Q&A: The concerns and precautions for pregnancy in a pandemic
Pregnancy can be an anxiety-filled time for many expectant parents, and COVID-19 is only adding to the uncertainty. UConn Today asked Dr. Christopher Morosky, associate professor and a member of the obstetrics and gynecology team at UConn Health, what we know about the impact of the virus on pregnant women and how UConn Health has prepared to provide care to pregnant patients during the ongoing pandemic.
How much do we know about the potential effect of COVID-19 on pregnant women?
We actually have very little published data on this. There's been only a few case reports, and so there really isn't a lot of data for us to base our recommendations around COVID-19 infection in pregnancy, for either the mom or the baby.
That said, we do have some reports that are coming out globally, and a few reports also coming out from New York. What we're learning is that, for the mom, the risk of contracting this infection is no higher than the general population.
If moms do become infected with COVID-19, this seems to follow other respiratory infections—like influenza and the previous SARS and MERS infections—where pregnant women are more at risk for developing severe pulmonary complications, or having respiratory failure, as well as experiencing complications of preterm labor and birth if they contract the virus earlier in the pregnancy.
The more recent reports that we're seeing also show that, for moms with actual COVID-19 infection, the cesarean section rate is quite high, approaching 95 percent. We're not really sure if that's because they were going into respiratory failure and were very sick, or if there were obstetrical reasons for these deliveries, or if the obstetrical teams were just trying to get these women delivered quickly because, in these case series, the indication for c-section is not being reported.
Early studies also appear show that COVID-19—similar to SARS, MERS, and influenza—doesn't seem to cross through the placenta to infect the baby while the mom is pregnant, though we do need more data here as well. Also, while the data is limited, it does appear that COVID-19 does not enter breastmilk. For moms who are COVID-19 positive, obviously there's concern about respiratory spread to the newborn baby. But with proper hygiene and masking, we think that moms certainly can express milk, and then that milk can be given to the baby.
When you're pregnant, it already limits the types and varieties of medications that you can use. Are there effective treatment protocols for pregnant women right now?
I should start by saying that the medications that are being investigated right now—hydroxychloroquine and azithromycin—have no evidence for effect in COVID-19 infection. That said, we do know that, outside of COVID-19 infection, hydroxychloroquine and azithromycin can safely be given to pregnant women during their pregnancy, following delivery, and while breastfeeding. Previously, for other indications like malaria, pneumonia, or other bacterial infections, we have used these medications for pregnant women for those indications.
The general public has been asked to follow guidelines for limiting the spread of COVID-19—things like social distancing, hand washing, not touching your face, and limiting size of groups. Are there any additional precautions that women in particular should take if they are pregnant or think they might become pregnant?
Fortunately for women in the community right now, the recommendations for pregnancy are exactly the same as outside pregnancy—staying home, whenever possible; limiting going out and traveling into the community, and social distancing when you do; paying very good attention to hand hygiene. These are the very same recommendations for the general population, as well as pregnant women.
How is UConn Health now handling prenatal care?
In looking along the spectrum of prenatal visits, we have transitioned visits where we can from in-person visits in the clinic to telemedicine—particularly, telephone visits. I've done several of these, and I think that it is a good contact with patients. We're getting to answer their questions, whether it's related to COVID-19 or regular prenatal questions we would normally be handling, and it's working out very well.
When women need to come to the office for blood draws or ultrasounds, we are still scheduling and seeing patients in the office, and we're trying to coordinate those required tests and interventions within a visit so that women are coming back and forth to the office less often. That also seems to be working very well.
How is UConn Health preparing for in-patient—particularly, labor and delivery—during this pandemic?
I am extremely impressed with all of the hard work that our OB/GYN department has been doing over the past weeks, preparing for this crisis. Everybody's been working hard, day shifts, night shifts, in-patient and out-patient, to make as many changes as we possibly can, and things are changing rapidly.
On the in-patient side, there's been a lot of hard work done with how to figure out getting women safely admitted in labor, for inductions, and for cesarean sections. We've had a lot of conversations about labor support. We still maintain a policy of one visitor coming to the hospital with women. That has to be the same person, and they're not allowed to leave. We're trying to make some accommodations where they can order from the cafeteria, just like our patients do. We just feel it's really important for women to have that birth support, and it's also important for the family member or spouse to experience the birth of that child.
In terms of the visitor policy, the visitor and the patient both need to screen out through our regular hospital-wide protocol for suspected COVID-19 infection. Some of our moms are going to begin to be admitted with COVID-19 infection, or be suspected of having the infection. In that case, we are not allowing the visitor, so what we're trying to do now is ramp up our telecommunications technology so that people can video chat into the labor room and provide that support and experience at this really special and important time.
Is the protocol now, for a mother who is positive, to remove the baby after birth?
Yes, that is the recommendation from the CDC, and that's what we're following at John Dempsey Hospital.
A COVID-19 positive or suspected positive mother, after she delivers her baby, that baby is taken quickly from the delivery room and then handed off, in a way to limit exposure to staff, to awaiting neonatologists, who will take the baby and bring the baby into a separate room. The baby would then stay there, and either be cared for by the visitor support person, if they've been screened out or tested negative, or they could stay with a family member. Or, if that person either can't be there or was also under suspicion of suspected infection, then our staff would be caring for the baby.
Recommendations are for these moms not only to be separated from their baby here in the hospital, but when they go home, they're supposed to be separated from their baby for 10 to 14 days. Talk about anxiety! Thinking about an unaffected family member caring for your baby out of your house—how do you produce breastmilk? How do you feed the baby? What about pediatrician visits?
We've started trying to figure out workflows for staying in regular communication on our end with our post-partum mothers, helping them with breastfeeding concerns, helping them with communication with their pediatrician, coordinating all that care, while taking care of their illness.
Pregnancy can cause expectant parents a great deal of anxiety when they aren't in the midst of a global pandemic. As a doctor, what can you say to patients who are experiencing increased anxiety right now to help them reassure them in this situation?
The first thing I'm letting all of my patients know is that this feeling of increased anxiety is very normal. It is very uncertain how this is going to progress. It's also uncertain what this virus does in pregnancy, and so I share an elevated level of anxiety with my patients. But I want patients and their family members to feel as informed as possible and to know the good, hard work that we're doing here at the hospital, the protocols that we're trying to put in place to keep them and their babies safe and that, if they have any concerns, if they have questions, to contact us regularly and often.
Even though we are limiting in-office visits, it doesn't mean that we're not going to be available. Everybody in our department—from our low-risk and high-risk doctors to our nurses, our nurse managers, our medical assistants –is coming in every day and trying to work through all possible outcomes and trying to think through ways that we can help women through this uncertainty.
We are available 24 hours a day, seven days a week, as we always have been. We want to hear from our pregnant women so we can answer their questions and do our best to give them the information they need to maybe calm some of that anxiety.