Update on COVID-19 in pregnancy and the puerperium

Curated by Alfredo Vannacci and Claudia Ravaldi

CiaoLapo ETS Foundation; University of Florence

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Last updated 12.03.2020

1. Severity of the disease in pregnant women

SARS-CoV-2 is a new human pathogen, unknown until a few weeks ago, but as it has important similarities with other known coronaviruses, such as SARS-CoV-1 (79% genomic analogy) and MERS -CoV (50% analogy), it was to be expected in principle that it would behave in a similar way. Both other viruses distinguished themselves for causing a particularly dangerous respiratory infection for pregnant women: SARS had a lethality of about 30% in pregnancy (i.e. one third of affected pregnant women died, compared to less than one tenth of the general population) and 60% required intensive care (compared to 20% of the general population)¹ ; with regard to MERS, the numbers are much less clear (less data are available), but the disease appears to have been equally severe with an ICU entry rate of 60-80% and a lethality of 20-40% ^{1, 2} . Generally speaking, viral pneumonia in pregnancy has an important burden for both the woman and the fetus, with an increase in maternal mortality, the risk of eclampsia, low birth weight and preterm birth ^3,4 , hence the fundamental recommendation to always carry out the seasonal flu vaccination.

Fortunately, however, at present, COVID-19 does not seem to be more serious in pregnant women than in the general population: in the first published series (9 women infected during the third trimester of pregnancy), the clinical conditions were comparable to those of non-pregnant women. in pregnancy ⁵ , allowing for moderate optimism ⁶ . In a total case series of 18 women, only one case has been described to date of a woman at the 30th week of gestation who required mechanical ventilation and a caesarean delivery, both with a positive outcome, with a decidedly lower morbidity than that described in China for the general population ^7.8 . In a work available in preprint (submitted to The Lancet) a series of 15 women is presented, of which 11 have given birth (1 vaginally and 10 by caesarean), while 4 are still pregnant; the data confirm that all cases were mild and 14 out of 15 women recovered negatively for the virus, in 4 cases even in the absence of antiviral therapy ⁹ .

In summary:

at present, SARS-CoV-2 infection does not appear to be more severe during pregnancy than in the general population

2. Risks for the child

Coronaviruses are generally agents known to cause even significant problems to the baby during intrauterine life (including pregnancy termination, growth retardation, preterm birth) ⁶ . This was the case in both SARS and MERS ¹ . Currently, negative pregnancy outcomes have not been described in the few cases of children born to mothers who had contracted COVID-19 in the third trimester (mothers affected in earlier stages of pregnancy have not yet given birth) ^5,10 . Since the cases of pregnancies described so far are only about thirty (and almost exclusively in Chinese women infected in the third trimester) it cannot be excluded that adverse events may be recorded in the future: to get more information it will be necessary to wait for the outcomes of the pregnancies currently in progress. . A single study published in Chinese in three women with symptomatic infection in the third trimester showed no histopathological placental damage. ¹¹

In summary:

at present, SARS-CoV-2 infection does not appear to cause specific harm to the child during intrauterine life

3. Vertical transmission

Transmission of the SARS-CoV-2 virus occurs through direct person-to-person contact, through breath droplets that can be transmitted with saliva, cough or sneezing from infected people and through contaminated (not yet washed) hands. to the mouth, nose or eyes ¹² . The series available to date does not support the hypothesis that the virus can be transmitted from mother to child during intrauterine life (‘vertical’ transmission): in analogy with what has already been observed in the case of SARS, the virus was not detected in the amniotic fluid , in umbilical cord blood, nor any child born to an infected mother tested positive ¹³ . We have no information regarding a possible transmission to the baby during vaginal birth, given that all the deliveries relating to the series published by the researchers in China were performed by caesarean section ⁵ . Only one child born to a mother with SARS-CoV-2 subsequently tested positive for viral swab, but it seems likely that he became infected after delivery via the airway ^5,14 .

In summary:

at present, SARS-CoV-2 infection does not appear to be vertically transmitted from mother to child

4. Natural or caesarean birth

The current orientation in Chinese cases has been to proceed with caesarean section, partly due to problems of mothers independent of the virus, partly due to the fear that the child could be contaminated during the passage through the birth canal ⁵ . However, there is currently no specific contraindication to vaginal birth, so the indications for management remain the same as for women not affected by COVID-19, pending the publication of specific data ¹⁴ . The International Society of Ultrasound in Obstetrics & Gynecology recommends that the timing and modality of delivery be evaluated on a case-by-case basis, individualizing the intervention based on the gestational age and clinical status of the patient, as well as the condition of the child. If spontaneous labor has already begun, delivery should be carried out vaginally as far as possible ⁴ .

In summary:

at present there does not seem to be a specific indication for cesarean delivery in case of SARS-CoV-2 infection

5. Breastfeeding

To date, SARS-CoV-2 has never been detected in breast milk or colostrum, nor have any infections occurred following breastfeeding (breast or expressed milk) ⁵ . Although some authors suggest caution in breastfeeding, proposing to isolate mothers from infants for 14 days while expressing milk ^6.14 or even advise against breastfeeding ¹⁵ , there appear to be no real reasons behind this choice, so that it is the Center for Disease Control and Prevention (CDC) in Atlanta ¹⁶ , both the Italian National Institute of Health (ISS) believe that in clinical conditions that allow it and in compliance with the mother’s wishes, breastfeeding should be started and / or maintained directly in the breast or with expressed breast milk. ¹² . The same position has been adopted in the United Kingdom by the Royal College of Obstetricians and Gynecologists (RCOG) ¹⁷ .

In summary:

at present the passage of SARS-CoV-2 into breast milk is not known and there does not seem to be sufficient reason to contraindicate breastfeeding

6. How to behave

Under normal conditions (i.e. in the absence of signs or symptoms of infection) the recommendations for pregnant and postnatal women are the same, valid for all:

• Wash your hands regularly and frequently by scrubbing well for 20-30 seconds with soap and water or an alcohol-based cleaner
• Avoid contact with anyone who coughs and sneezes
• Maintain a safety distance of at least 1 meter from anyone
• Avoid touching your eyes, nose and mouth with your hands
• Cover your mouth and nose with disposable tissues when sneezing or coughing. If you do not have a tissue, sneeze or cough in the crook of the elbow (NOT in the hands).
• Stay at home as much as possible, strictly following the government guidelines valid for EVERYONE
• Promptly report any suspicious signs or symptoms to your doctor (if you do NOT go to the hospital yourself)

Regarding checkups , some appointments may be postponed or canceled, others confirmed. In any case, it is important to follow what is indicated by your carers. More information on this topic in this document.

In the event of breastfeeding by swab-positive women, as the primary concern is that the virus may be transmitted via aerosols rather than breast milk, positive nursing mothers should wash their hands and wear a surgical mask before touching the baby. . In case of rooming-in , the baby’s cradle must be kept at least two meters away from the mother’s bed, possibly separating them with a curtain ⁴ .

The question of assisted fertilization deserves a separate note: at the moment there is no scientific evidence that indicates a dangerousness of the procedures and the data available, albeit limited, are comforting. With this in mind, the Italian Society of Human Reproduction (SIRU) still advises as a precaution to suspend all new medically assisted procreation treatments for at least one month, instead completing the treatments currently in place ¹⁸ .

The authors

• Alfredo Vannacci is a toxicologist, professor of Pharmacology and Toxicology at the University of Florence. Founder, vice president and head of scientific research of the CiaoLapo ETS Foundation for the protection of pregnancy and perinatal health.
• Claudia Ravaldi is a psychiatrist and psychotherapist, research fellow in epidemiology and PhD candidate in Neuroscience at the University of Florence. Founder and president of the CiaoLapo ETS Foundation for the protection of pregnancy and perinatal health.

Bibliographical references

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