By Oluwatosin Goje, MD
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Emerging infections have an important impact on pregnant women and the unborn child, with increased risk of complications as seen with the 2009 H1N1 influenza virus pandemic and the more recent outbreak of Zika virus infection. This is thought to be a multifactorial problem, due in part to physiologic changes in pregnancy.
COVID-19 is an evolving pandemic, and although the virus has been a serious health threat for months, we still know very little about its effect on pregnant women and infants. Pregnant women have largely been excluded from research and we are relying on the knowledge we gleaned from historical epidemics.
Pregnant women at higher risk of hospitalization
The CDC recently released data indicating that, at 0.2%, death rates among pregnant and non-pregnant women with COVID-19 are the same. Despite this similarity, pregnant women with COVID-19 were 5.4x more likely to be hospitalized, 1.5x more likely to be admitted to the ICU and 1.7x more likely to receive mechanical ventilation.
Still not enough evidence to suggest vertical transmission based on reported cases
Looking at SARS-CoV and MERS-CoV, there is no evidence to suggest vertical transmission from mother to infant, although it’s still very early in COVID-19 to talk about vertical transmission. From recent data reported on COVID-19, there is no evidence for vertical transmission to the fetus although data is very limited. From what we have seen, the primary mode of transmission with COVID-19 appears to be via respiratory droplets. Hopefully, we’ll gain more certainty as new information becomes available.
The recent COVID-19 case series reviewed nine different cases of infected mothers who delivered fairly healthy infants via cesarean section. Researchers tested for SARS-CoV-2 in the amniotic fluid, cord blood, neonatal throat swab and breast milk – these tests all came back negative. The pregnant patients, however, presented with symptoms in their second or third trimesters. Little is known right now about the impact of COVID-19 in the first trimester. Looking again at other viruses and the physiology of pregnancy, we know that when patients have a high fever early in pregnancy, it can increase their risk of certain birth defects. In general, we know that there could be adverse pregnancy outcomes from infections in the first trimester; however, that has not been documented in COVID-19 as of July 13, 2020.
At Cleveland Clinic, we have plans in place for managing both asymptomatic and symptomatic pregnant women. For example, if a pregnant woman presents in with symptoms suggestive of COVID-19 or who is COVID-19 positive or a person under investigation, we will work with our infection prevention colleagues at our delivery hospitals to isolate her in a single person room, which could also be a negative pressure isolation room.
We maintain infection control via cloth face masks and hand hygiene for all patients and caregivers. If a patient wishes to breastfeed and is confirmed to have COVID-19 or is a person under investigation, she must maintain all hygiene precautions including wearing a face mask. Expressing breast milk is preferred, and a dedicated breast pump is given to the mother.
If a new mother is confirmed to have COVID-19, we have plans to reduce exposure of the newborn to the disease, and these include discussing the possibility of separating the mother and the baby as needed, or colocation if that is the mother’s preference. Colocation involves mother and baby sharing a room with a physical barrier (a screen or curtain separating them); in this arrangement, baby’s crib or isolette is kept at least 6 feet away from its mother. We know that separation can be difficult, and will have conversations about the risks and benefits of temporary separation with these patients.
A great time for virtual visits
The Cleveland Clinic Ob/Gyn & Women’s Health Institute has always advocated for virtual care whenever possible, and this is a great time for providers to consider taking some of the prenatal visits online if they haven’t already. Additionally, we are championing telephone triage and virtual visits for respiratory symptoms. Some pregnant patients based on their medical and obstetric history, and need for closer surveillance, will continue to have in-person obstetric visit.
Virtual triage allows us the opportunity to get more history, trace contacts and discuss recent travel. If a pregnant patient needs testing, whether it’s the respiratory viral panel or a test to detect SARS-CoV-2, often times, we can make that decision without a physical exam. If a patient does need to be seen, this triage aids us in getting her to the right location, and allows us time to give the infection prevention team a heads up that she is coming.
Although we are several months in, the COVID-19 pandemic remains an emerging situation. Prior epidemics give us a frame of reference for what can happen with influenza or respiratory viral infections in pregnancy. We’ve not seen vertical transmission of COVID-19 in the cases that have been reported from China. However, that does not mean we will cease taking all preventive precautions.
We’re going to keep working toward preventing any form of transmission because the disease is still evolving. Pregnant patients are considered high-risk for influenza and other respiratory infections — including COVID-19. Pregnant patients should be encouraged to get the influenza vaccine, and to practice hand hygiene, cough etiquette and social distancing.
About the author: Dr. Goje is an Ob/Gyn and a fellowship-trained Reproductive Infectious Diseases specialist.