Covid-19 and pregnancy update 2021
It is roughly a year since South Africa had its first reported Covid -19 case. Below is an update for my patients of developments applicable to pregnancy in 2021. Please see original notes on Covid in pregnancy posted in 2020, as well as the recent discussion on Covid vaccination in pregnancy.
Please note that there is considerable uncertainty regarding the timing and severity of the third and fourth waves this year, but we have made significant progress in our understanding of the disease.
What do we know about the severity of the disease?
The covid-19 pandemic has resulted in significant morbidity and mortality around the world.
The spectrum of COVID-19 is broad, from clinical disease requiring intensive medical care to less severe symptoms that are treated with supportive care. The good news is that many COVID-19 patients, including pregnant patients, have mild or no symptoms. We define asymptomatic or pre-symptomatic disease as a positive COVID-19 test result with no symptoms.
Experience has shown that in the majority of patients with Covid, the symptoms last less than 6 weeks. Nevertheless, the morbidity from Covid-19 is significant and can affect multiple body systems, most frequently the cardiac, pulmonary, haematological, musculoskeletal and gastrointestinal systems.
A useful, practical classification is therefor to define Covid as: asymptomatic, mild, moderate or severe disease.
It is clear that the full scope of the emotional and economic impact of Covid is still to be determined.
What is mild disease?
Mild disease is defined as flu-like symptoms (eg fever, cough, muscular pains, loss of taste and smell) without shortness of breath or abnormal chest imaging.
Many Covid-19 patients, including pregnant patients, have mild disease. Outpatient monitoring with a 14-day self-quarantine can be considered for pregnant patients with Covid-19 who have mild symptoms or are asymptomatic. We use a combination of clinical judgment, as well as tests, against the background of the spread in a local community to decide who should be tested. Due to the unique factors affecting management in pregnancy, we test all pregnant women suspected of having Covid.
What is moderate disease?
This is defined by evidence of lower respiratory tract (lung) disease. We look at the rate of breathing, blood oxygen levels, evidence of lung involvement on chest imagining, as well as severe fever not responding to usual medications.
We have a low threshold to admit pregnant women with moderate disease. One must however remember that we need to balance the bed availability, as well as the risk for staff and the available resources. In-patient monitoring is usually needed for women with co-morbidities ( diabetes, kidney disease, heart disease, as well as those with a depressed immune system due to medication or disease).
What is severe disease?
We classify Covid as severe based on the respiratory rate of the mother, as well as the blood oxygen saturation percentage or oxygen fraction. More than 50 % lung involvement on imaging studies would also qualify as severe disease.
Do we have guidance for outpatient management of pregnant moms?
We usually advise rest, oral hydration and paracetamol at home. You should be able to perform daily self-assessment and will be given instructions about when to contact us or present to the hospital. Our practice will contact you regularly by e mail or phone. Often your GP will also be involved to help with monitoring if practical.
Reasons to seek help would include: worsening in shortness of breath, unremitting fever, inability to tolerate oral fluids or medications, as well as persistent chest pain or severe tiredness/lethargy.
If a pulse oximeter is available, it may help in outpatient management. Any obstetrical complains e.g. premature contractions; bleeding or decreased fetal movements would also qualify for assessment as usual.
It is reasonable to have a follow-up visit at least once within 2 weeks of the diagnosis of Covid-19.
What do we now know about the risks for pregnant women?
It is important to note that pregnancy does not increase your risk of acquiring severe Covid disease. We now know that pregnancy does appear to worsen the clinical course of the disease compared to non-pregnant women. You can still expect a more than 90% chance of full recovery. The statistics show that pregnant women with Covid have an increased risk of a caesarean section, as well as premature delivery. Most preterm delivery in this scenario however is due to induced labour or a scheduled Caesarean section. If you however develop Covid early in pregnancy, then the timing of delivery should not be affected. Towards the end of pregnancy unique factors apply and we individualise decisions regarding birth.
What about the risk for the baby?
There is no evidence of a risk for abnormalities of the baby with infection acquired early in pregnancy. There has also not been any increase in miscarriage rates after first trimester Covid infection.
There does seem to be an increased risk of premature delivery, but this is linked to planned early delivery. The data from overseas point towards more small for gestational age babies (low birth weight) being born, following Covid infection.
Research has indicated that in-utero transmission of Covid -19 is possible, but very rare. Transmission of the virus from the mother to her baby during pregnancy or childbirth therefor seems very uncommon. The mode of delivery and whether or not the baby stays with you after birth does not seem to influence the chances of the baby getting Covid. Remember that experience has shown that even if the baby develops Covid soon after birth, the baby would be expected to remain well.
What has the experience in pregnancy been locally?
The vast majority of cases have been asymptomatic or mild and patients have in general been able to cope at home and recover fully. Data from South Africa has been sparse. Personal experience has shown that severe Covid after 37-38 weeks poses unique challenges. It is very difficult to balance the possibility of clinical deterioration during expectant management, with the implications of immediate delivery on the health of the mother and baby, as well as the risk of exposure to health care workers in a time of high viral load.
The fact that all our antenatal and post-natal rooms are private rooms in Mediclinic Stellenbosch has been a massive advantage during the Covid pandemic.
What about in-patient treatment in pregnancy?
The treatment is generally supportive.
There has been evidence that intravenous steroids are of benefit to those patients on ventilators, as well as those requiring oxygen. We believe that the benefits of mortality reduction showed with this research outweigh any fetal risk of this short course of therapy in pregnancy.
Antibiotics are administered if a lung co-infection is suspected. Blood thinners are considered on all admissions during pregnancy.
Oxygen is administered by nasal cannula or face mask and pressure devices, depending on the severity of the disease. The severity of illness may dictate earlier delivery.
Are there any important lessons learned so far that are applicable to my care during pregnancy?
It is clear that ante natal care needs to be adapted to the level of Covid in the community. Experience has shown that adequate ante natal care is possible during the pandemic and our pregnant patients have adapted admirably. Modifications can be tailored for high and low risk pregnancies, but it continues to be vital to attend for scans and appointments in pregnancy.
Following Covid during pregnancy, a growth scan is advised in 2 weeks.
All pregnant patients are encouraged to get a flu immunisation. Please see previous entries on Covid in pregnancy, as well as immunisations in pregnancy.
What about returning to exercise after Covid?
It is important to note that researchers have had the opportunity to study SARS since 2003. When following survivors with severe SARS in Hong Kong for 6 months, they showed that the exercise capacity and health status of the survivors were considerably lower than that of a normal population. This is true for athletes who have had Covid-19 to any degree.
Any Covid patient with an underlying condition should first consult a physician before attempting to become active, even if asymptomatic. Consultation with a physician is also recommended if patients who had Covid develop fever, shortness of breath at rest, cough, and chest pain or heart palpitations.
General guidelines are that any otherwise healthy patient with a self-limited course of Covid who has been asymptomatic for 7 days, may begin resuming physical activity. It is important to note that each patient with Covid-19 recovers at an unique rate and it is better to be safe than sorry. It is therefore advised to return to activity in a slow, stepwise manner. General advice is to start at 50 % of normal volume and to slowly increase by 10% each week. This should be adjusted by the severity of the disease and may require a graduated return to activity occurring over many months rather than weeks.