The most common symptoms of COVID-19 infection, to include in pregnant women, include fever, cough, and shortness of breath.
The Bottom Line

December 1, 2021: There are currently no data on the newly identified Omicron variant that are specific to pregnancy. International health regulatory authorities anticipate publishing more information in the next few weeks. However, as very little is currently known regarding Omicron and the general public, it will likely take an additional few weeks or longer to determine if Omicron will be more severe than, or similar to, prior variants during pregnancy. (Learn more about the safety and effectiveness of COVID-19 vaccination during pregnancy, breastfeeding, and while trying to conceive.)

According to currently available case series and cohorts as of December 2021, data indicate pregnant women are not more susceptible to contracting COVID-19 than non-pregnant women, and fetal and symptomatic neonatal infection appear to be rare events.

However, pregnant women who contract COVID-19 appear to be at higher risk of certain complications from the disease than non-pregnant women of reproductive age. These complications include Intensive Care Unit admission, mechanical ventilation, and the need for extracorporeal membrane oxygenation (ECMO), as well as the risk of death (although overall risk remains low).

Research indicates pregnant women can experience a complete lack of symptoms (asymptomatic) to a wide range of acute and long-lasting symptoms, similar to the general population. These include fever, shortness of breath, cough, nausea, congestion, runny nose, vomiting, diarrhea, chills, loss of smell, sore throat, headaches, body aches, and excessive phlegm.

Therefore, pregnancy remains a risk factor for possible severe infection. Any pregnant woman experiencing one or more of the above symptoms should call her health care provider (HCP) for an evaluation.

Women also need to report to their HCP any exposure they have had to an individual with confirmed or suspected COVID-19. As pregnant women can experience asymptomatic infection, some HCPs may recommend these women be tested, especially women with certain underlying conditions (obesity, diabetes, hypertension, asthma).

For detailed information on the safety and effectiveness of COVID-19 vaccination and its effects on fertility, pregnancy, and breastfeeding, click here.

Women should ask their HCP any questions or concerns they have regarding COVID-19 or its vaccines and visit the CDC website for more information.

*If you are experiencing trouble breathing or extreme shortness of breath, seek emergency medical care immediately or dial 911*

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updated

Most Recent Updates

December 1, 2021: There are currently no data on the newly identified Omicron variant that are specific to pregnancy. International health regulatory authorities anticipate publishing more information in the next few weeks. However, as very little is currently known regarding Omicron and the general public, it will likely take an additional few weeks or longer to determine if Omicron will be more severe than prior variants during pregnancy. Learn more about the safety and effectiveness of COVID-19 vaccination during pregnancy, breastfeeding, and while trying to conceive.

November 29 (chart): Cases of COVID-19 among Pregnant Women by Week of Diagnosis

Note: The final bar in the chart on the right hand side is incomplete data and gets adjusted near the end of the week. CDC. "Data on COVID-19 during Pregnancy: Severity of Maternal Illness" 29 November 2021. https://covid.cdc.gov/covid-data-tracker/#pregnant-population. Accessed December 1, 2021.

Weekly COVID-19 Pregnancy Data from CDC ( *As of November 29, 2021):

  • Total Cases: 148,327

  • Hospitalized: 25,178 (data only available for 121,973)

  • Total Deaths: 241

These numbers likely do not include all pregnant women with COVID-19 in the United States and must be interpreted with caution.

Overall Key Findings

  • Pregnant women do not appear to be at an increased risk of infection from COVID-19 over non-pregnant women (i.e. same infection rate).

  • However, pregnant women appear to have an increased risk of intensive care unit (ICU) admission, mechanical ventilation, and extracorporeal membrane oxygenation (ECMO), as well as death (but overall risk is low).

  • Rates of pneumonia and preterm delivery may also be increased compared to pregnant women without infection, but these results are inconsistent.

  • There is a significant racial disparity; pregnant Hispanic and non-Hispanic Black women experience even higher risks of complications from COVID-19 infection.

  • Regarding fetal and neonatal health, current results are reassuring and indicate newborns of mothers who contract COVID-19 appear to be born healthy.

  • Current evidence also indicates the virus does not readily cross the placenta or infect the fetus. Although there are case reports of this occurring, the event appears to be rare and likely depends on severity of infection.

  • Preliminary research indicates COVID-19 infection in early pregnancy does not appear to increase the risk of miscarriage, but more research is necessary.

  • Infant infection from exposure to an infected parent or caregiver likely accounts for most infections reported in newborns; majority of these infections appear to be asymptomatic or mild.

  • There is currently no evidence that COVID-19 infection can be transferred to the baby through breast milk; breast milk of previously infected mothers appears to contain COVID-19 antibodies (no reason to separate mother and baby after delivery).

  • There is currently no long-term data on how COVID-19 infection during pregnancy could affect women or their babies.

Background

In December 2019, health officials in China indicated they had a serious outbreak of a respiratory illness caused by a new type of coronavirus, COVID-19, or “coronavirus disease 2019”.

In February 2020, the virus was given the specific name “severe acute respiratory syndrome coronavirus 2” or SARS-CoV-2. In March 2020, the World Health Organization (WHO) officially declared the outbreak a worldwide pandemic.

This page will refer to SARS-CoV-2 as COVID-19.

Various coronavirus infections during pregnancy – such as severe acute respiratory syndrome (SARS) and Middle-East respiratory syndrome (MERS) – have been associated with a higher incidence of severe illness in the mother and adverse outcomes for the fetus.

Fortunately, current evidence indicates that COVID-19 is significantly less lethal than SARS and MERS and pregnant women may only have a slightly higher risk of certain complications over non-pregnant individuals. However, there is still very little data regarding pregnancy-related outcomes and COVID-19.

Coronaviruses – General

The term coronavirus derives from the Latin word corona, which means crown or halo. Under electron microscopy, the virus particles display a crown-like pattern on its outside, similar to spikes, which has resulted in the very common computer-generated image of the virus below. In general, coronaviruses cause illnesses ranging from asymptomatic infection to fatal infection.

CDC graphic.

There are seven coronaviruses currently infecting humans. COVID-19 is the third coronavirus to cause a major epidemic, after SARS and MERS. However, COVID-19 has infected a far greater number of people than SARS and MERS combined.

Information on the effects of SARS and MERS during pregnancy was being used early in the pandemic to help manage pregnant women with COVID-19. However, more current data has shown several differences between SARS, MERS, and COVID-19, with data indicated COVID-19 is far less lethal in pregnant women compared to SARS and MERS.

Symptoms of SARS consisted of fever, chills, headache, general discomfort, muscle pain, and diarrhea, with an incubation period of around 4.6 days, but a range of 2 to 14 days. Almost all patients contracted pneumonia. Case fatality rate was estimated at 9% to 10%.

SARS-CoV-2 (COVID-19)

Sequencing data show that COVID-19 has a 79% genetic similarity to SARS and about 50% to MERS. However, as of July 5, 2021, COVID‐19 has an overall significantly lower fatality rate, estimated around 1.8% in the United States (2.6% in the UK, 1.8% in Canada, and 3.0% in Australia). Pregnant women appear to have the same fatality rate as non-pregnant women.

Human-to-human transmission occurs through close contact via respiratory droplets; incubation time averages 4 to 5 days but can range from 1 to 14 days. It is estimated almost all infected individuals develop symptoms by 11.5 days.

Infected droplets can also spread to distances of up to 6 feet and deposit on surfaces (fomites). These fomites can then infect healthy individuals who touch the unsanitized surface and then touch their mouth, nose, or eyes.

COVID-19 infection can be described in 3 stages:

  • Stage 1: Incubation period; may include asymptomatic infection

  • Stage 2: The virus is detectable and presents with minor or mild symptoms such as a fever

  • Stage 3: Severe symptoms arise which may require hospitalization and could result in respiratory distress or death

Individuals can experience a complete lack of symptoms to a wide range of acute and long-lasting symptoms. These include fever, shortness of breath, cough, nausea, congestion, runny nose, vomiting, diarrhea, chills, loss of smell, sore throat, headaches, body aches, excessive phlegm, coughing up blood, pneumonia, and blood clotting issues.

Studies of hospitalized patients with COVID-19 indicate that severe pneumonia is common and approximately 17% to 29% of these cases progress to acute respiratory distress syndrome. It is currently estimated that once hospitalized, these patients may have a 4% to 15% fatality rate.

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General Pregnancy-Specific Data

Overall, when compared to the non-pregnant population, pregnant women with COVID-19 appear to have an increased risk of hospitalization, ICU admission, mechanical ventilation, and the use of ECMO, as well as death (especially in the third trimester). While overall risk remains low, "pregnancy is an independent risk factor for respiratory deterioration in patients infected with SARS-CoV-2".

In general, the increase in progesterone in pregnancy causes the nasal capillaries, nasal mucosa, and upper respiratory tract to swell; this helps viruses attach and makes it harder for immune cells in the nasal cavity to kill these pathogens.

Further, along with upper respiratory tract swelling, lung expansion is restricted as the uterus enlarges; this can lead to a greater need for intensive care and mechanical ventilation during pregnancy in case of severe respiratory virus infection.

A November 2020 study of 252 pregnant women who tested positive for COVID-19 indicated that approximately 5% of all pregnant women with COVID-19 infection develop severe or critical illness. A separate study from July 2021 of 926 pregnatn women indicated this risk appeared to be around 13%. According to the Society for Maternal Fetal Medicine as of November 23, overall low absolute risks appear to be: 2.9 per 1,000 for invasive ventilation, 0.7 per 1,000 for ECMO, and 1.5 per 1,000 for death.

According to a large-scale multinational study published in April 2021, women with COVID-19 diagnosis (compared with those without COVID-19 diagnosis) "were at substantially increased risk of severe pregnancy complications, including preeclampsia/eclampsia/HELLP syndrome, ICU admission or referral to higher level of care, and infections requiring antibiotics, as well as preterm birth and low birth weight. The risk of maternal mortality was 1.6%, [or] 22 times higher in the group of women with COVID-19 diagnosis."

Photo by Dominic Blignaut on Unsplash

However, "these deaths were concentrated in institutions from less developed regions, implying that when comprehensive ICU services are not fully available, COVID-19 in pregnancy can be lethal. Reassuringly, we also found that asymptomatic women with COVID-19 diagnosis had similar outcomes to women without COVID-19 diagnosis, except for preeclampsia."

Across numerous studies, pre-existing conditions consistently play a role in disease severity, such as obesity, older maternal age, hypertension, diabetes, and asthma. Black and Hispanic pregnant women also appear more likely to experience severe infection and hospitalization.

Stage of pregnancy may also be a factor, similar to influenza, although data is limited. COVID-19 is a pro-inflammatory virus that causes severe and excessive inflammation throughout the entire body. Early pregnancy and near term (third trimester) are considered pro-inflammatory, which could make COVID-19 infection more severe at these stages, but more research is necessary. Currently, it appears that third trimester may be the riskiest time period for infection.

Current variants (Alpha, Delta) appear to increase the risk of severe outcomes in pregnancy compared to the original strain.

According to a study published in July 2021, of 3371 pregnant women, the proportion that experienced moderate to severe infection significantly increased between the orginal strain and Alpha periods, and between Alpha and Delta periods.

Symptomatic women admitted in the Alpha period were more likely to require respiratory support, have pneumonia, and be admitted to intensive care. Women admitted during the Delta period had further increased risk of pneumonia (Vousden et al. 2021).

This was corroborated by a study published in September 2021 Increased morbidity was observed in pregnancy with COVID-19 during the recent surge associated with the Delta variant, particularly in an underserved pregnant population where vaccine acceptance is low. The overall rates of severe or critical illness in this cohort are consistent with the previously published data from our institution. However, recent trends demonstrate that along with increasing case volume, the proportion of cases requiring hospitalization is rising. The potential pathophysiologic mechanisms for the increased severity of illness with B.1.617.2 in pregnancy are unclear. Our results highlight the urgency of the requirement of prevention measures including COVID-19 vaccination during pregnancy (Adhikari et al 2021).

The largest cohort of pregnant women (to date) tested for COVID-19 worldwide was published in July 2021:

  • Severe adverse outcomes, defined by maternal death, admission to ICU and/or advanced oxygen support were observed in 9.9% of cases.

  • Pulmonary comorbidities, hypertensive disorders and diabetes mellitus were significantly associated with an increased risk of severe maternal outcomes.

  • No difference in the livebirth rate was observed between pregnant women with severe adverse outcomes and patients with an uncomplicated course.

  • However, a significant increased risk of caesarean section, preterm birth, and neonatal admission to the intensive care unit was observed, highlighting that obstetrical and neonatal outcomes are influenced by the severity of maternal disease.

Blood clot risk remains inconclusive, but appears to be uncommon (despite pregnancy itself increasing the risk of blood clots). A study published in July 2021 indicated that COVID-19 infection can be complicated by coagulopathy (excessive bleeding or clotting), featuring blood clots and other thrombosis events, which has been termed "COVID-19 associated coagulopathy" (CAC). Data concerning CAC in pregnancy is limited, but:

Photo by Hush Naidoo on Unsplash

The study above determined that of 1,546 COVID-19 positive pregnancies, 1% developed CAC, indicating CAC appears to be uncommon in pregnancy. However, the authors noted that urgent research is required to determine appropriate anticoagulant dosing and duration in pregnant women with COVID-19 infection.

Pregnant women experience the same symptoms as the general population, and may even be largely asymptomatic. Symptoms include shortness of breath, fever, fatigue, chills, muscle aches, and cough. Infection appears to significantly more common in the third trimester, but this may be due to universal testing as women are admitted for labor and delivery.

Regardless of severity, pregnant women may experience a longer duration of symptoms, as at least one study indicated some COVID-19 positive pregnant women experienced symptoms eight weeks or longer after diagnosis (but many others have no symptoms).

COVID-19 is rarely detected in vaginal secretions.

In a study published in June 2021 of 16 COVID-19 positive pregnant women, none tested positive for SARS-CoV-2 in vaginal secretions (but one non-pregnant women tested positive via vaginal secretions). Thirteen patients delivered during the study period; all delivered at term without obstetric complications and all newborns were healthy (Barber et al. 2021). 

Although most studies to date have indicated pregnant women are not more susceptible to infection than the non-pregnant population, a February 2021 study determined the COVID-19 infection rate in pregnant women in Washington State was 70% higher than similarly aged adults, which could not be completely explained by universal screening at delivery.

Although risk of preterm delivery remains inconsistent, reports finding an association are becoming more frequent. Preterm birth might be caused by changes in the placental circulation induced by the virus that results in fetal distress (and a lack of oxygen, triggering contractions). However, in some reports, cesarean section was performed to improve the mother’s condition, the baby’s condition, or was triggered for other reasons that may not have been related to infection.

According to a November 2020 CDC report, among 3,912 infants born to women with COVID-19, 12.9% were preterm, which is higher than the national estimate of 10.2%. Among 610 of those infants with testing results, 16 were positive for COVID-19, primarily those born to women with infection at delivery. Eight of those 16 infants were born preterm.

In a large population-based study published in July 2021, COVID-19 diagnosis increased the risk of preterm birth, particularly among those with medical comorbidities. (If the mother's condition deteriorates, preterm birth is often recommended.)

There is also informal and anecdotal reporting of a lack of preterm deliveries overall during the pandemic. This phenomenon could be due to women resting more, staying at home, having more familial support, or lack of infections in general, not just COVID-19 (infection is a primary cause of preterm birth). There may also be a decrease in preterm induction, usually indicated by HCPs for medical reasons.

COVID-19 viral shedding may last longer in pregnant women.

A case report published in July 2020 indicated that a pregnant woman who tested positive at 28 weeks of pregnancy still tested positive at 38 weeks, and did not test negative until almost 50 days after delivery. The newborn, as well as placenta, cord blood, meconium, and breast milk samples were all negative for the virus. The cord blood was positive for antibodies.

The authors of the study assessed that pregnancy may cause slower clearance of the virus. However, this does not mean the virus is contagious (or active) during this time frame (Molina, et al. 2020).

Despite a possible increased risk of preterm birth, a study published in April 2021 identified no significant differences in abnormal fetal ultrasound and Doppler findings observed between pregnant women who were positive for COVID-19 and controls.

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COVID-19 Infection in Early Pregnancy or when TTC

As of December 2021, it does not appear that COVID-19 infection early in pregnancy increases the risk of miscarriage, but laboratory results have indicated it is possible (although likely rare):

At least three studies assessing whether COVID-19 had any impact on early pregnancy loss determined the infection appears to have a favorable maternal course at the beginning of pregnancy and does not appear to increase the risk of miscarriage.

A nationwide study published in June 2021 indicated the risk of pregnancy loss at less than 20 weeks gestation due to COVID-19 was similar to the rate of early pregnancy loss in pregnant women without COVID-19 infection.

However, at least three separate studies (from August/September 2020 and July 2021) identified COVID-19 receptors in the early oocyte and blastocyst; therefore, it is possible that infection in early pregnancy could have adverse effects on the embryo. Significantly more research is necessary in larger populations of women.

A case study published in March 2021 found COVID-19 nucleocapsid protein, viral RNA, and particles in the placenta and fetal tissues of an early pregnancy miscarriage from a pregnant woman who had tested positive for the infection. The study also determined that fetal organs, such as lung and kidney may be targets for coronavirus.

Regarding fertility and trying to conceive (TTC), a study published in June 2021 found that seropositivity to the SARS-CoV-2 spike protein (due to infection) does not prevent embryo implantation or early pregnancy development. The study used in vitro fertilization frozen embryo transfer as a model for evaluating the impact of COVID-19 seropositivity on implantation. 

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Infection Transmission to Fetus/Newborn

In general, vertical transmission of any virus from the mother to fetus is not well understood, but can occur through amniotic fluid, placental transfer, umbilical cord blood, or vaginal delivery.

Note: Maternal and fetal blood never directly mix during pregnancy; this exchange takes place in the placenta.

As of December 2021, it does not appear that COVID-19 readily crosses the placenta (although it can affect the placenta), enters amniotic fluid or umbilical cord blood, or transfers to the newborn via vaginal delivery (which does occur with other viruses). Further, neonates born to mothers who tested positive for COVID-19 appear to remain relatively healthy (and may receive their mother's COVID-19 antibodies). However:

As of December 2021, COVID-19's ability to infect the placenta is well-established. COVID-19 is theorized to harm the placenta due to the placenta's expression of ACE2 receptors, which the virus uses to infect cells. However, this occurrence appears to vary widely among individuals. Gestational age at exposure may also be an important factor determining how the placenta responds to the maternal infection.

Recent findings indicate placental damage may occur even if neonates are born healthy. A study published in August 2021 found that a significant proportion of placentas where COVID-19 occurred during pregnancy showed histopathological findings suggesting placental damage.

A separate study examined sixteen placentas from COVID-19 infected women. Third trimester placentas were more likely to reflect a systemic inflammatory or hypercoagulable state (tendency for blood to clot). Despite these changes, all neonates tested negative for the virus and were discharged within four days.

In contrast, a separate study that examined twenty-one third trimester placentas of women who tested positive for COVID-19 did not find any major adverse effects on placental structure and pathology, and another study from December 2020 identified no placental or fetal transfer of the virus.

Despite this inconsistency regarding placental infection/damage, neonates have tested positive for the virus within 30 minutes of delivery, and the virus has been identified in placental tissue and amniotic fluid. But overall, this appears to be rare and likely depends on severity of infection, stage of pregnancy, and how long the fetus is exposed to the virus (i.e. time of infection in the mother to time of delivery).

Despite its rarity, recent studies have shown transmission can occur at all stages of pregnancy.

A study published in September 2021 included 42 pregnant women who tested positive via nasopharyngeal test at 24-48 hours before delivery. All women were asymptomatic at the time of the test, but approximately 59% developed mild disease after delivery. Newborns were tested immediately at birth and at 24 hours. There were five cases of intrauterine transmission of COVID-19.

According to a study published in May 2021, among 1448 newborns who underwent PCR testing, fifty-nine (4%) were PCR-positive. Neonates testing positive were born to both symptomatic and asymptomatic women, and nearly all were born to women with infection identified near delivery.

Two stillbirths have been documented from severe infection, one in the second trimester and one in the third trimester, indicating possible transmission. Further, at least one fetal demise has been identified in a woman who contracted COVID-19 in the first trimester.

Note: Overall, data regarding risk of stillbirth and COVID-19 are inconsistent, but it does appear to be rare. While some reports have indicated a slight increased risk, others have not found an association. Further, in at least one study that indicated an increased risk, this increase was thought to be due to factors other than COVID-19 infection (more in Prenatal Care/Appointments).

Therefore, it is likely (although rare) that vertical transmission could happen during any trimester but additional research and clarification between COVID-19 positive newborns and timing of infection in the mother is necessary.

There is currently a lack of evidence the virus can be transmitted through breastmilk.

It is very unlikely COVID-19 infection can be passed from mother to baby via breastmilk. Further, breastmilk from infected mothers was found to contain COVID-19 antibodies and neutralized COVID-19 activity.

However, for currently infected mothers who wish to breastfeed, it is still possible to transmit the infection when the neonate is in close contact. Therefore, it is advised women should consider wearing a face mask during feedings or using a breast pump until they test negative (Pace et al., 2021; Zhu et al., 2021; WHO, June 2020; Dong et al. 2020).

Regarding the postpartum period, transmission can occur from the mother to the newborn. According to a U.K. study of 66 newborns who tested positive for COVID-19, 17 were suspected of contracting the infection from their mother after delivery.

The authors indicated that despite these numbers, the newborns did not experience severe illness, and the benefits of remaining with the mother after delivery appear to outweigh the possibility of infection. Symptoms in these newborns included high temperature, poor feeding, vomiting, a runny nose, cough and lethargy.

Long-term outcomes: A study published in July 2021 found that there was no difference in growth, neurodevelopment, and hospital readmission at 6-months of age between infected and non-infected babies born to COVID-19 positive mothers.

Testing

According to the CDC, there are two types of tests (decisions about testing are made by state or local health departments or healthcare professionals).

  • viral test is used to test for current infection. Two types of viral tests can be used: nucleic acid amplification tests (NAATs) and antigen tests.

  • An antibody test (also known as a serology test) can detect a past infection. Antibody tests should not be used to diagnose a current infection.

The most used test for current infection is the RT-PCR (real time reverse transcription-polymerase chain reaction, a type of NAAT). This type of test is used to identify the genetic material of a virus (see Resources). Specimens are collected from the patient’s nose or throat using nasopharyngeal or oropharyngeal swabs.

It is often recommended that if the first test is negative, but the disease is highly suspected, a second test should be performed. A negative result can be confirmed through two negative tests in a row, spaced at least 24 hours apart. Researchers do not yet know the most optimal timing to administer the test (especially in newborns).

HCPs may also use a chest CT scan for COVID-19 diagnosis, as this has been reported to be superior in early diagnosis compared with RT-PCR. The CT can show what is called “ground glass”, or white spots on the lungs that indicate the infection is present. For pregnant women, the diagnostic value of the CT may outweigh possible radiation risk to the fetus (read Radiation).

Women should have a risks and benefits conversation with their HCP regarding any imaging scans during pregnancy.

Some health care facilities may universally test all pregnant women prior to delivery, as pregnant women can also be asymptomatic, similar to non-pregnant individuals.

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Management and Treatment

The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have developed an algorithm to aid practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19 (read more).

Overall: There is no definitive treatment regimen for pregnant women with COVID-19; therefore, all management is currently individualized based on disease severity, stage of pregnancy, and risks and benefits of any medications.

It is also recommended that every pregnant woman with COVID-19 be monitored carefully due to possible complications, even if a woman initially presents without symptoms.

Formally, and depending on severity, recommendations include isolation, infection control procedures, diagnostic testing, oxygen therapy if needed, antibiotics (secondary bacterial infection risk), fetal and uterine contraction monitoring, and an individualized delivery plan.

Antiviral Medication: Currently, there is no specific drug for COVID-19; further, if a drug does appear to be safe and effective in the non-pregnant population, there is likely no scientific data to guide its use during pregnancy.

Medications such as Type I interferon, lopinavir, ritonavir, and tocilizumab are still being studied in the general population and are not (routinely) recommended for pregnant women; studies on safe and effective treatments for COVID-19 positive pregnant women remain ongoing.

Pregnant women were routinely excluded from early COVID-19 clinical trials.

As of April 2020, only 1.7% of COVID-19 trials included pregnant women, and only three involved an intervention or medication (Smith et al., May 2020).

As of December 2021, numerous clinical trials are underway regarding COVID-19 infection and pregnancy, treatment methods, and newborn outcomes, as well as the safety and effectiveness of vaccination.

Remdesivir is also not routinely recommended for pregnant women due to a lack of safety data as well as effectiveness. However, it may be used in severe cases under compassionate use and has been linked with initial positive results (very small case studies). Side effects of remdesivir in pregnant woman may include possible liver complications.

Monoclonal antibody treatment: A study published in August 2021 described successful use of of monoclonal antibody treatment for symptomatic COVID-19 in four pregnant patients. The authors found no evidence of pregnancy complications or treatment failure. All four patients avoided progression to severe disease and none required additional COVID-19 related medical visits or hospitalizations.

A separate case report was published in September 2021 of two unvaccinated pregnant individuals with moderate COVID-19, one in the second trimester and one in third trimester. They were treated with casirivimab and imdevimab. Neither experienced an adverse drug reaction, and neither progressed to severe disease.

Blood clotting: Both pregnancy and COVID-19 are associated with an increased risk for blood clotting – to include in asymptomatic women in isolation at home. However, this is also slightly debated as not all studies have found an increased risk. Further, although case reports exists, widespread reporting of blood clotting issues from COVID-19 infection in pregnancy has not been reported.

Some guidance indicates that suspected and confirmed COVID-19 pregnant women should receive preventative low-molecular-weight heparin (LMWH) before and after delivery (unfractionated heparin if delivery is close). Other reviews indicate there is not enough evidence to recommend heparin, and this medication could increase the risk of bleeding.

Delivery: Since there is currently no evidence that vaginal delivery can increase the risk of vertical transmission, mode of delivery should also be individualized and depends on stage of pregnancy, health of the fetus, and the mother’s overall health.

Fetus/Newborn: Prior to delivery, it is recommended that women undergo regular fetal heart monitoring and ultrasounds to monitor growth. Steroids may be considered for fetal lung maturation, depending on gestational age and severity of the mother’s disease.

After delivery, guidelines also conflict on whether the newborn should be separated from the (infected) mother to prevent infection transmission. However, most obstetric organizations agree the benefits of the mother and baby being together outweigh the possible risks of transmission. Women and their HCPs should have individualized discussions regarding infant separation for mothers suspected or confirmed to have COVID-19.

Photo by engin akyurt on Unsplash

Antibody Transfer to Fetus after Infection (via Placenta and/or Breast Milk)

Current data on COVID-19 antibody transfer to the fetus/newborn after maternal infection during pregnancy:

  • All types of COVID-19 infections – asymptomatic, mild, severe –initiate antibody transfer across the placenta.

  • Antibody levels from mild COVID-19 infection during pregnancy appear to decline more quickly than after severe infection (may be faster decline for asymptomatic, but this has not been studied).

  • A longer interval between infection and delivery provides more time for effective transplacental transfer of antibodies (e.g. two months better than two weeks; also likely depends on severity of infection).

  • However, infection in early pregnancy may not provide lasting antibody protection to fetus/newborn (vs. infection in late pregnancy) as this interval could be too long.

  • Antibody levels passed to a newborn after COVID-19 infection during pregnancy have been shown to decline in infants approximately 6 to 11 weeks after birth.

  • Despite this decline, passive immunity may persist in infants up to six months of life.

  • Infection in early to mid-pregnancy + vaccination later in pregnancy appears to be safe and produces strong antibody transfer across the placenta (and is recommended).

  • COVID-19 infection during pregnancy also transfers antibodies to colostrum and breastmilk; these antibodies are effective at neutralizing the virus.

  • Of note, it is currently unclear how long this lasts, but at least one study indicated antibodies were present in breast milk up to 10 months after a positive COVID-19 test. However, this amount and level of protection is likely highly variable, depending on stage of pregnancy during infection, severity of infection, whether the infant is exclusively breastfed, and length of time the infant is breastfed.

Timing: A study published in November 2021 determined that, after infection, pregnant women have COVID-19 antibodies around 8 to 16 days after confirmed infection. However, the presence of cord blood antibodies took about 26 days.

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Prenatal Care/Appointments

Women who attend their prenatal appointments should be assessed for fever each time and evaluated for signs and symptoms of a respiratory infection.

Women need to express any concerns they have with their HCP, to include their appointment schedule (virtual or in person), fetal monitoring, what they should do in-between appointments if they suspect infection, and what to do if they experience contractions, especially if nearby hospitals have changed their procedures.

Pregnant women should not be afraid to seek medical care, including emergency care, during the pandemic.

Reporting indicates that some pregnant women may avoid certain HCP appointments or even possible emergency department visits out of fear of being infected with COVID-19.

However, this can be incredibly dangerous during pregnancy, especially if bleeding and/or abdominal pain is present (i.e. ectopic pregnancy, placental complications). Women with these symptoms, or any indication in which they believe they need medical care, should visit their HCP/emergency department immediately (Comeau, CMAJ 2 July).

Further, if women are nervous about in-person appointments, they can talk to their HCP about the possibility of virtual visits, in otherwise healthy, uncomplicated pregnancies.

Women should continue to see their HCP when recommended, or when they feel they may be experiencing a concern.

At least one study noted an increase in the stillbirth rate in one U.K. hospital during the pandemic. Of note, none of the stillbirths were indicated in women who tested positive for COVID-19. This indicates that a decrease in appointments, prenatal care, routine screenings, or ultrasounds may have occurred that led to this increase. (Note: Other facilities have noticed a decrease in stillbiths.)

Women also need to tell their HCP how they are coping with the pandemic. Increasing isolation, preventative measures, anxiety about their health and the health of their baby, and a significant amount of uncertainty can increase women’s risk for depression and anxiety during pregnancy and the postpartum period.

Pregnant women and those trying to conceive should also consider being vaccinated against COVID-19, although this is a completely personal choice.

Latest Organizational Recommendations

The latest organizations recommendations regarding pregnancy and COVID-19 vaccination from:

  • U.S. Centers for Disease Control and Prevention

  • American College of Obstetricians and Gynecologists

  • Society for Maternal-Fetal Medicine

  • UK Royal College of Obstetricians and Gynaecologists

  • The Society of Obstetricians and Gynaecologists of Canada

  • The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

CDC: On August 11, 2021, the U.S. Centers for Disease Control and Prevention (CDC) formally announced new guidance to officially recommend COVID-19 vaccination for all people aged 12 years and older, including people who are pregnant, breastfeeding, trying to get pregnant now, or might become pregnant in the future. CDC further added:

  • No safety concerns were found in animal studies.

  • No adverse pregnancy-related outcomes occurred in previous clinical trials that used the same vaccine platform as the J&J/Janssen COVID-19 vaccine.

  • COVID-19 vaccines do not cause infection, including in pregnant individuals or their babies.

  • Early data on the safety of receiving an mRNA COVID-19 vaccine (Moderna or Pfizer-BioNTech) during pregnancy are reassuring.

  • Early data suggest receiving an mRNA COVID-19 vaccine during pregnancy reduces the risk for infection.

  • Vaccination of pregnant individuals builds antibodies that might protect their baby.

Read the full announcement here.

Photo by CDC on Unsplash

American College of Obstetricians and Gynecologists: On July 30, 2021, ACOG updated their COVID-19 Vaccination Practice Advisory to recommend "that all eligible persons, including pregnant and lactating individuals, receive a COVID-19 vaccine or vaccine series." They further added:

  • "Pregnancy testing is not a requirement prior to receiving any EUA-approved COVID-19 vaccine.

  • Claims linking COVID-19 vaccines to infertility are unfounded and have no scientific evidence supporting them. ACOG recommends vaccination for all eligible people who may consider future pregnancy.

  • COVID-19 vaccines may be administered simultaneously with other vaccines, including within 14 days of receipt of another vaccine. This includes vaccines routinely administered during pregnancy, such as influenza and Tdap."

Society for Maternal-Fetal Medicine: On July 30, 2021, SMFM updated their Provider Considerations for Engaging in COVID-19 Vaccine Counseling With Pregnant and Lactating Patients on 30 July to recommend "that pregnant and lactating people be vaccinated against COVID-19". They further added:

  • "Vaccination is the best method to reduce maternal and fetal complications of SARS-CoV-2 infection. Counseling to support the recommendation for vaccination should include available data on vaccine efficacy, as well as data on vaccine safety during pregnancy and lactation."

UK Royal College of Obstetricians and Gynaecologists (RCOG): On July 22, 2021, RCOG released the following statement: "Health chiefs are encouraging more pregnant women to come forward for their COVID-19 vaccine, as new data from Public Health England (PHE) show for the first time that 51,724 pregnant women in England have received at least one dose...On 16 April 2021, the Joint Committee on Vaccination and Immunisation (JCVI) advised that pregnant women should be offered the COVID-19 vaccine at the same time as the rest of the population, based on their age and clinical risk group."

Photo by Toa Heftiba on Unsplash

The Society of Obstetricians and Gynaecologists of Canada (SOGC): On May 25, 2021, SOGC revised and reaffirmed their original guidance from December 2020:

  • "Pregnant individuals should be offered vaccination at any time during pregnancy or while breastfeeding if no contraindications exist.

  • All available COVID-19 vaccines approved in Canada can be used during pregnancy and breastfeeding, but the SOGC recommends following provincial and territorial guidelines on type of vaccine to prioritize for pregnant and breastfeeding individuals.

  • The decision to be vaccinated is based on the individual’s personal values, as well as an understanding that the risk of infection and/or morbidity from COVID-19 outweighs the theorized and undescribed risk of being vaccinated during pregnancy or while breastfeeding. Individuals should not be precluded from vaccination based on pregnancy status or breastfeeding.

  • Given that pregnant people are at increased risk of morbidity from COVID-19 infection, all pregnant persons should be eligible to receive a COVID-19 vaccination."

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG): On August 17, 2021, RANZCOG released a joint statement with the Australian College of Midwives to recommend that pregnant women are routinely offered Pfizer mRNA vaccine at any stage of pregnancy:

"Global surveillance data from large numbers of pregnant women have not identified any significant safety concerns with mRNA COVID-19 vaccines given at any stage of pregnancy. Furthermore, there is also evidence of vaccine-induced antibodies in cord blood and breastmilk, which may offer protection to infants through passive immunity."

Action

According to the above recommendations, the best way to prevent the virus is to avoid being exposed and to get vaccinated.

Pregnant woman should also:

  • Seek care immediately if experiencing a medical emergency. Emergency symptoms can include trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or bluish lips or face. This is not an inclusive list, and women should always call their HCP or visit an emergency room when necessary.

  • Report any and all symptoms of a respiratory infection to their HCP, to include cough, fever, shortness of breath, and diarrhea

  • Avoid unnecessary traveling, use of public transportation, and contact with sick people

  • Wear a mask (to protect others) in public settings

  • Quit smoking (risk factor for infection)

  • Follow personal and social distancing rules

  • Regularly wash hands for at least 20 seconds (if soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol)

  • Avoid touching their eyes, nose, and mouth with unwashed hands.

  • Do not skip prenatal care appointments or other health appointments that may be necessary

  • Tell their HCP if they get tested in a location other than their HCP's office

  • Make sure to have at least a 30-day supply of prescription medications

  • Learn about stress and coping

  • Get adequate sleep and physical exercise

  • Go outside in open areas for walks, fresh air, and a change of scenery

Any pregnant woman who has traveled in a state or country with a high rate of COVID-19 infection or who has had close contact with an individual with confirmed infection should be tested and quarantined.

Women should refer to the CDC and ACOG COVID-19 web pages below for additional information (see Resources).

Note: Stay-at-home orders and isolation recommendations have increased the risk some women may experience domestic violence. 

Women can:

The National Domestic Violence Hotline can help women create a safety plan and locate resources in their area, if available. Women can call them 24/7 at 1-800-799-7233 or chat live via their website.

Partners/Support

Partners, family members, and other adult family members who live with a pregnant woman need to practice the same hygiene and social distancing habits and procedures as they do.

This includes maintaining a distance of at least 6 feet from other individuals, wearing a mask in public settings, washing hands for at least 20 seconds, and regularly disinfecting commonly touched surfaces in the office or at home.

Household transmission of COVID-19 is common and occurs early after illness onset.

CDC advises that persons should self-isolate immediately at the onset of COVID-like symptoms, at the time of testing as a result of a high risk exposure, or at time of a positive test result, whichever comes first.

All household members, including the infected person case, should wear masks within shared spaces in the household.

Symptoms can include:

  • Fever or chills

  • Cough

  • Shortness of breath or difficulty breathing

  • Fatigue

  • Muscle or body aches

  • Headache

  • New loss of taste or smell

  • Sore throat

  • Congestion or runny nose

  • Nausea or vomiting

  • Diarrhea

Emergency symptoms can include trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or bluish lips or face. This is not an inclusive list, and individuals should always call their HCP or visit an emergency room when necessary.

Infected persons should also:

  • Get vaccinated. (Vaccination does not cause "shedding". Learn more.)

  • Stay home. Most people with COVID-19 have mild illness and can recover at home without medical care. Individuals should remain at home unless they need to seek medical care.

  • Get rest and stay hydrated.

  • Stay in touch with an HCP and seek emergency medical care for difficulty breathing.

  • Avoid public transportation, ride-sharing, or taxis.

Individuals should refer to the CDC COVID-19 page for additional detailed information and resources.

Resources

Total cases in the United States/COVID tracker (U.S. Centers for Disease Control and Prevention

COVID-19 Home Page (U.S. Centers for Disease Control and Prevention)

COVID-19 Testing Page (U.S. Centers for Disease Control and Prevention)

Management Considerations for Pregnant Patients With COVID-19 (Society for Maternal-Fetal Medicine)

How does the RT-PCR test work? (International Atomic Energy Agency)

Novel Coronavirus 2019 (COVID-19): Practice Advisory (American College of Obstetricians and Gynecologists; December 2020)

Management Algorithm (American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine)

COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics (American College of Obstetricians and Gynecologists)

References

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