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Essential Questions About Pregnancy and the Risks of COVID-19

What to expect while expecting during a pandemic

Published on: June 12, 2020

Stressed out expectant mother

Ellen Bariyev is in the second trimester of her pregnancy and being pregnant during a pandemic is something that she never anticipated. In a time where she should be excited about baby showers and stocking up on bottles, pacifiers and onesies, Bariyev now worries about what will happen to her and her baby during this time.  Turning to her doctor isn’t an option. He, like Bariyev, is learning about the virus right alongside her.

As a result, for every pregnant woman the questions are different yet just as poignant. Mostly, they want answers in a time when no one knows the outcome. Unfortunately, questions about how the COVID-19 virus will impact pregnancy are numerous. 

Am I at a higher risk for COVID-19 because I’m pregnant?

Current data on COVID-19 reflects that pregnant women are not at higher risk any more than an average person is. Just like other people, pregnant women should practice social distancing, wash their hands and wear a face mask in public. 

Still, many viruses can cause problems during pregnancy, says obstetrician Kristian Adams-Waldorf, M.D., of the University of Washington Medical Center.  Viruses like influenza can put a pregnant woman at higher risk for preterm birth. Evidence has shown that if a pregnant woman contracts a virus like SARS or MERS during pregnancy, those infections, if severe enough, may induce preterm birth, miscarriage or even birth defects.

“However, we don’t know whether preterm birth will become more common because the virus triggers inflammation in the placenta or because obstetricians need to deliver an [infected] woman so they can breathe more easily,” says Adams-Waldorf. “With COVID-19, I would not be surprised to see an increase in the rates for miscarriage, stillbirth and preterm labor.”

Through her studies on pregnancy and COVID-19 are just getting started, Adams-Waldorf started her research activities in mid-January. “We are continuing to roll out the study at UW as well as a bigger study in Washington state on birth outcomes for pregnant women and newborns,” says Adams-Waldorf. Her previous research includes studying the impact of streptococcus B, E. coli and the Zika viruses and their effects on pregnant women.

If I get infected with COVID-19, will my pregnancy make the infection worse?

At first glance, it doesn’t appear “that pregnant women are more likely to have a severe infection than nonpregnant women,” says Adams-Waldorf.  But to date, with COVID-19, there hasn’t been a disproportionate number of women hospitalized or who die from COVID-19, she notes.  Still, she’s not sure the reasons for this, saying it could be attributed to the fact that pregnant women tend to be younger and healthier.

A report from the United Kingdom supports this.  According to a New Scientist article, pregnant women did not have any worse symptoms than those who were not pregnant. Still, underlying preexisting medical conditions could influence how a pregnant woman responds to the infection.

Can I be pregnant and positive for COVID-19 and have no symptoms? 

Yes. Since COVID-19 symptoms develop over 14 days, a pregnant woman can be asymptomatic upon entering the hospital but deliver her baby when infected with COVID-19. “Inductions of labor can happen over several days, so you might come into labor and delivery on Monday and then not deliver until Wednesday or even Thursday,” says Adams-Waldorf. During that period, a pregnant woman may have no inkling she was infected.

This happened in two New York City hospitals when seven pregnant patients were admitted as positive for COVID-19, though two admitted were asymptomatic. As a result, the hospitals began a universal testing program of all pregnant women. They later found 88 percent of pregnant women admitted with obstetric complaints or for delivery had no symptoms at all.

Eighty-six percent of patients had mild symptoms, and 4.7 percent eventually experienced critical symptoms. None of the women delivered infants with COVID-19 infections. The study concluded with the recommendation to universally test all pregnant women before they are admitted to the labor unit. 

Should hospitals conduct universal testing for COVID-19 of all pregnant women?

Some hospitals, such as New York City Presbyterian Allen Hospital and Columbia University Irving Medical Center, do require universal testing of all pregnant women. These hospitals implemented a universal testing program after they found two cases of asymptomatic women who tested positive for COVID-19. The study further states that the potential benefits of universally testing are to establish if early infection control measures such as isolation are necessary, to inform neonatal care and to safeguard labor and delivery personnel from infection with personal protective equipment (PPE).  

The CDC now recommends prioritized testing for all pregnant women suspected of having COVID-19 or who develop symptoms at admission. 

If I am infected with COVID-19, can I give the infection to my new baby?

Two previous studies found no clinical findings of COVID-19 in babies born to infected mothers.  All samples of amniotic fluid, cord blood and breast milk also tested negative for the virus.  However, a March 26, 2020 study found 33 newborns in Wuhan, China were infected with mild symptoms. Three of the 33 were found with early-onset symptoms, and therefore scientists could not rule out transmission of the virus from the mother as a possibility.

If I am infected, is it possible that I might pass antibodies to my baby?

Adams-Waldorf has seen two reports that suggest the antibody IgM to the COVID-19 virus was found in cord blood. Antibodies, or immunoglobulin, are the proteins that adhere to antigens, creators of immune responses. In specific cases, IgM antibodies are produced after exposure to a virus, and IgG pertains to the body’s later response. IgG is the body’s most-produced antibody. But IgM antibodies are much larger than IgG, thus too large to cross the placenta in pregnancy. 

In the last trimester, the placenta is actively capturing the mother’s antibodies, which are usually IgG antibodies.  As a result, the baby has roughly the same levels of antibodies against bacteria and viruses as his/her mother.

According to the Journal of the American Medical Association (JAMA) study, six babies in China had IgG antibodies that were likely to have been delivered through the mother’s placenta. All six babies had IgG antibodies against COVID-19. The study suggested that they may have gotten these antibodies from the mother.  But two infants had IgM antibodies as well as IgG antibodies, leading study authors to speculate that the babies either generated their own antibodies or the mother’s placenta may have been damaged, thereby allowing the transfer of the larger IgM antibodies.  This evidence was based on the detection of elevated IgM antibodies in blood drawn from the babies after birth. None of the six infants had COVID-19.  

However, Adams-Waldorf is waiting for more evidence before she decides.  “These tests are early days. However, it would not be out of the question or impossible that the COVID-19 virus crossed the placenta.”

What happens if I have COVID-19 symptoms and it’s time to deliver? What happens to my baby after delivery?

It depends on whose guidelines are being followed. The CDC recommends separating the newborn from the infected mother and other infants for two weeks after birth.  The WHO, however, suggests that the infected mother and baby share a room and breastfeed, but follow respiratory hygiene practices such as wearing a mask when feeding a newborn.  Pregnant women should ask their doctor what guidelines their hospital follows.

Does having COVID-19 infection require a Caesarean birth?

According to Adams-Waldorf, being infected doesn’t automatically make the pregnant woman a candidate for Caesarean delivery.  Why? Because it depends on her symptoms and the extent to which the infection has spread. “If she is significantly compromised in her ability to breathe, we can make that better by delivering the baby,” says Adams-Waldorf. So, it depends on what stage she is in during her pregnancy and if it is safe for the baby, says Adams-Waldorf.

Should I wear a face mask when I am pregnant?

The CDC recommends that all people, including pregnant women, wear a face mask when they are in public, especially since studies have shown that asymptomatic people can spread the virus.  At the same time, all pregnant women should, even if wearing a face mask, continue to practice social distancing.  

Can my newborn become infected by drinking breastmilk?

At present, insufficient data exists as to whether a newborn can become infected with COVID-19 by breastfeeding.

What kind of hospital delivery and labor room restrictions have hospitals implemented?

That depends on the hospital and its ability to protect its health-care workers and preserve PPE.  At the University of Washington Medical Center, one partner plus one labor support is allowed for a pregnant woman who is not infected with COVID-19. If the patient is positive for COVID-19, no one extra is allowed.

Alek Kruse is having her baby at Evergreen Health in Kirkland, the epicenter of the virus in Washington.  “My hospital allows one support person, which will be my husband,” she says.

How will my prenatal visits be handled?

For Kruse, after her anatomy scan, her teleconferences started right away. As a result, her husband could participate in the teleconferences even though he wasn’t allowed at any future in-person visits.

For Bariyev, her husband Alex has not been able to attend any of her prenatal visits, which is exceedingly difficult for her despite understanding why these precautions are in place. “I feel like it is Alex’s appointment as much as it is mine,” says Bariyev. “I feel like he deserves to have the right to know all the information about the baby. I feel like it is a letdown for him.” 

Should I have a home birth or go to the hospital for labor and delivery?

For Bariyev, having the baby at home is a consideration if her hospital begins to increase its COVID-19 patient risk. She is not alone in thinking this.

While Adams-Waldorf believes that hospitals are still the safest places to deliver, especially if the pregnant woman is symptomatic or infected with COVID-19, many pregnant women are evaluating the risk of hospital labor and delivery. Some do not want to give birth in a hospital that is at risk of being overwhelmed by COVID-19 cases. Other women are considering delivering at home because they want to minimize the risk to themselves and their babies or avoid the added restrictions placed by the hospital on who can be present at the birth.

What should I expect after the baby is born and at home?

It depends. At the minimum, mothers should restrict visitors at home and stay at home during the early days. Handwashing, wearing a mask in public and minimizing exposure to the public are advisable.

What about breastfeeding my new baby?

The CDC recommends that if a mother can breastfeed her baby, she should.  However, if that mother is infected with COVID-19, she should wear a face mask when breastfeeding, taking special care to wash her hands before each feeding.

If the mother is temporarily separated from the baby, the CDC recommends expressing breast milk. A mother, however, should practice good hand hygiene before touching the pump or expressing milk.  The breast pump should be thoroughly washed and disinfected before using it. Then the milk should be fed to the baby by a healthy caregiver.

What can I do if I feel depressed, anxious or afraid?

First and foremost, remember that you are not alone and that it is okay to seek help.   Kruse and her husband had been trying to conceive for the last five years, so, for her, the pandemic just adds to the nightmare of infertility. Because of the pandemic, she, like other pregnant women, have had to put aside baby showers and last-minute date nights to celebrate what Kruse calls “the married couple without kids” chapter endings. All the excitement of being pregnant and having a baby has been muted. Such losses and the stresses of isolation take a toll on the mental health of expectant mothers.

With hospitals limiting or even eliminating support systems during labor and delivery, one of the biggest concerns pregnant women are having is the absence of support from loved ones.

Gladys Rodriguez, LSWAIC, has been seeing a higher rate of anxiety, depression and perinatal mood disorders in the women she counsels. Because they do not connect with their support networks regularly, these women are worried about being separated from their newborn or not being able to have the support system they planned on during labor and delivery, says Rodriguez. “As they continue to feel isolated, their symptoms can worsen.”

Rodriguez herself is pregnant during this time. “As a pregnant woman, it’s been very easy for me to lie on the couch and lose the desire to do the things I know will make me feel better during these times,” says Rodriguez. “I find myself ruminating on scary thoughts about my pregnancy and delivery.”  But, she says, she tells herself immediately to stop thinking such thoughts.

For women who are having a tough time, she recommends practicing grounding and mindfulness. “I’ve found some amazing free apps that offer great meditations, even ones specific to pregnancy.” 

If an expectant mother is getting to the point where she cannot cope, Rodriguez recommends that she works with a licensed professional who specializes in perinatal mental health. She should tell her doctor about her concerns, says Rodriguez. While doctors are prioritizing the physical health of mothers and babies, more focus, says Rodriguez, needs to be placed on the mental health of pregnant women. Mothers need to limit their stress to limit the strain on their baby.  And at a time like this, managing stress is more important than ever.

About Perinatal Support Washington

Perinatal Support Washington is a nonprofit that shines a light on perinatal mental health. It provides a resources directory and a “Warm Line” to support parents in need. The Warm Line is manned by trained staff, parent peers and licensed therapists. Calls are answered live Monday–Friday, 9 a.m.–4:30 pm., in English and in Spanish: 1-888-404-7763 (email: warmline@perinatalsupport.org). The organization also offers a number of virtual new parent support groups throughout the week. Talk with other parents and get information and support!

 

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