#MSCOVID19 – what about pregnancy?

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My husband and I were hoping to start a family this year. What do you advise; should I attempt to fall pregnant or wait until after the COVID-19 pandemic? 

How long is a piece of string? Mouse Doctor 2 would tell you to divide the string in half and the length of the original piece of string is twice that of one of the halves. With the flattening of the curve and the extension of the tail COVID-19 pandemic is likely to extend beyond 2020 and into 2021. Some epidemiologists are predicting the tail going out to 2022. Therefore, in my opinion, COVID-19 pandemic is not necessarily a reason to put your life on hold. 

Image of flattening=the-curve is from the CDC

Clearly, for some people, there are economic reasons why they wouldn’t want to start a family in the current climate. For example, if you or your partner have lost your job, or you are uncertain about your long-term employment prospects, these economic factors will potentially impact on your decision to start a family.

What about SARS-CoV-2, a coronavirus, and pregnancy?

There is no published data that coronavirus infections are associated with foetal abnormalities or a higher miscarriage rate. It looks as if transplacental infection of the foetus with SARS-CoV-2 is unlikely. Saying this there is one case report of a neonate, born by caesarian section from a mother who had severe COVID-19, who tested positive for the virus. The problem with this case is that the neonate could have been infected at the time of birth. The good news is that children, including very young children, don’t seem to get COVID-19. Why children are resistant to COVID-19 is unknown at present, but it must have something to do with the biology of the virus. Therefore, it is unlikely that newborn babies are at significant risk of severe COVID-19 and there is no evidence to suggest worse foetal outcomes. 

The other important thing to realise that if you do fall pregnant and get infected with SARS-CoV-2 and develop COVID-19 or not the antibodies you produce against the virus will cross the placenta and should give your newborn child some protection against will-type viral infection in early life (6-12 months). These transplacental antibodies may be sufficient to protect them and bridge the gap until we hopefully have an effective vaccine against SARS-CoV2. 

What about being pregnant when you get COVID-19?

So far the data is very reassuring in that the case reports from China and elsewhere suggest being pregnant doesn’t increase the risk of getting severe COVID-19 and possibly to the contrary, i.e. less severe disease. However, there are relatively small numbers of pregnant women who do get severe COVID-19, whether this is a smaller proportion than the general aged-matched population is at present unknown.

As severe COVID-19 is a major stressor it may trigger premature labour. In an Italian case series of 42 pregnant women with COVID-19 and who were admitted to hospital only seven required respiratory support and eventually did well. Out of the 42 pregnancies, two premature labours occurred. This suggests COVID-19 in itself is not associated with adverse pregnancy outcomes. Saying this it is clear from the published data that if you are in the third trimester of pregnancy and you present with COVID-19 infection then a large number of women are having their babies born by caesarian section. I assume this is being driven by the medical condition of the mother; I doubt many women hospitalised with COVID-19 will be in a state to go through with normal vaginal delivery. 

Overall, I think the data is reassuring in that it is unlikely being pregnant puts you at greater risk of COVID-19 or severe COVID-19. Based on the published data to date it is likely that pregnancy a state of mild immunosuppression may actually protect you from severe COVID-19. 

What about the babies of woman who have had COVID-19 and subsequently delivered their babies?

The third-trimester data looks reassuring, but it is too early to make a call on the outcomes of babies born to mother who had COVID-19 during the first and second trimesters of pregnancy. Based on the biology of coronaviruses and pregnancy these babies are likely to be fine but will have to wait for the data to emerge. It will be important that not only the children of mothers with COVID-19 need to be studied but those born to mothers who had asymptomatic SARS-CoV-2 infection. For the latter, we need good population-based antibody studies to be done.

Please note some obstetricians have looked at what happened to pregnancy outcomes from the original SARS and MERS epidemics to make some predictions about SARS-CoV-2. I am not sure we can use this data as these two outbreaks were due to more virulent viruses with a much higher case-fatality rate. 

Conclusion: So my advice, in general, would be not to put your lives on hold unless you have to for other reasons. It is unlikely that SARS-CoV-2 causes foetal abnormalities, transplacental transmission of the virus is likely to be rare and there is no suggestion of an increase miscarriage rate due to COVID-19. Pregnancy itself doesn’t put you at increased risk of COVID-19 or severe COVID-19 and may actually protect you from the latter. In the case of getting severe COVID-19 whilst pregnant, there is a small chance of premature labour and a high likelihood that if you are ready to deliver the delivery will be by caesarian section. 

Zaigham & Andersson. Maternal and Perinatal Outcomes With COVID-19: A Systematic Review of 108 Pregnancies. Acta Obstet Gynecol Scand. 2020 Apr 7. doi: 10.1111/aogs.13867.

Introduction: The pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has exposed vulnerable populations to an unprecedented global health crisis. The knowledge gained from previous human coronavirus outbreaks suggests that pregnant women and their fetuses are particularly susceptible to poor outcomes. The objective of this study was to summarize the clinical manifestations and maternal and perinatal outcomes of COVID-19 during pregnancy.

Material and methods: We searched databases for all case reports and series from February 12 to April 4, 2020. Multiple terms and combinations were used including COVID-19, pregnancy, maternal mortality, maternal morbidity, complications, clinical manifestations, neonatal morbidity, intrauterine fetal death, neonatal mortality and SARS-CoV-2. Eligibility criteria included peer-reviewed publications written in English or Chinese and quantitative real-time polymerase chain reaction (PCR) or dual fluorescence PCR confirmed SARS-CoV-2 infection. Unpublished reports, unspecified date and location of the study or suspicion of duplicate reporting, cases with suspected COVID-19 that were not confirmed by a laboratory test, and unreported maternal or perinatal outcomes were excluded. Data on clinical manifestations, maternal and perinatal outcomes including vertical transmission were extracted and analyzed.

Results: Eighteen articles reporting data from 108 pregnancies between December 8, 2019 and April 1, 2020 were included in the current study. Most reports described women presenting in the third trimester with fever (68%) and coughing (34%). Lymphocytopenia (59%) with elevated C-reactive protein (70%) was observed and 91% were delivered by cesarean section. Three maternal intensive care unit admissions were noted but no maternal deaths. One neonatal death and one intrauterine death were also reported.

Conclusions: Although the majority of mothers were discharged without any major complications, severe maternal morbidity as a result of COVID-19 and perinatal deaths were reported. Vertical transmission of the COVID-19 could not be ruled out. Careful monitoring of pregnancies with COVID-19 and measures to prevent neonatal infection are warranted.

Ferrazzi et al. COVID-19 Obstetrics Task Force, Lombardy, Italy: Executive Management Summary and Short Report of Outcome. Int J Gynaecol Obstet. 2020 Apr 8. doi: 10.1002/ijgo.13162.

From February 24, 2020, a COVID-19 obstetric task force was structured to deliver management recommendations for obstetric care. From March 1, 2020, six COVID-19 hubs and their spokes were designated. An interim analysis of cases occurring in or transferred to these hubs was performed on March 20, 2020 and recommendations were released on March 24, 2020. The vision of this strict organization was to centralize patients in high-risk maternity centers in order to concentrate human resources and personal protective equipment (PPE), dedicate protected areas of these major hospitals, and centralize clinical multidisciplinary experience with this disease. All maternity hospitals were informed to provide a protected labor and delivery room for nontransferable patients in advanced labor. A pre-triage based on temperature and 14 other items was developed in order to screen suspected patients in all hospitals to be tested with nasopharyngeal swabs. Obstetric outpatient facilities were instructed to maintain scheduled pregnancy screening as per Italian guidelines, and to provide pre-triage screening and surgical masks for personnel and patients for pre-triage-negative patients. Forty-two cases were recorded in the first 20 days of hub and spoke organization. The clinical presentation was interstitial pneumonia in 20 women. Of these, seven required respiratory support and eventually did well. Two premature labors occurred.

Yang et al. Clinical Features and Outcomes of Pregnant Women Suspected of Coronavirus Disease 2019. J Infect. 2020 Apr 12; S0163-4453(20)30212-7.

Background: 2019 novel coronavirus disease (COVID-19) has become a worldwide pandemic. Under such circumstance pregnant women are also affected significantly.

Objective: This study aims to observe the clinical features and outcomes of pregnant women who have been confirmed with COVID-19.

Methods: The research objects were 55 cases of suspected COVID-19 pregnant women who gave a birth from Jan 20th 2020 to Mar 5th 2020 in our hospital-a big birth center delivering about 30,000 babies in the last 3 years. These cases were subjected to pulmonary CT scan and routine blood test, manifested symptoms of fever, cough, chest tightness or gastrointestinal symptoms. They were admitted to an isolated suite, with clinical features and newborn babies being carefully observed. Among the 55 cases, 13 patients were assigned into the confirmed COVID-19 group for being tested positive severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) via maternal throat swab test, and the other 42 patients were assigned into the control group for being ruled out COVID-19 pneumonia based on new coronavirus pneumonia prevention and control program(the 7th edition).

Results: There were 2 fever patients during the prenatal period and 8 fever patients during the postpartum period in the confirmed COVID-19 group. In contrast, there were 11 prenatal fever patients and 20 postpartum fever patients in the control group (p>0.05). Among 55 cases, only 2 case had cough in the confirmed group. The imaging of pulmonary CT scan showed ground- glass opacity (46.2%, 6/13), patch-like shadows(38.5%, 5/13), fiber shadow(23.1%, 3/13), pleural effusion (38.5%, 5/13)and pleural thickening(7.7%, 1/13), and there was no statistical difference between the confirmed COVID-19 group and the control group (p>0.05). During the prenatal and postpartum period, there was no difference in the count of WBC, Neutrophils and Lymphocyte, the radio of Neutrophils and Lymphocyte and the level of CRP between the confirmed COVID-19 group and the control group(p<0.05). 20 babies (from confirmed mother and from normal mother) were subjected to SARS-CoV-2 examination by throat swab samples in 24 hours after birth and no case was tested positive.

Conclusion: The clinical symptoms and laboratory indicators are not obvious for asymptomatic and mild COVID-19 pregnant women. Pulmonary CT scan plus blood routine examination are more suitable for finding pregnancy women with asymptomatic or mild COVID-19 infection and can be used screening COVID-19, pregnant women, in the outbreak area of COVID-19 infection.

Monteleone et al. A Review of Initial Data on Pregnancy During the COVID-19 Outbreak: Implications for Assisted Reproductive Treatments. 2020 May 1;24(2):219-225. doi: 10.5935/1518-0557.20200030.

The current outbreak of the novel 2019 coronavirus disease (COVID-19) started in China in December 2019 and has since spread to several other countries. On March 25, 2020, a total of 375,498 cases had been confirmed globally with 2,201 cases in Brazil, showing the urgency of reacting to this international public health emergency. While in most cases, mild symptoms are observed, in some cases the infection leads to serious pulmonary disease. As a result, the possible consequences of the COVID-19 outbreak for pregnant women and its potential effects on the management of assisted reproductive treatments, demand attention. In this review, we summarize the latest research progress related to COVID-19 epidemiology and the reported data of pregnant women, and discuss the current evidence of COVID-19 infections during pregnancy and its potential consequences for assisted reproductive treatments. Reported data suggest that symptoms in pregnant women are similar to those in other people and that there is no evidence for higher maternal or fetal risks. However, considering the initial data and lack of comprehensive knowledge on the pathogenesis of SARS-CoV-2 during pregnancy, human reproduction societies have recommended postponing the embryo transfers and do not initiate new treatment cycles. New evidence must be considered carefully in order to adjust these recommendations accordingly at any time and to guide assisted reproductive treatments.

Alzamora et al. Severe COVID-19 During Pregnancy and Possible Vertical Transmission. Am J Perinatol. 2020 Apr 18. doi: 10.1055/s-0040-1710050. 

There are few cases of pregnant women with novel coronavirus 2019 (COVID-19) in the literature, most of them with a mild illness course. There is limited evidence about in utero infection and early positive neonatal testing. A 41-year-old G3P2 with a history of previous cesarean deliveries and diabetes mellitus presented with a 4-day history of malaise, low-grade fever, and progressive shortness of breath. A nasopharyngeal swab was positive for COVID-19, COVID-19 serology was negative. The patient developed respiratory failure requiring mechanical ventilation on day 5 of disease onset. The patient underwent a cesarean delivery, and neonatal isolation was implemented immediately after birth, without delayed cord clamping or skin-to-skin contact. The neonatal nasopharyngeal swab, 16 hours after delivery, was positive for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) real-time polymerase chain reaction (RT-PCR), and immunoglobulin (Ig)-M and IgG for SARS-CoV-2 were negative. Maternal IgM and IgG were positive on postpartum day 4 (day 9 after symptom onset). We report a severe presentation of COVID-19 during pregnancy. To our knowledge, this is the earliest reported positive PCR in the neonate, raising the concern for vertical transmission. We suggest pregnant women should be considered as a high-risk group and minimize exposures for these reasons. 

Rasmussen et al. Coronavirus Disease 2019 (COVID-19) and Pregnancy: What Obstetricians Need to Know. Am J Obstet Gynecol. 2020 Feb 24;S0002-9378(20)30197-6. 

…… In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks’ gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently, no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk of pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

CoI: multiple

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

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