Recently, pregnancy was added to the list of those conditions that put people at higher risk of contracting Coronavirus. Similarly, pregnant women were shown to have increased hospitalization rates, increased risk of severe pneumonia, increased admission to intensive care units, and increased need to be put on a ventilator. Despite this, data has not shown an increased risk of death from Coronavirus when compared with non-pregnant patients of the same age.
The recommended precautions vary by country and, in some cases, by state and city:
Yes. It is very important that you continue to attend your scheduled routine care when you are well.
Maternity care is essential and has been developed over many years to reduce complications in mothers and babies. There is a potential risk of harm to you and your baby if you don’t attend your appointments, even in the context of COVID-19.
If you are well, you should be able to attend your antenatal care as normal. If you have symptoms of possible COVID-19, you should contact your health care professional to postpone routine visits until after the isolation period is over.
At this time, it is particularly important that you allow professionals to take care of you. If you have had an appointment cancelled or delayed and you are not sure of your next visit with your health care professional, call them.
The following suggestions may be helpful:
Whatever your personal situation, consider the following:
The symptoms of COVID-19 during pregnancy are the same as those experienced by the non-pregnant patient. They include fever, dry cough, fatigue, sputum production, shortness of breath, muscle or joint pain, headache, and sore throat. Additional symptoms could include nausea and diarrhea. Not everyone who is infected with the virus will experience all the symptoms. An infected person could experience one or any combination of symptoms.
It is important to keep in mind that recent data has shown that pregnancy increases the risk for acquiring SARS-CoV-2 infection. Additionally, when compared to non-pregnant women of the same age, pregnant women are more likely to require hospitalization for COVID-19-related complications, admission to the intensive care unit, and the use of a mechanical ventilator.
If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include:
Data from pregnant women infected with COVID-19 are very limited. However, case series from China indicate that the signs of COVID-19 infection during pregnancy are similar to those of non-pregnant adults with COVID-19 infection.
Two other members of the Coronavirus family were responsible for serious diseases in recent years: Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). Although there have been a small number of known pregnancies exposed to SARS or MERS, they provide a useful context to which pregnancies infected with COVID-19 can be reviewed.
To date, this is what is known:
Yes, the amount of radiation dose to you and to your developing baby is negligible and safe for both. If you have COVID-19, chest imaging, especially computed tomography (CT) scan, is essential for the evaluation of your clinical condition.
We do not know at this time what, if any, risk is posed to your developing baby. None of the pregnancies affected with SARS that we are aware of resulted in a baby born with a birth defect. However, fever is common in COVID-19-infected patients. Data obtained before the COVID-19 pandemic have shown that maternal fever in early pregnancy may cause birth defects, especially neural tube defects, or miscarriage. Use of acetaminophen in pregnancy, including in the first trimester, has been shown overall to be safe and may attenuate the pregnancy risks associated with fever exposure. As with any pregnancy, consuming 400 micrograms (mcg) of folic acid every day may help prevent some of the birth defects.
Infected women, especially those who develop pneumonia, appear to have an increased frequency of preterm labor, prelabor rupture of membranes, preterm birth, preeclampsia, and cesarean delivery for abnormal fetal heart rate tracings, which is likely related to severe maternal illness. In 41 COVID-19 pregnant patients, a systematic review reported the following rates of complications: preterm birth <37 weeks (41.1%), preterm prelabor rupture of membranes (18.8%), preeclampsia (13.6%), cesarean delivery (91.1%), miscarriage (not reported); and for the baby: stillbirth (2.4%), admission to a neonatal ICU (10%), and neonatal death (2.4%). It is important to emphasize these data reflect small numbers and women mostly intubated with COVID-19 pneumonia, and the perinatal deaths were not directly due to fetal /neonatal infection with the coronavirus. In addition, in women with severe COVID-19 in the third trimester, there may be a bias to intervene that is catalyzed by the belief that management of the mother's respiratory disease will be improved by delivery; this is still unclear.
Additionally, it has been shown that because SARS-CoV-2 invades the blood vessels, infection with the virus could impede the blood flow between mother and fetus by inducing injury to the placenta. In a small cohort of pregnant patients who tested positive for COVID-19, placental injury included blood clots and abnormal blood vessels that affected how much blood was getting to the fetus. Furthermore, some of the placentas were found to be smaller than expected. There is concern that the placental injury caused by COVID-19 infection could lead to preeclampsia and hypertension in the mother and possibly miscarriage, intrauterine growth restriction, or preterm birth for the fetus, although this has not been the case in the small group of patients that have been studied.
Because of the concern for the health of both mother and fetus, extra monitoring for pregnant women diagnosed with COVID-19 should be considered. Options include: non-stress test to monitor whether or not a fetus is getting a sufficient oxygen supply and frequent ultrasounds to monitor fetal growth.
At this point, there is little evidence to suggest that pregnant women infected with COVID-19 could transmit the virus to their baby during pregnancy or delivery (medically referred to as ‘vertical transmission’). Information on vertical transmission of COVID-19 is limited. Two articles recently reported from separate research teams in China (See Dong et al. 2020 and Zeng et al. 2020 here) present details of 3 newborns who may have been infected with SARS-CoV-2 in utero from mothers with COVID-19. Evidence for such transmission is based on elevated IgM (Immunoglobulin M) antibody values in blood drawn from the babies. It should be noted, however, that most congenital infections are not diagnosed based on IgM detection because these assays can be prone to false-positive and false-negative results. Although these 2 studies deserve careful evaluation, more definitive evidence is needed before the findings they report can be used to counsel pregnant women that their fetuses are at risk from congenital infection with SARS-CoV-2.
It should be, although that depends on where you will deliver. Some hospitals have a designated section (an entire floor, a wing) for COVID-19 and the rest of the facility is isolated from it. In smaller hospitals and clinics, this may be difficult to do.
Bear in mind that family and friends of hospitalized people with COVID-19 may be in the hospital’s waiting areas, restaurant, gift shop, etc. They may look healthy to you but be infected with COVID-19. Stay at a distance of at least 6 to 10 feet (2 to 3 meters) from them. Partners of women going into labor should probably stay at home or go to an open area, as much as possible. You should call your hospital to check if there are any regulations to be aware of. Some hospitals ban visits to maternity wards and restrict the number of people who can accompany a pregnant person during childbirth to one, which means that a doula and a partner are not allowed at the same time.
Every health care facility is making different plans for dealing with this scenario. Talk with your doctor or midwife as soon as possible.
This is a personal decision that should consider the benefits and the risks of getting pregnant and having a baby at this time. Considerations include: whether or not you are comfortable with telehealth physician visits, possibly limited options for fertility treatments, mental health, available support system, and financial well-being in this uncertain time.
Yes. You are highly discouraged, from traveling for leisure at this time. Check your local health agency recommendations for instructions on people movement.
Temporary separation of mothers with known or suspected COVID-19 from their newborns has been proposed to reduce the risk of mother-baby transmission, but may also have adverse consequences. For example, not rooming-in and avoiding skin-to-skin contact can be stressful for mothers, disrupt breastfeeding, and have negative effects on newborn stress, feeding, and bonding.
The World Health Organization (WHO) recommends that mothers who have suspected, probable, or confirmed COVID-19 virus infection should be enabled to remain together and practice skin-to-skin contact. The CDC advise determining whether to separate a mother with known or suspected COVID-19 and her infant on a case-by-case basis, using shared decision making between the mother and the clinical team. Factors to consider include:
If mother-baby separation is implemented, the following should be considered:
If separation is indicated (mother is on transmission-based precautions) but not implemented, other measures may be utilized to reduce potential mother-to-infant transmission and include:
After hospital discharge, the American Academy of Pediatrics advises:
Every hospital has different policies. Contact your hospital or labor and delivery unit a week or so before delivery to get the most up-to-date restrictions.
In general, if your support person needs to leave, they would be allowed back unless they knew they were exposed to COVID-19 after leaving your company.
Yes, she should not leave her house unless necessary. If she is over 60 or has any serious chronic medical condition (such as heart disease, lung disease, or diabetes), she is at higher risk of serious illness from COVID-19 and should avoid all travel.
Not necessarily, as COVID-19 is not an indication to alter the route of delivery. Cesarean delivery is performed for standard obstetric indications.Even if vertical transmission is confirmed, this would not be an indication for cesarean delivery since it would increase maternal risk and would be unlikely to improve newborn outcome (reports of COVID-19 infection in newborn babies have generally described mild disease).
Pregnant health workers have additional concerns. A common, widely accepted human resources precautionary measure is that pregnant health workers in the third trimester, particularly ≥36 weeks, stop face-to-face contact with patients to help reduce their risk of acquiring infection and its consequences.
All clinicians with person-to-person contact should wear a surgical mask in the health care setting, under the assumption that every patient and health care colleague might be infected with COVID-19. Some institutions have asked all asymptomatic patients and their asymptomatic support persons (if allowed to be present) to wear masks as well.
Ideally, pregnant COVID-19 inpatients should be cared for in specially equipped (eg, negative-pressure) rooms in antepartum, intrapartum, and postpartum COVID-19-only units, similar to other adult COVID-19 inpatients who are usually placed in dedicated COVID-19-only units, halls, or hospitals. Patients with suspected or confirmed COVID-19 are normally instructed to wear a mask, including during labor and delivery, but this may be difficult during active pushing, and forceful exhalation may allow spread of the virus by respiratory droplets despite the mask. Infection control precautions regarding pregnant patients with confirmed or suspected infection are similar to those for other hospitalized patients and are reviewed separately.
Specific issues in pregnant patients include fetal monitoring in those who are at a viable gestational age. The need for and frequency of fetal testing depend upon gestational age, stability of maternal vital signs, other maternal comorbidities, and discussions with the patient and her family that consider the possibly increased risks of stillbirth and perinatal morbidities in the absence of testing as well as the possible risks from increased contact with health care personnel performing this testing.
Maternal oxygen saturation (SaO2) should be maintained at ≥95 percent during pregnancy, which is in excess of the oxygen delivery needs of the mother.
Several medications are being evaluated for treatment of COVID-19. Although some of them are clinically available for other indications (eg, hydroxychloroquine or chloroquine), their use for COVID-19 remains investigational. There are no high-quality studies documenting the role of hydroxychloroquine or remdesivir in the treatment of pregnant women with moderate or severe COVID-19 disease. At some hospitals, pregnant women with moderate COVID-19 are being treated with hydroxychloroquine, and those with severe COVID-19 are being offered remdesivir in a compassionate-use protocol.
Both hydroxychloroquine and chloroquine have been reported to inhibit SARS-CoV-2 in vitro, but their role in treatment of COVID-19 is under investigation. Hydroxychloroquine crosses the placenta. Accumulation in fetal ocular tissues has been observed in animal studies, but fetal ocular toxicity has not been observed in humans, which is reassuring given that the drug has been widely used by pregnant women for treatment of systemic lupus erythematosus or for prevention of malaria.
Remdesivir is a novel nucleotide analogue that has activity against SARS-CoV-2 in vitro and related coronaviruses (including severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome-related coronavirus [MERS-CoV]) both in vitro and in animal studies. Compassionate use in nonpregnant adults has been suspended by the manufacturer, although there are plans for an expanded access program. It has been used without reported fetal toxicity in some pregnant women with Ebola and Marburg virus disease.
Investigational drugs for COVID-19 that are known to be teratogenic include ribavirin and baricitinib.
Use of medications to manage pregnancy complications:
Treatments and vaccines currently in development for COVID-19:
At this time, there is no evidence to suggest that COVID-19 is transmissible from mother to baby via breastmilk. It is unknown whether the virus can be transmitted through breastmilk. The only report of testing found no virus in the maternal milk of six patients. However, droplet transmission could occur through close contact during breastfeeding. In addition to its many other benefits, breastmilk is a passive source of antibodies and other anti-infective factors and, thus, may provide passive antibody protection for your infant.
If you and your baby are separated, ideally, your baby should be fed expressed breastmilk by another healthy caregiver until you recovered or proven uninfected, provided that the other caregiver is healthy and follows hygiene precautions. In such cases, you should use strict handwashing before pumping and wear a mask during pumping. The CDC have issued guidance about cleaning breast pumps. If possible, the pumping equipment should be thoroughly cleaned by a healthy person.
If feeding by a healthy caregiver is not possible, you should take precautions to prevent transmission to your baby during breastfeeding (including assiduous hand hygiene, use of a face mask, and disinfecting shared surfaces that you contacted).
Ideally, if you choose to formula feed, another healthy caregiver should feed your baby. If this is not possible or desired, you must also take appropriate infection control precautions (including assiduous hand hygiene, use of a face mask, disinfection of shared surfaces) to prevent transmission through close contact when feeding.
If you are too unwell to breastfeed your baby due to COVID-19 or other complications, you should be supported to safely provide your baby with breastmilk in a way possible, available, and acceptable to you. This could include: