November 24, 2020

Management of Pregnant Women With COVID-19 Infection Proves Complex

Preterm delivery and other complications of COVID-19 in pregnancy

pregnancy&cancer_650x450

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

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Severe illness and adverse birth outcomes were observed among hospitalized pregnant women with COVID-19.

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.

Advertisement

“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.

Advertisement

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.

Related Articles

Stellate Ganglion Block
May 17, 2023
Nerve Block Shows Promise for Long COVID-Related Olfactory or Gustatory Dysfunction

Patients report improved sense of smell and taste

Covid image
April 26, 2023
What Long COVID Means for Rheumatologists (Video)

Clinicians who are accustomed to uncertainty can do well by patients

Covid related skin effects
April 4, 2023
Cutaneous Manifestations of COVID-19 in Special Populations

Unique skin changes can occur after infection or vaccine

Glucometer
February 10, 2023
Effects of COVID-19 on Blood Sugar and Type 2 Diabetes

Cleveland Clinic analysis suggests that obtaining care for the virus might reveal a previously undiagnosed condition

covid-19
January 13, 2023
Optimal Management of High Risk Immunocompromised Patients in the COVID-19 Era

As the pandemic evolves, rheumatologists must continue to be mindful of most vulnerable patients

covid-19 virus
January 12, 2023
Real World Experience with Tixagevimab/Cilgavimab in B-Cell-Depleted Patients

Early results suggest positive outcomes from COVID-19 PrEP treatment

Eosinophilic Fasciitis
November 29, 2022
New Onset Eosinophilic Fasciitis after COVID-19 Infection

Could the virus have caused the condition or triggered previously undiagnosed disease?

COVID-19 and rash
June 16, 2022
Common Skin Signs of COVID-19 in Adults: An Update

Five categories of cutaneous abnormalities are associated with COVID-19

Ad