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
  • Vaccine Consideration
  • SARS-CoV-2 Testing
  • NIH Recommendations: COVID-19 Therapeutics and Pregnancy
  • Monoclonal Antibodies in Pregnancy
  • Oral Antivirals in Pregnancy
  • Vertical Transmission to Newborns
  • Risk for Miscarriage or Congenital Anomalies
  • Risk for Preterm Birth or Stillbirth
  • Obstetric Care Appointments During the Pandemic
  • COVID-19 and Antenatal Surveillance
  • Lactation Considerations
• Key Points
  • When to Deliver
  • Postpartum Care
• Learn More – Primary Sources

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

SMFM and ACOG recommend that pregnant people receive a COVID-19 booster shot at least 6 months after their primary series for mRNA-based vaccines (ie, Pfizer or Moderna) and at least 2 months after their primary vaccination for the Janssen vaccination

As with the primary series, the booster dose can be given at any stage during pregnancy and postpartum

• Bivalent booster dose
  • In addition, SMFM and ACOG support the CDC regarding bivalent boosters that recommends

…all pregnant, recently pregnant, or lactating people receive a bivalent booster, to mitigate increased risk of adverse maternal, fetal, and obstetric outcomes of COVID-19 disease

Additionally, the bivalent booster should be given at any point in pregnancy

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

SARS-CoV-2 Testing

• Individuals should undergo viral testing
  • Immediately for those 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

NIH Recommendations: COVID-19 Therapeutics and Pregnancy

The NIH Panel provides guidance on COVID-19 therapy in patients who are pregnant or lactating and states the following

The COVID-19 Treatment Guidelines Panel (the Panel) recommends against withholding COVID-19 treatments or vaccination from pregnant or lactating individuals specifically because of pregnancy or lactation 

In general, the therapeutic management of pregnant patients with COVID-19 should be the same as for nonpregnant patients, with a few exceptions

The Panel recommends against the use of molnupiravir for the treatment of COVID-19 in pregnant patients unless there are no other options and therapy is clearly indicated 

There is insufficient evidence for the Panel to recommend either for or against the use of therapeutic anticoagulation in pregnant patients with COVID-19 who do not have evidence of venous thromboembolism

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

Note: Additional information on use of monoclonal antibodies, including use for postexposure prophylaxis, can be found in the NIH management summary in ‘ObG Project Topics’

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

• SMFM addresses the use of molnupiravir and concerns regarding mutagenicity
• The NIH Panel states

The Panel recommends against the use of molnupiravir for the treatment of COVID-19 in pregnant patients unless there are no other options and therapy is clearly indicated

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

Obstetric Care Appointments During the Pandemic

• Strategies that alter Ob appointments will depend on local circumstances and practice
• Telehealth can be used
• Antenatal surveillance for high-risk conditions should continue when indicated

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

NIH COVID-19 Treatment Guidelines: Pregnancy, Lactation, and COVID-19 Therapeutics

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

SMFM: COVID-19 Outpatient Treatment in Pregnancy

NIH: Molnupiravir and COVID-19 Treatment Guidelines

SMFM: SARS-CoV-2 Bivalent Vaccination in Pregnancy