Living in a society where COVID-19 exists and will continue to exist for the foreseeable future is becoming a reality for most reproductive-aged women. In the early stages of the pandemic, the COVID-19 task force of the American Society for Reproductive Medicine (ASRM) recommended a moratorium on non-urgent care until the disease surge, transmission rates and burden on the healthcare system were better understood.
Fertility Treatment and Risks
In considering when and how to provide reproductive care during the pandemic, several factors are weighed against the time-sensitive nature of infertility. These include the risk of transmission to patients, staff and physicians, as well as the utilization of healthcare resources. Both the ASRM and American College of Obstetricians and Gynecologists (ACOG) assert that infertility is considered a medical disease that warrants timely treatment. Over time, an increasing number of patients whose care has been delayed are now in a situation that has become more urgent. It is important to emphasize, however, that the willingness of fertility specialists to provide treatment should not be misinterpreted as an indication that risk is minimal, but instead as recognition and respect for patient autonomy in regards to pursuing fertility treatment and pregnancy.
Pandemic Realities for Reproductive Healthcare
Risks of pursuing fertility treatment in the setting of the COVID-19 pandemic include the risk of exposure at clinic appointments, the potential for cancellation due to exposure with financial consequences, the unavailability of PPE, and changes in regulations. There are also physiological and mechanical changes in pregnancy that increase a pregnant woman’s susceptibility to infections, particularly when the cardiorespiratory system is affected, and it causes rapid progression toward respiratory failure. The pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, also leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system.
COVID-19 vs. Historical Data
Historically, pregnant women have been thought to be at increased risk of severe morbidity and mortality from specific respiratory infections (e.g. influenza). Therefore the initial thinking that COVID-19 behaves differently was somewhat surprising. Related coronaviruses SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome) were also associated with higher complication rates among pregnant women. While early statements from ACOG suggested that there were no increased risks associated with COVID-19 in the setting of pregnancy, their practice advisory update published on July 1, 2020, reveals data to suggest this early impression was not correct.
Early Findings with SARS-CoV-2 and Pregnancy
To date, however, there is also no conclusive evidence of fetal risk, including miscarriage and congenital disabilities. A recent study by Shanes et al. (May 2020) reported an increase in the rate of features of Maternal Vascular Malperfusion (MVM), as well as intervillous thrombi in sixteen placentas obtained from patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Such findings have previously been associated with oligohydramnios, fetal growth restriction, preterm birth and stillbirth. Maternal hypertensive disorders are also significant risk factors for MVM. Whether systemic vascular changes due to maternal COVID-19 are responsible for the histologic changes of MVM cannot be determined. Intervillous thrombi are also generally considered incidental findings but associated with maternal hypertensive disorders or coincident infarctions. Whether these represent the placental deposition of thrombi in response to the virus remains to be seen. In this same study, all the live infants were tested by a nasopharyngeal and throat swab at greater than 24 hours of life, and none were positive.
Pandemic Precautions for Pregnant Women
All in all, we are still learning how the illness affects pregnant women, and pregnant women should take the same precautionary measures as the non-pregnant population to avoid infection. These precautions (e.g., hand washing, wearing face masks, sanitizing, maintaining physical distance from others) should be taken seriously. The CDC website contains other specific recommendations. It is also important to note that while recognizing that many patients are experiencing new concerns because of COVID-19, hospital and accredited birth centers remain the safest settings for birth even during the COVID-19 pandemic. Healthcare facilities have implemented processes to ensure the safety of their laboring patients.
Exposure in Childbirth and Breastfeeding
Lastly, based on current research, it is not likely that COVID-19 passes to a fetus during pregnancy, labor or delivery. However, after birth, a newborn can get the virus if he or she is exposed. While unlikely, there is also not enough information yet on whether women who are sick can pass the virus through breast milk. Breast milk provides antibodies and is the best source of nutrition for most babies. Currently, the primary concern is not whether the virus can be transmitted through breast milk, but rather whether an infected mother can spread the virus through respiratory droplets during the period of breastfeeding.
The Role of Women’s Health Providers
In summary, family planning and pursuing pregnancy are personal and involve value-based decision making that each woman needs to undertake for herself. In doing so, she would have to use her own level of risk tolerance to reach a conclusion that is most appropriate for her life. It is recommended that women considering pregnancy consult Maternal-Fetal Medicine specialists (MFMs), who are physicians specializing in high-risk obstetrics. MFMs help to thoroughly understand the latest research and potential risks as they pertain to their health histories and specific situations before making a decision. Healthcare providers must be advocates for reproductive choice and are therefore supportive of a decision to pursue pregnancy as well as a decision to postpone pregnancy due to any concern a woman may have.
