Case Report
Severe Acute Respiratory Teaching Points
Syndrome Coronavirus 2
(SARS-CoV-2) Antibodies in
Neonatal Cord Blood After
Vaccination in Pregnancy
Lisa Gill, MD, MS,
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 10/29/2021
and Cresta W. Jones, MD
BACKGROUND: Studies evaluating the safety and effi-
cacy of currently available vaccines for severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) do
not include pregnant participants. No data are available
to counsel on vaccine safety and potential for neonatal
passive immunity.
CASE: A 34-year-old multigravid patient working in
health care received the Pfizer-BioNTech (BNT162b2)
mRNA vaccine for SARS-CoV-2 in the third trimester of
pregnancy. Uncomplicated spontaneous vaginal delivery
of a female neonate with Apgar scores of 9 and 9
occurred at term. The patient’s blood as well as neonatal
cord blood were evaluated for SARS-CoV-2–specific
antibodies. Both the patient and the neonate were pos-
itive for antibodies at a titer of 1:25,600.
CONCLUSION: In this case, passage of transplacental
antibodies for SARS-CoV-2 was shown after vaccination
in the third trimester of pregnancy.
(Obstet Gynecol 2021;137:894–6)
DOI: 10.1097/AOG.0000000000004367
N
ewly available vaccines for severe acute respira-
tory syndrome coronavirus 2 (SARS-CoV-2) are
of great interest to patients and health care profes-
sionals. Initial studies of the two currently available
From the Department of Obstetrics, Gynecology and Women’s Health, Division
of Maternal-Fetal Medicine, University of Minnesota, Minneapolis, Minnesota.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Published online ahead-of-print March 8, 2021.
Corresponding author: Lisa Gill, MD, MS, Department of Obstetrics, Gynecol-
ogy and Women’s Health, Division of Maternal-Fetal Medicine, University of
Minnesota, Minneapolis, MN; email: lgill@umn.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2021 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/21
894 VOL. 137, NO. 5, MAY 2021
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
1. Pregnant patients have been excluded from SARS-
CoV-2 vaccine trials, leading to uncertainty regarding
safety, efficacy, and potential for neonatal passive
immunity.
2. Vaccination in pregnancy produced a robust immune
response for the patient, with subsequent transpla-
cental transfer of neutralizing antibodies.
mRNA vaccines have shown them to be safe and
effective in nonpregnant adults.1,2 Importantly, preg-
nant and lactating individuals were excluded from
initial safety and efficacy trials, despite data demon-
strating higher risks of severe infection and
pregnancy-related morbidity and mortality.3 The
American College of Obstetricians and Gynecologists
and the Society for Maternal-Fetal Medicine released
a joint statement in January 2021 advocating that
pregnant individuals at high risk for contracting the
virus should be able to decide whether they will
receive the vaccination during pregnancy or while
breastfeeding.4
In addition to safety, the potential for transplacental
transfer of neutralizing maternal antibodies is also a
consideration. The neonatal period is marked by an
immature immune system, making it a vulnerable period
for infection. Maternal antibodies generated during
pregnancy are able to cross the placenta into the fetal
circulation, providing immune protection for the neo-
nate. This has been demonstrated previously in pregnant
patients receiving several other vaccines in pregnancy.4–7
In this case, we report on a pregnant individual
who received the Pfizer-BioNTech (BNT162b2)
mRNA vaccine for SARS-CoV-2 at 32 weeks of
gestation, with documented antibodies present in
neonatal cord blood.
CASE
We present the case of a 34-year-old multigravid patient
(G4P2012) who works as a nurse in a large health care
system. System guidance allowed for pregnant individuals
to opt in to receive a vaccine when it was available based
on the tier system established by the Centers for Disease
Control and Prevention. The patient’s pregnancy was com-
plicated by a history of fetal growth restriction in both prior
pregnancies and hemolysis, elevated liver enzymes, low
platelet count (HELLP) syndrome in one prior pregnancy.
Fetal growth was monitored by ultrasonography and was
normal throughout the pregnancy.
OBSTETRICS & GYNECOLOGY
 Vaccination became available when the patient was at
32 weeks of gestation. She received her first dose of the
BNT162b2 mRNA vaccine at 32 6/7 weeks of gestation and
her second dose at 35 2/7 weeks. She reported no adverse
effects from vaccine administration, with the exception of
soreness at the injection site.
The patient presented in spontaneous labor at 38 6/7
weeks of gestation. She underwent an unmedicated vaginal
delivery without complication. The newborn course was
also uncomplicated—the neonate had Apgar scores of 9
and 9 at 1 and 5 minutes, and weight was appropriate for
gestational age. Cord blood and maternal blood were ob-
tained and evaluated for the presence of antibodies to
SARS-CoV-2. Maternal blood was positive for immunoglob-
ulin G at a titer of 1:25,600. The cord blood was also
positive for SARS-CoV-2–specific immunoglobulin G at a
titer of 1:25,600.
In the course of her pregnancy, the patient was tested for
SARS-CoV-2 infection multiple times by polymerase chain
reaction nasal swab. The patient received testing when
experiencing any upper respiratory symptoms, occasional
asymptomatic surveillance testing, and testing on admis-
sion for delivery. She reported no known SARS-CoV-2
exposures. All test results were negative for the presence
of SARS-CoV-2 during her pregnancy. A prior antibody test
was performed as part of a system-wide effort to determine
the incidence of infections among health care profes-
sionals, and the results were negative. Table 1 reviews all
test results for the patient and the neonate.
DISCUSSION
To our knowledge, this is the first case report
documenting transplacental transfer of neutralizing
SARS-CoV-2 antibodies in the setting of maternal
mRNA vaccine administration (PubMed search con-
ducted on February 12, 2021, with the following
search terms: “SARS-CoV-2 vaccine in pregnancy”
or “COVID-19” or “SARS-CoV-2 vaccine in cord
Table 1. Evaluations for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection
Sample Source Timing of Test (wk of Gestation)
Maternal Prepregnancy
Maternal 4 3/7
Maternal 11 4/7
Maternal 17 2/7
Maternal 26 4/7
Maternal 27 2/7
Maternal 28 2/7
Maternal 38 6/7
Neonatal umbilical venous blood At birth
IgG, immunoglobulin G; PCR, polymerase chain reaction.
* Maternal vaccination occurred at 32 6/7 weeks of gestation (first dose) and 35 2/7 weeks of gestation (second dose).
VOL. 137, NO. 5, MAY 2021
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
blood”). No apparent complications were noted in
the patient or the neonate.
Antibody transfer after vaccination in pregnancy
ideally would confer protection for both the pregnant
patient and the neonate. Studies evaluating the neo-
natal immune response to maternal vaccine adminis-
tration have demonstrated neonatal protection from
transplacental antibody transfer for a number of
vaccines, including tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis (TDaP); influenza virus;
and respiratory syncytial virus.6–9 Our case supports
that this may also be true for the SARS-CoV-2 vac-
cine. Although it is possible that neonatal antibodies
were from undetected maternal infection with SARS-
CoV-2, this is unlikely given the frequency and high
sensitivity of polymerase chain reaction testing in this
case.
Transplacental passage of SARS-CoV-2 anti-
bodies after infection in pregnancy has been reported.
A recent study evaluating the vertical transmission of
SARS-CoV-2 as well as transplacental passage of
antibodies after infection in pregnancy showed low
rates of vertical transmission of the virus and also low
rates of transplacental antibody transfer. The authors
conclude that this low rate of antibody transfer may
leave neonates susceptible to infection.5 Our case sug-
gests that a more robust immune response may be
achieved after maternal vaccination than after natural
infection with SARS-CoV-2. A prospective trial is cur-
rently planned at our institution to compare neonatal
immune responses in populations of vaccinated preg-
nant people and pregnant people with SARS-CoV-2
infection.
Importantly, data surrounding vaccines are fre-
quently generated with the exclusion of pregnant
patients. Although pregnancy imparts many ethical
Test Result
SARS-CoV-2 IgG Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 RNA RT-PCR Negative
SARS-CoV-2 IgG Positive
Titer 1:25,600*
SARS-CoV-2 IgG Positive
Titer 1:25,600
Gill and Jones Neonatal SARS-CoV-2 Antibodies 895
dilemmas, the ability of pregnant patients to consent
to participate in a clinical trial is not one of them.
Recently, many experts have advocated for the
inclusion of pregnant patients in clinical research in
which the results may be useful in a pregnant
population.10–12 However, Smith et al13 found that
fewer than 2% of coronavirus disease 2019 (COV-
ID-19) clinical trials listed on international registries
included pregnant patients. Given this lack of data,
there is understandable confusion over whether preg-
nant people should be vaccinated. Additional evi-
dence related to transplacental antibody transfer, as
well as other risks and benefits of SARS-CoV-2 vac-
cination in pregnancy, will allow patients to make
informed choices regarding vaccination. Inclusion of
pregnant people in future clinical studies is critical.
REFERENCES
1. Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R,
et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine.
N Engl J Med 2021;384:403–16. doi: 10.1056/NEJMoa2035389
2. Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lock-
hart S, et al. Safety and efficacy of the BNT162b2 mRNA
Covid-19 vaccine. N Engl J Med 2020;338:2603–15. doi: 10.
1056/NEJMoa2034577
3. Ellington S, Strid P, Tong VT, Woodworth K, Galang RR,
Zambrano LD, et al. Characteristics of women of reproductive
age with laboratory-confirmed SARS-CoV-2 infection by preg-
nancy status - United States, January 22–June 7, 2020. MMWR
Morb Mortal Wkly Rep 2020;69:769–75. doi: 10.
15585/mmwr.mm6925a1
4. American College of Obstetricians and Gynecologists, Society
for Maternal-Fetal Medicine. ACOG and SMFM joint statement
on WHO recommendations regarding COVID-19 vaccines and
pregnant individuals. Accessed February 14, 2021. https://s3.am-
azonaws.com/cdn.smfm.org/media/2726/WHO_Response.pdf
5. Edlow AG, Li JZ, Collier AY, Atyeo C, James KE, Boatin AA,
et al. Assessment of maternal and neonatal SARS-CoV-2 viral load,
896 Gill and Jones Neonatal SARS-CoV-2 Antibodies
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
transplacental antibody transfer, and placental pathology in preg-
nancies during the COVID-19 pandemic. JAMA Netw Open
2020;3:e2030455. doi: 10.1001/jamanetworkopen.2020.30455
6. Quach THT, Mallis NA, Cordero JF. Influenza vaccine efficacy
and effectiveness in pregnant women: systematic review and
meta-analysis. Matern Child Health J 2019;24:229–40. doi:
10.1007/s10995-019-02844-y
7. Cunningham W, Geard N, Felding JE, Braat S, Madhi SA,
Nunes MC, et al. Optimal timing of influenza vaccine during
pregnancy: a systematic review and meta-analysis. Influenza
Other Respir Viruses 2019;13:439–52. doi: 10.1111/irv.12649
8. Munoz FM, Bond NH, Maccato M, Pinell P, Hammill HA,
Swamy GK, et al. Safety and immunogenicity of tetanus diph-
theria and acellular pertussis (Tdap) immunization during preg-
nancy in mothers and infants. JAMA 2014;311:1760–9. doi: 10.
1001/jama.2014.3633
9. Mahdi S, Polack FP, Piedra PA, Munoz FM, Trenholme AA,
Simoes EAF, et al. Respiratory syncytial virus vaccination dur-
ing pregnancy and effects in infants. N Engl J Med 2020;383:
426–39. doi: 10.1056/NEJMoa1908380
10. Spong CY, Bianchi DW. Improving public health requires
inclusion of underrepresented populations in research. JAMA
2018;319:337–8. doi: 10.1001/jama.2017.19138
11. Goldkind SF, Sahin L, Gallauresi B. Enrolling pregnant women
in research—lessons from the H1N1 influenza pandemic. N Engl
J Med 2010;362:2241–3. doi: 10.1056/NEJMp1003462
12. Macklin R. Enrolling pregnant women in biomedical research.
Lancet 2010;375:632–3. doi: 10.1016/s0140-6736(10)60257-7
13. Smith DD, Pippen JL, Adesomo AA, Rood KM, Landon MB,
Costantine MM. Exclusion of pregnant women from clinical
trials during the coronavirus disease 2019 pandemic: a review
of international registries. Am J Perinatol 2020;37:792–9. doi:
10.1055/s-0040-1712103
PEER REVIEW HISTORY
Received February 14, 2021. Received in revised form February 23,
2021. Accepted February 24, 2021. Peer reviews and author corre-
spondence are available at http://links.lww.com/AOG/C254.
OBSTETRICS & GYNECOLOGY