Hi everybody! We have been doing so many updates about all aspects of this virus and it’s effects lately. It seems to be all we can talk about. However, I feel like we have forgotten about the preggies. It’s time to review a little bit about what we know about COVID and pregnancy. Please keep in mind that whatever I explain right now this minute could still change tomorrow. The following is a break down of the recent commentary about COVID and pregnancy in the journal Obstetrics and Gynecology.
First, let’s keep in mind that the WHO only declared a global pandemic as of March 11th, so there hasn’t been a ton of time or pregnant women to study since then. Let’s go over what we do know and what we have seen. Keep in mind that this situation is changing rapidly. As of March 17th, more than 189,000 people have been diagnosed with COVID globally with more than 7,500 deaths and more than 150 countries involved. Realistically, this is probably just the tip of the iceberg because of the limitations of testing so far. We know the common symptoms of dry cough, fever, and fatigue. We know that the incubation period is up to two weeks. We know some of the findings on chest x-ray and in lab tests that can occur with COVID and we are working on a serum test instead of the nasal swab. We also know that there are multiple very similar coronaviruses that have been around since the 1980s! Hmm. How new is this thing really? I am asking for purely academic interest only I promise. Has it really been around all this time in bats like the other viruses and somebody just finally ate the right/wrong bat in a soup so it could make the jump to humans?
Ok. I am getting distracted. I was supposed to talk about COVID and pregnancy. So, what do we know about the preggies anyway? So far, there have been three case series for a total of 31 pregnancies affected by COVID that have been published. We also have a WHO report from China with some limited information on 147 pregnancies. We also have reviews looking at features of other coronaviruses like SARS(Severe Acute Respiratory Syndrome-Associated Coronavirus) and MERS( Middle East Respiratory Syndrome-Related Coronavirus) in pregnancy. The American College of Obgyn has already published guidelines for pregnancy and the CDC has posted answers to frequently asked questions about COVID and pregnancy, but there is still a lot we do not know for sure right now.
So, what are the answers and what are the questions? One of the biggest questions is the case-related fatality of the disease in pregnancy. It is hard to sort through the data on the fatalities because the fatality rate really depends on the co-morbidities of the patients, the quality of the health care provided and the age and health of the patients affected. It’s not just straight numbers. So far, rates around the world have been reported in a range from .9% to 9%. But remember, these rates are overall rates, not adjusted for the variables mentioned above. Plus, mild or asymptomatic cases can be missed so the fatality numbers can actually be overestimated. We don’t fully know the fatality rate in the United States yet and as of yesterday, we do not have any fatalities reported in pregnant women that I am aware of.
We still have questions about all the routes of transmission of COVID as well. We are still looking at how long the virus survives on surfaces. So far, 9 days is the magic number, depending on the surface and the particular coronavirus. We are still looking at whether asymptomatic people can transmit the virus. For a pregnant woman, the biggest question if there is vertical transmission of the virus. Vertical transmission refers to transmission of the virus from a pregnant woman to her fetus. We really haven’t had enough pregnant women yet to compare to nonpregnant women of similar age. There was a small study comparing SARS in similar aged pregnant and non-pregnant women that suggested that pregnant women may have a greater incidence of severe disease and death, but we are not seeing that so far with COVID.
As far as vertical transmission, we really don’t know the answer yet. SO FAR, we have not seen it yet in the small number of COVID pregnancies reported up until this point. This sounds great, but I don’t think we can count on this just yet. I am going to hang on to this bit of potential good news anyway for now. I will say that the in the group of pregnancies studied so far, the vast majority of women were infected in the third trimester and most of them had delivery by c section. We don’t really have any pregnancies to refer to at this point where the women were infected in the first or second trimester.
There is a question about pregnant health care workers and COVID. Should they be given special consideration? In the past, the CDC has recommend different guidelines for different viruses. For H1N1, they recommended that pregnant workers follow the same precautions as other workers, but maybe avoid any procedures that could generate aerosols( infected respiratory droplets). A different systemic review of 1862 publications rated the following as the aerosol-inducing procedures with the highest risk of infection transmission of SARS: tracheal intubation, tracheotomy care, airway care, and cardiac resuscitation, non-invasive ventilation and manual ventilation before intubation. Results were mixed as far as nebulizer treatments. With Ebola, the CDC recommended that pregnant workers not even care for those patients. We just don’t have enough data yet to make specific recommendations for pregnant workers and COVID.
Currently, hospitals are recommending immediate separation of newborns from COVID positive mothers postpartum. At our hospital currently, COVID positive mothers will remain in negative airborne isolation throughout their stay. Immediately after birth, the neonate is put into an isolette, separated from the mother and moved into the nursery under negative airborne isolation. Those mothers that choose to have their infants remain in the room for bonding must wear PPE( personal protective equipment) and the infant must stay in the mother’s room throughout the entire stay. Remember that so far, we have not seen vertical transmission (mother to fetus in the womb), but the neonate could still get infected after exposure to the mother after birth. Luckily, so far, it looks like children in general are mildly affected by COVID, but we really don’t know about neonates.
So, where does that leave breastfeeding? We have a very small amount of data that suggests that SARS is not transmitted through breastmilk, but we really don’t know about COVID. Even the SARS data is too limited to apply on a broad scale.
I get it. I just basically said that we really don’t know anything solid about COVID and pregnancy. The situation is just evolving too fast. We do have some possibly good news about the lack of vertical transmission but we need to keep watching. At this point, the best thing to do regarding pregnancy and COVID is to keep using the same methods that we already are to prevent the spread of other viruses like the flu. Tell patients to not go around known ill persons. Tell them to wash their hands frequently and not touch their face. Tell them to cover their coughs and sneezes and not just blast into the open air. Screen pregnant patients for upper respiratory symptoms, travel, cough and fever and triage accordingly. Separate ill patients from well patients. Limit visitors to labor and delivery and postpartum. Cancel mass gatherings and concerts. Maintain social distance. The reality is that pregnancy care does not truly lend itself to telehealth as a rule. These patients need regular visits. We need to take every universal precaution, like we should anyway. Give patients copies of their records frequently in case their care gets disrupted.
Basically, this situation is going to keep changing until it runs it’s course. This is the best info we have available right now. Until we have more data on more pregnant women, this is all I have to offer you right now. I think the key for now is to use common sense and universal precautions and to stay tuned for more updates as they arise. Hang in there and try to have a great day.
Dr. Katz
