Management of Pregnant Women With COVID-19 Infection Proves Complex

Emerging infections can have an important impact on pregnant women and their unborn children, leading to an increased risk of complications. SARS-CoV-2 is no exception, and as the COVID-19 pandemic has evolved, data have emerged indicating that pregnant women with the virus are 5.4x more likely to be hospitalized, 1.5x more likely to be admitted to the intensive care unit (ICU) and 1.7x more likely to receive mechanical ventilation than women who are not pregnant.1

The Cleveland Clinic Women’s Health Institute (WHI) has taken steps during the public health crisis to prevent transmission of the virus to mothers-to-be and to promote healthy pregnancies. Researchers at the institution also are helping lead a city-wide, multi-institution study of COVID-19 on maternal and fetal health.

Pregnancy management during the pandemic

The WHI has been at the forefront in advocating for virtual care whenever possible. The staff also is championing telephone triage and virtual visits for respiratory symptoms. In-person visits continue for some pregnant patients based on their medical and obstetric history and their need for closer surveillance.

Pregnant patients are considered high-risk for influenza and other respiratory infections — including COVID-19. They are encouraged to get the influenza vaccine, and to practice hand hygiene, cough etiquette and social distancing.

In the CDC report,1 symptomatic nonpregnant women with COVID-19 reported higher frequencies of headache, muscle aches, fever, chills and diarrhea than symptomatic pregnant women with the virus. The severity of some symptoms appears to be higher in pregnant women with COVID-19 than in the nonpregnant cohort, as 31.5% of pregnant women with the virus were hospitalized compared with 5.8% of nonpregnant women.

“Management of pregnant women with COVID-19 is complex, as they have increased risk of complications, such as ICU admission and intubation, in part due to physiologic, anatomic and immunologic changes in pregnancy,” says Oluwatosin Goje, MD, an Ob/Gyn and fellowship-trained reproductive infectious diseases specialist. “This is in line with our experience in prior public health crises, like the 2009 H1N1 influenza virus pandemic and the Zika virus outbreak.”

Preterm delivery and other complications of COVID-19 in pregnancy

Emerging studies also point to a higher risk of preterm birth and prematurity in pregnant women with COVID-19, with incidence of 28%.2 More recently, a retrospective analysis of a much smaller cohort of patients from rural France reported preterm delivery in 36% of patients.3

“Prematurity is one of the complications you’ll find when pregnant women become very sick with COVID-19,” says Dr. Goje. Among pregnancies resulting in live births, pregnant women with symptomatic COVID-19 infection were about 3x more likely to deliver preterm; specifically preterm delivery was reported for 23.1% of symptomatic women and 8.0% of asymptomatic women.4

That point was brought home by the recent case of a woman in her early 30s in her late second trimester, who presented to the emergency department for weakness, myalgia, subjective fever and a dry cough. Like her husband, she tested positive for SARS-CoV-2. She was admitted into the hospital due to the severity of symptoms and managed per protocol; she received betamethasone and magnesium sulfate after the possibility of early delivery was discussed in multidisciplinary meetings. When her disease progressed and she went into respiratory failure, she was intubated and her infant delivered by cesarean section at 26w2d. Unfortunately, the child died of complications of extreme prematurity. Thanks to the excellent care of maternal-fetal-medicine experts at Cleveland Clinic, the mother recovered and was discharged home seven days after the procedure.

Says Dr. Goje, “COVID-19 is novel and we are still gathering information about optimal management of women who are pregnant and positive for COVID-19. It is well-known in the MFM literature, however, that delivery can help to treat mothers in the setting of worsening respiratory failure, and with intermittent hypoxia, fetal well-being is at risk in utero.”

Research desperately needed

Severe illness and adverse birth outcomes were observed among hospitalized pregnant women with COVID-19. Further research is desperately needed, according to Dr. Goje, on COVID-19 in pregnancy, including what impact other comorbidities may have on outcomes in this population. The limited data that exist about transmission of COVID-19 during pregnancy and delivery indicate that the virus may cross and infect the placenta, which raises concerns about vertical transmission.

That very issue will be investigated in the collaborative study between Cleveland Clinic, University Hospitals Cleveland Medical Center, and Cleveland’s MetroHealth System, in conjunction with Case Western Reserve University and the National Institutes of Health. Key questions include when transmission might occur during pregnancy and what the effects are for both maternal and fetal health.5 These findings highlight the importance of preventing and identify­ing COVID-19 in pregnant women.

References

1. Ellington S, Strid P, Tong VT, et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 Infection by Pregnancy Status — January 22–June 7, 2020. Morbidity and Mortality Weekly Report (MMWR). 2020 Jun;69(25);769-775.
2. Trippella G, Ciarcia M, Ferrari M, et al. COVID-19 in pregnant women and neonates: a systematic review of the literature with quality assessment of the studies. Pathogens. 2020 Jun;9(6):485.
3. Vivanti AJ, Mattern J, Vauloup-Fellous C, et al. Retrospective description of pregnant women infected with severe acute respiratory syndrome coronavirus 2, France. Emerg Infect Dis. 2020 Sep;26(9)2069-2076.
4. Delahoy, MJ, Whitaker M, O’Halloran A. Characteristics and maternal and birth outcomes of hospitalized pregnant women with laboratory-confirmed COVID-19 — COVID-NET, 13 states, March 1–August 22, 2020. Morbidity and Mortality Weekly Report (MMWR). 2020 Sept 25;69(38);1347-1354.
5. Farrell R, Michie M, Pope R. Pregnant women in trials of COVID-19: a critical time to consider ethical frameworks of inclusion in clinical trials. Ethics Hum Res. 2020 Jun;42(4):17-23.