TWO PATIENTS IN ONE
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An additional concern in pregnant patients recovered from COVID-19 is potential ongoing risk to the fetus . Given early recognition of an increased risk of stillbirth , preterm delivery and possible intrauterine growth retardation , we initially felt that frequent monitoring with ultrasound or non-stress testing might be necessary . We have evolved from weekly or biweekly monitoring to a single assessment of fetal growth four to six weeks after a COVID-19 episode . We do encourage daily low dose aspirin due to concern about higher risk of thromboembolic events , along with a newer recognition of increased risk of pre-eclampsia following COVID-19 infection .
Theoretically at first , now confirmed by experience , vaccination should reduce the excess maternal / fetal risk imparted by COVID-19 infection . Both physicians and patients have always taken a fairly conservative approach to the adoption of new medications during pregnancy , due to concern about unknown impact on the fetus . In addition , rapid uptake of vaccination in our population was inhibited by several societal and institutional factors . Certainly increased political divisiveness about science and medicine was not helpful , but several institutional failings also occurred . Despite recognition that pregnant women were at higher risk for severe disease , they were not included in early studies of the vaccine . This led to very tepid recommendations by leading authorities ( CDC , FDA , ACOG ) citing inadequate safety data , and uncertainty about administration of the vaccination during pregnancy . Despite 40 to 50 years of accumulated obstetrical experience in similar non live viral vaccines , it took at least four to five months after the vaccine was available before it became widely recommended by these groups . That caused many patients and quite a few physicians to be very cautious about the vaccine . It is hard to convince a patient to get a vaccine when the “ expert opinion ” is that we don ’ t have enough information .
An additional failure was not considering pregnant mothers to be a high-risk group . Since pregnant women are generally young , those not working in health care who desired vaccination had to wait for months before their age group became eligible . One fortunate institutional decision shortly after vaccine availability was that many health systems mandated vaccination of their employees . Since many medical staff are young women , this gave us an early group ( after a lot of reassuring discussions ) to eventually provide observational data . After a year of vaccine availability , about 70 % of our patients have been vaccinated . Of the remainder , some have received one or two doses prior to pregnancy , but may remain reluctant to dose during pregnancy . The recognized risks of vaccination ( anaphylaxis , malaise , myocarditis ) occur at the same very low rates in pregnant women as in the general population . We recommend against the use of the Johnson & Johnson vaccine during pregnancy due to increased ( although still very rare ) risk of DVT . It was quickly recognized that women receiving the COVID-19 vaccine provide passive immunity to their newborns from trans-placental IgG antibodies . There is additional benefit from antibodies in breast milk . This protection probably accounts for the reduced risk of severe disease noted in newborns .
As we enter the third year of the pandemic , our experience has evolved . In the third wave ( mostly Delta ), we started to see more seriously ill obstetrical patients . Most of the groups at our hospital have now had patients in the ICU , with many early deliveries for severe illness . We have lost several young women in their 20s and 30s during pregnancy . Reflecting the general experience , all of the severely ill patients were unvaccinated . Despite the higher risk of severe disease , most pregnant patients will have a relatively mild course , with only about 3 % of recognized cases admitted to ICUs , and less than 1 % dying .
It is difficult to stay intensely vigilant over such a prolonged period of time . While still careful , overall protocols are more relaxed . Due to many factors ( youth , societal relaxation of protocols , more infectious viral mutations ), we are now seeing a much higher percentage of our population testing positive during the Omicron wave . Fortunately , due to viral mutations and the higher percentage of vaccinated patients , most are mild cases . We are still seeing about the same absolute number of ICU cases and deaths , but a smaller percentage of overall cases . At times in the past couple of months , as high as 30 % of our inpatient obstetrical service has been actively infected with COVID-19 , while an additional 30-40 % had been infected in the past three to four months . This has made it impractical to segregate all COVID-19 patients in certain wards , so they are just mixed in to the regular mother baby floor . Even in the nursery we now do circumcisions , just keeping COVID-19 babies six feet from unaffected babies .
In both our group experience and also in very recently published academic data , we are seeing a significant increase in some adverse outcomes in pregnancy . This winter we have frequently had half to three-quarters of our inpatients diagnosed with pre-eclampsia , which may be a result of lasting cardiovascular inflammatory changes caused by the virus , or perhaps misdiagnosis caused by aforementioned liver enzyme and hematologic laboratory changes due to the virus . Published studies suggest a doubling of pre-eclampsia risk . We have also recently seen a higher-than-expected rate of miscarriages occurring at 12-14 weeks after noting normal fetal cardiac activity at 10-12 weeks . While this makes theoretical sense in a prothrombotic inflammatory environment after infection , it is not well confirmed in studies yet .
Since our obstetrical population is generally young , often with small children , we have observed many of the stresses imposed by the virus and resulting governmental and institutional response . Working from home can be initially liberating , but in many cases enforced togetherness may lead to increased stress and discord at both a partnership level and if school age children are involved . There have been concerns that domestic abuse might be increased by both the stress and increased time together .
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