Key Takeaways
- Not a lot of information available on COVID-19 in pregnancy other than small case series (see below)
- Most common reported symptoms in pregnant mothers have been fever and cough; however, emerging reports indicated gastrointestinal (diarrhea, vomiting), musculoskeletal (muscle ache and weakness), and general "jetlag" symptoms in patients with mild disease
- Extrapolated data have indicated an increased risk for preterm delivery, and fetal growth impairment in infected mothers, but not miscarriage or stillbirth
- Risk of mother-to-fetus transmission (vertical transmission) is unknown; however, none of the studies to date on COVID-19 or MERS/SARS have demonstrated cases of transmission to the fetus during the pregnancy (testing performed on amniotic fluid and cord-blood)
- Most published cases of deliveries in women infected by COVID-19 have involved elective cesarean delivery due to concern for possible transmission with passage through birth canal, therefore no good information exist on mode of delivery
- A baby born to an affected mother should be treated as PUI (person under investigation) until confirmed to be unaffected
- Breastfeeding should be okay (not contraindicated) as there is no evidence of transmission through milk but hygiene precautions are highly recommended
- Ideally an ill mother should be separated from an unaffected newborn to minimize COVID-19 exposure; however, if electing to room together, they should be separated by at least 6 feet and a cloth barrier, and when breastfeeding a mask worn and hand hygiene exercised until the mother's transmission precautions are discontinued
COVID-19 Background
At the end of 2019, a cluster of pneumonia cases in Wuhan, China garnered a lot of attention as a novel coronavirus was identified as a cause, and believed to have been transmitted from an animal. The virus quickly spread across China, causing an epidemic. In early 2020, the World Health Organization formally classified these cases as COVID-19, which stands for coronavirus disease 2019. Other names you'll see used for the virus causing COVID-19 are SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) or 2019-n-CoV. Although not too much data are available on COVID-19 yet, the close relationship of the virus to the Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) has been been helpful in extrapolating data for management recommendations.
Existing COVID-19 Pregnancy Data
There are not a lot of data available on COVID-19 in pregnancy. A great recent commentary in the Lancet summarizes the existing evidence on COVID-19 in pregnancy along with some points from experience with MERS and SARS. In essence, the data to date have shown that mothers commonly present with fever and cough. The risk of transmission from mother to fetus (inside the womb) is very low. The virus does not appear to cause specific birth defects, but there are some reports of increased risk of preterm labor and growth restriction in ill mothers but no significant risk in miscarriages or stillbirth. The mode of delivery remains a topic of debate. Most reports include elective cesareans as the providers remain uncertain about the risks of transmission to the baby as it passes through the birth canal and gets exposed to vaginal secretions and blood. Although the risk of transmission is low, the baby should be treated as a potentially infected individual until testing rules this out. The mother should be encouraged to express breast milk. Breastfeeding does not appear to increase transmission, though precautions (masks, hand hygiene) need to be in place to minimize risk of transmission.
Lastly, we can not stress enough that the information above is based on case series from regions where testing of patients with no or mild symptoms was not always available, therefore the findings may be exaggerated. The more updated data are showing 0.7% (Korea) to 4.9% (Italy) overall mortality risk from COVID-19, with most severe symptoms and mortality among the elderly and those with chronic underlying conditions.
Prenatal Care During Infection
Should you experience symptoms suggestive of COVID-19:
- Call your provider or delivery-hospital first and do not just show up so that appropriate contact precautions can be put into place.
- Most pregnant women are healthy and 18-40 years-old meaning symptoms should be mild. Stay in close contact with your pregnancy provider as they'll guide your pregnancy management closely (ranging from isolation at home with frequent check-ins to hospitalization).
- Testing for COVID-19 will depend on most recent CDC guidelines and local resources.
- Given that there are no proven treatments for COVID-19, management will include supportive care. In the event your symptoms worsen, you'll be admitted to the hospital for close monitoring of you and the baby (including fetal heart tracing (if you are beyond viability) or ultrasound assessment of your baby's well being until the resolution of your symptoms.
- Being infected does not mean automatic delivery. In fact, in many similar cases, mothers getting sick near full term are allowed to recover before proceeding with delivery.
- Most practitioners will likely monitor the baby's growth after your infection. Routine antenatal testing (weekly biophysical profiles or non-stress tests), timing of delivery, and mode of delivery after you've recovered will likely be based on your usual pregnancy care irrespective of your recent COVID-19 infection.
Minimize risk
A lot of the efforts outlined below may seem like common sense, but it's good to refresh on some of the most common things you can do to minimize your risk of exposure. These also serve as general best practices when not dealing with a pandemic to ensure good health and hygiene.
At home
- Wash and clean hands at the door, and regular intervals
- Remind everyone to cover coughs/sneezes
- Increase ventilation by opening windows or adjusting air-conditioning to improve air-flow
- Ensure all surfaces and utensils are cleaned nightly
- If in a household with a sick individual, give them their own room if possible with door closed as much as possible, and have 1 family member caring for them if possible to minimize exposure
At work
- Stop handshakes
- Wash and clean hands at the door, and regular intervals (perhaps set email or calendar reminders)
- Remind everyone to cover coughs/sneezes
- Increase ventilation by opening windows or adjusting air-conditioning to improve air-flow
- Disinfect surfaces such as door knobs, desks, handrails regularly
- Use video conferencing whenever possible
- Hold in-person meetings in large, well-ventilated areas
- Cancel large gatherings
- Avoid non-essential air-travel
- Limit food sharing
- If using a cafeteria, ensure strict hygiene practices are in place
- Stay home if sick or have a sick family member
- If working in healthcare, ask team to limit exposure to sick patients (perhaps desk duty or non-patient-facing activities)
At school
- Stop handshakes
- Limit large gatherings or functions mixing different grades and classes
- Limit after school activities
- Wash and clean hands at the door, and regular intervals
- Remind everyone to cover coughs/sneezes
- Increase ventilation by opening windows or adjusting air-conditioning to improve air-flow
- Disinfect surfaces such as door knobs, desks, handrails regularly
- Use video conferencing whenever possible
- Hold in-person meetings in large, well-ventilated areas
- Cancel large gatherings
- Avoid non-essential air-travel
- Limit food sharing
- Ensure strict hygiene practices with the cafeteria staff
- Stay home if sick or have a sick family member
At stores
- Stop handshakes
- Use tap and e-pay (limit handling cash)
- Use on-line transactions (shopping) if possible
- Disinfect hands at the door, and regular intervals
We encourage you to share this post with friends and family to increase the awareness of minimizing risk and exposure to COVID-19 during pregnancy.
Additional reading from official and trustworthy sources:
- Advisory from American Congress of Obstetricians and Gynecologists
- Statement from Society of Obstetricians and Gynecologists of Canada
- Interim COVID-19 guidelines from the CDC
- Who should be tested? Here's the COVID-19 testing criteria from the CDC
- Guidelines from the Society of Maternal-Fetal Medicine
