Though hospitals, clinics, and doctors are busier than ever, many patients feel alienated by the healthcare system and left in the dark about what happens next in their fertility and pregnancy journeys. We had the opportunity to hear from the front lines with OBGYN Dr. Naz as she shared some first-hand advice about coronavirus and pregnancy.
**Please realize answers to these questions may change as we learn more about COVID-19.
What is known about COVID-19 in pregnancy?
Currently, there is limited information from published scientific reports about the susceptibility of pregnant women to COVID-19 and the severity of infection. The available data are reassuring, but limited to small case series. In general, pregnant women experience immunologic and physiologic changes that make them more susceptible to viral respiratory infections, including potentially COVID-19.
It is reasonable to predict that pregnant women might be at greater risk for severe illness, morbidity, or mortality compared with the general population, as is observed with other related coronavirus infections [including severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)], and other viral respiratory infections, such as influenza, during pregnancy.
Data from MERS-CoV and SARS-CoV, although limited, suggest that infection in pregnancy may be associated with severe infection and adverse neonatal outcomes, including increased risk of miscarriage, fetal growth restriction, and preterm birth. But again, data specific to COVID-19 are not yet available.
The currently published data on COVID-19 infection in pregnancy include two case series, totaling 18 women, only one of whom suffered severe respiratory morbidity requiring intensive care unit admission and mechanical ventilation (lower than the reported general population risk).
While these data are reassuring that pregnant women did not have severe outcomes, they must be interpreted with caution given the small numbers. At this time, it appears that severe illness from COVID-19 occurs predominantly among the elderly and those with significant medical comorbidities.
Does getting pregnant have risks?
In terms of risks for pregnancy including miscarriage or congenital anomalies, there is very limited data regarding risks associated with infection in the first and second trimesters. There is mixed data regarding the risk of congenital malformations in the setting of maternal fever in general. Additionally, there is an inadequate amount of data on COVID-19 and the risk of miscarriage or congenital anomalies. However, data from the SARS epidemic are reassuring, suggesting no increased risk of fetal loss or congenital anomalies associated with infection early in pregnancy.
The ASRM states that if you’re at risk or have confirmed COVID-19, you should avoid pregnancy, but there is no cause for alarm if you’re already pregnant. Thus, given the information we do have, while it would be wise for individuals with confirmed or presumed COVID-19 infection to avoid pregnancy, there appears to be no cause for alarm for those already pregnant.
Nonetheless, out of an abundance of caution, patients who have high likelihood of having COVID-19 (fever and/or cough, shortness of breath, and either exposure within 6 feet of a confirmed COVID-19 patient and within 14 days of onset of symptoms, or a positive COVID-19 test result), including those planning to use oocyte donors, sperm donors, or gestational carriers, should strive to avoid a pregnancy. If these patients are undergoing active infertility treatment, we suggest that they consider freezing all oocytes or embryos and avoid an embryo transfer until they are disease-free.
Should obstetric care appointments be altered?
Alternate prenatal care schedules have been proposed as a strategy in the effort to control the spread of COVID-19. Community mitigation efforts are important; however, the implementation of such strategies will depend on local practice and population factors and resources. Where available, telehealth (including telephonic and other remote services) can be a tool leveraged to allow access to care for these patients while implementing community mitigation efforts.
OBGYNs and other prenatal care practitioners should ensure that patients with certain high-risk conditions continue to be provided necessary prenatal care and antenatal surveillance when indicated.
What about prenatal visits?
There are parts of prenatal care that have to be in-person: ultrasounds, bloodwork, and genetic testing, if you choose to pursue. Some places are trying to bundle care.
I tell my patients, I'm not trying to see you less or provide less care. We’re just thinking about how we can efficiently provide your care in fewer in-person visits and then use telehealth for check-ins. I recommend that my patients purchase a blood pressure cuff (not a wrist one) to use at home as blood pressure is one of the most important vitals that we want to follow. And once the baby is moving more consistently, we can use kick counts to evaluate fetal well-being—I don’t think people need to go out and buy dopplers.
Has anyone heard whether OB practices are loosening their video/facetime policies if they are not permitting a spouse/partner attend appointments with you?
I think most health care providers would welcome use of FaceTime to include a support person for office visits and counseling. At my institution, we've been encouraging it! Four ears are better than two with these difficult conversations!
Are there delivery considerations?
Timing of delivery, in most cases, should not be dictated by maternal COVID-19 infection. For women infected early in pregnancy who recover, no alteration to the usual timing of delivery is necessary. For women infected in the third trimester who recover, it is reasonable to attempt to postpone delivery (if no other medical indications arise) either until a negative testing result is obtained or quarantine status is lifted in an attempt to avoid transmission to the neonate.
In general, COVID-19 infection itself is not an indication for delivery. The reported series have included primarily cesarean deliveries, but the mode of delivery should be dictated by usual obstetric practice. The youngest individual to have documented infection with COVID-19 was a 36-hour-old neonate born by cesarean delivery, suggesting neonatal rather than vertical transmission.
At this time, the CDC recommends that facilities should consider temporarily separating (eg, separate rooms) a woman with confirmed COVID-19 or who is a PUI for COVID-19 from her infant until the woman’s transmission-based precautions are discontinued. Maternal-fetal medicine subspecialists are encouraged to check the CDC site frequently, as new guidance is added daily.
What do you think about no partners in the delivery room? How long do you think that will last?
I find it heartbreaking, and I know at our institution (USCF) we are working hard to ensure one support person is available. For friends of mine who may be facing this, I ask them to understand where this is coming from and look for innovative ways to include their partners (FaceTime, Skype, etc). And please know that health care providers will be supportive (we can't replace family, but this is part of why we entered our fields).
What's the policy on doulas? What is your take on if hospitals will allow doulas?
In most places the doula counts as the support person. It's a really strict limit on one support person. Whether you want to utilize a postpartum doula in the house is something that you can consider, potentially, if circumstances are very dire, but this is why many hospital settings are working so hard to address risk reduction. I think the medical community is very much aware of the importance of having support during this time.
What do you think about home birth during these times?
I read a really great open letter from the New York Homebirth Collective to the birth community to address the number of questions people had regarding the option of home birth
“People choose to have a homebirth because they seek autonomy in their pregnancy and birth because they believe home is the safest place to give birth, or because they desire to experience all that homebirth offers, from the intense and challenging to the joyful and transcendent. Fear and panic do not lend themselves to an empowering homebirth.”
This is true, generally, and it is true now during what is unequivocally a scary time for so many of us. If a pregnant person originally chose a hospital because they believed it to be the safest location in which to give birth, that belief continues to make the hospital the safest place for that person to give birth.
Is there evidence of vertical transmission of COVID-19?
Researchers found no evidence of COVID-19 in the amniotic fluid or cord blood of 6 infants of infected women. While this report includes only a small number of cases, the lack of vertical transmission is consistent with what is seen with other common respiratory viral illnesses in pregnancy, such as influenza.
I am pregnant and work in a healthcare position. Is it safe to continue to work if I am exposed to a wide range of patients?
The American College of OBGYN (ACOG) says: “Pregnant healthcare personnel (HCP) should follow risk assessment and infection control guidelines for HCP exposed to patients with suspected or confirmed COVID-19. Facilities may want to consider limiting exposure of pregnant HCP to patients with confirmed or suspected COVID-19, especially during higher risk procedures (e.g., aerosol-generating procedures) if feasible based on staffing availability.”
Society for Maternal-Fetal Medicine (SMFM) also states: “Pregnant healthcare personnel (HCP) should follow the Centers for Disease Control risk assessment and infection control guidelines for HCP with potential exposure to patients with suspected or confirmed COVID-19. While pregnant HCP may continue to work, facilities may want to consider limiting their exposure to patients with confirmed or suspected COVID- 19, especially during higher risk procedures (e.g., aerosol-generation.)”
This is to say—if you're a health care provider or staff, you can talk to your manager or boss to see if there are opportunities to reduce patient-facing roles. In our department (at USCF), we've asked that all pregnant doctors continue telehealth visits, but have taken them off labor and delivery and in-person clinic visits.
For more COVID-19 reproductive health updates and guidance from OBGYNs, check out our full library of COVID-19 resources to support you during this time.