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The current Coronavirus pandemic is ever-evolving and we are learning more every day about SARS-CoV-2/COVID-19 and pregnancy. Click here to see the most recent episodes, articles, and resources on this topic.

Overview

A big challenge of covering the topic of the coronavirus is to find a balance among taking precautions, getting accurate information, being safe and prepared, and not inducing hysteria and fear. That has been part of the reason I have waited to cover this in an episode. I am very cautious about my sources of information, as you should be. There is a lot of alarming information about the coronavirus and there are a lot of unknowns. This is my attempt to synthesize all of the data and information I have been taking in, along with professional guidelines, and the actionable steps you should be taking right now to protect yourself. There are many ways in which this pandemic can affect you during pregnancy, whether or not you get exposed to this virus. You may see changes to your access to prenatal care and changes in your birth plan as a result of this pandemic. This is an ever-evolving situation and this article is the most recent info and data available as of March 15th.

Helpful Links

Article and Resources

What is Coronavirus?

Coronaviruses are a class of viruses. Coronaviruses cause respiratory infections, like the common cold. Coronavirus was also responsible for past outbreaks like the SARS virus in 2003 and MERS in 2012. It seems like we have a major outbreak about every decade. SARS-COV-2, which is a coronavirus, is technically the name of the virus in the current outbreak. The disease it causes is named COVID-19.

Where Did SARS-CoV-2 Come From?

All of the data we have shows that SARS-CoV-2 originated in Wuhan, in the Hubei Province in China towards the end of 2019. It originated in bats and was likely spread to humans in a market. Now it is worldwide. The World Health Organization declared this a pandemic on March 11, 2020. That was significant because that means that this will spread worldwide. The WHO expressed their reluctance to label it a pandemic because they hoped that countries would not stop trying to contain the spread of this virus and are urging countries to take this seriously. Currently, Europe is the epicenter of this pandemic. The U.S. has had an increase in cases, although testing is very limited, and I am certain the numbers currently published are grossly understated. This is a problem no matter where you live.

Symptoms

The main symptoms of this virus are fever, cough, and shortness of breath. These could appear anywhere between 2-14 days after exposure to the virus. Emergency warning signs include difficulty breathing or shortness of breath, persistent pain or pressure in the chest, confusion or inability to arouse, and bluish lips or face. If you have any symptoms you definitely want to reach out to your doctor or midwife right away. You want to be proactive as much as possible and not wait.

Defining Mild, Moderate, & Severe Symptoms

NPR has a good article that breaks down how the symptoms are defined into the categories of mild, moderate, and severe. The good news is that the vast majority of people (80%) who are getting this virus are having only mild to moderate symptoms. Keep in mind that this can still be a nasty virus with mild to moderate symptoms. A mild infection can involve fever, aches, pains, and a dry cough. Even a mild infection can include a mild form of pneumonia. A moderate infection includes fever, coughing, chills, and fatigue. For 1 in 5 patients, the infection gets worse and is considered severe. About 14% of cases can develop into severe disease, requiring supplemental oxygen. And 6% of cases become critical and may experience septic shock. This means a significant drop in blood pressure that can lead to stroke, heart or respiratory failure, failure of other organs or death.

Testing

It is clear that the U.S. has made a lot of mistakes in rolling out testing. Placing blame on our shortfalls with testing is not where we should be focusing our energy. The short story is that the CDC was developing its own tests. The original tests shipped out across the country were flawed which resulted in huge delays in making them available. The U.S. is involving private companies like Quest Diagnostics to help with testing. Talking about making testing available at your local Walmart, CVS, and Target. Fingers crossed this becomes widely available so we can have a better picture of how this is spreading.

ACOG and the Society for Maternal-Fetal Medicine have an algorithm to aid practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19. If you do not have symptoms they will not test you. This seems to be pretty much across the board in the United States. In the coming weeks as testing becomes more widely available that could change. I am hearing a lot of anecdotal reports that even people with symptoms are unable to get tested.

This is Not the Same Thing as the Flu

Earlier on a lot of people were comparing this virus to the flu. While there are some similarities, this is not the flu, it is much more serious. There is a great graph that shows a lot of infectious diseases and where they lie on a graph looking at how contagious they are and how lethal they are. Thank you to the New York Times for the graph pictured below:

While this virus is not as deadly as the MERS or SARS outbreaks we have had in the past, it is a lot more transmissible. It is estimated that one person infects 2-4 other people. This is a virus that grows exponentially. This stat is known as the Ro and is the rate of infectability. To put this into perspective, the seasonal flu has an Ro of 1.2-1.3. Measles has a very high rate of transmission with a Ro of 12-18.

In one study in the Journal of the American Medical Association they estimated the R to be 2.68 and that the epidemic is doubling every 6.4 days. That was as of 1/25 based on numbers from China. From I am seeing now they are pinning the Ro between 2-4.

Estimates of How This Disease Will Spread

Epidemiologists are using models to predict how many people this will spread to and then applying the assumed mortality rate. These are useful, but not perfect. The truth is that we will not have an accurate picture of how this spreads until this entire pandemic has run its course. I considered including some conservative & worst-case predictions. These numbers range all over the map and it is safe to say that this is spreading exponentially.

Experts have been hopeful that there is a seasonality to this like there is for the flu. It is possible this will calm down as summer arrives in the U.S. Although that could mean it kicks back up in the fall. Right now, we do not know whether this is the case.

Mortality Rate

The mortality rate of COVID-19 is somewhere between 0.6-3.4%. To put these numbers into perspective, the mortality rate of the flu is 0.1. Among older populations, the mortality rate is much higher at 10-20%. If you want to dig into more data this podcast from Dr. Peter Attia is an excellent resource.

How This Virus is Transmitted

The SARS-CoV-2 virus is transmitted primarily from air droplets. When someone who is infected coughs, breathes or sneezes the virus can travel in aerosols in the air, which could be breathed in or land on a surface. This study compares the current virus with SARS-CoV-1, which is closely related and we have data on how long that virus remains on surfaces. Aerosols can remain in the air for up to 3 hours. On copper, the virus can survive up to 4 hours, up to 24 hours on cardboard, and up to 2-3 days on plastic and stainless steel. The danger is that you could be touching a surface contaminated with this virus and then touch your face, which introduces the virus to your body. The biggest problem is that someone can be infected with SARS-CoV-2, be asymptomatic, and still spread the virus.

Who is Affected?

Kids and young adults are among the least affected by this virus. A huge sigh of relief from anyone who is a parent and who is young. The reality is that even if they are not getting really sick, young adults and kids are still carrying the virus. This is a major problem for those who are more susceptible, which especially pertains to people who have underlying health conditions or that are over the age of 70. The underlying health conditions that are shown to increase risk the most are diabetes, high blood pressure, and heart disease, on immunosuppressive therapy. Older individuals have the highest risk. If you followed what happened in the nursing home in Seatle, we need to take big precautions to avoid this happening in other areas.

How Pregnancy Affects Your Risk

According to the World Health Organization in an investigation of 147 pregnant women (64 confirmed, 82 suspected and 1 asymptomatic), 8% had severe disease and 1% were critical. This isn’t a lot higher than we are seeing in non-pregnant patients, which is good news.

According to the American College of Obstetricians and Gynecologists, pregnant women do not appear to be at a higher risk for severe disease. This is awesome news. However, ACOG does state that pregnant women are known to be at greater risk of severe morbidity and mortality from other respiratory infections such as influenza and SARS-CoV. As such, pregnant women should be considered an at-risk population for COVID-19. There are some changes during pregnancy that could affect you if you are exposed to SARS-CoV-2. First, your immune system is suppressed during pregnancy which can make it more difficult to fight off a virus. Second, as your pregnancy progresses and your baby and uterus grow you will have a decreased lung capacity. That is due to less space for your lungs, which is not ideal for a respiratory illness.

Can You Pass SARS-CoV-2 to Your Baby?

When something is transferred from you to your baby during pregnancy it is called vertical transmission. Currently, it is unclear if SARS-CoV-2 or COVID-19 can cross through the placenta to your baby. A very small study from China included 9 pregnant patients who all had a cesarean birth in the third trimester. Cesarean Amniotic fluid, cord blood, neonatal throat swab, and breastmilk samples from six patients were tested for SARS-CoV-2, and all samples tested negative for the virus. All nine births had a 1-min Apgar score of 8–9 and a 5-min Apgar score of 9–10. All mothers survived the infection. Again, this is a very small study, but promising.

According to ACOG infants born to mothers with confirmed COVID-19 should be considered patients under investigation. As such, these infants should be isolated according to the Infection Prevention and Control Guidance for PUIs. ACOG goes on to state that to reduce the risk of transmission of the virus from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued. I want to make sure that you understand exactly what ACOG is saying here. If you are positive for COVID-19 the recommendation is that you will be separated from your baby at birth. That is perhaps the most alarming thing I read in all of my dozens of hours of research for this episode. That alone should be enough information to tell you that you want to avoid this virus and that you should be taking every precaution to do that. ACOG releases these guidelines for all OBGYNs and it would be good to ask your doctor or midwife hypothetically, what would happen if you are positive for COVID-19 at birth.

The Royal College of Midwives takes a little bit of a different approach. They state that literature from China has advised separate isolation of the infected mother and her baby for 14 days. However, routine precautionary separation of a mother and a healthy baby should not be undertaken lightly, given the potential detrimental effects on feeding and bonding. Given the currently limited evidence, we advise that women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate post-partum period.

How to Protect Yourself

There are some very basic things you can do to protect yourself and limit the spread of this virus. This includes:

  • Handwashing with soap for at least 20 seconds
  • Using a hand sanitizer that is made with at least 60% alcohol is helpful if you cannot wash your hands
  • Avoid touching your face, especially when you are out in public
  • Avoid touching surfaces as much as possible

Social Distancing

I cannot emphasize enough how important social distancing is right now. I know this comes at a cost. We could find out later that this was an unnecessary precaution. From all of the information I am taking in I doubt that will be the case. The CDC recommended that for the next 8 weeks that any events over 50 people are canceled or postponed. Schools are canceled for the next 3 weeks in several states. Events are being canceled or postponed everywhere. The governor of California recommended all bars and restaurants close. Puerto Rico is under a curfew from 9:00 p.m. to 5:00 a.m. and the only businesses that are permitted to be open are supermarkets, gas stations, pharmacies, and banks. I suspect that we will be seeing more restrictions in the coming weeks.

The U.S. first case was likely at the beginning of February. We are now in March and are making big changes. The aim of social distancing is to flatten the curve. This article from the Washington Post  or this article from the New York Times explains how slowing the spread of this virus can allow us to manage those who are being infected at a pace that hopefully will not overwhelm the medical system. Image credit: New York Times.

How We Can Expect the Health Care System to Be Affected

One major aim of flattening the curve is to not overwhelm hospitals. Other countries have seen a bottleneck in the hospital system with decreased staff, not enough beds, limited supplies, etc. Remember, China was constructing new hospitals in days. In the U.S. and many other countries, we do not have the resources to do that. Hospitals will be protecting labor and delivery wards and you can be sure that hospitals are taking every precaution. I do not want to freak you out about how this could affect your prenatal care or birth. It is important to be aware of how the spread of this virus and policy changes and recommendations could change your prenatal care or your birth plan.

Precautions in Hospitals

Hospitals are relying on pregnant patients who have confirmed COVID-19 or who are persons under investigation for the disease to notify the hospital before you go in. Again, due to the lack of testing, this could expand as we see that it is more widespread as people are tested. Notifying the hospital ahead of time allows them to prepare ahead of time to keep the infection from spreading within the hospital. This is done via isolation, using personal protective equipment for medical workers, they will be using all precautions possible. The good news is that these measures should help keep this area of the hospital safe for those who are not infected.

Precautions That Could Affect Your Labor and Birth

The CDC guidelines for healthcare facilities could impact your labor and birth. Let’s take a look at their recommendations and how you could be affected.

Healthcare facilities should consider limiting visitors, with the exception of a healthy parent or caregiver. This means that you may get pushback if you have a doula, or any additional person other than your birth partner who you want at your birth. You can advocate for yourself and make sure your care provider understands that your doula is not a visitor they are a critical support person for your birth. Also, talk to your doula about what they are seeing in their practice. If you are planning to have a photographer or anyone else present that may be really challenging depending on the rules being put in place where you are planning to have your baby.

The next recommendation is that visitors should be instructed to wear appropriate PPE (personal protective equipment), including gown, gloves, face mask, and eye protection. If another healthy family or staff member is present to provide care (e.g., diapering, bathing) and feeding for the newborn, they should use appropriate PPE. For healthy family members, appropriate PPE includes gown, gloves, face mask, and eye protection. A heads up that this could be required and it would be good to give your partner a heads up on this.

If colocation (sometimes referred to as “rooming in”) of the newborn with his/her ill mother in the same hospital room occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, facilities should consider implementing measures to reduce exposure of the newborn to the virus that causes COVID-19. They recommend to consider using engineering controls like physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the ill mother. If no other healthy adult is present in the room to care for the newborn, a mother who has confirmed COVID-19 or is a PUI should put on a facemask and practice hand hygiene1 before each feeding or other close contact with her newborn. The facemask should remain in place during contact with the newborn. These practices should continue while the mother is on transmission-based precautions in a healthcare facility. This is a little less stringent than the guidelines we heard about from ACOG. It is very important that you have a discussion with your doctor or midwife about what their policy or recommendation is in the event you do get this virus.

Risks to Healthcare Workers

Health care workers and first responders are at a higher risk for COVID-19. This could be due to a higher level of exposure. Plus, they are in very stressful environments and working long hours. This could impact our health care system as these people get sick and are taking these critical workers out of the workforce. This is a concern that has been mentioned by ACOG and they state that OBGYNs and other prenatal care practitioners should consider creating a plan to address the possibility of a decreased health care workforce, potential shortage of personal protective equipment, limited isolation rooms, and should maximize the use of telehealth across as many aspects of prenatal care as possible.

If this is something you are concerned about you should be asking your care provider what they are doing to prepare. A great question to ask is what is your doctor or midwife’s plan if they become sick? While I am sure they are taking every precaution, if they get this virus they will not be available. Who is their backup? If you are in a practice that has multiple doctors or midwives this may be less of an issue than if you are seeing an independent practitioner.

How This Can Impact Your Birth

We addressed how changes in hospital policies could impact visitors and what could happen if you are infected. If you have symptoms or are positive for COVID-19 you will likely expect to see continuous electronic fetal monitoring. This could limit your mobility during labor if you are tethered to a machine. You may see increased isolation, whether you have any symptoms or not, as hospitals are being more diligent about preventing the spread of the virus. Instead of walking through hallways you could be asked to remain in your room. You may see fewer staff members than would typically be around for labor and birth. Staff present may be wearing more protective equipment. Your care provider or nurses may be increasing how often they are checking for oxygen saturation if you have any symptoms. If you are planning to use nitrous oxide there may be a filter added to this or it could be discouraged because that could increase the risk of spreading the virus if you have any symptoms. I am sure as we learn more in the coming weeks we will have more information on how the strain on the hospital system could affect labor and delivery units and their policies.

How Other Countries are Reacting

While this article is mainly focused on the outbreak in the United States how this is being handled in other countries can give us some clues as to what works and what doesn’t. Countries like China and South Korea have been quarantining and screening large numbers of people. Japan closed all schools and universities weeks ago. Italy shut down the entire country. International travel is restricted to some degree everywhere. The U.K. is taking a unique approach and has talked about focusing on herd immunity rather than trying to avoid the virus. Everyone will be watching to see how this plays out in other countries.

Vaccine

We are at least 12 months away from having a vaccine, probably longer. There are three phases a vaccine has to go through to prove safety and efficacy. These timelines can be compressed some, but this is not something we will have anytime soon. A problem with previous corona vaccines is that they created immune enhancement where the vaccine actually makes things worse. Vaccine trials started in Washington state. Unfortunately, many vaccine trials exclude pregnant women.

Medications to Treat COVID-19

It is tempting to be able to use drugs that are already developed because that cuts way down on the time to get something to market. Some drugs like Remdesivir which is an antiviral has moved to phase 3 trials and we will hopefully know more about whether this is a promising treatment next month. There is a possible treatment proposed that antibodies from people who have survived COVID-19 could be used to treat those who are sick or be utilized prophylactically to prevent people from getting sick. That is a very simplified version of a complex process but hopeful news that there could be treatments coming.

Tips for Travel

The general recommendation is that if you do not need to travel you shouldn’t. Travel is restricted to specific countries. Cruise ships have halted travel. I expect we will see more restrictions and canceled flights and travel. There is the possibility that if you are traveling abroad you could be detained or quarantined upon re-entry. If you need to travel you could consider driving, if you are not going too far.

In the event you are planning a babymoon or other travels understand that there may be things out of your control that affects your travel plans. Consider travel insurance that allows for cancelation for any reason or purchase refundable tickets. Southwest airlines allow you to cancel and have a credit for a year from the date of purchase for your ticket. For more information on coronavirus disease and travel see the CDC website.

There are not travel restrictions within the US right now but that could change. Trump has mentioned the possibility of limiting travel to states like California and Washington. There are many restrictions on travel to and from other countries. While these restrictions do not apply to American citizens the flights will be very limited, screening at airports may be intense. The bottom line is that if you do not need to travel, please don’t.

Tips for Your Health

The number one thing you can be doing right now is taking good care of your health. You want your immune system functioning at the best it can possibly be right now. The basic components of that are to be sleeping well, to eat healthy whole foods, stay hydrated, and make sure you are taking a prenatal vitamin. I want to dig into the evidence on natural immune support and remedies very soon. If you have something that is your go to for immune support, run it by your doctor or midwife for their thoughts on the safety of it. Remember you should always run any supplements or medications by your doctor or midwife, even if it is something that is available over-the-counter. You need to prioritize your health and please wash your hands often.

Tips for Home

Anyone you live with should also be taking every precaution. If you live with someone who has any symptoms you want to isolate them to keep yourself as healthy as possible. Open windows and get fresh air in your home. When you walk into your home the first thing you should do is wash your hands. You can clean frequently touched surfaces like light switches or door knobs. Switch out and wash hand towels often. Being diligent about making your home safe is important.

Tips for Work

This pandemic is affecting all businesses. If you have the option to work remotely, do it. I think anything you can do to limit your risk is prudent. Yes, there is a cost to this, but until we know more, I would be as cautious as possible. If your employer is not talking about allowing employees to work remotely, bring it up and start that conversation.

For a lot of employees, it may not be an option to work remotely. You want to know what your company’s sick or paid leave policy is. You may already have a good handle on this if you started planning for maternity leave. Employers are being understanding about this situation and I would hope that they would be especially understanding for an employee that is pregnant. If you will still be going to work take precautions that you can to limit your exposure to people and practice good hygiene like washing your hands and not touching your face, and take steps to sanitize your workspace.

If you have any symptoms of a cold, flu, or COVID-19 please stay home. First, because you need to rest and prioritize getting healthy. Secondly, you want to keep others healthy.

Stocking Up on Supplies

Depending on where you live stocking up on groceries could be challenging as stores are cutting hours, and dealing with reduced inventory. It would be a good idea to send your partner or someone else to the store to reduce your exposure to other people. If you have the opportunity to get groceries delivered that could be a good option.

If you due soon and are planning to stock up on diapers I wouldt get a ton of diapers in size zero. Maybe get one box of size zero and the rest in size one. If you think that you will want to supplement breastfeeding with a formula you could get some of that ahead of time. Everyone is stocking up on groceries right now and while we want to be prepared, we also want to be mindful about other people who may not be able to stock up ahead of time.

Stay Calm

It can be particularly challenging to remain calm during this time. It is important no to freak out over the news and pay close attention to your sources and what you are exposing yourself to. If you feel like you need to take a break from the news or social media, you should. You want to check in with local resources for your city, county, or state for instructions that will apply to you.

How Can I Help?

There is so much that I did not cover in this article and there will be more information to come. I would like to do some shorter Q&A episodes and cover more of your questions. Please email me and let me know what resources I can help you find and how I can help you navigate this challenging time.

Talking to Your Doctor or Midwife

Please discuss this topic with your doctor or midwife for their thoughts and recommendations. They are your trusted partner during your pregnancy and birth and can help you navigate this. It could be a good idea to get copies of your health records. You want to have access to this information in the event your care gets transferred. If you have any questions, please ask.

Helpful Links

 

Thank you to the amazing companies that have supported this episode.

Zahler makes high-quality prenatal vitamins that have the active form of folate plus omega 3s and DHA. For the current promo code to save on an amazing prenatal vitamin click this link Zahler Prenatal + DHA. During the month of March 2020 you can save 20% off the Prenatal +DHA, plus get free infant vitamin D3 drops with your purchase. Click here for details.

BLUblox makes the best blue light blocking glasses and you can save 15% with the promo code PREGNANCY. Your circadian rhythms drive your hormones and you want to be blocking blue light after the sunset. Blue light can affect everything from your fertility to your breastmilk and these glasses mitigate the risks of blue light exposure at night. To check them out click here and use the promo code PREGNANCY to save 15%.

Boppy makes a lot of incredible products for you and your baby. My favorite products are their pregnancy pillows which are going to help you get in a comfortable position to get a good night of sleep during every stage of your pregnancy. You can click here to check out the pillows and use the promo code PREGPOD20 to save 20% until 06/30/20.

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