’s an RNA virus. RNA viruses are simple in structure, they have RNA in the middle, and they have proteins surrounding them. The RNA guides their behaviour. Dr Galindo explains that viruses are not complete. They are natural parasites, and they can’t reproduce by themselves, they need a cell to reproduce. In this case, these viruses require cells specifically from the respiratory tract to do their aim, which is reproducing as many copies of them as they can. Their main behaviour is looking for these cells that are friendlier in surface for them, and they invade these cells using all cell’s infrastructure to reproduce and make copies of themselves, and then, go out and invade another cell.
The two previously mentioned epidemics that professionals knew about are pretty small compared with the COVID-19 pandemic, so there are not any cases to learn about. Firstly, SARS-2002 was in China and affected around 8,000 patients and in the case of the Middle East Respiratory Syndrome 2012 (MERS-2012), there were around 2000 patients affected. At that moment, SARS-CoV-2 was getting close to 2 million patients affected around the world, which is big a scenario compared with the previous scenarios.
As mentioned before, the virus discussed has a special affinity for a receptor called AC2, which is primarily located in the respiratory tract but can also be found in some intestinal cells. This receptor allows the virus to potentially cause symptoms in the intestines, although it is mainly a respiratory virus. There is currently no evidence of the virus being present in urine samples or vaginal swabs. The virus seems to have very specific targets, mostly respiratory cells and, to a lesser extent, intestinal cells.
Initially, the virus was zoonotic, meaning it was transmitted from animals to humans, and many mammals can have coronavirus infections. However, it is now primarily human-to-human transmission. The virus spreads through droplets produced by infected individuals when coughing, sneezing, or talking. Direct contact with contaminated surfaces can also spread the disease, although this is less common.
These little spots themselves are fragile, and while they can survive on surfaces for a few days, they do not last indefinitely. In the air, outside of droplets, the virus does not remain viable for long.
Currently, the World Health Organization has officially declared a pandemic, with nearly two million people affected.
The primary symptoms of the illness are fever, cough, and shortness of breath. In more moderate cases, fatigue, body aches, headaches, and sometimes diarrhoea can occur. However, these intestinal symptoms are less common. The illness mostly affects the respiratory tract, and medical findings typically show pneumonia, either unilateral or bilateral. On imaging, small white spots are visible, indicating the infection. Blood markers also tend to be altered.
When comparing this virus to the flu (influenza), there are similarities but also significant differences. The flu hits the body quickly and has a short duration, whereas the SARS-CoV-2 virus is more complex. Initially, it infects cells and causes a peak in viral replication, but in some patients, the virus is eventually controlled. However, in other specific cases, after the virus begins to decrease, the immune system overreacts, causing a cytokine storm. This storm occurs when the immune system aggressively tries to fight the virus, causing potential damage to the body. These immune bursts are particularly concerning in patients who don’t recover quickly after the initial infection. The body’s immune response can become overwhelming, making recovery difficult for some individuals. This is a significant concern for patients who do not fare well early in their illness.
In terms of symptom frequency, cough, fever, fatigue, and shortness of breath are the most common symptoms of COVID-19. Compared to influenza, shortness of breath is rarer, and with a typical cold, symptoms like a runny nose or sneezing are more common.
The population reacts differently to the virus. Around 30% of the population contracts the virus but experiences little to no symptoms. These individuals often develop immunity and may not even realize they were infected. This group includes most children, who typically serve as vectors, spreading the virus without showing severe symptoms.
According to Dr Anna, for 55% of the population, the symptoms are mild to moderate. Pregnant women are particularly important to categorize correctly, as mild symptoms may not require medical intervention, but moderate symptoms can be concerning. These patients tend to remain contagious for a longer period and experience symptoms for about four to seven days. During this time, the virus replicates rapidly and invades cells, but their immune systems respond well, preventing a cytokine storm. These individuals recover gradually, stop being contagious, and develop immunity.
However, 15% of the population experiences more severe symptoms. These patients initially show symptoms caused by the virus, but later, their immune system overreacts, triggering a burst of immunity that can worsen their condition. This overreaction, known as a cytokine storm, causes the immune system to attack not only the virus but also the patient’s own cells. These patients are classified as severe or critical cases.
Pregnant women present unique challenges as they are two patients in one: the woman and the developing baby. Care must be taken for both. Pregnancy is a special time in a woman’s life, and the status of both the mother and the baby must be closely monitored. 
One concern is that the average age of pregnant women is typically younger, and younger individuals are generally at lower risk for severe symptoms. Pregnancy also alters a woman’s immune system, making it less rigid, as the body has to accommodate the growing fetus. Dr Galindo affirms this altered immunity could potentially help or hinder the mother’s response to the virus, but the impact is not yet fully understood.
Anatomical changes also occur during pregnancy, particularly in the third trimester. The rapid growth of the belly pushes the uterus and intestines higher up in the abdomen, which can crowd the diaphragm and reduce lung capacity. If a pregnant woman contracts the virus, these anatomical changes may exacerbate respiratory difficulties, making symptoms worse. Therefore, the third trimester is of particular concern when managing pregnant patients, due to these physical changes.
Overall, current data does not suggest that pregnant women are at a higher risk of contracting the virus than the general population, and the percentage of pregnant women affected by COVID-19 mirrors that of the broader population.
A key concern is whether pregnant women are at higher risk of more severe disease. Based on current evidence, Anna says it does not appear that pregnant women are more likely to experience severe symptoms, except for those in the third trimester, where anatomical changes may exacerbate the effects of the virus. These changes, particularly in lung capacity, could contribute to more pronounced symptoms like shortness of breath or coughing. However, the anatomical changes themselves do not directly cause the severity of the disease.
Another topic of concern is vertical transmission, which refers to the transmission of the virus from the mother to the baby before birth. It is difficult to confirm whether vertical transmission of SARS-CoV-2 occurs. Based on data from China suggests that while there are a few cases of newborns born to COVID-19-positive mothers, no signs of the virus have been found in these babies. Nevertheless, in some rare instances, babies tested positive for IgM antibodies against the virus, which is a sign of an immune response. IgM antibodies cannot cross the placenta, so the presence of these antibodies in the babies suggests that they may have been exposed to the virus while in utero. However, PCR tests, which detect the virus directly, were negative in these babies, suggesting that the virus was not transmitted directly. This evidence is still inconclusive, and most reported cases do not indicate vertical transmission.
Regarding the possibility of the virus being transmitted through breast milk, no virus particles have been detected in the milk of mothers infected with COVID-19. However, there is insufficient evidence to confirm whether breast milk could be a route of transmission, as the data is still limited.
Pregnant women are considered a higher-risk group due to the unique challenges of caring for both the mother and the developing baby. It is crucial to manage both patients effectively, especially when the mother contracts the virus.
Pregnancy is divided into 3 trimesters, and each carries its own set of risks. In the first trimester, which spans from weeks 1 to 12, the development of the baby and the formation of the placenta are critical. This stage is particularly sensitive, as the placenta is essential for providing nutrients and oxygen to the baby. Miscarriages and birth defects are concerns during this period, as some viruses can lead to malformations, although there is no conclusive evidence yet for COVID-19. According to Dr Anna, previous data from MERS, a virus similar to SARS-CoV-2, showed a higher miscarriage rate in pregnant women during the first trimester. In comparison, SARS, which is more similar to COVID-19, had a slightly higher miscarriage rate, but it was not as significant as in MERS.
When comparing both viruses, MERS had a higher mortality rate (around 35%), while SARS, which circulated in 2002, had lower mortality rates and is more comparable to COVID-19 in terms of severity. Based on this comparison, current concerns are more aligned with SARS than MERS. Data on COVID-19 during pregnancy is still being gathered. In the clinic where Dr Anna Galindo works, patients who became pregnant after December are being closely monitored, but international data is still limited.
More research is needed to determine whether miscarriage is a significant issue for pregnant women infected with COVID-19. Based on subjective impressions, the miscarriage rate does not seem to be substantially higher, though this observation is not supported by robust data. Additionally, birth defects have not been reported yet. In summary, while pregnancy presents unique challenges, current data does not strongly suggest that COVID-19 significantly increases the risk of miscarriage or birth defects. However, further studies are necessary to provide definitive answers.
The second trimester of pregnancy spans from 13 to 27 weeks. During this stage, the organs of the baby undergo their final stages of development, including neurological maturation, the beginning of hearing and sight, the production of blood cells by the bone marrow, and the growth of hair. This is a critical period in the baby’s development, and the primary concerns during this stage include structural and functional malformations, major birth defects, late miscarriage, or preterm delivery.
In terms of COVID-19, evidence regarding the second trimester is limited, as it is a relatively new area of study. There is no significant data to suggest a higher risk of congenital malformations, but it is important to note that there could be a higher risk of preterm birth. This could be due to the infection itself or, in severe cases, due to medical intervention when labour is induced to protect both the mother and the baby independently.
The third trimester, from 28 to 40 weeks, is the final stage of fetal development, where the lungs complete their development and the baby undergoes final neurological maturation. The baby grows significantly during this trimester and compresses the thorax, which can put pressure on the mother’s respiratory system. Concerns in the third trimester include premature membrane rupture, preterm delivery, intrauterine growth restriction, and other obstetric complications.
As for vertical transmission—transmission of the virus from the mother to the fetus—the evidence remains inconclusive. While the virus could theoretically be transmitted in utero, reports are suggesting that antibodies against the virus produced by the mother might protect the baby. These antibodies, specifically IgG, can cross the placenta and provide some defence. However, vertical transmission has not been demonstrated conclusively. Similarly, transmission during labour is also not yet confirmed, and vaginal swabs in infected women have been negative for the virus. This indicates that while the virus prefers AC2, these receptors in the respiratory and intestinal tracts, it does not target the reproductive tract as much, offering some protection in this area.
In cases of intrauterine growth restriction, the cause is likely related to the impaired respiratory status of the mother, as oxygenation may be compromised, rather than direct viral infection of the fetus.
Severe maternal infections, particularly those involving the lungs, may necessitate cesarean sections, as labour could be too taxing on a compromised respiratory system. A study from The Lancet reported that samples from newborns born to COVID-positive mothers, including amniotic fluid, blood, neonatal throat swabs, and breast milk, all tested negative for the virus.
Treatment for pregnant women infected with COVID-19 depends on the severity of the disease. For mild cases, treatment generally includes rest, hydration, and medication such as paracetamol to control fever. These patients can remain at home with strict preventive measures to protect other family members. However, patients with underlying comorbidities such as high blood pressure, diabetes, pregestational diabetes, other heart conditions or chronic lung disease may need to be hospitalized for closer monitoring and treatment.
Moderate cases may involve the use of antiviral drugs like hydroxychloroquine to limit the virus’s replication, as well as prophylactic heparin to prevent blood clots together with obstetric follow-ups.
Severe cases may require intensive care, mechanical ventilation, and additional medications like interferon to manage the immune response and prevent further damage to the lungs. In certain cases, where the pregnancy is in the third trimester and the mother’s condition is stable, it may be deemed safer to deliver the baby early to protect both the mother and the baby.
Regarding breastfeeding, current evidence suggests that the virus has not been found in breast milk. However, the close contact involved in breastfeeding may pose a risk of transmission through respiratory droplets. If breastfeeding is considered, strict hygiene measures should be followed, including the use of masks, hand washing, and sanitizing surfaces. If the mother is PCR-negative, breastfeeding can proceed normally, but if the mother is still infected, having another family member feed the baby may be a safer option.
In conclusion, prevention remains the best strategy. Pregnant women are considered a vulnerable population, so they should avoid unnecessary exposure to others, maintain a healthy diet, stay hydrated, exercise indoors, and avoid smoking, alcohol, and drugs. It is crucial to stay home and minimize interactions with potentially contagious individuals.
The evidence regarding COVID-19’s impact on pregnancy is still evolving, and more data is needed to make definitive recommendations. For now, if symptoms appear, it is important to remain calm, contact a healthcare provider, and follow their instructions.
Pregnant women should take extra care, especially fertility patients, those with comorbidities or advanced age. Vertical transmission appears highly unlikely, and breastfeeding seems safe when appropriate precautions are followed. The status of the mother and the potential risks to both mother and baby should always be carefully considered.
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We don’t have any data as we stopped treatments as soon as we knew that this infection spread all over the world. What I’m going to tell you is my guess. I guess that this virus has a very concrete target, which is the receptors that are located in the respiratory tract or intestinal tract, so my guess is that this virus might not affect the embryo implantation directly by being there. On the other hand, if a woman is infected, if the system of a woman is in an ongoing infection, of course, it’s going to be less receptive for this implantation. This is another thing, it is the general status of a woman that may impact the implantation, but I doubt this is going a be directly the virus.
I think and it’s my impression, it’s not something based on facts, it’s just a feeling again, I think that probably COVID won’t have receptors to attach to the egg because comet these little spikes that it has are very picky when they get attached to the membrane of one cell and they are dedicated to the respiratory tract and the intestinal tract, so I doubt that the egg will have these specific receptors for COVID. As far as we don’t know, all the clinics probably from now on, we are going to make sure that our donors are not in active infection when they donate the eggs. When we start treatments again. What this means, is testing these donors for immunity and doing PCR, which is the direct tests of these donors to make sure that they are not infected during stimulation or pickup. Probably it’s going to be different sampling at different stages of the donation to make sure that these donors are healthy at the moment of the process. That they donate healthy eggs. I don’t know about the eggs that are stored already, but I can tell you these are probably all the resources that are going to be put in the future protocols.
If you are right now in our clinics we take very special care of separating patients who are not infected from patients that are confirmed as infected. And also in the delivery rooms, that are not infected, clean delivery rooms, we perform a really thorough clean up after every delivery in case a patient didn’t know she had the virus so it would not spread. It doesn’t stay on the surfaces because we clean all the surfaces and these are the protocols that are taken in all the hospitals to ensure the safety of the patients.
If you don’t meet these terms you have been reported as positive these special precautions are just being with your baby nothing else. If you are positive for COVID then you deliver in a special delivery room, and we take special measures to protect the baby too. It could get to this horizontal transmission, not the vertical inside of the uterus, but the horizontal which is transmitted through droplets or surfaces. So cleaning your hands very very often for patients who are positive, wearing a special mask. And very specifically not touching the surfaces and everything that contacts the baby is the best way to go.
The baby is another vulnerable individual in society. Nowadays I would say for the moment to stay at home with your baby and protect your baby. The baby while it is breastfed is getting antibodies also from the mother and is being protected. But I would put all the general isolation measurements until this baby is at least six months old or a little older. But this is just an opinion. Right now, babies have to stay at home and should not have contact with friends or family.
Medications that are used in pregnant women are medication that is considered safe considering risk and benefit. This means that are medications that don’t have evidence of malformations so we can use them in pregnant women. They are accepted, of course, they are not the A classification. The medications are classified from A to X, considering the risk on the baby. A is the safest medication X is the forbidden one during pregnancy. Usually, they are B or C class medication, so these medications are considered beneficial compared with the risk. Just give it to the mother. That’s why they are not used in mild or cases.
We don’t really know when we are going to start because we are waiting for the government and society’s recommendations. We are facing a plateau and a little drop in the number of cases so we are happy about it. We are looking forward to these recommendations, hopefully, it will be either late May or June. But this is a hope, it’s nothing official. And what are we going to do, probably, we are going to start building testing protocols for patients and practitioners, for cleaning staff. It is important to know which patients that the patient is safe. When it comes to the patient who comes to the clinic, we want to know the status of the workers. Which one has been infected and already cured. Which one has not been infected and is at risk but not infected, or which one can’t work because it’s in an infective phase of the sickness. As to the workers, we are going to recommend them to stay home if they are infective and the other ones we will take strict measures or less strict depending on their status. For patients, it is going to be the same probably. If the patient is one of the thirty percent of the population that already had the COVID infection and is already cured, theoretically, it would be safe to go through treatment if PCR is negative.
IgG, which is the marker for pure is positive and IgM for the SARS is negative if the patient is susceptible to get the infection. That would be the thing just informing the patient and probably recommending specific preventive measures. For these patients it would be the way to go and also if they are infected at this time, we would recommend not to start and wait.
Well, that’s a tricky question yeah. We’re building our protocols. Probably the key point is going to be how often we will test the susceptible population of patients and staff. Because the already immune staff or patient are individuals we do not need to worry about. The susceptible ones are the ones who are going to be really the key point. In terms of staff, we have still to figure it out. In terms of patients, we have more or less figured it out testing them right when they start testing for the final test for treatment when they start treatment and right before going for pickup and right before the transfer if it’s the aim of treatment in cryo transfers or IVF treatment. When it comes to donors, it is going to be done a little bit more often to make sure that the donors are healthy. We are working on our protocols. That’s what we are working on right now to ensure safety for patients, for donors and also for the staff.
Well, we know that rhinoviruses, in general, are pretty unstable individuals. Such little spots when they copy themselves they make mistakes pretty often so these give these viruses a lot of variability in the copies. Every X copies they have a little variable. An example of this is influenza, which is the flu virus and the cause of the flu. Every year we have to build new vaccines because of these little variations. Mainly it is the same virus, but these little variations make people sick, so probably COVID or SARS is going to act similarly. We know that there are little variations detected in different areas of Europe. In the SARS’ main variations somebody that has been in contact with one of the cousins of this virus can react better, that’s my opinion. What we also know in general, is that this minimum variation you have been in contact with, the cousin, the next generation of the virus probably is going to affect you less severely, but this has to be confirmed. We need to know more about this virus, but probably this virus is going to have little mutations that are going to make us make vaccines and change the vaccines once in a while to be updated to these little changes.
