Ask the Expert - COVID-19: Maternal Care

There is evidence, for example, that the Delta variant is more infectious. In general, the data in non-pregnant adults are similar to the data in pregnancy. The important thing is that the vaccine covers these different variants so far, as far as far as we know, so it is really important to give the vaccine to women. Only about 35%* of pregnant women have been vaccinated, and that needs to increase. However, there is also safety data on over 250,000* women in the US reported to the CDC. So, there are different strains that can affect women a little bit differently in terms of infections, but the vaccines cover [them]. Also, I really need to emphasize the need for women to get vaccinated as soon as they can get a handle on the vaccine. In fact, in the US, they should even get boosters because some US and other women have been vaccinated six or more months ago.
Dr Vincenzo Berghella
* Data correct as at 2 Dec, 2021
 

It really depends mostly on the viremia. And the viremia – so, that the virus in the blood of the mother – depends on how sick she is. So in general, the chance that there is a virus in the blood of the woman is 1% or less. In those cases, if you have a symptomatic mild disease, the chances that the baby gets it is extremely small. If the woman gets really sick – she is critically ill, intubated in the ICU, she has pneumonia – then she has a 30% or higher chance that the virus is in the blood, and that there is viremia. Those are the cases in general that have been reported rarely to have transmission through the placenta to the baby. There are receptors in the placenta, the virus can accept that and go to the baby. But again, there are very few reports; it does exist, but those babies actually did well. So in the rare, very sick woman who passes the virus to the baby, those babies did well anyway.

The neonatologist will normally do a throat swab if there's a COVID positive woman which should be done right away after birth, without delay, as the mother may have transmitted their COVID virus after birth. Then you can do cord blood antibodies and there are some reports with IgM antibodies found in the newborn, and finding that would confirm that transmission. You could look at the amniotic fluid and there are very few reports of positive amniotic fluid. So, these few reports need to have better confirmation – the nasal swab after birth by itself is not enough for me, because there could be contamination. But you could also study amniotic fluid, cord blood, placenta, and other ways to prove the transmission, and there are a handful of good reports like those.
Dr Vincenzo Berghella
 

We have arrived at evidence of a link between COVID-19 and preeclampsia which is compelling and this has been illustrated by the analysis by Professor Romero. It is not just an association between preeclampsia and COVID, but also response relationships. Women who have severe COVID are more likely to develop preeclampsia compared to those who have mild or asymptomatic COVID. For the angiogenic marker, certainly it would be helpful in differentiating between COVID and preeclampsia, because you would expect in preeclampsia that the escalated one level will be increased and the placental growth factor would be reduced. 

But what about if we don't have access to the angiogenic markers? In this case, we can rely on other clues. So, for example, if the woman has respiratory symptoms or fever, that would be more consistent with the diagnosis of COVID. If she has the virus, you can also use imaging; for example, lung ultrasound or lung CT scan, where you would expect to see features of COVID compared to if she has preeclampsia. 

Of course, preeclampsia does not get better until you deliver the baby, while COVID, in the majority of the cases, you would expect to get better with the right support and treatment. But ultimately, you would have to treat the patient in front of you. So if she has hypertension, you need to give antihypertensive treatment; if she has a respiratory compromise, you need to give respiratory support.
Prof Asma Khalil

If you look at the literature, you can see clearly the vast majority of the benefits and also on the data related to the potential safety concerns, referred to the mRNA vaccines, which are basically Pfizer and Moderna. Looking at the available literature, if we have to choose, we would opt for either of these two vaccines. Of course, we have four options, so if a patient had the Johnson & Johnson vaccine, that's fine. If the patient has already had a first dose of the AstraZeneca vaccine, she can have the second dose; there is no reason why she shouldn't do this. But if we can choose, Pfizer or Moderna are the best options based on the available evidence.
Prof Andrea Dall'Asta
 

We already know that the antibodies pass through the placenta to the to the fetus, specifically IGA, and that is very important. When [the baby is] born, the mother passes IGA to the to the neonate through milk. But it has also been suggested that, after several months, people will need a booster vaccine because the antibodies will decrease through time. However, does the booster vaccine protect the unborn baby? Then no, because probably due to the very low vertical transmission that we know, we still don't know the consequences to the unborn baby. Will it protect the baby after it is born? Probably yes, but the mother will pass IGA to the fetus.
Dr Raigam Jafet Martínez Portilla
 

Firstly, the mRNA cannot work itself into our DNA or the baby's DNA, so there is no risk of altering the genes of a baby or a mother. This is very important because often on social media, there is a lot about making genetic changes to the code of the mother and baby, and that simply is not the case. The second is that the mRNA gets into a cell and instructs the cell to produce lots of, for instance, the spike protein of the virus. So, it is just really asking us how to produce lots of material that becomes immunogenic and stimulates an immune response, and the mRNA does not cross the placenta. So on all those counts, vaccines are safe, they don't affect the genetic code of mother and baby and they are very unlikely to affect anything in respect of the baby. 
Prof Christoph Lees
 

We don't know, is the honest answer. Like many things during the COVID-19 pandemic, we don't really have robust evidence to guide us. But certainly the current guidance is that if you have COVID-19, you should defer the vaccination until four weeks from the positive swab, or from the start of COVID-19 symptoms once the infection is confirmed. Therefore, my answer would be to defer the second dose of the vaccination, and then four weeks from COVID.
 
With current guidance in the UK, we have an interval of eight weeks between the two doses of the vaccinations, but that can vary among the countries. We have launched the country's largest clinical trial that would be able to help us answer what is the best dosing interval of the COVID-19 vaccination. But certainly, for this question, you would say defer the second dose of vaccination until four weeks from contracting the virus. 

An important point is to do with reactogenicity – meaning the symptoms after the vaccination. So we know that if you had COVID-19, you're more likely to get more severe symptoms after getting the vaccine. Just to put things in perspective, it's not as severe that it could harm the mother or the baby. So number one, you're more likely to get severe symptoms if you had COVID-19 and you're more likely to get some of the symptoms after the second dose of the vaccine. 

Therefore, if the woman is near the end of the pregnancy and you worry about the potential consequences of severe symptoms, particularly fever after giving the second vaccine, I think it's also reasonable to defer it until she has had the baby. But certainly if it's in the first half of the pregnancy and we want to give the full protection of the vaccine as ingested deferred four weeks from getting COVID.
Prof Asma Khalil
 

There is no evidence concerning the long-term adverse effects for the mother or the baby and for the pregnancy itself related to the administration of the COVID-19 vaccine during pregnancy. So on this basis, the recommendations for all pregnant women are to get the vaccine while pregnant at any trimester – ideally prior to the third trimester because it has been proven to carry benefits for the pregnancy itself.
Prof Andrea Dall'Asta

In terms of the safety of the vaccine, we should reassure pregnant women that we don’t have any concerns that the vaccine can harm the mother or the baby. There are studies which are collecting data and, in talking to pregnant women, often they have no concern about themselves – their main concern is about the baby and the development of the baby. 
Prof Asma Khalil
 

Yes, the answer is yes. Women actually should have their analgesic during labor. This is also endorsed in a statement by the Society for Maternal and Fetal Medicine. The main reason for this is that positioning a catheter for a relief during early labor ideally prevents the risk of generating, let's say, aerosol generating procedures in the event of, for example, an emergency C-section. So, on this basis, women should get the catheter positioned ideally as early as possible. Of course, in the event of more severe COVID-19, care should be taken in order to exclude the thrombocytopenia or coagulation issues which have been reported, but this of course is not the case for most patients who have mild or asymptomatic COVID-19.
Prof Andrea Dall'Asta
 

There are many complications from the COVID-19 infection in pregnancy including, in the mother, higher risks of preeclampsia, mechanical ventilation, of ending up on ECMO, or Intensive Care Unit admission, and even dying. But for the baby as well, with fetal growth restriction, there is good evidence of increased risks for preterm birth, especially if you have a severe or critical COVID-19 infection, for fetal death, etc. There are wonderful reports about COVID-19 infection causing microthrombi in the placenta, and now systematic reviews of those and especially in mothers who are really sick. We do know that there is an inflammatory cascade and, in fact, we should anticoagulate women who have severe COVID, and maybe even therapeutically anticoagulate women who have critical COVID such as those intubated in an ICU.

COVID-19 vaccination will protect the baby from any of these complications, as the mother – even if she acquires COVID - doesn't get very sick, and usually doesn't get COVID at all. All of these complications will be prevented, so it’s really important to get vaccinated. 

In terms of the vaccine, I haven't seen any reports of that causing microthrombi. The vaccine, especially the mRNA vaccine, dissolves after it makes antibodies, so it cannot cause any problems in the baby or the placenta.
Dr Vincenzo Berghella
 

We've learnt a lot. There have been 1,000s and 1,000s of papers in on COVID in pregnancy. We've learned that the virus can affect women, that pregnant women actually get worse infections compared to same aged non-pregnant women. That they have more severe and critical disease, and can even die more often.

We learned that the baby can be affected, because a baby can be born too early if the mother is very sick, and dies – COVID-19 can have severe consequences for the baby. I think the most important thing that we've learned is that women - pregnant women – therefore, should be even more prioritized to get the vaccine than non-pregnant adults. They are a risk more than other people, and should be on the top of the pyramid to get the vaccine sooner than other people, and so be protected. Counsel pregnant persons on the fact that if they stay healthy, they can protect the baby and have a much healthier baby. And in fact, if one gets the vaccine during pregnancy, the protection for the mother and the baby can last for a long time as those antibodies get transmitted to the baby via the placenta. 
Dr Vincenzo Berghella

I'm going to give you a very short answer. We should embrace technology. We could not have carried on living and communicating the way we always did without technology. And therefore I think, for me, I should embrace technology and get the best out of it. 
Prof Asma Khalil

From our perspective that I’ve read, I think we have learned that we were not ready for such a pandemic, and that we really needed more quality in our health services. We need to take care of our population in order to avoid these extreme situations of more high mortality and pneumonia, and things like that.
Dr Raigam Jafet Martínez Portilla 

We've learned a lot of things in pathophysiology, etc. But most importantly, we've learned how to cope with that, how to protect ourselves so healthcare professionals will learn how to manage our patients. And now with vaccines, we have an important weapon to target this infection.
Prof Andrea Dall'Asta
 

We need to look forward to all the possible factors that may be related to adverse outcomes in their population. Not only those that are clinically easy for us to measure, but all socially implicated in instances like this.
Dr Raigam Jafet Martínez Portilla

We definitely need to know more in the long term what is going to happen and particularly looking at vaccines. We know how to manage patients and patients with COVID, with mild disease, with severe disease, etc. We don't know that much in the long term concerning the vaccine effects. At the moment, as I said, there is no evidence of adverse events. In the future, we don't know, but it's our job to see what may happen. 
Prof Andrea Dall'Asta

The world suffers from a huge gap in health equality, and we need to support women adequately, we need to ensure that women's health and the health of their unborn babies are best served, whether during the pandemic or even when it's over.
Prof Asma Khalil

I think we need to make sure that new developments in non-pregnant adults get implemented as soon as possible in pregnant women. We can’t wait weeks, months, we can’t even wait days. We need pregnancy-specific safety and efficacy data for women for vaccines, and for interventions; and, we also need to be on the lookout for new variants, of course, and how they can affect pregnancy.
Dr Vincenzo Berghella