COVID-19 and Pregnancy
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19). Information about COVID-19 is constantly evolving and in this post I will attempt to summarize what we currently know about COVID-19 in pregnancy, delivery and postpartum. I have thrown in references/studies throughout the post. UpToDate “Coronavirus disease 2019 (COVID-19): Pregnancy issues” was used heavily for this post. I highly recommend checking out the website pregnancycovid19.com which is presented by physicians and researchers currently working on the front lines caring for obstetric patients who are fighting the virus. It contains up to date information as well as links to professional society websites/recommendations.
The question of whether someone should try to conceive during the COVID-19 pandemic is beyond the scope of this post. The answer is not black and white and there are a lot of individual and societal circumstances to consider. I encourage anyone pondering this to schedule a tele-health visit with their primary care, OB/GYN or fertility provider to discuss their situation in detail.
Recommendations for avoiding exposure to the virus are the same for pregnant and non-pregnant women, however, pregnant women should be particularly careful. These recommendations include staying home as much as possible, maintaining a distance of at least 6 feet from others when away from home, avoiding ill individuals, practicing diligent hand washing or use of hand sanitizer containing at least 60% alcohol when hand washing is not possible, respiratory hygiene (covering coughs and sneezes), avoiding touching the face (particularly eyes, nose and mouth), cleaning and disinfecting objects and surfaces that are frequently touched and wearing a cloth face covering when in public places where social distancing is difficult to achieve, especially in areas with substantial community transmission.
Symptoms of COVID-19 are similar in pregnant women to those of the non-pregnant population and include fever, fatigue, dry cough, decreased appetite, muscle aches and smell and/or taste changes. Less common symptoms include headache, sore throat, runny nose and gastrointestinal symptoms (nausea and diarrhea).
Disease Course in Pregnancy:
“Currently, it is unknown if the rate of COVID-19 infection is different in pregnant compared with nonpregnant women of similar age. It is also unclear if pregnant women are at increased risk for severe disease once infected compared with individuals of similar age. The patient group most commonly affected by severe disease includes older adults (>60 years), particularly with comorbidities, and most pregnant women are younger than middle age; however, they may have comorbid conditions that increase their risk”. From UpToDate: Coronavirus disease 2019 (COVID-19): Pregnancy issues. “Available data suggest that pregnancy and childbirth do not consistently worsen the clinical course, and most infected mothers recover without undergoing delivery”. Liu D, Li L, Wu X, et al. Pregnancy and Perinatal Outcomes of Women With Coronavirus Disease (COVID-19) Pneumonia: A Preliminary Analysis. AJR Am J Roentgenol 2020; :1. In pregnant women who develop COVID-19, early data show the same rate of ICU admissions as in the nonpregnant population and there have been no maternal deaths shown in reported case series.
Fever, which is common in COVID-19 infections, is a concern, especially in the first trimester as it may be associated with increased risk of congenital anomalies such as neural tube defects as well as miscarriage. However, use of acetaminophen has been shown to be safe in pregnancy and may help reduce the risk of fever exposure.
Infected women, especially those who develop pneumonia, may have increased frequency of preterm labor, premature rupture of membranes, preterm birth and preeclampsia. However, the data reflect very small numbers of women, most of whom were intubated with COVID-19 pneumonia.
Mullins E, Evans D, Viner RM, et al. Coronavirus in pregnancy and delivery: rapid review. Ultrasound Obstet Gynecol 2020.
Outcome of Coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy:. Am J Obstet Gynecol 2020.
Di Mascio D, Khalil A, Saccone G, et al. Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020.
Transmission of virus from mother to baby seems unlikely at this point. In a review of 38 women with COVID-19 infection, no cases of intrauterine transmission were documented.
Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med 2020.
Labor and Delivery:
Perhaps the most controversial issue regarding infection control for women in labor and delivery units is whether to allow a support person. Some institutions in both the United States and abroad (eg, Italy) do not allow any support person and instead promote support via video. Others recognize that a support person is important to many laboring women and permit one support person who must remain with the laboring woman (may not leave her room and then return). Pregnant women and their support person are encouraged to contact the facility where they will deliver to inquire about policies.
COVID-19 is not an indication to alter the route of delivery (vaginal vs c-section). Even if transmission from mother to baby was confirmed with additional data, this would not be an indication for c-section as it would increase maternal risk and be unlikely to improve neonatal outcome.
The Centers for Disease Control and Prevention (CDC) have advised hospitals to consider temporarily separating (eg, in separate rooms) the mother with confirmed or suspected COVID-19 from her baby until the mother is no longer under transmission precautions. Additionally, infants born to mothers with confirmed COVID-19 should be considered a “person under investigation” and appropriately isolated and evaluated.
It is unknown whether the virus can be transmitted through breast milk. The only report of testing found no virus in the maternal milk of six patients.
Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020; 395:809.
However, droplet transmission could occur through close contact during breastfeeding. A potential benefit of breast milk is that it may be a passive source of antibody protection for the infant. In mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19, to minimize direct contact, ideally, the infant is fed expressed breast milk by another caregiver until the mother has recovered or has been proven uninfected, provided that the other caregiver is healthy and follows hygiene precautions. In such cases, the mother should use strict handwashing before pumping and wear a mask during pumping. The pumping equipment should be thoroughly cleaned by a healthy person. If feeding by a healthy caregiver is not possible, mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19 should take precautions to prevent transmission to the infant during breastfeeding (including hand hygiene and use of a face mask). Women who choose not to breastfeed must take similar precautions to prevent transmission through close contact when feeding the infant formula.