Fetal concerns in pregnant patients with COVID-19
Limited data are currently reassuring regarding fetal risks in the setting of maternal COVID-19 infection. There is no definitive evidence of fetal transmission despite over 3 million cases of COVID-19 worldwide. Thus far, there is one reported fetal death, to a woman with critical illness and multi-organ dysfunction in several reported series
Intrapartum or postpartum fever without a clear cause
A fever that is unexplained by another cause during labor or immediately postpartum should be evaluated as usual. However, it is recommended that the patient also be tested and/or screened for COVID-19 according to the obstetrical care provider's institutional policy and guidelines.
Preterm labor
Preterm delivery has been reported among infants born to women positive for COVID-19 during pregnancy. However, it appears that many cases are iatrogenic and not due to spontaneous preterm labor. Other severe systemic illnesses appear to increase the risk of preterm birth by approximately two-fold to three-fold.
Preeclampsia
Laboratory findings for COVID-19 can overlap with those found in HELLP syndrome and preeclampsia with severe features. The diagnostic criteria for preeclampsia remain unchanged during the pandemic, and management should be dictated by established guidelines. However, it is reasonable to consider PCR testing for SARS-CoV-2 if a patient with transaminases and thrombocytopenia has additional risk factors for COVID-19.
SMFM strongly recommends that pregnant and lactating people have access to the COVID-19 vaccines and that they engage in a discussion about potential benefits and unknown risks with their healthcare providers regarding receipt of the vaccine. At this time, due to limited vaccine supply, the Centers for Disease Control and Prevention’s (CDC) recommended priority group for vaccination are healthcare personnel and long-term care facility residents. As vaccine availability increases, vaccination recommendations will expand to include more groups, with the ultimate goal of access to all populations as the vaccine supply increases.
Maternal and obstetrical risk of disease
Recent data indicate that pregnancy is an independent risk factor for COVID-19 disease severity, with an increased risk of ICU admission, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and death among pregnant patients with symptomatic COVID-19 infection compared with symptomatic non pregnant patients. Although the absolute risk of severe morbidity and mortality remains low, reports have demonstrated a 3-fold increased risk for ICU admission, a 2.4 -fold increased risk for needing ECMO, and a 1.7-fold increased risk of death from COVID-19. Women with comorbidities (body mass index higher than 35 kg/m2, diabetes, and heart disorders)and older-aged women appear to have a particularly elevated risk of adverse maternal outcomes. Other conditions that the CDC has identified as increasing the risk for severe illness from SAR-CoV-2 infection include cancer, chronic kidney disease, chronic obstructive pulmonary disease, heart conditions, immunocompromised state from organ transplant, sickle cell disease, and smoking. People of color, specifically Latina and Black patients, also continue to be disproportionately affected by severe maternal morbidity and
Mortality and appear to have a disproportionately higher prevalence of COVID-19 infection and death. These disparities, which are caused by social determinants of health that act as barriers to health and well-being, have become more apparent and exaggerated during this crisis.
Vaccine mechanism and administration
Pregnant and lactating people have been excluded in the recent vaccine trials; therefore, there are no data on the safety of the COVID-19 vaccines in pregnant people. Further studies are ongoing, and safety data will become available in the coming months. The mRNA vaccines contain mRNA, a genetic material that encodes the SARS-COV-2 spike S protein, the predominant immunomodulatory target associated with adverse effects. They are not live vaccines, and preclinical data suggest rapid degradation (approximately 10-20 days) by normal cellular processes. There is no risk for insertional mutagenesis, as the mRNA does not enter the cell's nucleus. In other words, there is no risk of genetic modification to people receiving the vaccine. A pregnancy test prior to vaccination is not recommended, nor are there data to guide timing of conception following vaccination. If a person decides to receive the vaccine, there are no trimester-specific vaccine considerations at this time.
Lactating Persons
What should be considered when counseling lactating persons regarding COVID-19 vaccination? Vaccination is recommended for lactating persons. Counseling should balance the lack of data on vaccine safety and a person’s individual risk for infection and severe disease. The theoretical risks regarding the safety of vaccinating lactating people do not outweigh the potential benefits of the vaccine.
Limited data are currently reassuring regarding fetal risks in the setting of maternal COVID-19 infection. There is no definitive evidence of fetal transmission despite over 3 million cases of COVID-19 worldwide. Thus far, there is one reported fetal death, to a woman with critical illness and multi-organ dysfunction in several reported series
Intrapartum or postpartum fever without a clear cause
A fever that is unexplained by another cause during labor or immediately postpartum should be evaluated as usual. However, it is recommended that the patient also be tested and/or screened for COVID-19 according to the obstetrical care provider's institutional policy and guidelines.
Preterm labor
Preterm delivery has been reported among infants born to women positive for COVID-19 during pregnancy. However, it appears that many cases are iatrogenic and not due to spontaneous preterm labor. Other severe systemic illnesses appear to increase the risk of preterm birth by approximately two-fold to three-fold.
Preeclampsia
Laboratory findings for COVID-19 can overlap with those found in HELLP syndrome and preeclampsia with severe features. The diagnostic criteria for preeclampsia remain unchanged during the pandemic, and management should be dictated by established guidelines. However, it is reasonable to consider PCR testing for SARS-CoV-2 if a patient with transaminases and thrombocytopenia has additional risk factors for COVID-19.
SMFM strongly recommends that pregnant and lactating people have access to the COVID-19 vaccines and that they engage in a discussion about potential benefits and unknown risks with their healthcare providers regarding receipt of the vaccine. At this time, due to limited vaccine supply, the Centers for Disease Control and Prevention’s (CDC) recommended priority group for vaccination are healthcare personnel and long-term care facility residents. As vaccine availability increases, vaccination recommendations will expand to include more groups, with the ultimate goal of access to all populations as the vaccine supply increases.
Maternal and obstetrical risk of disease
Recent data indicate that pregnancy is an independent risk factor for COVID-19 disease severity, with an increased risk of ICU admission, mechanical ventilation, extracorporeal membrane oxygenation (ECMO), and death among pregnant patients with symptomatic COVID-19 infection compared with symptomatic non pregnant patients. Although the absolute risk of severe morbidity and mortality remains low, reports have demonstrated a 3-fold increased risk for ICU admission, a 2.4 -fold increased risk for needing ECMO, and a 1.7-fold increased risk of death from COVID-19. Women with comorbidities (body mass index higher than 35 kg/m2, diabetes, and heart disorders)and older-aged women appear to have a particularly elevated risk of adverse maternal outcomes. Other conditions that the CDC has identified as increasing the risk for severe illness from SAR-CoV-2 infection include cancer, chronic kidney disease, chronic obstructive pulmonary disease, heart conditions, immunocompromised state from organ transplant, sickle cell disease, and smoking. People of color, specifically Latina and Black patients, also continue to be disproportionately affected by severe maternal morbidity and
Mortality and appear to have a disproportionately higher prevalence of COVID-19 infection and death. These disparities, which are caused by social determinants of health that act as barriers to health and well-being, have become more apparent and exaggerated during this crisis.
Vaccine mechanism and administration
Pregnant and lactating people have been excluded in the recent vaccine trials; therefore, there are no data on the safety of the COVID-19 vaccines in pregnant people. Further studies are ongoing, and safety data will become available in the coming months. The mRNA vaccines contain mRNA, a genetic material that encodes the SARS-COV-2 spike S protein, the predominant immunomodulatory target associated with adverse effects. They are not live vaccines, and preclinical data suggest rapid degradation (approximately 10-20 days) by normal cellular processes. There is no risk for insertional mutagenesis, as the mRNA does not enter the cell's nucleus. In other words, there is no risk of genetic modification to people receiving the vaccine. A pregnancy test prior to vaccination is not recommended, nor are there data to guide timing of conception following vaccination. If a person decides to receive the vaccine, there are no trimester-specific vaccine considerations at this time.
Lactating Persons
What should be considered when counseling lactating persons regarding COVID-19 vaccination? Vaccination is recommended for lactating persons. Counseling should balance the lack of data on vaccine safety and a person’s individual risk for infection and severe disease. The theoretical risks regarding the safety of vaccinating lactating people do not outweigh the potential benefits of the vaccine.
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