COVID Impacts

Recently, new evidence about the lower urinary tract (LUT) as a potential target for SARS-CoV-2 infection has emerged, as urothelial cells have enhanced expression of angiotensin-converting enzyme 2 (ACE2) receptor, which is the binding site of SARS-CoV-2 to human cells. A hyperactivated renin-angiotensin system (RAS) can lead to an activation of proinflammatory pathways and increased cytokine release in COVID-19 patients.

It's been hypothesized that an increment in inflammatory cytokines are released in the urine and/or expressed in the bladder, which are responsible for the presence of associated bladder dysfunction. Consequently, the urinary and male genital system are an important target for SARS-CoV-2 infection.

Multiple studies have indicated that the testicular pain, erectile dysfunction, hypogonadism, reduced sperm count and quality, and decreased fertility associated with SARS-CoV-2 infection are a direct consequence of infection of cells of the male reproductive tract and not indirect mechanisms such as fever and inflammation.

Currently, studies analyzing the impact of SARS-CoV-2 infection on the menstrual cycle are scarce. A recent study indicated that 20% of SARS-CoV-2-positive women showed a decrease in menstrual volume, 9% showed an increase in menstrual volume, and 75% showed no change in menstrual volume. Another study reported that about 16% of women experienced menstrual disturbances following SARS-CoV-2 infection.

Pregnant people with severe COVID-19 also may be more likely to develop other health problems as a result of COVID-19. They include heart damage, blood clots and kidney damage. Moderate to severe symptoms from COVID-19 have also been linked to higher rates of preterm birth, high blood pressure or preeclampsia.

Pregnant women who have COVID-19 and show symptoms are more likely than nonpregnant women with COVID-19 and symptoms to need care in an intensive care unit (ICU), to need a ventilator (for breathing support), or to die from the illness. They are also more likely to have a c-section birth, preeclampsia or eclampsia, and blood clots.

There was an increase in maternal death rates attributed to COVID-19 as compared to pre-pandemic death rates. In addition, there was an increased requirement for intensive care treatment, including extracorporeal membrane oxygenation (ECMO), in severe acute respiratory syndrome coronavirus (SARS-CoV-2) infected mothers.

Fetal Complications

Infections in early pregnancy do not lead to an increased risk of miscarriage. However, COVID-19 infection during the third trimester of pregnancy increases the risk of pre-term birth as well as stillbirth. There is also evidence that the infection can be transmitted to the fetus.

Recent studies have shown that fetal demise is typically due to SARS-CoV-2 binding to the angiotensin-converting enzyme 2 (ACE2) receptors of the trophoblastic cells of the placenta, causing intervillositis and perivillous fibrin deposition, which causes a severe hypoxic environment for the fetus, resulting in death. The most common mechanism of fetal death appears to be severe hypoxia resulting from placental infection and not direct SARS-CoV-2 viral infection of the fetus.

Neonatal Complications

Newborns exposed to SARS-CoV-2 in-utero are at risk for both direct and indirect adverse health outcomes. Perinatal transmission of SARS-CoV-2 appears to be uncommon,  but accumulating evidence indicates that some neonates who are born to mothers with SARS-CoV-2 test positive for the virus after birth. Systematic reviews of case series of mothers with SARS-CoV-2 reported a neonatal test result positivity rate of 3.1% to 9.1%, however these were small studies and it can be difficult to make generalizations.. Larger multihospital cohorts from New York City included up to 149 mothers with SARS-CoV-2 and reported a test result positivity rate of less than 1% in neonates. Overall, considerable uncertainty remains about the true incidence of neonatal test result positivity.

Fetuses who survive intrauterine chronic fetal hypoxia or acute fetal hypoxia have an increased risk of detrimental effects that may manifest in the pediatric or adult time period. Neonates born to mothers with symptomatic COVID-19 also showed an increased incidence of neurological abnormalities.