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      Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature

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          Abstract

          Dear Editor, As of February, 2018 a total of 2143 cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) have been reported to the World Health Organization, including 750 deaths in 27 countries. 1 There were 10 reported cases of MERS-CoV in pregnancy.2, 3, 4, 5, 6, 7 Here, we present two cases form our hospital with MERS-CoV infections during pregnancy. Case 1 The first patient was a 29-year-old female (gravida 2, para 1) at 6 weeks gestation and with no underlying medical conditions. She was asymptomatic and identified as part of the contact tracing of her mother, a positive MERS-CoV patient. On examination, she was afebrile, breathing normally and Lungs were clear to auscultation. The abdomen was gravid, soft, non-tender, non-distended, and normal bowel sounds. Nasopharyngeal swab testing by RT-PCR for MERS-CoV showed a positive result for ORF (Ct value 32). She had two repeated nasopharyngeal swab testing by RT-PCR for MERS-CoV and these showed probable results (Ct value 36) and the 4th swab was negative by PCR for MERS-CoV. The patient did not deliver during hospitalization and she was discharged on 24th August 2015, and subsequently delivered a healthy infant at term. Case 2 The second patient was a 39-year-old female (gravida 6, para 5) with history of end stage renal disease (ESRD) and hypertension on hemodialysis. She used to have hemodialysis at Wadi Aldawasir hospital during an active MERS-CoV outbreak there. She presented at 24 weeks of gestation after a contact with a positive MERS-CoV patient. Nasopharyngeal swab testing by RT-PCR was positive for MERS-CoV with E gene (Ct value 34) and OFR (Ct value 34). She was admitted to a regular ward. Subsequently, she had negative RT-PCR for MERS-CoV and she was discharged home. Respiratory samples (Nasopharyngeal swabs or tracheal aspirates) were tested for MERS-CoV using real-time reverse-transcription polymerase chain reaction (RT-PCR) as described previously. The clinical presentation of MERS-CoV is variable and ranges from a mild disease or asymptomatic presentation to a more severe and fatal cases. There are sparse data on the effect and the likelihood of MERS-CoV during pregnancy.2, 3, 4, 5, 6, 7 We searched the MEDLINE database for articles published in English literature from January 2012 to July 2016. The references in the retrieved articles were further searched for any additional references. A summary of previous reports and the current two additional cases of pregnancy associated MERS-CoV is presented in Table 1 . Of all the cases, the mean age ± SD was 33.7 ± 4.3 years and the gestation age was 26.3 ± 9 weeks, and there were four (36%) primi-gravida. The source of infection was not identified in 3 cases; contact with family members who had MERS-CoV was elucidated in two cases; four patients had health-care associated infection, two of them were healthcare workers. Six (54%) patients required ICU admission and three (27%) patients died during the hospital stay. Two of the deceased had an exposure during the third trimester and one acquired the infection during the second trimester. The infant death rate was 27%. The outcome was favorable in the majority of pregnancy-associated MERS-CoV cases. The exact prevalence of MERS-CoV antibodies and exposure of pregnant women to MERS-CoV is not known. All the reported cases were symptomatic. Among the 11 pregnancy-associated MERS-CoV infection, the case fatality rate was not statistically different when compared to the overall case fatality rate of 35%, P = 0.75. Regarding the infants, three (27%) infants had died. Table 1 A summary of pregnancy associated MERS-CoV infection. Table 1 Age Nationality Gravida (G), Para (P) Source of infection Gestational age at illness onset (weeks) ICU admission Maternal comorbid conditions Maternal outcome Fetal outcome Delivery details Reference Patient 1 (PMAH) 29 Saudi G2, P1 Household contact 6 NO None Survived Survived Delivery at term Current report Patient 2 (PMAH) 39 Saudi G6, P5 Contact with MERS-CoV case in HD 24 NO ESRD on hemodialysis, HTN Survived Survived Delivery at term Current report Patient 3 34 Saudi G7, P6 Unknown 34 YES Preeclampsia Survived Died Intrauterine Fetal death at 34 weeks 3 Patient 4 32 Saudi G2, P1 Unknown 38 YES None Died Survived Vaginal delivery at 38 weeks 3 Patient 5 31 Saudi Primigravida HCW, occupational exposure 24 YES Asthma, pulmonary fibrosis Died Died Caesarean section at 24 weeks 3 Patient 6 27 Saudi Primigravida Unknown 22 YES None Survived Survived Full term delivery 3 Patient 7 30 Saudi Primigravida HCW, occupational exposure 23 YES None Survived Survived Full term delivery 3 Patient 8 39 Jordanian G7, P6 Household contact 20 NO None Survived Still birth Still birth at 5 months 6 Patient 9 32 United Arab Emirates G3, P2 Visited camel barn 32 YES None Died Survived Caesarean section at 32 weeks 5 Patient 10 39 South Korean G2, P1 Contact with MERS-CoV Patient in hospital 35 weeks and 4 days NO Gestational Diabetes Survived Survived Caesarean section at 39 weeks 2, 7 Patient 11 33 Saudi Primigravida Contact with MERS-CoV Patient 31 Yes Hypothyroidism and primary infertility Survived Survived Caesarean section at 32 weeks 4 The overall case fatality rate remains high and is comparable to the overall case fatality rates. The disease had also resulted in fetal demise in 27% of cases.

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          Stillbirth During Infection With Middle East Respiratory Syndrome Coronavirus

          Abstract We conducted an epidemiologic investigation among survivors of an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Jordan. A second-trimester stillbirth occurred during the course of an acute respiratory illness that was attributed to MERS-CoV on the basis of exposure history and positive results of MERS-CoV serologic testing. This is the first occurrence of stillbirth during an infection with MERS-CoV and may have bearing upon the surveillance and management of pregnant women in settings of unexplained respiratory illness potentially due to MERS-CoV. Future prospective investigations of MERS-CoV should ascertain pregnancy status and obtain further pregnancy-related data, including biological specimens for confirmatory testing.
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            Middle East Respiratory Syndrome Coronavirus Infection During Pregnancy: A Report of 5 Cases From Saudi Arabia

            Abstract Little is known about the effects of Middle East respiratory syndrome coronavirus (MERS-CoV) during pregnancy. In Saudi Arabia, 5 cases of MERS-CoV infection among pregnant women were reviewed, and all cases resulted in adverse outcomes. MERS-CoV infection during pregnancy may be associated with maternal and perinatal disease and death.
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              Is Open Access

              Impact of Middle East Respiratory Syndrome coronavirus (MERS‐CoV) on pregnancy and perinatal outcome

              Background Middle East Respiratory Syndrome coronavirus (MERS-CoV) is a viral respiratory disease. Most people infected with MERS-CoV develop severe acute respiratory illness. It was first reported in Saudi Arabia in 2012 and has since spread to several other countries. We report the clinical course of MERS-CoV infection in a pregnant woman who acquired the infection during the last trimester. Case presentation The patient is a 33-year-old female working as a critical care nurse. She was 32 weeks pregnant when she presented with respiratory symptoms after direct contact with a MERS-COV patient. Although the patient was in respiratory failure, necessitated mechanical ventilation, and intensive care (ICU) admission, a healthy infant was delivered. The mother recovered. To the best of our knowledge, this is the first reported case of a laboratory-confirmed Middle East Respiratory Syndrome Coronavirus in a pregnant woman. Conclusions Middle East Respiratory Syndrome coronavirus (MERS-CoV) known to cause severe acute respiratory illness associated with a high risk of mortality Various factors may have contributed to the successful outcome of this patient such as young age, presentation during the last stages of pregnancy, and possible differences in immune response.
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                Author and article information

                Contributors
                Journal
                J Microbiol Immunol Infect
                J Microbiol Immunol Infect
                Journal of Microbiology, Immunology, and Infection
                Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.
                1684-1182
                1995-9133
                2 June 2018
                June 2019
                2 June 2018
                : 52
                : 3
                : 501-503
                Affiliations
                University of British Columbia, Vancouver, Canada
                Corona Center, Infectious Diseases Division, Department of Pediatric, Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministry of Health, Riyadh, Saudi Arabia
                Indiana University School of Medicine, Indianapolis, IN, USA
                Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
                College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
                Infectious Diseases Division, Department of Medicine, Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministry of Health, Riyadh, Saudi Arabia
                Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
                Author notes
                []Corresponding author. P.O. Box 54146, Riyadh 11514, Saudi Arabia. zmemish@ 123456yahoo.com
                Article
                S1684-1182(18)30152-X
                10.1016/j.jmii.2018.04.005
                7128238
                29907538
                © 2018 Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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                saudi arabia, mers-cov, pregnancy

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