COVID-19 and Pregnancy

 (This article is based on the latest data concerning COVID-19 and pregnancy. This information is amenable to change in case new data emerge)

Since its beginning in Wuhan China in December 2019, more than 14 million people were inflicted with COVID-19, with more than half a million deaths worldwide. It occupied the headlines of all medical and non-medical journals and was a hot topic on every tongue. It was capable of infecting everyone without any discrimination, however some individuals were more negatively impacted by the virus as they were considered to be part of a “vulnerable population”, such as people with existing medical conditions, lung disease and advanced age. But what about pregnancy? Are pregnant women at a higher risk for infection or disease progression? And should they seek more preventive measures?

The name COVID-19 was designated by the World Health Organization (WHO) in February 2019, and it represents the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) which is the causative agent of the pandemic. The main mode of transmission is human to human through close-range contact, mainly via respiratory droplets (when coughing, talking, sneezing). Other reported modes of transmission include hand-mouth, hand nose and hand-eye transmission, after contact with contaminated surfaces. 

In this article, I will only be focusing on the Pregnancy related issues in the era of COVID-19.

 

Symptoms

The most commonly reported symptoms for COVID-19 infection are fever, cough, dyspnea (difficulty breathing), sore throat, fatigue, muscles and joint pains, chills, headache, runny nose, chest pain and possibly nausea/vomiting. These can also be experienced by pregnant ladies, so stay on the lookout for such new symptoms during pregnancy.
The disease has been classified based on the severity of its symptoms in both pregnant and non-pregnant individuals. This severity depends on the overall status of the patient, the presence or absence of lower respiratory symptoms (difficulty breathing, chest pain ...) and the need for mechanical ventilation. 

 

Prevention

You all know by now that masks, social distancing and proper hand hygiene are the most effective protective methods against the virus, as (till now) we do not have any effective marketed vaccine for this virus. A face mask is recommended as per the CDC because of the proven possibility of viral spread by COVID positive people before the emergence of symptoms. Pregnant women are advised to follow the same preventive recommendations as non-pregnant individuals. 
A special population of pregnant women are those who have kids, as the latter can harbor the virus and be totally asymptomatic yet infective. That’s why the CDC recommends that children should not have playdates with children from other households, they should remain more than 2 meters away from strangers and they should wear masks whenever they are in public places. 
Pregnant ladies who work in occupations other than health care, can continue their jobs regularly while applying the same general preventive measures. 
As for pregnant ladies working in health care (pharmacies, hospitals, clinics…) they are advised to follow the recommendations and guidelines of their employers to minimize their risk of exposure (ie. Not to work in the COVID unit, not to be frontliners in dealing with COVID-19 suspected individuals...)

Pregnancy Complications 

Based on the data we have till today, pregnancy itself is not reported as a risk factor for acquiring the infection. Also, the clinical course of the disease was not shown to be worse during pregnancy as most infected women (more than 90%) will clear the infection and recover without undergoing delivery. 
On the other hand, few other reports state that pregnant women are more likely to be admitted to the intensive care unit and to require mechanical ventilation.
Pregnant women infected with the virus, who end up developing pneumonia (lung infection) were shown to be more likely to have a preterm delivery (before 37 weeks of gestation) and cesarean section. This trend was seen with most respiratory infections during pregnancy as fever and low oxygen saturation (due to respiratory compromise) are associated with many pregnancy complications such as preterm labor, preterm membrane rupture, fetal distress and cesarean delivery. 
You should know that maternal death from COVID-19 during pregnancy has been reported, however this death rate was comparable to non-pregnant individuals.

Concerning the rate of miscarriage (early pregnancy loss), it was not shown to be worsened by a COVID-19 infection, however this is based on a still limited number of cases, so this fact might change in the future as more data arise. 
Moreover, another concern is related to the effect of first trimester fever with congenital malformations (namely fetal neural defects) however again this association was not seen with early pregnancy infection based on the body of evidence we have till today.

 

Does it transmit to the baby!?

Keep in mind that the majority of studies did not point toward a potential intrauterine mother to baby transmission, nevertheless we cannot exclude it as a possibility with certainty, as few cases showed a potential vertical transmission when the infection was acquired in the third trimester of pregnancy. However, the neonatal outcome was favorable in these reports. 

 

Should you delay your pregnancy?

Based on the general data reporting that pregnant women are (mostly) not at an increased risk for major pregnancy complications, maternal deterioration, miscarriage or even death, delaying or terminating your pregnancy during the era of COVID-19 based on the above mentioned concerns is NOT advisable.

Prenatal care

According to the America College of Obstetricians and Gynecologists and other obstetrical guidelines, telehealth became a big part of prenatal care. The number of visits were minimized to include only the mandatory ones, and depending on the obstetric risk of each pregnancy, the number of clinic visits can be tailored accordingly. 
Also, nowadays there is a trend to limit visitors with the pregnant lady in order to avoid further exposure. The same limit is applied on the number of staff in contact with each pregnant lady. Moreover, the timing of visits have been reduced to minimize the exposure time for both, the future mother to be, and the clinician. 
The clinician and the patient should be wearing a face mask at all times during the visit, and to practice the recommended basic hygienic routines. 
Do not feel ashamed to talk about your mental health during your visits, as the psychological impact of COVID-19 should be recognized and managed accordingly.

Pregnant women who are exposed to confirmed or suspected individuals should practice self-isolation and be monitored for symptoms. Remember that the incubation period is up to 14 days! In case of any new symptoms, you are advised NOT to visit the hospital but to call your health care provider who would request from you to stay in quarantine or come to the hospital depending on the severity of your symptoms.

Timing of the delivery

The timing of delivery in non-infected women, infected women with no symptoms and those with non-severe illnesses should only be dependent on the obstetric indications. It is preferable of course to postpone the delivery (if possible) till after maternal clearance of infection to minimize the risk of postnatal transmission to the baby (after birth). This decision requires balancing the risks of continuing the pregnancy versus delivering a baby to a COVID positive mother.

If you have a scheduled delivery (vaginal or cesarean section) most hospitals (not all) will screen you for COVID-19 infection prior to your scheduled delivery date, but this may not be performed in all hospitals and for all women, so make sure to check on this option with your clinician during your prenatal visits.

In women with severe symptoms, the decision for early delivery should be individualized according to the severity of symptoms and the expectation of whether the delivery will improve maternal condition or not. In such instances, the decision should be taken only after a collaborative multidisciplinary approach between your obstetrician, infectious disease and critical care specialists. In some critical cases of COVID-19 the recommended delivery is after 32-34 weeks of gestation (early preterm period), for maternal benefit, and in such instances a cesarean section would be safer for both, the baby and the mother. However, remember that the decision is not easily taken and has no robust guidelines to be based upon, so this information can vary with every case.

Mode of delivery

Obviously, in non-infected individuals, a cesarean section is only performed as obstetrically indicated (you can check my article about the indications for cesarean sections https://onlinewomenhealth1.blogspot.com/2020/07/cesarean-section-imminent-fate.html)
In COVID-19 positive ladies, a cesarean section is also performed as obstetrically indicated, but adding to that, a respiratory deterioration because of COVID-19 critical condition becomes an indication for cesarean section, as the labor process might further worsen the maternal respiratory condition. Strangely enough, a cesarean section was shown to cause more maternal complications even in COVID-19 women, so try to always be the first and strongest advocates for a vaginal delivery!

Spinal and epidural anesthesia can be performed regardless of your COVID-19 status. Only critical patients who require urgent delivery will be put under general anesthesia for a cesarean section. But the majority of pregnant ladies will experience a smooth delivery with regional anesthesia.

If you are COVID-19 positive, expect to be hooked to the fetal monitor throughout your labor process.

What about delayed cord clamping and skin-to-skin? 

Some institutions forbid delayed cord clamping in COVID-19 positive women, but the data in that regard is still controversial.

As for skin-to-skin, most guidelines prohibit its practice in COVID-19 positive women in order to decrease the chance of neonatal transmission, however the American Academy of Pediatrics has not advised against it.
Concerning the Vernix (the white material present on the baby’s skin after delivery), it can be kept for at least 24 hours after birth (as it contains antimicrobial peptides) as per most guidelines, however here again, the American Academy of Pediatrics says otherwise and advises bathing newborns as soon as possible in order to wash away any potential viral particles present on the baby’s skin. So, as you can see the data are still controversial in many COVID-19 related topics.

 

Mother-baby contact after delivery

Temporary separation of the baby from the mother has been proposed as a preventive measure to decrease the risk of viral transmission, however the WHO still recommends that COVID-19 positive and suspected women should be able to remain together with their infants and practice skin-to-skin contact. 
As per the CDC, the indication to allow mother-baby contact is based on many factors including:

• Breastfeeding status (encouraged)
• Baby’s COVID-19 status
• The mother’s and infant’s clinical conditions
• The hospital’s ability to accommodate for the mother-baby separation

A mother with symptomatic COVID-19 infection should maintain a distance of at least 2 meters from her newborn, and should wear a face mask, and practice hand hygiene for baby’s care until:

• 3 days have passed since last fever

AND

• 10 days have passed since first symptom

If the mother is COVID-19 positive but has no symptoms, then she can practice regular contact with her newborn when at least 10 days have passed since her first positive COVID-19 PCR test.

Breastfeeding

The risk of COVID-19 transmission through breast milk is still unclear, but we know that the benefits of breastfeeding outweigh potential risks and thus it is still favored by all medical societies. Even in women who are put in contact isolation from their babies, breast-milk expression is advisable over formula, firstly for neonatal benefits, and secondly for maternal sake as milk expression is important to support establishment of the maternal milk supply. But before breastfeeding or breast-milk pumping, mothers are requested to wear a face mask and practice hand and breast hygiene measures (clean hands, breasts, milk pump, and bottles with soap and water).

Your duties

It is your duty as a patient to notify your physician and hospital about a positive COVID-19 test, or an exposure to an infected individual before coming to the hospital (even in the setting of emergency). The earlier the notification is, the more prepared the hospital can be to accommodate for your complaints in a safe manner.

Even if you are asymptomatic and have no contact with a suspected or confirmed individual, expect to be bombarded with questions so bear with the system. You might be asked the same set of questions by your physician, his/her assistant and the nurse, so be ready for your hospital visit during this pandemic, and remember that this protocol only aims for your and your community's safety. 

Furthermore, it is advisable that you only bring one companion with you, since any extra personnel will most probably be asked to wait outside of the delivery unit. And you will be asked (along with your companion) to wear a face mask at all times even if you have no symptoms. This rule might not be applicable to all hospitals and with all physicians, so again here, make sure to discuss this issue with your physician during your prenatal live or web-based clinic visits. 

Don’t forget that vaginal delivery is the preferred mode of delivery unless otherwise indicated. 
Always ask your physician about their hospital specific guidelines in terms of delayed cord clamping, skin to skin and mother-baby separation. 
Breastfeeding or breast-milk expression is always favored over formula (unless otherwise proven in future studies), and thus are advisable along the practice of basic hygiene and preventive measures.

What should you do to avoid the Coronavirus? (as per the American College Guidelines)

• Stay up to date with your prenatal clinic visits
• Limit your contact with other people as much as possible (social distancing)
• Wear a face mask while in public
• Practice frequent hygienic methods (soap and water for at least 20 seconds)
• Avoid touching your face
• Try to stay home as often as possible 

Also, I would recommend not to let COVID-19 pandemic limit you, as it is always advisable for you to have healthy practices such as exercising during pregnancy, eating a balanced diet, avoiding alcohol and smoking, and getting enough sleep.

COVID-19 is a pandemic, and will remain among us for a while, so the best way we can work around it is by practicing the basic preventive approaches and keeping ourselves up to date with the latest recommendations. 

Stay safe!

 

Karam