Facing a threat that is foreign to all of us can leave us paralysed with fear. Not fully knowing what we’re up against can breed panic, even more so in women who are about to bring a life into the world. But panic can only take us right into the trap of irrational decision-making, especially in a time where COVID-19’s prevalence has stricken us all.
So, why not take what is already known and use that knowledge to ensure that you avoid this infection and have a healthy pregnancy.
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COVID-19: What we know so far
Coronavirus is an umbrella term that refers to a large family of viruses that can trigger illnesses that range from the common cold to severe diseases like the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).
The outbreak which started in December of 2019 was caused by a strain that hasn’t been identified in humans, hence the name 2019 novel coronavirus. In February 2020, the World Health Organization (WHO) officially named it SARS-CoV-2. This virus is the reason behind COVID-19 – the disease that is currently placing the world on hold as everyone is gripped with fear of an unseen enemy.
Coronaviruses are transmitted between animals and humans. SARS-CoV was passed on from civet cats, while MERS-CoV was transmitted from dromedary camels. However, for COVID-19, the definite cause has yet to be identified.
For person to person transmission, COVID-19 virus can be transmitted through contact with certain bodily fluids, such as droplets in a cough. It can also be transmitted by touching something an infected person has touched or sneezed on, and then bringing your hand to your mouth, nose, or eyes.
What’s so sinister about this illness is that it can be spread even before it shows any symptoms. As one study revealed, the disease can have an average incubation period (the time elapsed between the exposure and when the first symptoms become evident) of 5 days. Seeing how community transmission is fast-moving and widespread, now making it a pandemic, pregnant women should engage in strong precautionary measures, especially in public places.
Do pregnant women have a bigger risk of acquiring a COVID-19 infection?
Fortunately, based on the evidence so far, pregnant women don’t appear to have a higher susceptibility to a COVID-19 infection compared to the general population. However, pregnancy in a minority of patients can affect how the immune system responds to severe viral infections. At the moment, there is no evidence that coronavirus causes a viral infection worse in pregnant women, but the amount of evidence available is still quite limited. Hence, to be cautious, pregnant women should be given special consideration especially those with coexistent medical illnesses which make them immunocompromised and vulnerable to infection.
What are the symptoms?
In the beginning, the virus will create flu-like symptoms like cough, lethargy and fever. But as soon as the virus starts reproducing in your lung cells, it gradually destroys your lung tissue, affecting your ability to inhale oxygen. That is why one of the early symptoms is that people tend to experience shortness of breath which would render the need for hospital care.
In severe cases, the infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. This is commonly observed among those who are immunosuppressed or those with long-term conditions such as diabetes – which is also present in some pregnant women. Therefore, expectant moms who are also dealing with other health conditions should heighten their caution.
What happens if a pregnant woman gets infected?
Comparisons have been drawn between COVID-19 and influenza. Both cause respiratory diseases that comprise a wide range of illnesses, from asymptomatic to severe, with rare cases resulting in death. The large majority of pregnant women with COVID will experience only mild or moderate flu-like symptoms. This is reinforced by the Chair of the Society of Infectious Diseases of China Medical Association who shared that in Shanghai, pregnant patients had mild disease and there were no severe cases requiring intubation.
While COVID-19 may initially appear like the seasonal flu, here are important comparisons that should be noted so that you get prompt medical treatment.
Runny nose/ cold is NOT typically a symptom of COVID-19. In addition to fever, dry cough, muscle aches, headaches and diarrhea, a significant number of COVID 19 patients report a loss of smell and/or taste as their symptom.
As this is a new virus, we are just starting to be familiar with its outcomes. Currently, there is no evidence to suggest that COVID-19 can result in adverse pregnancy outcomes, such as miscarriage. However, looking at cases of infections from other related coronaviruses (SARS-CoV and MERS-CoV), these diseases have resulted in miscarriages and stillbirths.
A high-grade fever (more than 38 degrees celsius) during the first trimester of pregnancy is also a cause for concern among expectant women. It increases the risk of certain birth defects, such as neural tube defects affecting the brain and the spine, heart or facial abnormalities (e.g. cleft lip or cleft palate) in the fetus.
In COVID-19, fever is among the triad of symptoms, along with cough and shortness of breath. So, whether it’s a serious strain of the coronavirus or the common flu, the same risk is present if we focus on the fact that if a pregnant woman’s temperature goes through the roof, it can lead to serious complications to the unborn baby. Conversely, up to this point, there is also no concrete information on the real effect of the virus on women in early pregnancy.
Can infected pregnant women pass on the COVID-19 virus to her baby?
Passing on a disease-causing agent, such as the COVID-19 virus, from a mother to her offspring while pregnant or during birth is called vertical transmission. Two cases of possible vertical transmission have been reported. In both cases, it remains unclear whether transmission was prior to or soon after birth. Another recent report from China of four women with coronavirus infection when they gave birth found no evidence of the infection in their newborn babies. After testing amniotic fluid, cord blood, and neonatal throat swab, there was no evidence of intrauterine fetal infection. Hence, it is also presumed that it’s unlikely for the COVID-19 virus to cause congenital issues affecting baby’s development.
Expert opinion is that the baby is unlikely to be exposed to the virus during pregnancy.
Some babies born to women with symptoms of coronavirus in China have been born prematurely. It is unclear whether coronavirus caused early labour, or whether it was recommended that the baby was born early in order to preserve the mother’s health.
Additionally, the virus was not detected in samples of breastmilk, which means that there is no advice against breastfeeding for infected moms. In the United Kingdom, the current guidance is that there is no need for patients to be separated from their newborns. However, it’s important that precautionary measures are applied while doing so. Moms who are carriers of the virus should wear a mask while feeding, wash her hands before and after it, and disinfect contaminated surfaces. But if she’s too ill, she can express her milk for the baby using the necessary precautions. In hospitals, proper isolation and strict protocol should help in making sure that the baby is protected from acquiring a COVID-19 infection. In China, babies were kept strictly away from their infected mothers for 14 days to reduce the chance of transmission. There have been reports of very early neonatal infections where babies were severely ill so it may well be prudent to isolate until we have more data.
How can pregnant women protect themselves against a COVID-19 infection?
Since the COVID-19 virus can be transmitted by contact and droplets, public health measures were provided by the World Health Organization. These are applicable to all, and pregnant people can use it to protect themselves and prevent the spread of infection.
What can I do about pre-natal check-ups?
Part of the list of precautions that the government and healthcare workers have been constantly repeating to flatten the curve of community-acquired infection is to avoid crowded places and to practise social distancing. But what if you can’t avoid hospitals as COVID-19 spreads?
Pre-natal check-ups are vital in ensuring a safe and healthy pregnancy. There is a stronger need for visits to the doctor especially for those with delicate pregnancies, therefore these appointments can’t be postponed indefinitely.
In Singapore, the pre-natal check-ups will continue as usual. However, if you exhibit any fever and flu symptoms, some hospitals will not allow entry. Instead, you will be advised to see your local general practitioner (GP) for medications, and your appointments will be deferred until you are well.
Take note of the following reminders for this type of GP check-up:
- You are advised to wear a mask.
- You should maintain social distance.
- You will be assessed if you have high-risk factors of being positive for COVID-19.
- If you are considered low risk, you will be given medications for symptoms and told to isolate at home for five days but to return if worsening or persistent symptoms. It will be at the GP s discretion to determine if you warrant a referral to NCID for a swab test.
- In general, patients who have clinical pneumonia or prolonged flu symptoms or serving a stay-home notice from countries with heightened vigilance and any sort of acute respiratory symptoms are likely to be referred.
- If you are high risk, eg on home quarantine orders or have any contact with anyone who is positive for COVID-19, you should call for an ambulance to bring you to NCID directly if you have symptoms instead of going to a GP.
- Pregnant patients in NCID will be co-managed by KK Women’s and Children’s Hospital, if needed.
In cases of any pregnancy-related emergency or if you are in labour, co-existing with your symptoms, then you will be directed to the cordoned off triage area in your obstetric hospitals. Please telephone your specialist beforehand to highlight your situation so that preparations can be made prior to your arrival. If necessary, you will be admitted to a negative pressure labour wardroom for delivery. This is to protect you from coming into contact with other patients and reduce cross contamination room to room.
What will delivery be like for a woman who is positive for COVID-19?
Under the circumstances, the mode of delivery will be discussed with the mother. Doctors will not outright advise a Caesarean section for suspected COVID-19 patients. However, if the mother’s respiratory condition demands urgent delivery, a C-section would be an appropriate course of action. In China, most patients underwent a Caesarean section for delivery but it is still unknown if vaginal delivery increases infection. There was a report following up 9 pregnant patients of which 2 underwent normal vaginal delivery. The three babies (including 1 set of twins) did well post delivery and tested negative for infection.
Epidural anaesthesia is advised for pain relief during labour instead of Entonox gas because the latter poses a higher risk of aerosolisation increasing the risk of spreading the virus. To this effect, spinal anaesthesia rather than general anaesthesia is advised during a Caesarean section also to curb any risk of spreading infection.
Will the newborn be separated from an infected mother?
Health authorities advise separate isolation of the infected mother and her newborn for 14 days. However, routine precautionary separation of mother and a healthy baby shouldn’t be taken lightly considering the potential detrimental effects on feeding and bonding.
With the limited evidence, UK doctors advise that women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate postpartum period. A risk-benefit discussion between neonatologists and families is recommended to individualise care in babies that may be more susceptible. However, it is also emphasised that this guidance may change as the COVID-19 pandemic is rapidly evolving.
For the baby’s well-being and because of other reports of infection during the early neonatal period, Dr Pamela Tan prefers isolating the mother and newborn as a needed interim consideration to prevent transmission. The American CDC (Centers for Disease Control and Prevention) also suggests the same measure.
Is there a drug treatment or a vaccine for COVID-19?
At present, there is no direct treatment or a drug that can destroy the COVID-19 virus. What can be done to relieve symptoms is to apply supportive care. For example, if a person can’t breathe, they are given oxygen therapy, or if they cannot drink or eat, intravenous fluid replacements are introduced.
Possible vaccines and specific drug treatments are still under investigation. In some countries, drug trials are already underway, and just like the flu vaccine, let’s hope that these treatments would be safe for pregnant women too. A study from Wuhan reported that 7 pregnant patients with COVID 19 pneumonia were treated with oxygen therapy and antiviral therapy in isolation. The outcomes for both mother and neonate were good for the 7 patients. More trials are needed to prove the effectiveness of the drugs and effects on the fetus.
At a time where the disease is at its infancy but potently affecting many around the world, pregnant women should aim to keep themselves in harm’s way as much as possible.
While little is known yet about COVID-19 and how it affects pregnant women, Dr Pamela Tan would be happy to assist you with your concerns. You may check out our official FACEBOOK PAGE for recent updates on this topic, or you may give us a call at +65 6254 2878 (Thomson).
Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.