*** Last updated: July 22, 2020 ***
“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.
We now have information on more than 500 pregnant women who developed COVID and their babies. While our full understanding of COVID in pregnancy and babies continues to evolve, I continue to think that things are overall reassuring.
All pregnant women are mildly immunosuppressed during their pregnancy. This is actually a good thing because it helps your body not reject that tiny human growing in your uterus. The flip side is that when pregnant women get a viral infection, they can get more severe symptoms than a non-pregnant woman. Data out of New York City gives me some reassurance. 86% of infected pregnant women in New York City had only mild symptoms. 9% had severe symptoms, and 5% had very severe symptoms. This is actually slightly better than the general population (80%, 15% and 5% for mild, severe and very severe), which means that despite your immunosuppression in pregnancy, you do not seem to be at higher risk for a severe COVID infection. A Society of Obstetricians and Gynecologists of Canada statement from May 2020, continues to confirm that healthy pregnant women are not at higher risk from COVID complications than their non-pregnant counterparts. Most babies are born health and at term. Risk factors for more severe COVID infections in pregnancy include anemia, preeclampsia, diabetes, maternal age over 40 and obesity.
The data on ‘how bad’ Coronavirus is keeps changing because our denominator (how many people have mild or asymptomatic cases) is unknown. I earlier said it was probably on par with the flu. I amend that now to saying that it is likely more dangerous than the flu but still nowhere near as dangerous as SARS or MERs. (Plug for the flu shot: Please get the flu shot. It really helps keep you safe! I promise!)
For women early in their pregnancy journey, you do not need to be worried about an increased risk of miscarriage or congenital abnormalities. COVID-19 is somewhat similar to the SARS virus. During that epidemic, we did not see an increased risk of miscarriage or congenital anomalies in women who were infected with SARS. We are expecting this to hold true for COVID-19.
For women later in their pregnancy, getting any bad infection (COVID, the flu, a really bad cold that turns into pneumonia) can increase your risk of pregnancy complications. Data out of China indicates that women with COVID infections might be a higher risk of preterm labour and having a smaller baby (IUGR or intrauterine growth restriction), however these effects may have been due to other factors. Earlier we thought that the rate of late preterm birth was around 30%. We now think that this is more likely in the 6-15% range. This is great news!
Many I’ve spoken too aren’t too worried about their own health; they are worried about their babies! More good news on this front. Vertical transmission, or the passing of an infection from mother to baby during pregnancy or breastfeeding is highly unlikely. A study out of Wuhan, China has found evidence of an immune response to COVID in babies born to COVID-positive mothers, perhaps suggesting that a small amount of virus is transmitted across the placenta. However, the babies and all maternal fluids (amniotic fluid, vaginal secretions, breast milk) continue to test negative for COVID in this study. Testing done on newborns in New York City also found no evidence of vertical transmission.
Things continue to evolve and I’m here to keep you updated, so I’ll let you know of two recent studies that are questioning this ‘no vertical transmission idea. There is one report of probable in utero transmission in a Torontonian woman with a compromised immune system. The baby tested positive at birth. After a brief support for his blood sugars and temperature, he did very well. There is also now evidence of COVID-19 virus particles in one German woman’s breastmilk whose baby also tested positive for COVID-19 despite her following strict hand washing and mask wearing protocols. I am taking these two more recent studies to mean that if vertical transmission is possible, then it is rare. Even if you have COVID, it is still an excellent idea to breastfeed your baby.
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 (Chang, et al; see resources as of April 30th). 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. (Castagnoli et al.) 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 from the week of March 26th 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 (Breslin, et al). New reassurance from the 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.
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. Please also google a video of ‘transient tachypnea of the newborn,’ which is a normal behaviour. 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.