Pregnancy and COVID-19

We got pregnant with the onset of COVID-19, on November of 2019. In January 2020, we confirmed the news with an ultrasound as global reports of a new coronavirus became more pressing. My partner and I had an idea of how our first pregnancy would go, but our experience really changed with COVID-19 being declared a pandemic by the World Health Organization (WHO), on March 11th, 2020.

The world retreated online. Businesses, hospitals, clinics, and midwifery practices had to adjust to a new normal; in-person appointments became limited to just the birthing person. Our midwifery care has been exceptional and has given opportunities to both my partner and I to be equally involved through phone appointments. But, social distancing, though incredibly important, has really put a damper on our experience. Being away from family, especially, has been hard for us.

These times can be especially alarming for many pregnant and new parents because there does not seem to be enough research, let alone digestible information to communicate what to expect. For this reason, I sought to understand what the data says about COVID-19 exposure and transmission in pregnancy and newborns. This article will also list resources on what to expect during labour, as well as additional physical and mental health resources available for expecting individuals.

COVID-19 Risks in Pregnancy and Newborns

Clinical and epidemiological data from the literature and country reports

There are currently nearly 10 million COVID-19 confirmed cases reported worldwide by the WHO. To date, more than 500 cases of pregnant individuals with COVID-19 have been reported in scientific journals. There are currently 203 reports published in English worldwide. The world is slowly catching up with reporting on COVID-19 in pregnancy and more data is needed.

Most of the published COVID-19 confirmed pregnancy cases to-date are described with mild to moderate respiratory symptoms. Of the reported cases, very few have resulted in death. The data published thus far seems to indicate that the numbers of COVID-19-related severe illness are similar between pregnant and non-pregnant cases. Furthermore, there is little evidence in the literature to indicate a direct risk transmission of COVID-19 from birthing person to child. Though preterm labour has been most often reported, most pregnancies with confirmed COVID-19 have resulted in good outcomes. The number of reported adverse outcomes seems to be directly linked to the health of the labouring person rather than the health of the baby^1-8.

In The Netherlands, there have been 268 reported cases of pregnancies with COVID-19 symptoms to date. This number represents 0.5% of the total number of COVID-19 cases (52,404) reported in The Netherlands until July 24, 2020. Though 13 preterm births (less than 36 weeks) were also reported, only 2 miscarriages have been documented thus far. No newborns have tested positive for COVID-19 thus far and of those born, none have died. The Netherlands also reported that most pregnant individuals experience mild symptoms, with 45.8% reporting coughing, 37.6% fever, and 26.6% shortness of breath. About 10% of the cases have required respiratory support but less than 2% have been admitted to intensive care. Interestingly, they also performed vaginal cultures and only one tested positive for COVID-19. A Chinese study showed that transmission does not seem to happen from birthing person to child regardless of caesarean or vaginal birth⁹. As of July 17th, 13,268 critically ill individuals with confirmed COVID-19 have been admitted to the Intensive Care National Audit and Research Center in England, Northern Ireland and Wales. Of these reported cases, a total of 28 pregnant women have been admitted to hospitals for intensive care, and 14 of them received respiratory support.

Recently, the CDC reported 12,969 cases of pregnant individuals with COVID-19, and 35 deaths resulting from the disease for the period of January 22 to July 21st of this year. Of the reported cases, 27% have resulted in hospitalization, with nearly 5% requiring intensive care and about 2% mechanical ventilation once hospitalized. Most of the reported cases are from Hispanic or Latinx pregnant individuals, or within the age groups of 25 to 34 years old.

Most studies published to-date seem to point out that pregnant individuals might not be at a higher risk than other non-pregnant individuals; however, a recent report by the CDC COVID-19 Emergency Response cautioned that pregnant individuals may have an increased risk for severe COVID-19 illness that results in hospitalization¹⁰. Most COVID-19 disease was reported in pregnant individuals of Hispanic and non-Hispanic Black origin. Poor-quality medical care and outcomes have been reported to disproportionately affect Blacks and Hispanics in the US^11-12, but it remains unclear if these observations might play a role in COVID-19 illness severity in these populations. It is also difficult to conclude whether the report can be extrapolated to other countries worldwide.

In the UK, a study by the UK Obstetrics Surveillance System looked at 427 pregnant individuals admitted to hospitals with confirmed COVID-19 and, like the CDC report, found that more than half of these individuals were black, or of another ethic minority group¹³. The study also found that most women at risk were in the third trimester¹³, emphasizing the need to maintain hand hygiene, to wear masks and keep physical distance. It will be interesting to see the data gathered thus far on the prevalence of COVID-19 in pregnant individuals of different ethnicities in Canada, but such report has not been published yet. Based on these reports and others, the number of cases in these countries seems to reflect the number of reported cases in the bigger population. Other than the US, other countries have not reported drastic ICU or respiratory assistance usage for pregnant individuals, which might be indicative of health accessibility.

Canadian research network gathering data on pregnancy

Though information on pregnancy and coronaviruses is available for SARS and MERS, based on previous outbreaks and Canada’s own experience with a SARS outbreak in 2003, there is not enough evidence of COVID-19 exposure in pregnant individuals to appropriately face the disease. Obstetrician and gynecologist, Dr. Deborah Money, saw the immense need for additional data collection on COVID-19 exposure and transmission in Canadian pregnant individuals, new parents, and newborns. As part of the Infectious Diseases Committee for the Society of Obstetricians and Gynecologists of Canada (SOGC), Dr. Money is leading a large network of researchers and health practitioners in collecting and analyzing data on birthing parents and newborn outcomes from COVID-19 positive or suspected cases for the duration of the pandemic. The data acquired will be used to inform and update guidelines for pregnant individuals and new birthing parents to address the current pandemic and future respiratory pathogen outbreaks.

This network of medical doctors, nurse practitioners, midwives, and researchers, is interspersed throughout Canada, involving all provinces and territories. Information gathered includes the age of birthing individuals and babies from COVID-19 confirmed or suspected cases at the time of contraction or development of symptoms. Furthermore, clinical symptoms, severity of infection (including hospitalization requirements), any pathological signs, newborn weight, and breastfeeding status are being documented. Pregnant individuals and infants born to COVID-19-positive parents are also tested for the presence of the virus whenever possible via a laboratory test (e.g. nasopharyngeal swab). These data will be crucial in the development of protocols for hospitals, clinics, and midwifery care groups to facilitate better care for birthing individuals.

In Ontario, the body collecting this data is the Better Outcomes Registry and Network (BORN), and in May 16th, 2020, they published their first surveillance report online. Their report covers data gathered between March 1st and May 29th, 2020, from 54 hospitals, and 29 midwifery care groups that have participated thus far. BORN’s first surveillance report revealed that Ontario has 27 confirmed cases of COVID-19 pregnant individuals. The data remains preliminary as data continues to be collected from more hospitals and midwifery care groups. Some hospitals and midwifery care groups have experienced delays in reporting, and thus more cases could be reported. As recommended by the Government of Canada, precaution should continue to be exercised for protection, so expecting and new birthing parents are still recommended to keep wearing masks when stepping out to the grocery store, crowded places, and doctor appointments, and to maintain social distancing. Please consult the Government of Canada’s published recommended guidelines for pregnant individuals during the pandemic. The Provincial Council for Maternal and Child Health in Ontario has issued a set of general guidelines for hospitals and midwifery care groups to follow, and they can be viewed here.

Overall, based on the data gathered to date in Canada, pregnant individuals do not seem to be at a higher risk of contracting COVID-19 than the general population, and the clinical presentation of the disease is similar to that observed in the main population (fever, cough, shortness of breath, body aches, fatigue and sore throat). However, more evidence remains to be collected to assess whether transmission can occur via the placenta, during breastfeeding, or at delivery. The next BORN report is expected to expand upon initial findings. Hospitals and midwifery group practices are urged to continue monitoring confirmed and suspected cases, and to visit BORN Ontario for additional details on how to participate in the data collection. This research will ensure that health practitioners are informed about the health of pregnant and new birthing parents to facilitate and continue improving healthcare in Ontario and Canada.

COVID-19 Guidelines for Birth in Canada

Preparing for birth for first time parents can feel overwhelming. Certainly, understanding what to expect for birth during this pandemic can also feel stressful. However, new parents in Canada can rest assured that several guidelines have been implemented by the Provincial Council for Maternal and Child Health in every province to ensure the health of the newborn and that of the labouring person. I compiled information available from Cambridge Memorial Hospital and Cambridge Midwives who kindly provided pamphlets for more information. I should note that there are small differences across different birth centers and hospitals within the same province and across provinces in Canada. I invite you to consult your local hospital’s website for more information.

Hospital Births

Your labour has started, you have your hospital bag ready, and you are on your way to the hospital. Once at the hospital, both you and your partner will be checked for COVID-19 symptoms. Similarly to what you might have experienced at your healthcare provider’s office or clinic when going for prenatal appointments, you will be asked if:

1) You have tested positive for COVID-19 or have been in contact with someone who has tested positive for COVID-19,
2) You have travelled outside of Canada, or have been in contact with someone who has travelled outside of Canada within the last 14 days
3) You have had a fever, or a cough within the last 48 hours.

You will also likely be screened for fever and physical symptoms such as shortness of breath. You might also be asked about other COVID-19 related symptoms such as sore throat, difficulty swallowing, headaches, increased tiredness and/or muscle aches, nausea, vomiting, diarrhea and/or abdominal pain unrelated to contractions, decrease or loss of sense of smell and/or taste, chills, and runny nose or nasal congestion unrelated to allergies or other causes.

In the event that you have COVID-19 symptoms, both you and your partner will be tested for COVID-19 using a lab-based test such as a nasopharyngeal or throat swab to confirm for the presence of the virus. Upon arrival, only you as the labouring person will be admitted to the birthing area after screening. If your partner has passed screening and does not exhibit COVID-19 symptoms, they will also be allowed to join you. You may or may not be admitted depending on how much you have progressed in labour. Pregnant individuals might be recommended to stay at home during early labour.

At admission, you will be asked to wear personal protective equipment (PPE), including gowns, gloves, and masks. Neither you nor your support person should leave your assigned room. This will ensure exposure is limited. If you are intending to walk to ease labour, you will have to do so within the allocated room. If you are hungry, meals will be brought to you. It might be wise to pack some snacks in your hospital bag. Once admitted, your support person or birthing partner can stay with you for the entire labour and delivery.

For the entire labour process at the hospital, including delivery and post-partum chest-to-chest and nursing, you will be required to wear a mask. All hospital personnel attending you including your Ob-Gyn, midwives and/or nurses will be wearing PPE, including surgical masks. If you have tested positive for COVID-19, your baby will also be tested for the presence of the virus with a nasopharyngeal or umbilical swab lab test. This might be uncomfortable but it is a small inconvenience to endure for a healthy baby. Your support partner (your designated labour partner – e.g. husband, common-law partner, parent) will be allowed to stay with you in the post-partum unit; however, should your support person decide to leave, they will not be permitted to come back that day, and for the remainder of your time at the post-partum unit, your support person will only be allowed one visit each day. Finally, in the event your newborn requires special care, your support person will be allowed to visit the baby, as long as the labouring person remains admitted. However, once discharged, only one parent will be allowed to visit the baby.

Any visitor intending to visit newborns is expected to stay for the duration of their visit, and exit the room only once they are ready to leave for the day as they will not be allowed back until the next day. Twins up to 4 years of age will be allowed up to two visitors only, including parents. Leaving the room includes purchasing meals. Hospital staff will help you with meals should you stay for a long period of time in the Special Care Nursery or pediatric unit.

Home Births

If you are choosing to give birth at home, the Association of Ontario Midwives (AOM), recommends that adequate PPE (surgical mask, gloves, and gown) be available at home for those wishing to pursue home births. Just as in the hospital, your midwife will be wearing PPE that includes a surgical mask. You and others in your home will also be screened for COVID-19 symptoms prior to the midwives coming into your home. Following midwifery care mandates, if COVID-19 is suspected, an informed choice discussion will follow to assess the choice of birth place; in other words, if the severity of your symptoms is deemed high enough or there is no adequate PPE available, you might be recommended to give birth at the hospital. Family members other than the supporting partner and labouring person will be limited from being present at the birth. Furthermore, everyone, except for the supporting person, will be asked to wear masks, practice physical distancing, and frequent hand washing. Your supporting person or other family members will be asked to ensure that surfaces are also frequently disinfected with household cleaners.

If you are suspected of COVID-19 symptoms, your midwife will monitor your breathing, and temperature every hour. The baby’s health will be monitored frequently within the hour. Once born, your baby will be tested for the presence of the virus with a nasopharyngeal or umbilical swab. Because some studies have shown that SARS-CoV-2 can be found in feces^14-16, and because it is common to pass stool during birth, water birth is not currently recommended to decrease fecal-oral transmission. Hydrotherapy is also not recommended as the excessive use of PPE might be required due to gloves and gowns getting wet, leading to unnecessary waste. PPE is currently in high demand.

Additional Resources for maternal health during COVID-19

Other than the links provided throughout this article, the following resources are available to support pregnant parents during this time.

References

1. Chen, H. et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 395, 809-815, doi:10.1016/S0140-6736(20)30360-3 (2020).
2. Chen, L. et al. Clinical Characteristics of Pregnant Women with Covid-19 in Wuhan, China. N Engl J Med 382, e100, doi:10.1056/NEJMc2009226 (2020).
3. Breslin, N. et al. COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM, 100118, doi:10.1016/j.ajogmf.2020.100118 (2020).
4. Chen, R. et al. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anaesth 67, 655-663, doi:10.1007/s12630-020-01630-7 (2020).
5. Chen, S. et al. [Pregnancy with new coronavirus infection: clinical characteristics and placental pathological analysis of three cases]. Zhonghua Bing Li Xue Za Zhi 49, 418-423, doi:10.3760/cma.j.cn112151-20200225-00138 (2020).
6. Chen, Y. et al. Infants Born to Mothers With a New Coronavirus (COVID-19). Front Pediatr 8, 104, doi:10.3389/fped.2020.00104 (2020).
7. Khan, S. et al. Impact of COVID-19 infection on pregnancy outcomes and the risk of maternal-to-neonatal intrapartum transmission of COVID-19 during natural birth. Infect Control Hosp Epidemiol 41, 748-750, doi:10.1017/ice.2020.84 (2020).
8. Vintzileos, W. S. et al. Screening all pregnant women admitted to labor and delivery for the virus responsible for coronavirus disease 2019. Am J Obstet Gynecol, doi:10.1016/j.ajog.2020.04.024 (2020).
9. Wu, Y. et al. Coronavirus disease 2019 among pregnant Chinese women: case series data on the safety of vaginal birth and breastfeeding. BJOG, doi:10.1111/1471-0528.16276 (2020).
10. Ellington, S. et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status – United States, January 22-June 7, 2020. Report No. 1545-861X (Electronic) 0149-2195 (Linking), 769-775 (Centres for Disease Control, Morbidity and Mortality Weekly Report (MMWR), 2020).
11. Quality, A. f. H. R. a. Disparities in Health Care Quality among Racial and Ethnic Minority Groups: Selected Findings from the AHRQ 2010 NHQR and NHDR. (Rockville, MD, 2010).
12. Hostetter, M. & Klein, S. In Focus: Reducing Racial Disparities in Health Care by Confronting Racism, (2018).
13. Knight, M. et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 369, m2107, doi:10.1136/bmj.m2107 (2020).
14. Zhang, J., Wang, S. & Xue, Y. Fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia. J Med Virol 92, 680-682, doi:10.1002/jmv.25742 (2020).
15. Zhang, Y. et al. Isolation of 2019-nCoV from a Stool Specimen of a Laboratory-Confirmed Case of the Coronavirus Disease 2019 (COVID-19). China CDC Weekly 2, 123-124, doi:10.46234/ccdcw2020.033 (2020).
16. Holshue, M. L. et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med 382, 929-936, doi:10.1056/NEJMoa2001191 (2020).