Dr. Yuzuru Anzai has compiled information on COVID-19 and its effects on pregnant women.

Dr. Anzai is a past president of JMSA. He is an attending at Lenox Hill Hospital and President, New York Midtown OBGYN

COVID-19 and Pregnancy

Little is known about the effects of COVID-19 on pregnancy. Although information is very limited, I have summarized the current guidelines from China and the USA below.

1. Are pregnant women vulnerable to novel coronavirus infection?

Current literature indicates that pregnant women are not at increased risk for COVID-19. However, during pregnancy, due to the change in their immune system, women are more susceptible to certain viral infections, such as influenza and varicella. Also, pregnant women have higher rates of morbidity and mortality from other respiratory infections caused by coronaviruses, such as SARS and MERS. Therefore American College of Obstetricians and Gynecologists consider pregnant women to be a high-risk population for COVID-19.
The currently available two reports are from China, one of which describes the outcomes of 13 pregnant women with COVID-19. Three of them recovered and continued pregnancy. The remaining 10 delivered via Cesarean section. One patient became critically ill and required ICU admission. The rest of them had relatively mild symptoms. A rate of one out of 13 (7.6%) ICU admissions was comparable to that seen for COVID-related ICU admissions in the general population (5%), and they concluded that pregnant women were therefore not at a higher risk. In addition, 6 women delivered preterm (32-36 weeks) and one had a intrauterine fetal demise. If you consider the high rate of preterm delivery (presumably due to maternal condition), infection does appear to have an impact on the pregnancy outcome.
The new paper reporting the data on New York City pregnant patients became available online on 4/8/2020. They summarized the outcome of 43 women who tested positive for SARS-Cov-2. They say it should be interpreted with caution because this cohort includes asymptomatic women ( Other reports are based on the patients who presented with respiratory symptoms or fever, and generally do not include asymptomatic people). With that in mind, the outcomes were 86% were mild, 9.3% severe and 4.7% critical (ICU admission), which is not different from nonpregnant population. Therefore they concluded that pregnant patients are not at higher risk than general population. However, given the young age of pregnant population, and poorer prognosis seen in men compared to women, perhaps more ideal control group would be non- pregnant women in the same age group.
There is no information on rates of miscarriage or fetal anomaly in women who were infected during their first trimester.

2. Maternal fetal transmission.
In these reports from China, there was no vertical transmission from mother to fetus. However, in the new article from China published online on 3/26/2020, Dr. Zeng’s group reported 9% ( 3 out of 33) of likely vertical transmission to the neonate. All were delivered by cesarean section. Overall the symptoms of the neonates were mild and the most severe case may be due to prematurity rather than COVID-19. In the report from Columbia university, 18 out of 43 went on to deliver. All but one baby were negative based on PCR. One had indeterminate result and treated as “presumptive positive”, but remained asymptomatic. None of them developed symptoms consistent with COVID-19. Currently no recommendation exists as to the preferred mode of delivery.

SARS-CoV-2 was not detected in breastmilk when this was studied in a limited number of cases. There is discrepancy in recommendations, with Chinese literature recommending to separate the newborn baby from the mother for 2 weeks whereas the CDC and ACOG advise discussing this on a case by case basis with the patient, taking into account the benefits of breastfeeding, mother-baby bonding, and other such factors.

As outlined above, the information is very limited and the guidelines will likely to change as new data becomes available. For now, there are no specific precautions for pregnant patients, aside from practicing regular and frequent hand washing, as well as social distancing.

References
Liang H, Acharya G Novel corona virus disease (COVID-19) in pregnancy: What clinical

recommendations to follow? Acta Obstet Gynecol Scand.

Yangli Liu , Haihong Chen , Kejing Tang , Yubiao Guo , Clinical mani-
festations and outcome of SARS-CoV-2 infection during pregnancy, Journal of Infection (2020), doi: https://doi.org/10.1016/j.jinf.2020.02.028

ACOG Clinical Guidance: Practice Advisory Novel Coronavirus 2019 (COVID-19) CDC Coronavirus 2019 (COVID-19) Pregnancy and Breastfeeding