Women, pregnancy and COVID-19 disease

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Women, pregnancy and COVID-19 disease


Sunday, May 17, 2020

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In recent times there has been a heightened interest in COVID-19 in women, particularly pregnant women. There is also a lot of concern among pregnant women and those with young infants about possible infection and transmission of the infection to their unborn babies or to their young infants through breastfeeding.

This week, we shall attempt to address some of these concerns using the best available evidence. While this disease continues to evolve, we have data from over three million infections globally to draw some inferences.

Is there a gender difference in risk and manifestation of COVID-19 infection?

As the COVID-19 epidemic continues to spread, one of the interesting features of this disease has been the fact that the male sex appears to be at a higher risk of infection with SARS-CoV-2 or severe illness and complications when infected compared to women.

Data from a study in China looking at 1099 patients with COVID-19 disease found that almost 60 per cent of the patients were male. When infected, men have higher rates of severe or critical disease and an increased risk of death. A single centre study found that, among patients severely ill with COVID-19, over 67 per cent of critically ill patients were men. In China depending on the age cohort that was reviewed, men accounted for 67-82 per cent of COVID deaths. In Italy, 70 per cent of COVID deaths occurred in men.

While men bear a disproportionate risk from COVID-19 infection, the factors leading to this disparity are currently unknown. There have been several theories that have yet to be fully understood but some of the possible causes include possible protective or deleterious effects of the sex hormones (testosterone/estrogen) and speculated differences in the innate immunity of men and women.

Genetically, females seem to have a stronger immune response to SARS-CoV-2 infection when compared to males which could lead to more rapid and complete clearing of viral infectious agents. Baseline health status may also be an issue with men tending to have more pre-existing conditions such as cardiovascular disease or lung disease such as COPD. Men also tend to be more prone to abuse alcohol or drugs.

From a behavioural point of view, studies have also found that women are more likely to wash their hands and are more proactive in seeking health care. An interesting possibility is that of sex-related differences in the number and action of the ACE2 protein. This protein serves as an entry point for the SARS-CoV-2 virus to enter the cell. This protein does also play a role in marshalling lung defences during infection. The balance between the protective and deleterious effects of the ACE2 protein may be different in men and women and could potentially explain the variations in both infection risk and outcomes. One silver lining of men is their inability to get pregnant as certainly pregnancy is a source of concern/worry during this time.

Is pregnancy a risk factor for COVID-19 disease?

The answer to the question currently appears to be NO. Perhaps, it is worth restating that pregnancy is not an illness and even though some complications may arise in the course of pregnancy and delivery, for most women, pregnancy remains a normal physiologic process and largely uneventful.

We are still in the early stages of the pandemic, but it does not appear that pregnant women are at higher risk of getting COVID-19 disease when compared to non-pregnant women in similar health. It is important to note as well that pregnancy does not appear to be protective against getting infected. The major risk that would seem to occur with the pregnant state is the need for ongoing care during the pregnancy.

Pregnant women under normal circumstances have periodic antenatal visits throughout pregnancy for physician visits, blood draws, ultrasounds, etc. The pregnant female is less able to shelter in place when compared to the non-pregnant female and she is more likely to be in clinics and hospitals with sick people who may potentially be a source of COVID-19 infection.

Our own Ministry of Health has proposed guidelines to alleviate these risks which include spacing outpatient appointments so that waiting areas are not crowded, keeping the obstetric population away from the general hospital/clinic population and attempting to combine visits ie getting blood draws, physician visits, imaging in one sitting. While this could be a useful approach, it may not be feasible for all patients. For low-risk pregnancies, consideration may be given for the use of telemedicine or telephone visits where possible.

If a pregnant woman gets COVID-19 disease will it affect the pregnancy?

Like many things in medicine the answer to this question is that it depends. The spectrum of COVID-19 disease in the pregnant female is the same as that which occurs in the general population. Patients can be asymptomatic with the diagnosis being made when they undergo testing prior to admission for labour and delivery. Patients can present with mild to moderate symptoms of fever, cough and shortness of breath or they may present critically ill. The reported clinical experience is not large, but asymptomatic women and women with mild symptoms do not appear to have problems with pregnancy. For patients who become severely or critically ill requiring ICU care or develop respiratory or kidney failure, there appears to be an increased risk for both maternal and foetal complications or death. These cases, however, do represent a minority of pregnant patients with COVID-19 infection.

How is COVID-19 treated in pregnant women?

A patient who is diagnosed with COVID-19 disease during pregnancy is treated just the same as a non-pregnant patient from a maternal point of view. As the pregnancy progresses or if the disease is severe or critical then monitoring the health of the foetus becomes an issue. Generally, given the fact that most pregnant women are relatively young and healthy, co-morbidities that increase the risk of COVID-19 disease are uncommon in this population. However, if these co-morbidities are present, the patient may require closer supervision than a normal low-risk pregnancy. Particular attention therefore must be paid to pregnant women with pre-existing conditions or those who develop hypertension, diabetes or heart disease during the course of their pregnancy as these groups may be particularly vulnerable to severe complications and adverse outcomes.

Is there a risk of a mother with COVID-19 disease passing this to her baby in the womb?

At this point in time there is no evidence of uterine vertical transmission ie SARS-CoV-2 infection being passed from mother to child while the child is still in the womb. A few studies from China have looked at women who were known to have COVID-19 disease prior to delivery. Testing of the newborn babies have returned negative for COVID infection. Testing has been done on amniotic fluid, placenta, and vaginal fluid with no evidence of the SARS-CoV-2 virus being found. While a few reports have suggested the presence of SARS-CoV-2 in vaginal fluid or secretions, there is currently insufficient data to support transmission of infection via this route. There have been cases of babies having COVID infection shortly after birth but most of these cases are thought to result from person-to-person contact after birth.

If I have COVID-19 disease should I breast feed my infant?

We posed this question to Dr Chinyere Anyaogu, deputy chief medical officer and vice-chair for obstetrics and gynaecology for New York Health and Hospitals, who is leading the frontline battle against COVID-19 at North Central Bronx Hospital in New York. According to Dr Anyaogu, this issue is complicated given the benefits of breastfeeding or indeed maternal/infant contact after birth and the risks of COVID-19 disease to an infant with an immature immune system.

She recommends an individualised approach balancing the needs of the baby with the need to ensure that the baby remains safe and protected from COVID-19 infection. Worldwide, different authorities have proposed different solutions. The Chinese Government mandated separation of mother and infant in the scenario of a COVID-19 positive mother. The CDC in the United States has suggested a case-by-case approach after a discussion between the health care provider and the patient. Our own Ministry of Health has produced guidelines that consider the clinical condition of the mother and child. They suggest that if the mother and infant are both well, then they can be cared for together. It is important to note that if the mother and child are being cared for separately, the mother, if able, can express breast milk for the child. Studies so far have not found any evidence of SARS-CoV-2 virus in breast milk.

In cases in which a clinically well mother with COVID-19 disease is taking care of an infant, it is important that she takes precautions as far as is practical to reduce the risk of transmission to her child. This would include wearing a mask while breastfeeding or handling her child, careful hand washing prior to handling and keeping six feet away at other times. This may unfortunately be impractical for most nursing mothers.

What should I do if I am thinking of becoming pregnant?

In one word “wait”. Dr Chinyere Anyaogu, who is also an assistant professor at Albert Einstein College of Medicine in New York, believes that this is not an ideal time for planned pregnancy. Although the current experience suggests that most women can be successfully managed during pregnancy, the health care system is currently stressed by the demands of the ongoing epidemic. Getting optimal care under these circumstances can be challenging.

Dr Ernest Madu MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists at the Heart Institute of the Caribbean (HIC) and HIC Heart Hospital

Correspondence to emadu@caribbeanheart.com or call 876-906-2107

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