Since the advent of Covid-19 cases in January (2020), there has been no sign of any abatement in its relentless spread globally.
It has affected young and old, healthy and unhealthy, although it causes more severe illness and higher risk of death in certain groups, e.g. older adults with concurrent chronic medical conditions.
One group who might be particularly concerned about being infected with the SARS-CoV-2 virus are pregnant women, as they are not only worried about themselves, but also their unborn child(ren).
There is currently no local published data of Covid-19 in pregnancy.
However, useful information is found in a review of 77 studies worldwide published in the British Medical Journal on Sept 1 (2020).
In the review, the overall rate of Covid-19 found in pregnant women, including those early in their pregnancy, who attended or were admitted to hospital for any reason was 10%, i.e. 11,432 women.
The authors documented and compared the clinical features of Covid-19 in the pregnant women with those of non-pregnant women in the same reproductive age group.
They also identified risk factors for complications during pregnancy and delivery that might be associated with the coronavirus infection, and adverse outcomes for mothers and babies.
An interesting finding in the review was a 7% Covid-19 positive rate in pregnant women, of whom three-quarters were asymptomatic (i.e. had no symptoms).
These women had all undergone Covid-19 screening due to their pregnancy.
This positive rate reflects the many studies from the initial massive outbreak in New York City, United States.
Such an estimate emphasises the importance of universal screening during pregnancy for the provision of appropriate care for infected women and their families, and the protection of non-infected women and healthcare staff.
Higher chance of severe disease
The most common clinical features of Covid-19 in pregnancy were fever (40%) and cough (39%).
Compared with non-pregnant women, pregnant women with Covid-19 were less likely to have fever and muscle ache (myalgia).
This is not surprising as a large proportion of those found to have Covid-19 on screening were asymptomatic.
Severe Covid-19 was diagnosed in 13% of the women, with 4% having to be admitted to the intensive care unit (ICU).
Three percent required invasive ventilation and 0.4% required extracorporeal membrane oxygenation (ECMO) – a treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of those whose heart and lung functions are severely impaired.
There was an increased likelihood of admission to the ICU (1.62 times more likely), and need for invasive ventilation (1.88 times) for pregnant women, compared with non-pregnant women with Covid-19.
The likelihood was even higher when compared with non-pregnant women without Covid-19, particularly for admission to the ICU.
These findings emphasise the need for rigorous management of Covid-19 during pregnancy.
The risk factors associated with severe Covid-19 in pregnancy were:
- Increased maternal age (increased chance of having severe Covid-19 by 1.78 times)
- High body mass index (increased by 2.38 times)
- Chronic high blood pressure (increased by two times), and
- Pre-existing diabetes (increased by 2.51 times).
Having a pre-existing illness or medical condition increased a pregnant women’s chance of needing admission to the ICU by 4.2 times and invasive ventilation by 4.48 times.
Babies are well
Out of the 11,580 women in the review, 73 (0.1%) with confirmed Covid-19 died, although not necessarily from the infection.
The spontaneous pre-term birth rate (i.e. the rate of babies born before 37 weeks of pregnancy is completed) in the Covid-19 positive pregnant women was 6%.
The review found that the likelihood of pre-term birth, spontaneous or otherwise, was 3.01 times higher in pregnant women with the infection, compared with those without it.
One in four newborns of mothers with Covid-19 had to be admitted to the neonatal intensive care unit (NICU).
Meanwhile, a study from Wuhan, China, reported that the risk of pre-term birth for mothers with Covid-19 was increased by 3.13 times, compared to mothers without Covid-19.
However, it was not known if the pre-term births were associated with severe Covid-19 or if there were other predisposing factors that contributed both to severe Covid-19 and pre-term birth.
There is increasing evidence from other studies that Covid-19 can spread from mother to foetus (i.e. vertical transmission).
A publication from Italy reported evidence of the SARS-CoV-2 virus passing across the placenta to infect its foetal-derived cells.
However, it should be emphasised that to date, all newborn babies with Covid-19 diagnosed soon after birth have been reported to be well.
Based on current evidence, it is thought to be very unlikely that Covid-19 in pregnancy will cause problems with a baby’s development.
Having said that, these are still early days in the pandemic and we may discover more about Covid-19’s effects on babies in the future.
Advice for the pregnant
It is vital to remember that appropriate obstetric care is vital for optimal outcomes.
All pregnant women are advised to:
- Be active with regular exercise
- Adhere to a healthy balanced diet
- Consume iron, folic acid and vitamin D supplements to maintain a healthy pregnancy
- Be mobile and well-hydrated to reduce the likelihood of blood clot formation
- Attend to all antenatal appointments unless advised not to
- Discuss with the attending doctors and nurses if there are any queries or concerns, and
- Seek medical attention early if there are any concerns about one’s well-being or that of the unborn baby.
All pregnant women are advised to follow the guidance on non-pharmaceutical interventions that reduce the spread of Covid-19, i.e. physical distancing of one to two metres from others in public; avoiding crowded places, confined spaces and close contacts; using face masks properly in public and washing/sanitising their hands frequently.
If one is unwell or has come into contact with anyone who is Covid-19 positive or a person under investigation (PUI), it is best to inform your doctor and nurses before your antenatal appointment, and they will provide appropriate advice.
Being honest with your healthcare professionals will go a long way in ensuring optimal care.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email firstname.lastname@example.org. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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