In November last year, the US health authorities added pregnancy to the list of conditions that put people with Covid-19 at increased risk of developing severe illness, raising the vigil on pregnant women suffering from illness.
The American health authorities based their prognosis on a strong foundation: the Centre for Disease Control and Prevention conducted a large study, involving 409,462 symptomatic women of ages 15-44 who tested positive for the coronavirus, 23,434 of whom were pregnant.
The study found pregnant women afflicted with Covid were “significantly more likely to require intensive care, to be connected to a specialised heart-lung bypass machine, and to require mechanical ventilation than non-pregnant women of the same age that had Covid symptoms”.
“Roughly two-thirds of pregnant women with Covid-19 have no symptoms, while others have mild cold or flu-like symptoms,” says Dr Shuchita Meherishi, Obstetrics and Gynaecology Specialist at Aster Hospital — Al Qusais. “However, they are more likely to develop respiratory complications requiring intensive care than age-matched women who aren’t pregnant. There is an increased risk of premature births. Covid positive women are also more likely to have a caesarean delivery.”
She remembers the day she received an anxious phone call from a pregnant patient who tested positive. “She had a history of gestational diabetes, requiring metformin and insulin in both her previous and current pregnancies. She had to be hospitalised and was recommended a chest X-ray, besides antiviral medications.” The patient completely recovered and delivered a healthy baby in the 39th week of her pregnancy.
Covid positive pregnant women, especially those with comorbidities, struggle with several complications. “Pregnant women might be at an increased risk of becoming severely ill in the third trimester,” explains Dr Maya Alwan, Obstetrics and Gynaecology Specialist at Medcare Medical Centre, Jumeirah. “In a study conducted in the UK, of all women treated for Covid, 10 per cent required intensive care.”
Besides, babies born before 37 weeks are vulnerable to problems. “The more premature the baby is, the higher are the risks and associated problems. Most premature babies from Covid-affected women were admitted to the NICU, but have recovered well,” she adds.
The good news is that the risk of miscarriage is far lower in a Covid-infected woman if she is in the earlier stages of her pregnancy. “The transmission of the Covid-19 virus from the mother to her baby during pregnancy or childbirth, known as vertical transmission, seems to be uncommon,” says Dr Mona Mohammad Emad Saad, Obstetrics and Gynaecology Specialist at Burjeel Specialty Hospital in Sharjah. There is also no evidence of increased risk of stillbirth or infant death.
Pregnant women particularly need an individualised approach of Covid management, involving a team of infectious disease specialists, obstetricians, anaesthetists and neonatologists. Dr Meherishi believes that since drugs are administered only in the wake of severe Covid infection, the firmly etched guiding principle of prioritising a mother’s life over everything else comes into play. “Monoclonal antibody drugs such as Bamlanivimab, as well as interferons [that inhibits virus replication], nebulisation and thromboembolic prophylaxis are currently recommended in the case of severe infection.”
Dr Nashwa Magdy Abulhassan, Consultant and Head of Obstetrics & Gynaecology Department at Dr Sulaiman Al Habib Hospital, DHCC – Dubai, advises, “As pregnancy is a hypercoagulable state and the Covid-19 infection is likely to be associated with an increased risk of maternal blood clotting, anticoagulant treatment (blood-thinning) is usually considered to prevent thromboembolism (blood clots). There is no evidence that this is harmful to the foetus as it does not cross the placenta.”
Corticosteroids may be needed as well to stimulate foetal lung maturity, particularly if premature delivery needs to be induced (an early delivery offering women time to recover from Covid). “They are potent anti-inflammatory agents and considered relatively safe in pregnancy when used in low doses,” says Dr Abulhassan.
The toughest Covid case she has treated is a first-time mom-to-be who developed symptoms such as fever, cough and sore throat and tested positive for Covid-19 at 32 weeks of pregnancy. “Her symptoms continued to deteriorate, and she was suffering from muscle aches and chest pain. We admitted her to a special Covid-19 ward, under a multidisciplinary management programme involving an infectious disease consultant, an obstetric consultant and a cardiologist,” says Dr Abulhassan. While the fever and cough symptoms gradually receded after four days of treatment, the chest pain and difficulty in breathing were far more persistent over the next two days.
“The foetus showed signs of distress. As the patient had been given injections to stimulate lung maturity of her foetus when she was admitted, an emergency caesarean was performed at 33 weeks of her pregnancy. We noticed that her symptoms of chest pain and difficulty breathing began to improve dramatically after the delivery. The baby tested negative for the Covid-19 infection twice.”
Given the risks associated with Covid infection in pregnant women, prevention is a far more effective method to stay safe.
Expert opinion overwhelmingly veers towards not just getting vaccines against Covid, but also other diseases.
Dr Mansi Joneja, Internal Medicine Specialist at Medcare Women and Children Hospital, recommends taking these shots: MMR booster vaccination against rubella, which can cause birth defects, taken four weeks before planning pregnancy; Tetanus diphtheria pertussis vaccine (Tdap), taken between 27 and 36 weeks gestation period, which creates protective antibodies providing early protection to the baby against pertussis (whooping cough); and the flu shot or influenza vaccine, besides of course one of the anti-Covid vaccines.
“Clinical trials on the safety of Covid-19 vaccines are still being carried out,” says Dr Kassem Ahmad, Consultant Obstetrician & Gynaecologist at Prime Hospital. “We have limited data about the safety of those vaccines in pregnancy, but based on how these vaccines work in the body, it is improbable they will pose a risk in pregnancy.
“The Moderna and Pfizer-BioNTech vaccines are mRNA vaccines, which do not contain the live virus that causes Covid-19, so they cannot infect you with the disease. Also, mRNA vaccines do not interact with a person’s DNA or cause genetic changes.
“The J&J/Janssen and AstraZeneca Covid-19 vaccines are viral vector vaccines. This means they use a modified version of a different virus (the vector) to deliver essential instructions to our cells.”
If unvaccinated, pregnant women need to follow stricter prevention protocols. Dr Alwan advises them to maintain Covid-appropriate behaviour such as wearing a mask, social distancing, maintaining good indoor ventilation, and hand hygiene.
Women who are over 28 weeks pregnant need to be extra cautious as a severe disease is more likely in this period, says Dr Joneja. “They should avoid anyone who has symptoms suggestive of Covid-19, follow a healthy diet, take the prescribed supplements, and be physically active. Even at the development of the mildest symptoms suggestive of Covid disease, they need to seek medical help proactively.”
Dr Saad recommends taking folic acid and vitamin D supplements, and ensuring women get the pregnancy scans done regularly and keep antenatal appointments unless advised otherwise. Pregnant women with pre-existing diabetes and gestational diabetes form a special group who need frequent and strict monitoring. With defects in innate and adaptive immunity, they are more susceptible to infection. “Tight glycaemic control is an absolute prerequisite to ensure healthy outcomes.”
It is equally important for a pregnant woman infected by the coronavirus to take care of the increased amount of anxiety caused by both the disease and the isolation it enforces on you. Most pregnant women afflicted with Covid experience guilt and panic in equal measures, emotions that can further bring down immunity levels.
Medical authorities and experts globally suggest consulting mental health experts or a counsellor along with other doctors to ensure a pregnant woman recovers both mentally and physically.