COVID-19: Pregnancy and Breastfeeding
By Prof. Suranjith L Seneviratne, Krishna Moorthy
Viral infections may occur during pregnancy and cause ill health in both the woman and/or their new born babies. Infections may develop in the newborn child by transmission through the placenta or around the time of the birth (from vaginal secretions or blood) or after birth (from breast milk or other sources). This includes women who are pregnant or who are breastfeeding. At the start of the pandemic, the authorities did not know which effect COVID-19 would have on pregnancy and breastfeeding.
There were some data on SARS-CoV-1 and MERS-CoV infections during pregnancy, with some adverse pregnancy outcomes noted. In addition, we know that Influenza, an infection caused by a different RNA virus may adversely affect pregnancy and neonatal outcomes. In the UK, pregnant women have been considered as moderate risk (that is clinically vulnerable) individuals. This was done as a precaution as COVID-19 is a new viral infection and further information was needed on the potential effects on pregnancy. Several case series and reports on COVID-19 in pregnancy and breastfeeding have been published from around the world and this article would provide an outline on what is known at present about COVID-19 during pregnancy (and its potential effect on the mother and their baby) and breastfeeding.
Effects of COVID-19 during pregnancy
Pregnant women are not at greater risk of getting SARS-CoV-2 infections. Most pregnant women who get COVID-19 get mild or moderate symptoms. The main symptoms of COVID-19 are a high temperature, a new and continuous cough or a change or loss of the sense of smell (anosmia) or taste (ageusia). Most patients have at least one of these symptoms. If a pregnant woman develops any of these symptoms medical advice should be obtained and the maternity team informed.If a pregnant woman gets COVID-19, treatment is aimed at relieving symptoms and includes taking plenty of fluids and getting adequate rest and at times using medication to reduce fever, relieve pain or lessen coughing. If the symptoms are not improving or worsening, severe disease should be considered as a possibility and would need specialised care and advice.
In the UK, information on all pregnant women hospitalised with COVID-19 are included in the UK Obstetric Surveillance System (UKOSS) register.A first analysis of outcomes on 427 pregnant women and their babies was done in May 2020. This showed that most pregnant women only needed ward treatment before discharge, 10 per cent needed intensive care treatment and five died. Currently, it is unclear if COVID-19 was the cause of death.Most of those who become severely ill (and needed ICU admission) were in the third trimester of pregnancy (more than 28 weeks’ pregnant). The following groups of pregnant women were found to be at a higher risk of severe illness: those from Black, Asian and Minority ethnic backgrounds, older than 35 years, with a BMI of 30 or more, and with pre-existing medical problems (such as high blood pressure and diabetes).At an early stage of the COVID-19 pandemic, as it was still unclear if pregnant women would be at increased risk of severe disease, the UK Department of Health advised those beyond 28 weeks of gestation to work from home.
An analysis of COVID-19 patients in UK hospital critical care units was recently completed by the Intensive Care National Audit and Research Centre (ICNARC). They reported that from 1 September 2020 to 8 January 2021, the total number of pregnant women with COVID-19 treated in intensive care was 69. Another 43 had been recently pregnant.During the first week of 2021, the number of pregnant women in critical care increased by 13. Thus overall,one in nine of the women younger than 50 years admitted to a UK critical care unit with COVID-19 was pregnant or had recently given birth (that is 7.2 per cent were currently pregnant and 4.5 per cent were pregnant within the previous six weeks). This was nearly twice the rate of expectant mothers of the same age in the wider population.
The figures were lower during the first wave of COVID-19 (that is up to 31 August). There are a number of possible reasons as to why pregnant women may be more likely to need critical care. The enlarged uterus may compress the lungs and reduce lung reserves, there may be higher oxygen demands due to the presence of a baby, the technique of prone nursing (where patients are placed on their abdomen) is difficult for those at an advanced stage of pregnancy; and pregnant women are more at risk of excessive blood-clotting and this may be worsened by severe COVID-19.The report stated that the findings highlighted the need for pregnant women to take extra precautions with social distancing and hygiene especially after 28 weeks of pregnancy.
The following steps have been recommended for pregnant women during the COVID-19 pandemic: use of appropriate face covering, social distancing, hand-washing, keeping any contacts outside the household to a minimum and avoiding anyone with symptoms suggestive of COVID-19. Those in the third trimester of pregnancy were asked to be particularly attentive to social distancing. Other advice that is given includes: keeping mobile and hydrated to reduce the risk of blood clots, staying active with regular exercise, eating a healthy balanced diet and taking folic acid (usually up to 12 weeks of pregnancy) and vitamin D supplements, attending all pregnancy scans and antenatal appointments unless advised otherwise and to contact the maternity team if there are concerns about their or the unborn babies wellbeing.There are reports of low vitamin D levels increasing the risk of serious respiratory complications in COVID-19.
Reports published so far, do not point to an increased risk of miscarriage in early or late pregnancy. There is a signal towards a higher risk of preterm delivery. There are no specific contraindications to the use of corticosteroids or magnesium sulphate under such circumstances. A very small number of reports have been published of vertical transmission of COVID-19 to infants,by SARS-CoV-2 infected pregnant women. The mode of delivery should be based on obstetric indications. A caesarean section does not need to be undertaken unless there is a specific obstetric indication.
Effect of COVID-19 on breastfeeding
Research done so far has not found the SARS-CoV-2 virus in the breast milk of women with COVID-19. SARS-Cov-2 antibodies have been found in the breast milk of previously infected women. It is still unknown how much protection these antibodies provideto the babies.The current recommendation is that breastfeeding should continue. However, an aspect to be considered is whether an infected mother can transmit the SARS-CoV-2 virus to their baby through respiratory droplets during breast-feeding. Certain steps have been suggested with a view to reducing this risk such as washing their hands before touching the baby and, if possible, wearing a face mask during breast-feeding.
COVID-19 vaccines and pregnancy
Pregnant women and mothers who are breastfeeding are routinely and safely offered vaccines during pregnancy (for example to protect against tetanus, influenza and whooping cough). Many of these vaccines also protect their babies from the infection. Some types of vaccines such as live vaccines are avoided during pregnancy. The three currently approved COVID-19 vaccines are not live vaccines. Two are mRNA vaccines and the other is a viral vector vaccine.Women who are trying to become pregnant do not need to avoid pregnancy for any period after receiving a COVID-19 vaccine. There is no evidence that COVID-19 vaccines cause issues with fertility.
The clinical trials carried out so far on the currently approved COVID-19 vaccines did not include pregnant women. Various Obstetric and Maternal Health organisations have been calling on governments to fund studies specifically aimed at assessing the suitability and safety of COVID-19 vaccines in pregnant and breastfeeding women. On 30 Dec 2020, the Joint Committee on Vaccination and Immunisation of the UK (JCVI) confirmed that the available data do not indicate any safety concerns or harm to pregnancy. However, there was insufficient evidence to recommend the routine use of COVID-19 vaccines during pregnancy.They suggested a risk based approach, where pregnant women with high risk medical conditions (such as those meeting the criteria to be classified as clinically extremely vulnerable), should be considered for the COVID-19 vaccine. Public Health England (PHE), have also put out some information about COVID-19 vaccines in women of childbearing age (that is those who are currently pregnant, or planning a pregnancy or who are breastfeeding).
COVID-19 vaccines and breastfeeding
According to present guidance, breastfeeding women are to be offered the COVID-19 vaccine, if they are otherwise eligible (that is they are in a clinically extremely vulnerable group or are frontline health or social care workers). The findings from further studies should inform us about the use of the COVID-19 vaccine in other categories of breastfeeding women.
In this article, we have outlined the current thinking and recommendations on COVID-19 in pregnancy and breastfeeding. Pregnant women are not at greater risk of getting SARS-CoV-2 infections. Most pregnant women who get COVID-19 get mild or moderate symptoms. Several organisations recommend that pregnant women beyond 28 weeks of gestation should work from home.It is recommended that breastfeeding is continued. A risk based approach is suggested for COVID-19 vaccination in pregnant and breastfeeding women.