covid-19 + pregnancy: emerging information to know

by c. anne patterson, m.d. and tanya mack, rn

Within the past year of the global COVID-19 pandemic, much has been learned about the effects of this virus during pregnancy, but there are still many questions and much more to learn. Emerging information changes frequently. COVID-19 vaccination, viral transmission, and the effects of COVID on pregnancy are paramount for many pregnant women globally. In general, emerging information in this field is sparse, but what is surfacing is reassuring.

COVID-19 Vaccines + Pregnancy

Current Vaccination Recommendations: Pregnant women were excluded from the initial clinical trials by the COVID-19 US vaccine manufacturers. It is also understandable for people to be apprehensive about any new vaccine. Whether pregnancy increases a women’s susceptibility to COVID-19 viral infection is also unknown. Most of the current experience has come from vaccine trial volunteers who became pregnant during the clinical trials. The UK documented 53 pregnancies that occurred during trials of 3 vaccines. To date there have been no reported adverse outcomes from the various COVID-19 vaccines as it relates to pregnancy or the fetus. Nearly all vaccines are allowed in pregnancy if the benefits outweigh the risks --- with the exception of liveattenuated viruses (like the MMR vaccine). Since mRNA is the primary mechanism in the effectiveness of the first two COVID-19 vaccines in the US, there should be no adverse outcome for the fetus. This has been demonstrated form 16 years of experience with reassuring results in other mRNA vaccination.

Accepting the COVID-19 vaccine while pregnant is a personal decision; accurate information helps patients make this decision. Although more studies are underway on this topic, top agencies have weighed in. The American College of Obstetrics and Gynecology (ACOG), the Centers for Disease Control (CDC) and the Society for Maternal Fetal Medicine (SMFM) all recommend that pregnant women who meet the current criteria for vaccination discuss the COVID-19 vaccine with their healthcare provider and subsequently, may choose to be vaccinated. The World Health Organization reworded its advice on this topic in January 2021 stating that there is “no reason to believe that the risks outweigh the benefits of pregnant women being vaccinated for COVID-19.” As of February 2021, greater than 20,000 pregnant women in the US have received the COVID-19 vaccine and “no red flags have been raised.” COVID-19 Vaccination and Breastfeeding: ACOG currently recommends that COVID-19 vaccines be offered to lactating women who meet the current vaccination criteria.

COVID-19 Vaccination and Fertility: So far, there has been no evidence of COVID-19 vaccines affecting fertility. Still, some rumors surfaced earlier this year suggesting antibodies elicited by the COVID-19 vaccine affect a women’s fertility, but this rumor has since been refuted by the scientific community. There is no clinical evidence that indicates that the COVID-19 vaccine prevents pregnancy in humans. Similarly, follow-up of the vaccine trial volunteers, who became pregnant during the clinical trials, has shown no documented detrimental effect of vaccination on early pregnancy.

COVID-19 Transmission During Pregnancy + Post-Partum

Intrauterine Transmission: Intrauterine transmission has been documented, but appears rare for unknown reasons. Less than 1% of newborns born to COVID-19 positive mothers tested positive after delivery. However, it is unknown whether transmission occurred in utero or at delivery. This is presently being evaluated. In one CDC study, 42 infants born to COVID-19 positive mothers tested positive for COVID immediately at birth. However, 1,160 of the followed infant group in the study tested negative. Most hospitals have instituted new COVID policies that include labor and delivery. Women presenting to the Labor and Delivery (L+D) unit are now routinely screened for COVID infection and CDC precautions are followed closely. Many hospitals have also changed other Labor and Delivery policies to adapt to the COVID pandemic. For example, most hospital L+D units restrict those attending the birth process with the mother to one person. Obstetricians are also utilizing telehealth calls for postpartum follow-up appointments versus in-person visits. Transmission via Breastmilk: Mother to infant COVID transmission in the post-partum period via breastmilk appears “unlikely”, especially when using precautions like: wearing a mask during breastfeeding, washing hands, breast hygiene, and following other recommended CDC guidelines.

COVID-19 Infection During Pregnancy

General Study Findings: Findings relating to the effect of COVID-19 infections in pregnant patients have been inconsistent and are continuing; however, some significant facts have emerged at the one-year connexions 33

mark of the pandemic. One study that followed women who were infected with COVID-19 just prior to conception or were infected in early pregnancy, were no more likely to miscarry than the general population. A CDC study of > 450,000 women infected with the COVID-19 virus during pregnancy indicated that pregnant women, as a group, are at risk for severe complications of COVID-19. A JAMA Insight communication from February 8, 2021 reported that some studies suggest that pre-term birth might occur more often for infants born to COVID-19 infected mothers. Another study demonstrated that pregnant patients with a COVID-19 infection might be more likely to have increased risk of advanced pregnancy complications, especially if they also had comorbidities such as obesity, hypertension, and diabetes. According to a recent report in Beckers Hospital Review dated February 4, 2021, in the US, from January 22 to February 1, 2021, 64,075 pregnant women tested positive for COVID-19 during their pregnancy. Of these women, there were 74 COVID-19 related deaths. Again, studies are showing that it is plausible that COVID-19 vaccination will reduce these risks.

New Study Findings on Pregnancy Complications with Severe COVID-19 Cases: A recent study released by the University of Utah in February 2021 reported that pregnant women, who contracted COVID-19 while pregnant and showed severe COVID-related complications, were at increased risk of dying or having serious complications when compared to infected patients who were asymptomatic or experienced mild to moderate COVID symptoms. This study examined 1,219 pregnant women who tested positive for COVID in a 5-month time period in 33 hospitals across 14 states in the US. Most of the women in this study were in their third trimester. Regarding COVID symptoms: 47% were asymptomatic, 41% had mild to moderate symptoms, and 12% had severe or critical symptoms. Here are some of the results:

*12% of the women who became critically ill had comorbidities (HTN, diabetes, liver disease or obesity) *These women were at risk for poor advanced pregnancy outcomes (pre-term births, ICU admissions, hemorrhage) *60% of these patients had a C-section delivery and 50% had NICU babies

*Women with mild to moderate symptoms did not have greater risk of advanced pregnancy complications

Conclusion

While learning continues across the globe as it relates to the effect of COVID-19 and all aspects of pregnancy, there are still many questions to be answered. COVID-19 vaccination during pregnancy is recommended and consistently appears to reduce the risk of advanced COVID-19-related pregnancy complications. Patients can follow the updates on this topic on the CDC, WHO, ACOG and SMFM websites for the latest information.

RESOURCES: Male, V. Are COVID-19 vaccines safe in pregnancy?. Nat Rev Immunol ). https://doi.org/10.1038/s41577-02100525-y. Published 03 March 2021. Metzger, Kylene. “New Research Finds Pregnancy Complications in Severe COVID-19 Cases.” Healthcare, University of Utah. https://healthcare.utah.edu/ healthfeed/postings/2021/02/ covid19-pregnancy-research.php. Published 12 February 2021. Rasmussen MD, MS Sonja A. and Jamieson, MD, MPH, Denise. Pregnancy, Post-Partum Care and COVID-19 Vaccination in 2021. JAMA Insights. https:// jamanetwork.com/journals/jama/ fullarticle/2776447. Published 8 February 2021

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