TWO PATIENTS IN ONE
LOVE AND DEATH IN THE TIME OF CORONA - OBSTETRICS IN LOUISVILLE DURING THE COVID-19 PANDEMIC
Dwight Pridham , MD
In the practice of gynecology , beyond the realm of STDs we do not spend much time thinking about viral diseases . In obstetrics however , multiple viruses and vaccines are of concern . We are very concerned about the adverse effects of infections with rubella , varicella , influenza , CMV , parvovirus , herpes , HIV and hepatitis . We screen for antibody titers of rubella and varicella , screen for active hepatitis B or C , and aggressively promote vaccination against flu and TDAP . Some concern is related to suppressed maternal immune systems leading to more symptomatic infections , and some is due to possible vertical infection with potential impact on fetal development .
In 2016 we faced Zika virus , mostly confined to tropical areas with mild maternal symptoms but significant fetal risk if contracted in early pregnancy . We struggled to provide accurate risk assessments and travel recommendations during early pregnancy . That felt pretty important for several years , but in 2019 fell completely off the radar as the rapidly evolving COVID-19 pandemic completely changed world travel patterns .
In late 2019 , we followed the news out of China and Europe as COVID-19 was recognized , and epidemiologists struggled to define modes of transmission , population prevalence and ratios of severe to asymptomatic illness . Initial reports seemed very concerning , with high rates of hospitalization , ICU admission and death , but of course it ’ s always about the denominator . The eventual realization that many cases are asymptomatic lessened concern , but of course hastened worldwide spread . Early data on obstetrical impact was hard to come by , but some of the initial small series ( N = ~ 30 ) out of China were quite worrisome , with preterm delivery very common , ICU admissions at about 40-60 % and nearly 100 % cesarean delivery .
Despite daily news coverage of the spread in Europe , not until March or April 2020 did we see cases in our obstetrical population . Even 2 to 3 million cases in the U . S . are still less than 1 % of the population . Initially , most concern was for the elderly , particularly in retirement homes . Until widespread testing was available , the generally milder cases in our young population were under recognized .
At times , early institutional response and planning felt rather slow , occasionally fumbling , and we were all working with a lack of data . We seemed to simultaneously both over- and under-estimate the potential risk in different ways . As a provider trying to counsel young pregnant women in the work force ( especially health care ), the initial assessment by the CDC and American College of Obstetricians and Gynecologists ( ACOG ) that illness in pregnancy was no worse than in non-pregnant females seemed to ignore relevant comparisons to other viral pneumonias in pregnancy ( influenza , MERS , SARS ), all of which cause a two-to-threefold increase in hospitalization , ICU admission and death compared to non-pregnant controls . It was only three to four months later that the official position came around to our current understanding … COVID-19 in pregnancy is associated with two-to-threefold higher levels of severe disease than in non-pregnant women .
Prior to the availability of the vaccines , and particularly during the early PPE shortage , some of us took an aggressive stance about
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