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COVID-19 and expectant mothers: ‘Assume this is dangerous to her and her child’

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The report, issued by the US Centers for Disease Control and Prevention (CDC), found pregnant women with coronavirus are ‘significantly more likely’ to be hospitalised and admitted to intensive care units (ICU) than non-pregnant women of reproductive age with COVID-19.
 
Of the more than 11,000 pregnant women to have contracted the disease, at least 31 have died. Raw data show they had a 50% increased chance of being admitted to ICU, and a 70% higher chance of being intubated than non-pregnant women in their childbearing years.
 
The findings prompted the CDC to revise its advice and state that pregnant women ‘might be at an increased risk for severe illness from COVID-19’.
 
However, the report also exposed crucial gaps in the CDC’s data collection work, which may have affected the findings.
 
Dr Wendy Burton, Chair of the RACGP Specific Interests Antenatal/Postnatal Care network, told newsGP the omission of critical details is ‘disappointing’ as there is still much unknown about the effect of COVID-19 on pregnant women.
 
‘As the US is the leading nation in the world for case numbers, we really want to have this data,’ she said.
 
‘[But] we don’t even know for the women hospitalised, whether they were hospitalised for the birth, or they were hospitalised for COVID – that’s just such a basic [element] to be to be missing.
 
‘The ICU rates and the death rates are more controllable. But even then we don’t know – they could have been admitted to ICU for preeclampsia or something else. You just can’t say that was COVID-related.’
 
Dr Burton said similar reports that have emerged from the UK – in which most infected mothers had good outcomes and transmission of SARS-CoV-2 to infants was uncommon – paint a clearer picture, but she cautioned more research is needed.
 
‘Because it’s new, we just don’t know the end of this story,’ she said.
 
‘We are acting from first principles, and first principles would state that a woman in pregnancy is a higher risk.’
 
Australia has seen a sharp increase in coronavirus cases over the past few weeks, mainly fueled by community transmission in Melbourne, but also now spreading to other states. Victoria recorded another 317 new cases overnight – a new daily record for the state – while NSW is also seeing increased activity.
 
Advice issued by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) in April also states that pregnant women should consider themselves at higher risk. Dr Magdalena Simonis, a GP with a special interest in women’s health and member of the RACGP Expert Committee – Quality Care (REC–QC), says this has not changed.
 
‘It stands to reason that [pregnant] women with underlying chronic disease such as diabetes, cardiovascular disease or autoimmune conditions might be more susceptible to severe forms of the disease,’ she told newsGP.
 
‘Pregnancy should be a time of joy; however, as with most things that have changed, our management of pregnancy should consider COVID-19, as well as encourage bolstering a healthy pregnancy through lifestyle and healthy habits.
 
‘As GPs we should monitor the mental health of our pregnant patients and encourage them that hospital delivery is still the safest way to deliver their baby.
 
‘They should feel safe to attend hospital if there is a medical emergency and be encouraged to receive emotional support from a network of friends and loved ones.’
 
Dr Simonis noted the same missing information in the CDC’s report as Dr Burton, but did point out some of the findings were similar to those produced in other parts of the world.
 
‘[In the CDC study] pregnant women were more likely to be admitted to ICU compared to non-pregnant women and three times more likely to be intubated. A similar Swedish study indicates the rate of ventilation as being four times higher,’ she said. 
 
The CDC paper was released shortly before another study, published in Nature Communications, which confirmed the possibility of transplacental transmission of SARS-CoV-2 infection.
 
Dr Burton said this finding brings the issue of COVID-19 and its effects on pregnancy into sharper focus.
 
‘When we’re talking about pregnant populations, we’re not just talking about one individual, we’re talking about two or more,’ she said.
 
‘You not only have to look at what’s the effect upon the pregnant person, but what’s the effect upon their child or children – and they’re separate issues.
 
‘There’s just layer upon layer of complexity in the pregnant population that makes it quite a different conversation to what it is about any individual who is not pregnant.’

Dr Wendy Burton says GPs should try to limit the number and the length of face-to-face consultations while conducting antenatal care.
 
Both Dr Burton and Dr Simonis also raised concerns over the fact the long-term sequelae in these cases is unknown.
 
‘Despite MRI changes indicating neurological manifestations similar to those seen in adults, the baby [in the study] was discharged 18 days later and the follow-up at two months indicated full recovery, normal growth and no ongoing neurological sequelae,’ Dr Simonis said.
 
‘[But] this is one case study, so we shouldn’t be too comfortable that long-term sequelae do not occur.’
 
What does this mean for GPs?
Dr Simonis recommends the following advice be given to expectant mothers: 

• Hand washing regularly and frequently with an alcohol-based hand rub or soap and water
• Wear a mask in public, at supermarkets and if travelling on public transport
• Avoidance of anyone who is coughing and sneezing
• Avoid touching eyes, nose and mouth
• Social distancing and reducing general community exposure
• Early reporting and investigation of symptoms
• Prompt access to appropriate treatment and supportive measures if infection is significant
• Adhere to the state government advice depending on where you live in Australia and the degree of lockdown
• Limit the support person to one and restrict the number of people who come to visit you at home
• If your partner has COVID-19, or is symptomatic, they should not accompany you to the hospital

 Dr Burton says GPs should try to limit the number and the length of face-to-face consultations while conducting antenatal care, and other practical steps – such as booking pregnant women in for the first appointment of the day – can help mitigate risks.
 
‘How do we continue to provide high-quality antenatal care, but in a way that keeps women and their unborn children safe? That’s what we need to be thinking,’ Dr Burton said.
 
She also suggests that in areas with medium-to-high community transmission, women at low risk of complications related to delaying a pregnancy – such as age – could be encouraged to ‘press pause’ until more is known about the effects COVID-19 can have.
 
‘[Alternatively] to a woman who for various reasons, including, for example, advancing age, I would say, “By all means go ahead and conceive”. But it’s really important that she is very mindful of not getting COVID, because there are still just too many unanswered questions,’ she said.
 
‘We have had some women who have had COVID who have given birth here in Queensland … and so far they’ve done well and their babies have done well.
 
‘[But] when you start to layer risk on risk, then you just have to be on your game … assume that this is dangerous to her and her child.’
 
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