March 24, 2020

Covid-19 and need for research on its impact on pregnancy, birth and fetal-newborn outcomes

Just a few days ago a young woman who works at my retirement community told me that she has many friends who are pregnant and several just about to deliver. They are scared especially since we do not know much about the virus and birth. The virus she is talking about is no surprise, SARS-CoV2 which is the cause of Covid-19. Little is known of the natural history of Covid-19 in pregnancy at the present moment. The physiological alterations of pregnancy including the dampening of the immune system and the changes in the respiratory system as well enhance the pregnant women’s susceptibility to infectious disease and presumably to Covid-19. There have been a few small case studies that have been reported so far. There does not appear so far to be evidence that the SRAS-CoV2 can be transmitted across the placenta. However, it is possible that has infants are born vaginally they might get infected by exposure to the maternal microbiome. Since SARS-CoV2 is 79% similar to SARS-CoV1, the virus that causes severe acute respiratory syndrome,(SARS) studies of that virus during pregnancy and birth have been reviewed for clues to the impact of SARS-CoV2 on pregnancy and birth. These studies on SARS-CoV1 are limited as well but suggest that pregnancy maybe associated with severe disease if the mother develops SARS. SARS is associated with increased risk of spontaneous abortion ( miscarriage) fetal growth restriction and preterm births.

The US Centers for Disease Control and the professional societies of physicians – obstetricians and pediatricians as well as nurse-midwifery organizations have already considered these concerns and published guidelines for care. Duke Medical School where I am an Emerita Professor has established a special out patient facility for pregnant patients from all of their Duke Health system facilities and practices who develop the Covid-19 infection will be given prenatal care. Furthermore, they have established protocols for pregnant patients during labor and delivery. I am certain that they are not alone and that all hospitals and health systems across the county are doing similar things. Nurse-midwifes have written protocols and have conducted nationwide discussions regarding the care of their patients. I am certain that these protocols will change as we begin to understand this pandemic disease. The protocols are designed ensure the safety of mother and baby and will also protect the individuals giving care who are all at risk for acquiring the infection. If they get sick, they will need to stop working and that cannot happen. Some of parts of the protocols are upsetting to young families as visitors need to be limited so education of childbearing women and families are essential.

I am certain that my colleagues will all work very hard and will do so magnificently to care for all pregnancy women, their infants and families. I also am certain that they will learn many things about how this novel virus impacts reproduction and birth as time moves forward. During this very busy and chaotic time I hope that they will all understand the need for research. I am aware that it is very hard to remember to collect information when one is so busy, so tired and so fearful of what everything means. Information about SARS-CoV2 and Covid-19 is changing every day. The University of California San Francisco has established a national registry for pregnant women with Covid-19 to begin to discover outcomes

As I write this blog, we are learning more about how the virus spreads when a person has no symptoms. Do we need to need to begin to use universal precautions to protect everyone including those providing care? Do we need to test all pregnant women? What happens if a woman is infected but not symptomatic when she starts labor? Are there maternal “host factors” that are important in acquiring the disease or in its severity? How does the clinical classification of mild, moderate and serve Covid-19 impact pregnancy and fetal transmission? We know very little about the transmission of the virus to infants. We need to find out. As obstetricians, nurse-midwives, nurses, pediatricians, infectious disease specialists, intensivists and all others care for pregnant mothers and then their newborns we need to very carefully enter data into the record so that future research can be done. This is hard as all struggle to enter data into the electronic record now, and it will be even harder as the disease spreads. We need to set up ongoing studies that record information in real time patient histories, clinical course, outcomes, careful information of fetal growth, gestational age, all lab tests, course of pregnancy and labor, in short everything we think of. We need to determine the viral load of women with Covid-19 and how that effects pregnancy outcome. We need to think of testing pregnant women for the virus. There is new test that can be used in a clinical setting which provides results in 45 minutes. Is this something that can be used in the prenatal and birth settings? If we need to obtain amniotic fluid for any reason, a sample needs to be saved for further studies. We need to collect and save all cord blood for future studies and carefully observe all placentas. Research studies should save placental tissue for histopathology as well as viral load and studies of viral infiltration into the trophoblast and chorion. We need to carefully evaluate women at all stages of pregnancy and carefully record body temperature so that fever can be correlated with fetal and infant outcome. It can be hard to obtain tissue at the time of miscarriage but it can and should be done to determine if the virus is present. Covid -19 causes thrombocytopenia. How does this impact obstetrical hemorrhaging? We also need to observe and record the amount and types of stress pregnant women are under now. Does this increase in stress cause an increase in pregnancy complications such as preeclampsia, and preterm birth? What strategies can be developed and used to prevent stress? Can we develop virtual prenatal group care for some prenatal visits? For prenatal education? It is very important that we figure out ways to include fathers in the process of care and at the time of birth. We need new, flexible programs that will be safe, prevent contagion but at the same time enhance the family. Are we able to ensure that pregnant women are getting the nutrition they need? If not what programs to we need to ensure that this happens? How can we best provide education to pregnant women and their families about the virus and also about pregnancy and birth itself? There is no evidence that the virus is in breastmilk , but do we really know? We think women if they are sick should express breastmilk. But can they safely nurse if they take excellent precautions to prevent viral spread to their infant? It is also critical that pregnant women be included in clinical trials of treatment and in vaccine trials. I hope and trust that my colleagues at NIH are listening and over the next five or more years provide funding for important research and clinical trials. While the question of male reproductive health, especially the impact of the SARS-CoV2 on spermatogenesis is not crucial right now, it needs to be addressed in the near future. Can we develop pregnant animal models for Covid-19? Animal models for the impact of this novel virus on spermatogenesis? I am confident that we as professional can do all of this. We need to do all this and even answer more questions as SARS-CoV2 is going to be around for a long time. If we are successful, young women will not be scared in the future. Healthy reproduction is imperative if humans are to live on this planet.

Further reading and information:

Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and Pregnancy: What obstetricians need to know. American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/j.ajog.2020.02.017

Schwartz DA, Graham AL. Potential maternal and infant outcomes from (Wuhan) coronavirus 2019-nCoV infecting pregnant women: lessons form SARS, MERS, and other human coronavirus infections. Viruses. 2020 Feb 10:12(2). pii:E194,doi 10,3390/v12020194.

Comment: What are the risks of COVID-19 infection in pregnant women? The Lancet https://doi.org/10.1016/S0140-6736(20)30365-2

https://obgyn.duke.edu/sites/obgyn.duke.edu/files/field/attachments/COVID19_PDF.pdf

https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html

https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html

https://www.smfm.org/covid19

https://s3.amazonaws.com/cdn.smfm.org/media/2267/COVID19-_updated_3-17-20_PDF.pdf

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcareguidance.html).,

https://www.midwife.org/monitoring-covid-19

A nationwide registry for pregnant patients. Pregnancy coRonavIrus Outcomes RegIsTrY https://priority.ucsf.edu/ or . The last site will register patients for the purpose of determining outcomes through a questionnaire and review of medical records

https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/