Pregnancy and COVID-19

How does COVID-19 affect pregnancy? In this special episode of The Lancet Voice, Lancet editors speak to frontline staff around the world to see how approaches have evolved.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hi,

this is Jessamy and I'm a medical doctor. 

Gavin: And hi, I'm Gavin, and we're bringing you through the lines of voice some quick podcasts on COVID 19. This episode's gonna focus on COVID 19 and pregnancy, so Jessamyn, perhaps you could explain a little bit why this is such a difficult area and why the science is so fast moving.

Jessamy: This is a new disease that we've only known about since December. So we just don't have the evidence of how this affects women in their first or second trimesters because obviously those women haven't delivered yet and we don't have enough numbers. So through this episode what is this rapidly moving field with very hard working frontline staff around the world, corresponding with each other and trying to come up with sensible and evidence based ways to deal with these patients.

Gavin: Yeah, it's it's been amazing to hear you speak with some of these people on the frontline. It's incredible the job they're doing, putting themselves in harm's way around the world. So Yeah, you've spoken with some people who have taken the time to submit evidence and some of their experience to a few of our different Lancet journals.

Jessamy: So yes, we spoke, Huan Shi from China, who's a neonatologist, and he wrote into the Lancet Child and Adolescent Health about his experiences. And given the very early experiences that they had, they were obviously very cautious with COVID 19 patients and their babies. And they took the approach of isolating the babies from the mother.

However, what you'll see from the interviews as clinicians gained more experience as the epidemic moved around the world, Then they've moved to a more shared decision making process whereby the risks and benefits are discussed with the mother and with the father about how the mother and baby should be kept.

So those are the things to listen out to when you're listening to these interviews. 

Huan: Yes, I am in southwest of China, Chongqing Children's Hospital. We have a very big hospital. So doing the outbreak of the coronavirus disease. I am also a exclusive member of the Chinese Association of Pediatrics, the subgroup of Neonatal Nodes.

So I know in China right now, there are about 700 children suffering from this disease, but only a limited number of newborn babies suffering from coronavirus infection. Right up to now, to my knowledge, although a lot of Mothers, pregnant mothers suffering from coronavirus infections, but most of their babies not suffering from this disease.

Just a limited number of newborn babies infected with this disease. After their birth, The newborn babies will be isolated if the mother will suffer from confirmed or suspected coronavirus disease. Their newborn babies will be in an isolated unit to observe for at least 14 days. All those babies with some, something like infection, such as no reaction, has no feeding and sometimes with with a fever, but not very significant.

We found a significant sign of the newborn infants is not only the respiratory syndromes, but also gastroenteritis, such as vomiting, diarrhea, that the rate is higher than adult patients. 

Jessamy: So we next spoke to David Board and colleagues, and they'd had an exchange about how we should be dealing with pregnant women with COVID 19.

And I think there's some really interesting things that have come out from that about how clinicians share experiences and how different centers have really very quickly needed to set up new systems to be able to deal with these patients in the most appropriate and humane way. 

Gavin: Yeah, it's really interesting to see how there's decision making in hospitals.

I think it's developing so fast. 

David: So my name is David Boe. I'm the head of the obstetrics service in Lausanne, Switzerland. It's a university hospital that take care of All high risk pregnancy for the whole French part of Switzerland. And we share this with Geneva, which is another ary center in the French part of Switzerland.

And with my colleague who is a neonatologist, we have a special interest in infectious disease in pregnancy and in neonatology. 

Eric: Okay. My, my name is Eric. I'm a neonatologist. at the University Hospital of Lausanne. 

David: So the first things on the obstetrical point of view is that we today there is no identification of transmission from the mother to the fetus.

We have now data from China, some good data about China. We have also colleagues who share with us their data from Spain and Italy and so far no transmission from the mother to the fetus has been identified. This is one of the first things. Now, on the fetal point of view, it seems there is more fetal distress of this baby close to birth.

And this 

Jessamy: is if the mother has COVID 19 or is in distress herself? 

David: If the mother has COVID 19. Now, is it induced by the fact that the mother is affected or not. It's difficult now to say. We don't have enough experience with that. Something I would like to add also, it seems that the number of pregnant patients infected by the virus is the same as the patients who are not pregnant.

Jessamy: So we're saying that pregnant women are not at a high risk of getting this disease? 

David: It seems so, yeah. They are not at high risk to get the disease. And if they get the disease, it seems that the forms are more milder than in older patients. So when they get the disease, they are not more severely affected than the general population.

Jessamy: There have been no women who have been intubated because of respiratory distress, is that? Exactly. 

David: Okay. Except two that I know at the moment in Spain, but they were affected with preeclampsia, which is a disease that affects pregnant women. 

Eric: Yes. It 

David: is linked to high blood pressure and proteinuria. It seems when you have preeclampsia this woman might be more at risk to be intubated.

Is it linked to preeclampsia itself? Is it linked to COVID? Is it linked to a combination of both diseases? We don't know. 

Jessamy: After the baby is born. With COVID-19 patients, what's been the way that you've managed that situation? 

David: So on the obstetrical point of view, we manage them as other patient, except that they are in a area of the hospital dedicated for C 19 patient.

Eric: So in terms of feeding breast milk is really breast. the best nutrition for newborns and infants. We really encourage breastfeeding. In case the mother is is too sick for breastfeeding, we encourage expressing maternal milk and providing it to the newborn. Hand hygiene is really important during before breastfeeding.

And masks are also considered for the mother, of course, not for the baby. 

Jessamy: What are the kind of take home messages here, from your point of view? 

David: We need to reassure first our pregnant patient. The data so far are reassuring both in terms of maternal disease and in terms of the fetus. This is one of the first things to say.

The second thing is in our hospital, we do not separate mother and babies breastfeeding. Should be discussed and encouraged and maybe 

Eric: my colleague will add something. And I think regarding newborns, I think surveillance is important. Also isolation, of course, avoiding to, to spread the disease within the hospital.

is important and also, being aware that, data might change, so we must really be aware of what is getting published at the moment. 

Gavin: So basically what I'm getting from those interviews, Jessamy, is that there's no evidence of vertical transmission between mother and child at the moment.

Jessamy: Exactly. There's some really reassuring points, which is exactly as you say, that there's no evidence of vertical transmission. There's no evidence of the virus. being passed on in the breast milk, although obviously precautions do need to be taken when mothers are feeding their babies potentially wearing masks.

And also that just how important it is about keeping the babies and the mothers together whenever possible and just ensuring that conversation between the clinicians and the parents is open and really transparent about what the risks and benefits are about where to put these patients and how to deal with them.

Gavin: It is such a difficult balancing act for clinicians though, because Obviously, the first few days between a mother and child and their contact and breastfeeding are vitally important, but on the other hand, you've got this unknown disease for which we currently have no treatments at all. So I think you can understand the abundance of caution they started out with in China.

Jessamy: I think that kind of leads nicely on to how the Royal College of Obstetricians and Gynecologists have now rapidly collated all of the evidence. that's been going on in different parts of the world to publish these sort of most recent guidelines. I had the pleasure of speaking to the Vice President of the Royal College of Obstetricians and Gynecologists, Mr.

Patrick O'Brien. So my 

Patrick: name is Pat O'Brien, I'm a Consultant Obstetrician and Gynecologist I'm Vice President of the Royal College of Obstetricians and Gynecologists. I think the key messages in our guidance at the moment is that, and as the evidence stands, and we recognize that the evidence is still quite limited, there is still no evidence that this Infection is worse in pregnant women than anybody else, and there is no evidence as yet that the infection can pass from the mother to the baby while the baby is still in the womb.

Now, we recognize that, as I said, the evidence is limited, so the government, understandably, has taken a cautious approach with pregnant women and suggests that they We view it as a vulnerable group. But the evidence at the moment is quite reassuring. Now what we're doing is to look back at other kind of similar viruses in the past, SARS virus and MERS virus, but you can't really extrapolate directly from one to the other because we know For example, that the case fatality rate with SARS and MERS in, in in general for adults was a lot higher than it seems to be for this particular coronavirus.

So we're doing our best based on limited evidence and desperately seeking more. 

Jessamy: From my reading of the guidance, it seems that you're saying we should be dealing with COVID 19 patients like other patients who may be presenting with. pneumonia in that we don't think that it's necessary to deliver them early or in another way.

I know that some of the evidence that we've had from Chinese authors is that they were tending to deliver patients with COVID 19 with cesarean section, not necessarily because of clinical indications, but more kind of out of an anxiety to control the situation. 

Patrick: I understand. I think it's important to bear in mind that most pregnant women who get COVID 19 will be reasonably well.

They'll have some mild to moderate symptoms, but they'll still be pretty well in themselves. And we can't see any reason why we should be advocating the cesarean section for all of those women. You can imagine a woman, let's say, who said to Vaginal births in the past and would be expecting to have a straightforward vaginal birth again this time.

And if she's got COVID 19, but quite reasonably well in herself, we can't see a justification for advocating caesarean section for her. On the other hand, if you have a woman who's got COVID 19 who's got severe pneumonia, is unwell herself, then going through labor, the demands on the body. of going through labor for her might be too much and therefore cesarean section might be the best option and also in that situation delivering the baby and taking that extra demand from the woman's body and all that pressure from under her lungs being squashed by the baby and the uterus that might actually help with treating the mother so that she can get better quicker.

But, it has to be said that the. Implications if a pregnant woman becomes unwell are potentially greater because there's not just the risk to her own health, but if a pregnant woman becomes very unwell, and let's say, for example, she's just 28 weeks pregnant, it might well become necessary for the baby to be delivered in order to improve the woman's health.

And then of course you've got the consequences of being born prematurely for the baby as well. 

Jessamy: Moving to healthcare professionals who might be pregnant, it's obviously an extremely difficult and agonizing decision for them to make about whether they continue to work on the front lines being exposed to COVID 19 or whether they try and change their working situation.

What's your kind of feeling about it? 

Patrick: Now the implications of that for women who are pregnant and working are being worked out at the moment. So we're in discussions at the moment with the Department of Health and the government to, to try to get some practical advice for pregnant women who are working.

And by that we mean, pregnant women who are. Let's say working in a cafe or pregnant women who, let's say as a midwife or a doctor working in a hospital or just pregnant women who are not working. So trying to get advice for all of those women, that it's quite practical and based on the government's very cautious stance, which as I say, we're happy to support.

Gavin: So as well as hearing about all that interesting research going on COVID 19, it's also really important to think about healthcare workers who are currently pregnant, who face not only. Sometimes a lack of clarity around guidelines for how COVID 19 and pregnancy interact, but also what they should be doing in their jobs.

Jessamy: We spoke with Marta Pena, who's a surgeon in training in England. 

It's difficult because, obviously, you become a doctor to go and help people. And I suppose these are exactly the situations where you're most needed and obviously if I wasn't pregnant then I suppose less of an issue. It would be less of an issue You also think about your family and everything like that.

Yeah, but cool, especially since hopefully younger No, if you don't have any comorbidities Even if you get it, you should at least survive and be like a bad flu. But when you're suddenly pregnant as well, then comes a bit of a balance and a conflict between your duty as a doctor, but then also as obviously a mother And to your family, um, and anxiety and the problem is evidence of knowing what will happen.

So it's such a fast moving field. And in fact, since we recorded with Pat O'Brien, they've actually updated their guidelines further. And this provides a lot more clarity for healthcare workers. So they essentially say that pregnant healthcare workers should wherever possible be avoiding areas of high risk.

These are areas where you might be having more. aerosol generating procedures like the operating theater, the respiratory wards and the intensive care units. So for pregnant women who are later than 28 weeks gestation or have any underlying health conditions like lung or heart diseases. Then they're recommending that there's a sort of more precautionary principle that's put in place.

So women in this category should technically be working from home wherever possible. They should be avoiding contact with COVID 19 patients and reduce any unnecessary social contact. So the Royal College of Obstetricians and Gynaecologists suggests that this might mean that some of the NHS healthcare workers who are pregnant might be able to work more flexibly in different capacities.

So for example they might be able to do some more administrative duties or start undertaking some video consultations. They make it really clear that if people decide to go against this advice for whatever reason perhaps they can't work from home Then if they're in the hospital, they should be deployed in roles where they are not working with patients So they could be perhaps doing education or training new skills.

Gavin: Yeah, I think as we've been talking about throughout it's It's good to go along as we slowly get more clarity on the way that pregnancy and COVID 19 interact with each other But also to see this It's still abundance of caution because as we want to stress, this is still a virus that we know very little about.

Jessamy: Exactly. It's a moving field and what we can see from around the world, clinicians on the front line are trying to keep up to date, they're, regularly checking in with their specialties. There's a lot of sort of global collaboration to try and bring about some more understanding about how we should be dealing with different types of patients who may be.

faced with who may have COVID 19. And 

Gavin: I'm sure that this advice will progress and evolve again as we come to better understand the science behind this decision making. 

Jessamy: Undoubtedly, and for people who are interested, that guidance is on the Royal College of Obstetricians website, and I'm sure that it will be updated.

Very regularly over the next couple of weeks. 

Gavin: All right. Thanks, Jessamy. Thank you so much for listening to this special episode of the Lancet voice. As we said before, you can email us on podcasts at lancet. com with any feedback, any questions, anything to do with COVID 19 that you'd like us to look into so yeah, thanks for listening.

And we'll see you again very soon for another special COVID 19 episode.