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Essential Questions About Pregnancy and the Risks of COVID-19

What to expect while expecting during a pandemic

Rebecca Hill
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Published on: June 12, 2020

Stressed out expectant mother

UPDATE: Since this article was published, new research has come to light about pregnancy and COVID-19.  In efforts to collect additional data, the CDC received more than 325,000 reports of women who tested positive for COVID-19. Of those, 8,207 were pregnant. According to a recent article in ProPublica, the CDC abruptly changed its earlier direction after its first examination of U.S. data on pregnancy and COVID-19 and has issued updated guidance. Other studies, too, have been conducted. The most critical information found no difference existed in the risk of death for pregnant and nonpregnant women with COVID-19. Death occurred in both groups at .2 percent. But they also found that pregnant women were 5.4 times more likely to be hospitalized. However, CDC data were not able to distinguish between admission to the hospital for pregnancy or pregnancy and COVID-19.

Throughout this article, you will find new updates on the questions originally posed. 

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?

UPDATE: Recent CDC data suggest that pregnant Hispanic and Black women are “disproportionately” infected at significantly higher rates than white women are. The United Kingdom’s Obstetric Surveillance Study, which has been collecting data since the start of the pandemic, also found that Black, Asian and Middle Eastern women are far likelier to be hospitalized for COVID-19 than white women are. 

The CDC now reports that symptomatic pregnant women with COVID-19 had similar frequencies of cough and shortness of breath, but reported less frequently were headaches, muscle aches, fever, chills and diarrhea. 

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?

UPDATE: In consideration of age, underlying medical conditions and race/ethnicity, the CDC reported that pregnant women were 50 percent more likely to be admitted to the intensive care unit, and had a 70 percent higher chance of being on a ventilator. 

Finally, because CDC case surveillance did not collect information on pregnancy/birth outcomes, it is still unclear whether having a COVID-19 infection during pregnancy increases adverse outcomes such a pregnancy loss or preterm birth. The CDC does say that a pregnant woman may be at increased risk for adverse outcomes during pregnancy. 

Although more data are needed to ascertain the incidence of cardiomyopathy during COVID-19, recent research has found two cases where pregnant patients with COVID-19 infections did develop cardiomyopathy. Researchers suggested that pregnant women receive an echocardiogram if they are infected and present with pneumonia.

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? 

UPDATE: With the current surge in COVID-19 cases, asymptomatic spread continues to be a significant issue. Recent research from Yale University’s Center for Infectious Disease Modeling and Analysis has concluded, based on their modeling, that asymptomatic carriers and presymptomatic patients may be responsible for over 50 percent of transmissions. As a result, increased testing and contact tracing are recommended.  

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?

UPDATE: According to a May 2020 study by Yale New Haven Health, less than 3 percent of asymptomatic pregnant women admitted to three Yale New Haven Health tested positive for COVID-19 as compared to 13.5 percent of patients found in a study conducted in New York City during the city's peak period of infections. Though the review was of short duration and done within a single geographic area, it may indicate how universal testing of pregnant women helps identify asymptomatic carriers and allows hospitals to prepare for such patients. 

Aside from the risk to the pregnant woman, an asymptomatic carrier results in significant exposure to health-care workers. One study conducted by Columbia University Medical Center advocated that every admission and delivery presented a risk to health-care providers and hospitals should undertake restrictions to reduce that risk.

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?

UPDATE: In a British study of 427 pregnant women with confirmed COVID-19 infections between March 1 and April 14, researchers found that transmission of COVID-19 to the baby could occur but was uncommon. 

A study of 146 Italian women posted June 12, 2020 found that 6 percent of infants born tested positive for COVID-19 at birth. Of a total of nine newborns, four who were delivered vaginally and one by cesarean, three tested positive and were admitted to the NICU; none of them developed a severe illness.

Another June 8 UK study of 427 pregnant women found that 12 infants tested positive for COVID-19, 2 percent of them within the first 12 hours of birth, which “may suggest that mother-to-infant viral transmission may be occurring.” However, the study was unclear as to where or when the virus was transmitted to the infants.

Both studies demonstrate that the risk of vertical transmission of the infection remains low. A small study found blood clots and signs of abnormal blood flow between the mother and fetus within the placenta in infected pregnant women. Since the placenta is responsible for providing nutrients and oxygen to the fetus, the question remains whether this has any impact on a healthy pregnancy or delivery. Researchers recommended closely monitoring via ultrasounds or non-stress tests to see how the placenta is delivering oxygen to the fetus. 

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?

UPDATE: CDC guidelines as of May 20, 2020 state that infants less than 12 months of age may be at high risk of illness from COVID-19 as compared with older children, even though information among neonates is limited and based on case reports and small case series.  The reported signs of COVID-19 infection among neonates include fever, lethargy, runny nose, cough, increased breathing, vomiting, diarrhea and decreased feeding. The CDC states that all neonates born to mothers with confirmed or suspected COVID-19 must be assumed to be infected. So, all neonates born to infected mothers are recommended to be tested.

As for separation of the infant, the CDC believes that temporary removal either to a separate room or temperature-controlled isolette in the mother’s room should be strongly considered. 

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?

UPDATE: Based on a study of 675 women admitted for delivery to three New York City hospitals, those women with COVID-19 were 46.7 percent more likely to have a cesarean delivery because of severe COVID-19 symptoms. They also had an increased frequency of maternal complications in the postpartum period. Good news: Nearly all infants delivered, however, had good outcomes and were not positive for COVID-19. 

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?

UPDATE: Although no one is entirely protected from the virus, wearing a face mask along with social distancing can reduce the spread of COVID-19.  According to the CDC, a face shield for newborns and infants are NOT recommended because data does not support their use. These shields present the potential risk of sudden infant death syndrome and other respiratory illnesses.  

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 breast milk?

UPDATE: According to the National Institute of Health, Remdesivir has not been evaluated for safety and effectiveness in pregnant patients. Historically, clinical trials of Remdesivir and other drugs have excluded breastfeeding women. Therefore, no data on the presence of the drug during breastfeeding exist. However, the drug is administered via IV. Because it is a relatively small molecule, transfer through breast milk to the infant’s gastrointestinal tract means that “it is very unlikely that the active drug would reach the infant’s circulation.”

The National Institute of Health has issued COVID-19 treatment guidelines on Remdesivir. Those guidelines allow for the “compassionate use” of the drug, meaning it should be given “only when the potential benefit justifies the potential risk to the mother and the fetus.” 

In a study conducted by Gilead Sciences, Inc., the maker of Remdesivir, of 86 pregnant and postpartum women who were treated with Remdesivir, 96 percent of the pregnant and 89 percent of the postpartum women achieved improvement in oxygen support levels. Those with more severe COVID-19 infections achieved similarly high rates of clinical recovery, at 93 percent and 89 percent. 

The CDC shares the following: “We do not know for sure if COVID-19 can spread the virus to babies in their breast milk, but the limited data available suggest that it is not likely.”

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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