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Update on COVID-19 in Pregnancy

SUMMARY:

Pregnant patients are at increased risk for COVID-19 vs nonpregnant patients. Pregnancy should be considered a ‘high risk category’ (CDC) and should be managed as such. SMFM has updated a document regarding perinatal care that provides valuable information to professionals managing women with COVID-19 during pregnancy as well as helpful counseling tips to encourage vaccination to avoid complications due to infection.

Table of Contents  

Pregnancy and Increased Risks Associated with COVID-19 

COVID-19 Disease Severity During Pregnancy

  • 3-fold increased risk for both ICU admission and invasive ventilation
  • 2.4-fold increased risk for extracorporeal membrane oxygenation
  • 70% increased risk of death from COVID-19
  • Increased risk for adverse perinatal events, including mortality
    • Comorbidities
    • ≥35 years
    • Latina and Black women
  • Delta variant during pregnancy associated with increased risk for
    • Severe-critical disease | ICU admission | Ventilation | Death in pregnant patients
  • Moderate or severe COVID-19 infection during pregnancy associated with increased risk for worsened obstetric outcomes
    • Cesarean delivery: Adjusted relative risk (aRR) 1.6 (95% CI, 1.3 to 1.9)
    • Hypertensive disorders: aRR 1.6 (95% CI, 1.2 to 2.2)
    • Preterm delivery (<37 weeks): aRR 3.5 (95% CI, 2.4 to 5.1)
    • Severe maternal morbidity and mortality from obstetric causes: aRR 12.8 (95% CI, 8.2 to 9.1)

Vaccine Consideration

  • Vaccines are recommended for pregnant, postpartum and lactating people to reduce risk for COVID-19 and consequent complications

Note: Additional information regarding vaccination in pregnancy can be found below in ‘Related ObG Topics’

SARS-CoV-2 Testing

  • Individuals should undergo viral testing
    • With COVID-19 symptoms and/or
    • Within 5 days of known exposure
  • Test for other causes of respiratory illness such as influenza if clinically appropriate

Monoclonal Antibodies in Pregnancy

  • Use shared decision-making
    • Acknowledge limitations of current data

Therapies that would otherwise be given should not be withheld specifically due to pregnancy or lactation

Therapies including monoclonal antibodies, remdesivir, dexamethasone, baricitinib, and tocilizumab, can and should be provided to pregnant patients with COVID-19 who meet clinical qualifications

Oral Antivirals in Pregnancy

Paxlovid

  • Following FDA EUA for Paxlovid, SMFM issued a statement in support of the use of this medication in pregnancy for those with mild to moderate COVID-19 at risk for disease progression

SMFM supports the use of Paxlovid (nirmatrelvir [PF-07321332] tablets and ritonavir tablets) for treatment of pregnant patients with COVID-19 who meet clinical qualifications

Any therapy that would otherwise be given should not be withheld specifically due to pregnancy or lactation

Molnupiravir

  • Molnupiravir should be avoided during pregnancy due to mutagenicity risk

Vertical Transmission to Newborns

  • Evidence suggests a perinatal infection 1% to 4%
  • More research required to understand risk dynamics (e.g., timing during pregnancy)

Risk for Miscarriage or Congenital Anomalies

  • Studies have not demonstrated increased risk for miscarriage
  • Data “insufficient to suggest an increased risk of congenital anomalies associated with SARS-CoV-2 infection early in pregnancy”

Risk for Preterm Birth or Stillbirth

  • CDC data suggests a potential increase in the risk for stillbirth further supporting the strong recommendation for COVID-19 vaccination during pregnancy
    • Reports estimate that risk for stillbirth may be 4x
    • Study performed during Delta wave
    • Higher severity of illness may be related to increased risk of stillbirth, HDP, preterm birth and cesarean delivery

Note: More information on the CDC data regarding stillbirth and COVID-19 can be found in ‘Related ObG Topics’ below

COVID-19 and Antenatal Surveillance

  • Mild infection
    • Management similar to that of patient recovering from influenza
    • Be aware that a patient may initially have mild symptoms but decompensate | Instruct patients to call or seek care for worsening symptoms
  • Consider ultrasound following periconception or first trimester maternal infection
    • Detailed midtrimester anatomy scan
    • Interval growth assessments (depending on the timing and severity of infection, and other risk factors)
    • Data insufficient to recommend fetal surveillance for stillbirth risk

Lactation Considerations

  • SARS-CoV-2 has not been detected in breast milk
  • Breastfeeding is not contraindicated
  • Precautions should be undertaken to avoid transmission to the infant
    • Hand hygiene
    • Face covering
    • Proper pump cleaning
  • If patient is receiving therapeutic agents for COVID-19, decision to breastfeed

…should be a joint effort between the patient and the clinical team, including infant care providers

KEY POINTS: 

When to Deliver 

  • Maternal COVID-19 infection alone “is not an indication for delivery”
  • Infection in pregnancy with recovery
    • No change in timing of delivery
  • Infection at or near term
    • Individualize balancing risk for maternal deterioration against delivery support services, risk to attending staff re: viremia load
  • Critically ill patients
    • Shared decision making
    • Balance preterm delivery against possible improvement in maternal status
    • Cesarean delivery does not reduce risk for perinatal infection

Postpartum Care

  • High transmission area
    • Telehealth is reasonable
  • Contraception
    • Discuss options during prenatal care and make a plan “to facilitate immediate postplacental long-acting reversible contraception utilization if desired”

Learn More – Primary Sources:

COVID-19 and Pregnancy: What Maternal-Fetal Medicine Subspecialists Need to Know

SMFM: FDA Issues EUA for the Treatment of Mild-to-Moderate COVID-19 (Paxlovid)

CDC: Clinical Course: Progression, Management, and Treatment

CDC: COVID-19 Treatment Clinical Care for Outpatients

CDC: Testing for COVID-19

ACOG: COVID-19 (incudes vaccine & pregnancy resources)