What to expect when you’re expecting: The pandemic version

A guide for pregnant patients in Ottawa in the time of Coronavirus

*** Last updated: January 29, 2022 ***

“These are strange times” is something we’ve been hearing a lot lately. Stranger still when you’re growing a tiny human. My name is Jillian Bardsley and I am family doctor who practices low-risk Obstetrics and delivers at The Ottawa Hospital – General Campus. I decided to write this blog post to help give expectant moms some factual information on their risks with regards to COVID-19, as well as some idea about what to expect about their appointments and time in the hospital.

*** BIG NEWS! -- ***
Like you, I am also expecting! I will be starting maternity leave in March 2022 and as such, will take a break from updating this website until I return to work in January 2023. Maybe this will all be behind us by then. A girl can dream!

For now, I have added some new resources to the resources page. Please get your vaccines (I've had all three of mine, one while pregnant) and stay safe!

The New COVID – Time to get real

COVID is a virus that has is showing us it has the ability to mutate – and mutate fast! If any of you are still following along from when I started this, you may recall me writing that I thought COVID might be similar to the flu….then I said it was a bit worse…now for pregnant women, I’m going to go ahead and say it’s definitely worse. I know it can be confusing when what seems like basic information changes so quickly. The virus’ mutations and the scientific community’s drive to keep pace with up-to-date research is behind these changes. Please ask your doctor for updates if you feel concerned and look for reliable resources on the web. I have listed some good ones at the end of this blog post.

While otherwise healthy pregnant women seemed relatively protected from the ravages of COVID in the ‘early days,’ the new variants put pregnant women at much higher risk of ICU admission and serious complications than their non-pregnant counterparts.

There were some alarming/ist social media messages about a large portion of Toronto’s Mount Sinai Hospital’s ICU being occupied by pregnant women. While pregnant women are getting sicker than before, it’s helpful to know that Mount Sinai is the regional centre for high risk Obstetrics care –ergo any sick pregnant patient in the colossal GTA was there. The Ottawa –area ICUs have not been flooded by pregnant patients. The rate of COVID in pregnancy is likely somewhere between 7 to 18%; it is likely closer to 7% because this is the rate when ‘universal screening’ or testing everyone is done. Another study has found that approximately 1 in 20 women who show up to labour and delivery have COVID-19, even if they don’t have symptoms. These numbers came from the US and China, where either the government chose not to prepare or didn’t have time to prepare with public health measures. I suspect the rate in Ottawa is lower as our community COVID rate was not as high as these places. Research done by the wonderful Dr Darine El-Chaar at the Ottawa Hospital confirms that the rates of COVID in pregnant women in Ottawa follows our community rate, which has thankfully been low. We don’t have information from this third wave yet, but at least in Fall 2020 when the general community rate in Ottawa was 0.6%, pregnant patients showing up at the hospital had a lower positivity rate at 0.35%. Keep up that social distancing!

Health Concerns for Mum

Risk of Symptoms
I haven’t seen good data on the variants and rates of symptoms in pregnant women. With the old COVID, we could say that about 75-85% of infected pregnant women had only mild symptoms. 9% had severe symptoms, and 5% had very severe symptoms. The general population has rates of 80%, 15% and 5% for mild, severe and very severe COVID infections. As I explained above, the newer variants are marking pregnant women sicker than their non-pregnant peers. Compared to the early days of the pandemic, you are now more likely to develop symptoms if you are pregnant. The likelihood of a severe infection increased if the mothers had obesity, high blood pressure or diabetes. These are the same risks for the general population. If you are concerned that you have these risk factors, talk to your prenatal provider about ways to reduce your risk. Maintaining or increasing fitness in pregnancy is a great way to reduce your risk of hypertension, diabetes and excess weight gain. Eat for one, walk for two! Your body and your baby will thank you.

Risk of hospitalization and ICU admission:
Based on the most up to date Ontario and Quebec specific information that I have, about 8% of COVID positive pregnant patients are hospitalized (compared to 1.5% of the COVID positive general population). 40% of hospitalized pregnant patients will require admission to ICU. 1.5 to 2.5% of COVID positive pregnant patients will go to the ICU, compared to about 0.3% of the general population. This is about a 5 times risk for both hospitalization and about 5-11 times for ICU admission. The need for a breathing machine is still very low at 0.6%. The risk of death is not higher if you are pregnant.

Pregnancy Concerns for Mum:
Symptomatic and severe COVID infections carry a higher risk of a complication of preeclampsia (high blood pressure with possible organ damage) and Caesarean section. The risk is about 4 times above average.

Health Concerns for the Baby:

Risk of Preterm delivery
This is something else that has been evolving. The ‘old’ COVID showed possibly an increase the risk of pre-term birth- but the numbers were very muddled due to the early response to COVID positive pregnant women in China (which was basically, COVID positive! C-section that baby out of there stat!). Data out of Europe and the US, initially showed a preterm labour rate that was comparable with pre-COVID times. The new variants have nudged this upwards again. For the Ontario/Quebec population, the rate is around 12% (baseline being 8-9%). About half of these premies have labour start on it’s own and the other half have a doctor decide to get the show on the road to maintain mum or baby’s health.

Risk of Low Birth Weight
There has been a question about low birth weight babes after mum being COVID positive. This does not seem to be standing up in Canada with 82% of babies born to COVID positive mum’s are normal weight. The low birth weight data seen elsewhere is likely partially driven again by the initial response of ‘COVID!? Get the baby out now!’ and the population that was at higher risk for COVID in the US (women from lower socioeconomic groups often have smaller babies). This is something may continue to evolve with time.

Risk of NICU Admission
Wonderfully, in Canada we also do not see a high NICU admission rate for babies born to COVID positive mothers. Many institutions doing research in the US and China (which is really where most of the research is coming from) have a culture where if mum is COVID positive, the baby is taken to the NICU without mum, even if everyone is doing okay. The NICU rate in these places is up to 25%. Good news, Canadians! Hospitals have kept their cool here and mum and baby stay together as long as everyone is healthy. The NICU admission rate in Ontario/Quebec for COVID positive pregnancies is 16% . The baseline NICU admission rate is actually around 14% so I think we’re doing pretty good!

Risk of Stillbirth or Neonatal Death
Initial early COVID studies did not find an increase risk of stillbirth. Newer studies are starting to show perhaps an increased risk but the overall risk is still very low. Data out of Ontario, Quebec and Manitoba found a slightly higher stillborn rate in COVID positive pregnancies but it is very very close to baseline (1.2% vs 0.8% ). Other studies have reported a 2 fold increase, but again that moves us 4.7 in 1000 (0.47%) to 8.8 in 1000 (0.88%) . Given that the overall numbers are very low, these percentages may not be valid- in a good way (meaning the risk might not actually be higher).

We are not seeing an increased risk of birth defects if mum had an infection in pregnancy.

Risk of Baby Getting COVID
Likelihood of vertical transmission, or passage of infection from mother to baby remains low. Vertical transmission seems to be rare (about 3%) and is likely related to a severe COVID infection or an otherwise compromised immune system. Most of these babies do very well. I am aware of one case of proven vertical transmission in Canada. This baby was monitored for a few days for having some low blood sugar and a low temperature but then discharged home to his or her parents.

We can sometimes see evidence of COVID in the placenta. However, I’m not totally convinced about COVID positive babies getting COVID while in utero. The one study that swabbed newborns immediately at birth showed no COVID infections at all. The ones that found evidence of vertical transmission did the swabs by 48 hours of life, more than enough time for baby to catch COVID from mummy or daddy’s respiratory droplets.

With many illnesses, we worry about the effects on the very young and the very old. COVID-19 seems to be different, which children being spared severe disease relative to their adult counterparts. That does not mean that children can’t get sick. It means that very few infected children will get sick enough to cause permanent damage or death. A study that looked at pooled data from multiple other studies confirms that 98% of children with COVID will have mild illness. Another pooled study looked at the results of 444 patients under the age of 9 with COVID. There were no deaths in this entire group, and only 1 severe case. There is data on 60 pregnant women with COVID-19 and their babies in Wuhan, China. There was only one stillborn baby, born 6 weeks early to a mother with extremely severe COVID. The majority of mothers and babies have done very well. A Wuhan- based study reported good outcomes in a group of 7 women and their babies. Only one baby tested positive for COVID within 1 month of birth and recovered very well after a short admission. Data out of New York City also confirms that most mother’s with COVID do well, as do their babies. Th Canadian Paediatric Society, confirms that children with COVID fare better than their adult counterparts, with the caveat that infants under the age of 12 months, are more likely (around the range of 10%), to have severe disease than children over 12 months.

I’m happy to report that I have yet to see a study that shows an association between COVID infection and a higher risk of neonatal death. The vast majority of babies who get COVID in the neonatal period are asymptomatic. They may be irritable or extra sleepy, or have some trouble with feeding and maintaining their sugars but these are manageable problems. If your baby gets sick with COVID, expect the need for extra snuggles, some extra food and perhaps a short stint in the NICU but a good recovery.

Most children born to COVID-positive mothers do well but some newborns can get very sick so caution is needed. Red flags in newborns include fever (rectal temperature over 38 degrees Celsius), grunting/moaning, skin near their ribs sucking in when they are breathing and breathing very fast. When you have your baby, ask your nurse to teach you about normal newborn breathing and how to correctly take a temperature. These steps will help you make the judgement call about whether to seek care at CHEO if you think your newborn becomes ill after leaving the hospital.

Vaccination

Nike is the Greek goddess of victory. A slightly different Nike tells us to ‘Just Do It.’. For victory over COVID, just do it. Get your vaccine. Convince anyone who is near you or who might be taking care of you and baby postpartum to get their vaccine. Put on your armour mammas, and go to war.

First off, vaccination will reduce your risk of hospitalization and ICU admission. You deserve protection from COVID. A healthier mamma makes a healthier baby. So do it for you.

But also, do it for your baby! Most women who I meet who are vaccine hesitant are worried something in the vaccine will harm their baby. If you are worried about this, please put these worries to rest. Don’t get distracted from the real problem, which is a COVID infection. Be fierce and pick up a shield for yourself and your unborn child. We have evidence that many babies born to mum’s who get their vaccine have antibodies (think of these as immune system shields or mops) to COVID. This is great news because if your baby is exposed to COVID they may have some protection. The same applies to breastfeeding.

Also, while the COVID vaccine may be new, vaccines in pregnancy are not new. We have great evidence on the safety and effectiveness of the flu shot in pregnancy, as well as the Tdap or whooping cough booster that women are supposed to get in the later stages of pregnancy. We have been doing these for a long time. These vaccines make healthy mothers and babies and do not cause adverse side effects in long-term outcome studies. We are expecting the same thing for COVID vaccination.

And just to boldly put some misinformation to rest, vaccination will not cause infertility. It does not cause miscarriage (in fact, the miscarriage rate is lower than average – average being 25%, post vaccination rate ranging from 12-20%). There are no secret microchips. This is not big pharma trying to make a buck – this is human ingenuity and cooperation at it’s finest. The mRNA does not cross the placenta, people don’t shed it and transmit the virus. To those who say ‘But I never get sick and the one time I got the flu shot I got sick for days, so no vaccine for me’, I say this. If you have several days of body aches and fever from some dead virus (flu shot) or mRNA (COVID vaccine) in your arm, what do you think would happen if instead you had millions of live viral particles go for your lungs, heart and placenta? You need this vaccine.

Fever Management
Generally we want to avoid overheating from any cause in pregnancy (hot tubs, saunas, fevers) as there is some question of whether persistent high body temperatures negatively affect fetal development. However, we are also balancing this with the fact that anti-fever medications may decrease the effectiveness of your vaccine and cause you to lose out on protection for you and your baby. A conundrum.

But good news, mammas! Fever is less common in pregnant women post vaccination. Less than 1% of women get a fever after their first dose, and only around 8% of women after their second dose. You may want to talk to your prenatal provider about what is best for you but what I tell my patients is this. If you feel warm, take your temperature. A temperature over 38 degrees C (100.4 F) by mouth is a fever. If you get there keep an eye on your temperature every 4 hours. If you go about 38.5 C (101.3 F) I would consider taking Tylenol (acetaminophen). If you are over 38 C (100.4 F) for more than a day, I would also consider Tylenol. Please remember that Advil (ibuprofen) and Aspirin (unless prescribed by your doctor) are not safe for pregnant women.

Vaccinations and Other Injections
If you are Rh negative and your Rhogam is due near your COVID vaccine, just stick with the normal timing of things. No need to delay anything.

It is recommended that pregnant women get the Tdap vaccine to help protect their babies from whooping cough. This vaccine should be 14-28 days from either dose of your COVID vaccine. This is only to reduce the confusion of side effects between vacations for reporting purposes, not because there is any theoretical reason that giving them together isn’t safe. You’ve got a large window for the Tdap vaccination (21 to 32 weeks or beyond), so it shouldn’t be a problem either way.

Astra Zeneca Vaccination
If Astra Zeneca is what you can get, I would go for it. The risk of blood clots is very rare (on par with being struck by lightening, about 38 times lower than dying in a car crash every year) and your risk does not seem elevated by pregnancy.

Ontario is in the processes of phasing out the Astra Zeneca shots so this might not be a big issue any more, but if AZ is all you can get, I wouldn’t say no. My understanding is they have approved Pfizer or Moderna for a second shot in those who got an initial Astra Zeneca so again, less and less of an issue.

Want to help scientists save the world?
If you have been vaccinated while pregnant or breastfeeding, please stay tuned to this website. It will soon include a link so you can participate in research about your experience.
https://covered.med.ubc.ca

If you would like to participate in research about factors that lead people to choose or not choose vaccination, here is a link to a study run in Ottawa by the aforementioned wonderful Dr Darine El-Chaar.
https://survey.toh.on.ca/limesurvey/index.php?r=survey/index&sid=114767

Resources:

Scientific Review of COVID Pregnancy Related Outcomes

Reliable Vaccination in Pregnancy Resources:

Check out this website if you want to register in a study on COVID vaccination and pregnancy outcomes. The study isn’t live yet but stay tuned:

Articles in this series: