Navigating Pregnancy Risks In The COVID-19 Era
Carissa Helmer and her husband had been trying to get pregnant for five or six months by early April, when COVID-19 started to spike in the Washington, D.C., area where they live. Maybe, they mused, they should stop trying to conceive for a few months.
But then a pregnancy test came back positive.
"We were, like, 'Oh well — I guess it's too late for that!' " Helmer says, laughing.
In some ways, she says, there are a few convenient aspects to being pregnant now – starting with being able to work from home. Before the pandemic, she and her husband both commuted 90 minutes each way to their jobs in the city — driving to the subway, then taking the train downtown. Because she's now working from home in her job in the subscriptions department at the Kennedy Center for the Performing Arts, Helmer is able to get more sleep — and has been able to combat morning sickness with ginger ale and crackers. "On the Metro, you're not allowed to eat or drink at all," she says.
But other aspects of the pregnancy have been tougher than she expected. For one thing, she's had to go to all of her doctor's appointments by herself.
"It's completely understandable," Helmer says, "but I think that that's something ... we hadn't anticipated in a first pregnancy — that my husband wouldn't be able to be in the room."
Then there's the delicacy required in making rules about visits from relatives.
"We've been trying to be really strict with them," Helmer says, advising extended family: " 'You know, it's really important that you're quarantining for 14 days before you come and visit us.' I think that's been a little hard to explain to some folks, just to tell them that I'm more at risk, and it's not anything against them."
Though she sounds relaxed, Helmer tells me that she's worried about getting the coronavirus.
"I'm terrified," she says. "My husband's still going to the grocery store, and that's pretty much the only place that he goes. And the only place that I go is the doctor's office."
Digging into the data about COVID-19 and pregnancy
How worried should expecting parents be about any extra risks the coronavirus might pose to the mom or developing fetus?
The answer and advice may continue to change, public health officials say, as the evidence rolls in. In June, the Centers for Disease Control and Prevention published a study showing pregnant women may be more likely to develop a severe case of COVID-19 than other women their age when they become infected with the virus. And just this week, physicians in France published a case study that strongly suggests a newborn caught the coronavirus before birth from his mother via the placenta.
"Where you can, you need to decrease your exposures. But that has to be practical," says Dr. Laura Riley, an OB-GYN at New York-Presbyterian Hospital who chairs the department of obstetrics and gynecology at Weill Cornell Medicine, and has been involved in devising pandemic guidelines for practitioners and patients on behalf of the American College of Obstetricians and Gynecologists.
Because this coronavirus is relatively new to humans, the evidence about the added risks it imposes on a pregnancy is scant. The June CDC analysis was partly reassuring, suggesting that women who get COVID-19 when pregnant are at no greater risk of dying from the virus than nonpregnant women their age, though they do seem to be at somewhat greater risk of developing a severe case of the illness.
The study reviewed more than 91,000 U.S. women of reproductive age who had a lab-confirmed coronavirus infection; of those, roughly 8,200 were pregnant at the time. Compared with other women of reproductive age who tested positive for the virus, pregnant women more often went into the intensive care unit and were more likely to need mechanical ventilation.
The data also showed that pregnant women who are Hispanic or Black may be at higher risk of infection than white pregnant women. (Black and Hispanic people in the U.S. have been found to be at greater risk of contracting the coronavirus and at higher risk of death from COVID-19.)
But there were limits to the CDC study that are worth noting, Riley says — limits that may have made the added COVID-19 risk to pregnant women look bigger than it is.
First, pregnancy status was only known for 28% of the women of reproductive age who tested positive in the study. That means some infected women who went on to deliver perfectly healthy babies were likely not counted. And for those whose pregnancy status was known, data on race and ethnicity, symptoms, underlying conditions and outcomes were missing for a large proportion of cases. That, too, may have skewed their findings, the researchers who did the analysis say.
Then there's the matter of hospitalization rates for pregnant women. Many hospitals have implemented universal coronavirus screening for anyone admitted to a hospital's labor and delivery unit. What the evidence analyzed by the CDC doesn't reveal, Riley points out, is whether a pregnant woman was being hospitalized because of symptoms of COVID-19, or because she was going into labor.
"You can't tell from this data who came in because they were sick with COVID, and who came in because they were just going to deliver and were oh, by the way, COVID-positive," Riley says.
Plus, she says, it's hard to tell from the CDC data whether a pregnant woman was admitted to the ICU because her case of COVID-19 was severe, or because that particular hospital was only equipped to handle a pregnancy involving COVID-19 in an ICU.
There was one finding in the CDC data that does stand out to Riley as potentially worrisome: "It seemed pregnant women were more likely to need the mechanical ventilation, which suggests more severe disease."
Still, even there, she says, the number of coronavirus-positive pregnant women in the study who were sick enough to need a ventilator was quite small: 42 women out of 8,207 — that's half of 1%.
Riley says her own OB-GYN practice includes many high-risk pregnancies — including some older women, some who are pregnant with twins or triplets, and some who have underlying health conditions such as chronic hypertension or diabetes. So does this new data change what she tells her patients about pregnancy in the age of COVID-19?
Not really, she says.
"What it underscores, and what I tell my patients," Riley says, "is you just need to remain diligent in terms of all those things that we know work [to prevent infection with the virus]. We know social distancing works. We know that wearing a mask works. We know that washing your hands frequently works." Guidelines from the American College of Obstetricians and Gynecologists also advise "limiting contact with other individuals as much as practicable" and urge patients to "maintain an adequate supply of preparedness resources including medications."
Where it can get harder for her patients, she says, is that, to keep the mother-to-be protected, partners and other members of the household need to take those same precautions. "That may not be so easy," Riley says, "but it's absolutely critical."
If pregnant women do have symptoms of COVID-19 or have been exposed to the coronavirus, they need to let their doctors know so they can be tested and receive appropriate care, Riley advises.
''Am I just going to be housebound the whole of pregnancy?''
Taking every precaution can mean staying close to home.
Kate Bernard lives in Austin, Texas, where she works at a music nonprofit and sings with her band KP and the Boom Boom. Originally from Yorkshire, England, she met her husband 10 years ago on a trip to Austin, and they married 2 1/2 months later.
Their world changed suddenly in mid-March: "The coronavirus lockdowns were just being announced that week that we got pregnant," she says.
The pandemic led to canceling the gigs the band had scheduled, and Bernard says she's not sure how she would have fared if she'd had to perform, considering her pregnancy-induced nausea and the Texas heat. These days, Bernard says, just 20 minutes outside in the heat makes her queasy, "and some of those gigs were outdoor gigs where you're playing for an hour, two hours."
To try to steer clear of the coronavirus, she's doing her nonprofit job from home. Bernard says she's grateful that's an option — she has been able to work in bed whenever the sciatic pain in her back flares.
"I just can't imagine having to get dressed and get myself together" to go to the office, she says — she figures she would have felt compelled to keep her pregnancy under wraps at work until the end of the first trimester.
Not that concealing it would have been easy in her small, open-plan office. "We've just got one bathroom, and they'd have heard the puking," she says, laughing. "They'd have known."
Bernard says her life has been a roller coaster since March, and the current surge of coronavirus cases in Texas only adds to her concern.
"We don't know when this is going to end, and it doesn't give you hope when the numbers are going up in the state that you live in," she says. "Am I just going to be housebound the whole of the pregnancy?"
Before the new CDC data came out last month, Bernard had been encouraging her husband to go places such as a downtown park or swimming at Austin's aquifer-fed Barton Springs Pool. And she had been hoping to swim in the pool at their apartment complex and engage in other activities that bring her joy. But now she feels like they'll both need to be more cautious, and the pools have closed in light of the pandemic. In addition to being pregnant, Bernard has asthma — another risk factor that can make COVID-19 more severe.
"I like to make my own mind up about things," she says, adding that she and her husband both "try and think outside the box and live our life alternatively. But I just think it's just better to be safe than sorry at the moment."
Undeterred by COVID-19
So, do pregnant women really need to be housebound for nine months? Riley, the New York OB-GYN, says that would not be realistic.
For one thing, they need prenatal care. "Yes, we can do some prenatal care by telehealth, but we can't do it all that way. We can't assess your baby with you at home."
Plus, there are many other reasons to get out and move your body, she says: "Your mental well-being is not to be ignored." The need for fresh air or to take a walk are part of staying healthy, and going to work may be necessary financially, Riley says.
Dr. Carroll Medeiros is a professor at Brown University's Alpert Medical School and an OB-GYN at Southern New England Women's Health. She says many of her patients in Providence, R.I., don't have the luxury of working from home during the pandemic. Many are also Hispanic or African American.
Classified as essential workers, a number of her patients are still going in to do their jobs — often at hospitals or nursing homes, she says — or they live with an essential worker, and that, too, increases their risk of exposure to the virus.
Some of Medeiros' patients work in a factory where roughly 70 employees became infected with COVID-19.
"These people are mostly Black and brown," Medeiros says, "and it just shows the inequality. You have less of a chance of having a really good job in this country if you are Black and brown."
Many of her pregnant patients are worried about catching the virus, Medeiros says, but "it's hard for them to take off time when they feel like they are most at risk. You take off time — you might lose your job."
Despite all the anxieties and the unknowns, Medeiros says she hasn't seen indications in her practice that people are avoiding pregnancy out of fear of the pandemic.
"They are very few and far between — people who have told me, 'Oh, you know, we've changed our mind. We're not going to do it right now,' " Medeiros says. "People have come to have their intrauterine devices removed and to start trying. I don't think it's deterred anybody. But they have a lot of concerns about it."
''That hopefulness of having a child''
In Austin, Bernard anticipates that when her baby is due in December, the U.S. will still be grappling with the risks and effects of COVID-19.
And the current unrest over racial injustice and policing has added extra stress, Bernard says.
"I've just got to have hope for the new life," she says, "that bringing a baby in, we're going to teach it right from wrong. I think that's what I'll be holding on to — that hopefulness of having a child. And rather than it being doom and gloom in the current times, having hope that the next generations will do a better job." [Copyright 2020 NPR]
