COVID-19 in pregnancy

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COVID-19 in pregnancy
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Virtual model of coronavirus.
Classification and external resources
Patient UK COVID-19 in pregnancy
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Lua error in package.lua at line 80: module 'strict' not found. The effect of COVID-19 infection on pregnancy is not completely known because of the lack of reliable data.[1]

Predictions based on similar infections such as SARS and MERS suggest that pregnant women are at an increased risk of severe infection[2][3] but findings from studies to date show that clinical characteristics of COVID-19 pneumonia in pregnant women were similar to those reported from non-pregnant adults.[4][5]

There are no data suggesting an increased risk of miscarriage of pregnancy loss due to COVID-19 and studies with SARS and MERS do not demonstrate a relationship between infection and miscarriage or second trimester loss.[6]

It is unclear yet whether conditions arising during pregnancy including diabetes, cardiac failure, hypercoagulability or hypertension might represent additional risk factors for pregnant people as they do for nonpregnant people.[4]

From the limited data available, vertical transmission during the third trimester probably does not occur, or only occurs very rarely. There is no data yet on early pregnancy.[4]

Research about COVID-19 in pregnancy

Little evidence exists to permit any solid conclusions about the nature of COVID-19 infection in pregnancy.

Effect on pregnant women

In May 2020, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) reported the results from a UK Obstetric Surveillance System (UKOSS) study of 427 pregnant people and their babies.[7] This study showed that 4.9 pregnant people per 1000 were admitted to hospital with COVID-19 and 1 in 10 of these requried intensive care.[8] The findings of this study support earlier suggestions that pregnant people are not at greater risk of severe illness than non-pregnant people. Similar risk factors also apply: people in the study were more likely to be admitted to hospital if they were older, overweight or obese, or had pre-existing conditions such as diabetes or high blood pressure.[7] Five women died but it is not yet clear whether the virus was the cause of death.[7] Since the majority of women who became severely ill were in their third trimester of pregnancy, the RCOG and RCM emphasised the importance of social distancing for this group.[7] The study also found that 55% of pregnant people admitted to hospital with COVID-19 were from a black or other minority ethnic (BAME) background, which is far higher than the percentage of BAME people in the UK population. Speaking for the RCOG, Dr Christine Ekechi stated that it is of "great concern" that over half of those admitted to hospital were from a BAME background, that there were already "persisting vulnerabilities" for this group, and that the RCOG was updaing guidance to lower the threshold to review, admit and consider escalation of care for pregnant women of BAME background.[7]

A case series of 43 women from New York who tested positive for COVID-19 showed similar patterns to non-pregnant adults: 86% had mild disease, 9.3% had severe disease and 4.7% developed critical disease.[9] Another study found the cases of COVID-19 pneumonia in pregnancy were milder and with good recovery.[10]

A study of 9 infected women at the third trimester of pregnancy from Wuhan, China showed that they showed fever (in six of nine patients), muscle pain (in three), sore throat (in two) and malaise (in two). Fetal distress was reported in two. None of the women developed severe COVID-19 pneumonia or died. All of them had live birth pregnancies and no severe neonatal asphyxia was observed. The samples of breast milk, amniotic fluid, cord blood and neonatal throat swab were tested for SARS-CoV-2, and all results were negative.[5]

In another study on 15 pregnant women, majority of the patients presented with fever and cough, while laboratory tests yielded lymphocytopenia in 12 patients.[11] Computed tomography findings of these patients were consistent with previous reports of non-pregnant patients, consisting of ground-glass opacities at early stage.[11][12] Follow-up images after delivery showed no progression of pneumonia.[11]

Media reports indicate that over 100 women with COVID-19 might have delivered, and in March 2020, no maternal deaths were reported.[13] In April 2020, a 27-year old pregnant woman at 30 weeks of pregnancy died in Iran: her death may have been caused by COVID-19.[14]

The RCOG advised in early April 2020 that because pregnancy is a hypercoagulable state and that people admitted to hospital with COVID-19 are also hypercoagulable, infection with COVID-19 could increase the risk of venous thromboembolism and that this risk could be compounded by reduced mobility due to self-isolating.[15] Their guidelines thus advise that any pregnant person admitted to hospital with a COVID-19 infection should receive at least 10 days of prophylactic low-molecular-weight heparin after being discharged from the hospital.

Effect on labour

There are limited data concerning the implications of COVID-19 infections for labour.[4] Al-kuraishy et al. reported that COVID-19 in pregnancy may increase the risk of preterm labour. Preterm delivery is regarded as a chief outcome of COVID-19 pneumonia during pregnancy.[15] The UKOSS study found that median gestational age at birth was 38 weeks and that 27% of women studied had preterm births. Of these, most (47%) were interventions given because of risk to the mother's health and 15% were because of risk to the foetus.[6]

Effect on the fetus

There are currently no data to suggest increased risk of miscarriage or early pregnancy loss in relation to COVID-19.[15]

Transmission

Early studies indicated no evidence for vertical transmission of COVID-19 from mother to child in late pregnancy[5] but more recent reports indicate that vertical transmission may occur in some cases.[16][17]

Early research found two neonates to be infected with COVID-19 but it was considered that transmission likely occurred in the postnatal period.[18]

More recent small-scale findings indicate that vertical transmission may be possible. One infant girl born to a mother with COVID-19 had elevated IgM levels two hours after birth, suggesting that she had been infected in utero and supporting the possibility of vertical transmission in some cases.[16] A small study involving 6 confirmed COVID-19 mothers showed no indication of SARS-CoV-2 in their newborns' throats or serum but antibodies were present in neonatal blood sera samples, including IgM in two of the infants.[17] This is not usually passed from mother to fetus so further research is required to know whether the virus crossed the placenta or whether placentas of women in the study were damaged or abnormal.[17]

Predictions

Since COVID-19 shows similarities to SARS-CoV and MERS-CoV, it is likely that their effect on pregnancy are similar. During the 2002–03 pandemic, 12 women who were infected with SARS-CoV were studied.[19] Four of seven had first trimester miscarriage, two of five had fetal growth restriction in the second trimester, and four of five had preterm birth. Three women died during pregnancy. None of the newborns were infected with SARS-CoV.[19] A report of ten cases of MERS- CoV infection in pregnancy in Saudi Arabia showed that the clinical presentation is variable, from mild to severe infection. The outcome was favorable in a majority of the cases, but the infant death rate was 27%.[20]

A recent review suggested that COVID-19 appeared to be less lethal to mothers and infants than SARS and MERS but that there may be an increased risk of preterm birth after 28 weeks' gestation.[21]

Recommendations

The World Health Organization and Centers for Disease Control and Prevention of the United States advises pregnant women to do the same things as the general public to avoid infection, such as covering cough, avoid interacting with sick people, cleaning hands with soap and water or sanitizer.[1][3]

Antenatal care during pregnancy

The RCOG and RCM strongly advise that antenatal and postnatal care should be regarded as essential, and that "pregnant women will continue to need at least as much support, advice, care and guidance in relation to pregnancy, childbirth and early parenthood as before".[15]

In May 2020, a spokesperson for the RCOG suggested that black and other minority ethnic women should be warned that they may have greater risk of complications from the virus and should be advised to seek help early if concerned.[7] Moreover, healthcare professionals should be aware of the increased risk and have a lower threshold to review, admit and escalate care provided to women of BAME background.[6]

To minimise the risk of infection, the RCOG and RCM advise that some appointments may be conducted remotely via teleconferencing or videoconferencing.[15] A survey conducted in Shanghai among pregnant women in different trimesters of pregnancy identified a strong demand for online access to health information and services.[22] People expecting their first baby were more willing to have online consultation and guidance than who had previously given birth.[22]

The RCOG and RCM recommend that in-person appointments be deferred by 7 days after the start of symptoms of COVID-19 or 14 days if another person in the household has symptoms.[15] Where in-person appointments are required, pregnant patients with symptoms or confirmed COVID-19 who require obstetric care are advised to notify the hospital or clinic before they arrive in order for infection control to be put in place.[4][15]

Universal screening at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center found that out of 215 pregnant patients, four (1.9%) had symptoms and were positive for COVID-19 and 29 (13.7%) were asymptomatic but tested positive for the virus.[23] Fever subsequently developed in three asymptomatic patients. One patient who had tested negative subsequently became symptomatic postpartum and tested positive three days after the initial negative test.[23] The doctors conducting the screening recommended that in order to reduce infection and allocate PPE, due to high numbers of patients presenting as asymptomatic, universal screening of pregnant patients should be conducted.[23]

During labour

In the UK, official guidelines state that women should be permitted and encouraged to have one asymptomatic birth partner present with them during their labour and birth.[15]

There is no evidence regarding if there is vaginal shedding of the virus, so the mode of birth (vaginal or caesarean) should be discussed with the person in labour and take into consideration their preferences if there are no other contraindications.[13][15] If a patient has a scheduled elective caesarean birth or a planned induction of labour, an individual assessment should consider whether it is safe to delay the procedure to minimise the risk of infecting others.[15]

The RCOG and the RCM recommend that epidurals should be recommended to patients with confirmed or suspected COVID-19 in labour so that the need for general anaesthesia is minimised if urgent intervention for birth is required.[15] They also suggest that people with suspected or confirmed COVID-19 should have continuous electronic fetal monitoring.[15] The use of birthing pools is not recommended for suspected or confirmed cases of COVID-19 due to the risk of infection via faeces.[15]

Postnatal care

In the UK, official recommendations state that precautionary separation of a mother and a healthy baby should not be undertaken lightly and that they should be kept together in the postpartum period where neonatal care is not required.[15]

Literature from China recommended separation of infected mothers from babies for 14 days.[15] In the US there is also the recommendation that newborns and mothers should be temporarily separated until transmission-based precautions are discontinued, and that where this is not possible the newborn should be kept 2 metres away from the mother.[4]

See also

References

  1. ↑ 1.0 1.1 Lua error in package.lua at line 80: module 'strict' not found.
  2. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  3. ↑ 3.0 3.1 Lua error in package.lua at line 80: module 'strict' not found.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Lua error in package.lua at line 80: module 'strict' not found.
  5. ↑ 5.0 5.1 5.2 Lua error in package.lua at line 80: module 'strict' not found.
  6. ↑ 6.0 6.1 6.2 Lua error in package.lua at line 80: module 'strict' not found.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Lua error in package.lua at line 80: module 'strict' not found.
  8. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  9. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  10. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  11. ↑ 11.0 11.1 11.2 Lua error in package.lua at line 80: module 'strict' not found.
  12. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  13. ↑ 13.0 13.1 Lua error in package.lua at line 80: module 'strict' not found.
  14. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 15.12 15.13 15.14 Lua error in package.lua at line 80: module 'strict' not found.
  16. ↑ 16.0 16.1 Lua error in package.lua at line 80: module 'strict' not found.
  17. ↑ 17.0 17.1 17.2 Lua error in package.lua at line 80: module 'strict' not found.
  18. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  19. ↑ 19.0 19.1 Lua error in package.lua at line 80: module 'strict' not found.
  20. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  21. ↑ Lua error in package.lua at line 80: module 'strict' not found.
  22. ↑ 22.0 22.1 Lua error in package.lua at line 80: module 'strict' not found.
  23. ↑ 23.0 23.1 23.2 Lua error in package.lua at line 80: module 'strict' not found.
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