How COVID-19 Is Impacting Pregnancy
Published on: July 11, 2020
Midwife Emma McNerlin examines the emerging evidence surrounding COVID-19 (SARS-CoV2) and pregnancy and how being pregnant in a pandemic may affect your plan for birth.
By Emma McNerlin
As we welcomed in 2020, little did we know that life as we knew it was about to change. On 5 January, the World Health Organisation reported a cluster of pneumonia type illness cases in Wuhan, China. By 12 January, Thailand reported its first case of this newly identified Coronavirus. By 11 March, it was a global pandemic, and within five months almost 6 million cases have been reported, and nearly 400,000 people have died with the virus.
It is important to note that at the time of writing, it has been only 150 days since the first report of SARS-CoV 2, which in scientific terms, is infinitesimal. The two previous pandemics (SARS in 2003 and HIV/AIDS since the 1980s) have been brought under control through intensive scientific study, public health campaigns, and sound treatments developed over decades, not months. Despite this, the global scientific community has rallied for a better understanding of the physiology and impact of this virus and to begin developing a vaccine.
A Brief History of Coronaviruses
Coronaviruses, named for their crown-like shape and protrusions of protein spikes on their surface are not new. Up until the end of the last century, four of these animal viruses had been identified in humans, and these were relatively harmless and known to cause around 30% of all common colds (BBC Horizon 2020). In this century, three more serious coronaviruses have emerged, SARS, MERS and now COVID-19.
The SARS virus which emerged in South East Asia in 2003 was quickly brought under control following a spread to 29 countries and approximately 8,000 infections (the death rate was 15%), as it was less contagious and also less virulent than COVID-19. SARS virus replicated in the lungs and lower windpipe and sufferers required close contact to transmit the virus and were most infectious around day ten by which time symptoms were apparent and they could be isolated. MERS (Middle Eastern Respiratory Syndrome, migrated from birds to humans in 2008 but was similar to SARS in its physiology and impact. COVID-19, on the other hand, multiplies in the throat and upper respiratory tract, making it more transmissible with breathing. An infected person also sheds the virus earlier in the infection cycle, usually while still asymptomatic, so this virus can spread widely in densely populated areas. Without intervention, on average one person infects 2.5 more, giving COVID-19 the potential to spread exponentially within a population.
Symptoms and Impacts of COVID-19
The main symptoms of COVID-19 are high fever, and cough sometimes accompanied by chills and muscle pains. Other identified symptoms include nausea, vomiting and diarrhea and the loss of senses of smell and taste. Around 80% of those infected will have mild symptoms and fully recover, or they will be asymptomatic. For the rest, the virus will travel deeper into their lungs and they will go on to develop breathing difficulties and may require oxygen therapy and/or ventilation. When a virus enters a host, it binds to a particular type of cell and replicates there, killing or damaging the host cell. Emerging evidence into this virus suggests that it binds to ACE 2 receptors. These are found in the lungs and airways, but also in the lining of blood vessels. For a small percentage of people COVID-19 also affects the circulatory system, and in turn potentially every system in the body.
People with pre-existing conditions such as hypertension and diabetes are more susceptible to serious COVID-19 complications, and immunologists are still trying to understand the full effects of this inflammatory response.
COVID-19 and Pregnancy
COVID-19 was discovered and classified as a novel virus only five months ago, not even the full length of a pregnancy. Therefore there is much still unknown about its impact on both mother and fetus, especially its effect, if any, on fetal development in the first trimester as women who contracted the virus in early pregnancy have not given birth yet. Reassuringly coronaviruses generally don’t cause birth defects like other viruses (e.g. Zika, Varicella and Rubella) but more research is needed in this area (CDC, 2020).
Does pregnancy make me more susceptible to COVID-19?
Overall pregnancy does not appear to increase the risk of developing severe complications of COVID-19 infection, unlike the case for some Influenza Viruses (e.g. H1N1 Swine Flu). Pregnancy does not make a person more vulnerable to COVID-19 infection (RCOG, 2020), though conditions such as hypertension (high blood pressure) or diabetes (either pre-existing or pregnancy-induced) can increase risk of serious complications if infected. Emerging evidence suggests that serious infection is also more likely in the third trimester (RCOG) and the risk is also increased for certain ethnic groups, namely Black, Asian and Middle Eastern. Data published on 11 May from 427 pregnant COVID-19 patients in the UK who required hospital treatment suggests one in ten needed intensive care and five women in the study sadly died. For this reason, those who are pregnant are advised to practice social distancing, especially from 28 weeks of pregnancy, and to limit exposure to large crowds as well as following all the usual hand hygiene and respiratory hygiene protocols.
Does COVID-19 infection transmit from mother to fetus in utero?
There is insufficient evidence to prove beyond doubt that the COVID-19 virus can be transmitted from mother to fetus in utero (vertical transmission). In a review of 68 deliveries of 71 neonates to COVID-19 positive mothers, the virus wasn’t detected in the breast milk, amniotic fluid or placentas of any of those tested. If exposed to the virus, the fetus would mount an immune response and produce antibodies in its blood. One study detected such antibodies in the cord blood of one infant; a further two had the virus present in nose and throat and anal swabs on day two of life and displayed mild symptoms, and were negative when tested on day six. The incubation period of the virus is around three days so this would suggest exposure and incubation of the virus before birth, but it has not been proven (Lamaroux et al 2020). While the CDC and WHO are still cautious about suggesting vertical transmission, The Royal College of Obstetrics and Gynecology (RCOG) in the UK are advising that transmission in utero is likely.
Does COVID-19 increase the risk of miscarriage?
Whilst there have been isolated reports of COVID-19 positive women experiencing miscarriage and stillbirth, it has not been proven that the infection was the cause or even a contributing factor. More research and larger population studies are needed, but at present, it does not appear that COVID-19 infection statistically increases the risk of miscarriage or stillbirth.
Does COVID-19 increase the risk of pre-term birth?
Again, research is in its infancy and studies are small and not well controlled. Emerging reports suggest a correlation between severe COVID-19 infection and premature birth but the data is noisy. A University of Oxford study found 63 out of 247 infected women experienced pre-term birth. However, data is not available on how many of these were planned precautionary C-sections and how many were spontaneous labor. In the third trimester, pregnancy exerts significant stress. Where mothers are critically ill, clinicians will weigh the risks of planned pre-term delivery and associated neonatal care with continuing the pregnancy to term and will discuss this with her where possible and with her family.
What are the expected outcomes for babies born to COVID-19 positive mothers?
Early reports from Wuhan from 33 babies born to COVID-19 positive mothers in January and February found that three (9%) tested positive. Two displayed only mild symptoms and tested negative by day six of life. The remaining baby was born prematurely at 31 weeks and had co-morbidity of Sepsis and required ventilation. It is not known if COVID-19 or bacterial pneumonia was the predominant factor (Zeng et Al). Data emerging from a small Northwestern University hospital study in the US which examined the placentas of 16 women infected with COVID -19 found injury to the blood vessels within the placenta, though all their babies were healthy, so the significance of the placental damage is questionable (Goldstein et al 2020). Reports from European and US surveillance of newborns suggest that with proper measures for labor and birth, the transmissibility of the virus is low, and the majority of infected infants are either asymptomatic or experience only mild symptoms.
How might my pregnancy be affected in the age of COVID-19?
Most of the major hospitals in Bangkok are reviewing and rationalizing their prenatal care protocols in the light of lockdown and social distancing requirements. This may mean fewer appointments with your OBGYN in the case of low-risk pregnancies, in order to limit your trips to hospital. Clinics may be shorter or move to different areas of the hospital to facilitate social distancing. Your doctor may also encourage you to work from home where applicable and to limit social contact, especially in the third trimester. Hospital childbirth education classes may move to online platforms as well as group gatherings are restricted. If you have any concerns about your baby or yourself, you should see your doctor. If you have been in close contact with someone who tests positive, or you are having COVID-19 symptoms yourself, contact your OBGYN for advice on testing and self-quarantine.
How might COVID-19 affect my birth plan?
The WHO does not recommend planned C-Section for pregnant women positive for COVID-19 and recommends C-Section only where it is medically justified. You should discuss your birth plan with your doctor from around week 28 in your pregnancy. Depending on the doctor they may have extra requirements for labor for infection control purposes, such as testing of mum and birth partners (including Doulas), face masks, gloves and extra barrier nursing. Laboring in water may also be restricted. Talk to your doctor about any extra protocols you might expect for your labor and birth. At the time of writing Bangkok was subject to an overnight curfew from 11pm to 4am. For those who require transport to hospital during lockdown hours, some hospitals are offering free ambulance transfer. For those who need to plan their trip to hospital in labor, note that taxis and driver services like GRAB will not be available in curfew hours so you may need to have access to a private car. You should also ask your OB/GYN for a letter with your details and stating that you are pregnant and need to get access to the hospital overnight in the event of labor. The letter should include your name and passport number (or ID number) as well as that of anyone accompanying you in labor.
Will I be separated from my baby after birth?
The World Health Organization has stated that COVID-19 positive women should not be separated from their babies, that they should breastfeed and continue to practice skin to skin with their babies, providing that they practice hand and respiratory hygiene. In practice, there have been widespread reports of separation with the CDC recommending 6m distance between mum and baby. At the time of writing, if mums test negative either at or before admission at Bangkok’s international hospitals, there is no enforced separation on the basis of COVID status, but if hospitals have a pre-existing policy of separation then this will still be in force.
What can I do to avoid contracting COVID-19 in pregnancy?
The health promotion message is clear for all, and pregnant women are no exception. Wash your hands often or when you can’t, use alcohol gel. Do not touch your mouth, nose or eyes and practice social distancing. When in public, or where you cannot socially distance, wear a face covering. Due to increased risk of complications of COVID-19 pregnant women are encouraged to limit social contact in their third trimester. Keeping healthy and ensuring you eat well, rest well and get regular daily activity will all help to naturally boost your immune system. Ensure you are taking a good quality prenatal vitamin complex, and speak to your doctor about extra vitamin D supplementation which is known to lessen adverse effects of respiratory symptoms and may protect against COVID complications.
To conclude, the medical community has learned much about the SARS CoV2 Virus since it emerged in January, but much remains unknown. Early indications are that pregnancy is not a risk factor for serious complications of COVID-19 and most women who are affected do not transmit the virus to their babies. For those who do, the babies generally experience mild symptoms or none at all. There is a need to develop comprehensive epidemiological data and evidence-based guidelines to support women throughout their pregnancy journey. Attention should also be given to the psychosocial impacts of anxiety related to the fear of COVID-19 in pregnancy and isolation caused by strict social distancing and shielding in pregnancy and postpartum. The focus is now on developing a vaccine for this virus, but we are approximately 12-18 months away from that. Drug trials for therapeutics are also underway which is promising but COVID-19 is likely to dictate our new normal for the months and years ahead.
Disclaimer: This article is intended for information purposes and should not be taken as a substitute for direct medical advice.
WHO Coronavirus Timeline [Accessed 31.05.20]
WHO Coronavirus Dashboard [Accessed 31.05.20]
ACE2 receptor polymorphism: Susceptibility to SARS-CoV-2, hypertension, multi-organ failure, and COVID-19 disease outcome The Journal of Microbiology, Immunology and Infection. https://doi.org/10.1016/j.jmii.2020.04.01
Photos from Unsplash.
About the Author
Originally from Ireland, Emma is a UK-trained midwife who worked in the maternity unit at a busy NHS hospital just outside London. Emma moved to Bangkok with her husband in 2014; they have a 14-year-old son, Toby. Volunteering with BAMBI Bumps and Babies since August 2015, Emma regularly conducts sessions on pregnancy, birth, breastfeeding, and infant first aid. In her spare time, she enjoys baking and Muay Thai and is an active member of her son’s parent group at school.
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