During pregnancy we're fiercely protective of our health and feel especially responsible for everything we do and expose ourselves – and baby – to. If you’re pregnant, naturally, you’re concerned about COVID-19 for your own health and your baby’s. Who wouldn’t be? We’re inundated with an overwhelming amount of information about how fast it's spreading, and there’s still a lot of uncertainty about this infection. While a thorough search of the medical literature and the CDC website for data on COVID-19 and pregnancy shows just how very little is known at this time about the impact of COVID-19 on pregnancy and pregnancy outcomes, the good news is that what we do know so far is generally reassuring about the risks of this infection to otherwise healthy pregnant women and their babies.
Let’s look at the biggest areas of concern, who might be at higher risk, how to prevent COVID-19, and what to do if you should contract it.
First, I want to make something very clear: the efforts going on right now to contain COVID-19 doesn't mean it's a horrible, deadly virus to most people. It's a bad one, and spreading quickly, no doubt, but the big goal with all of the lockdowns is to contain it so that those who are at risk, have reduced likelihood of exposure from the rest of us who will just act as asymptomatic carriers, or people who just have it as a ‘cold.' To the best of our knowledge right now, aggressive containment is an appropriate public health, measure to stop the spread of something moving fast. We can all do our part in that for the sake of the few who might get really, really sick. So where do pregnant women fit into that scheme? How sick is this virus likely to make you?
Based on the data we have so far, it seems that, for some reason, women – including pregnant women – experience less severe infection than men. The largest majority of women who contract COVID-19 experience mild to moderate cold or flu-like symptoms (see COVID-19 symptoms here). Based on one small study published in the Lancet, using cases from early in the outbreak in China, of 9 pregnant women studied, symptoms were mild to moderate, none of the women developed severe complications, none died, and their babies were generally healthy.
That said, the data is still limited, that was a tiny study, the infection is very new, and pregnant women are susceptible to respiratory infections and to the development of severe pneumonia, especially if they have chronic diseases or pregnancy complications, so it’s essential to be vigilant about prevention and also early identification of severe symptoms.
Pneumonia and Other Respiratory Risks to Mom
Natural shifts in immunity during pregnancy, and additional demands on women’s respiratory systems, particularly as pregnancy gets more advanced, do put pregnant women at higher risk for severe complications should they contract flu, which we see particularly in influenza A (H1N1), with substantially greater risk to pregnant women with underlying medical conditions, for example, asthma, diabetes, or certain autoimmune conditions like lupus.
However, as opposed to flu, pregnant women do not appear to be at higher risk of severe disease from COVID-19, according to a World Health Organization official report. At present there is only one reported case of a woman with COVID-19 who required mechanical ventilation at 30 weeks’ gestation, following which she had an emergency caesarean section and made a good recovery. Nonetheless, there is some risk: In an investigation of 147 pregnant women in China from early in the outbreak (64 confirmed, 82 suspected and 1 asymptomatic), 8% had severe disease and 1% were critical. As do all pregnant women, pregnant women with underlying medical conditions really do want to be more diligent about preventing infection whenever possible by what I call hysterical hygiene – fastidious hand-washing and avoiding exposure to the extent you can.
Miscarriage, Preterm Birth, and Stillbirth
While both SARS and MERS, also forms of coronaviruses, did increase miscarriage and stillbirth rates, and severe influenza does increase miscarriage risk, at this time there is no reason to believe that COVID-19 increases either. There have been some cases of preterm births in women with the infection, however it is unclear, according to the medical literature, whether these were due to COVID-19 infection, and the risk still appears to be low.
Fever in Mom and Risks to Baby
Perhaps one of the biggest worries for pregnant moms is having a fever, due to association of maternal fever with increased risk of birth defects in the baby, particularly neural tube and cardiac defects However, this concern is controversial, with conflicting data from a number of different studies. For example, while a 2014 meta-analysis of 46 studies found that fever during the first trimester may be associated with cleft lip or palate, neural tube, or heart defects, some of the studies included in the review had insufficient evidence to confirm this association. The CDC reported an increased likelihood of neural tube defects in babies born to women who have fever in pregnancy, but a 2017 report based on a study of fever outcomes – the 77,344 pregnancies enrolled in the Danish National Birth Cohort over six years (1996 to 2002) where self-reported information on fever during first trimester of pregnancy was available – did not show any association between maternal fever in pregnancy and risk of congenital anomalies. Most studies suggested a protective effect of antipyretic medications (those that reduce fever, for example, Tylenol) when used during fever. Yet another 2017 study did support an association between fever around the time of conception and an increased risk for neural tube defects in baby, but found that this risk was lessened in mothers who took at least 400 mcg of folic acid daily
Further, it also seems that if there is increased risk, it is most substantial if the fever is in the first trimester, with ≥ 102.2°F (39°C).
In short, the risk of fever in pregnancy causing congenital defects in the baby is unclear, however if there is risk, it appears to be greatest in first trimester and with higher fevers, and risk is reduced if you’re already taking folic acid and use fever-reducing medication (discuss this with your midwife or doctor) to bring the fever down. While I don't recommend Tylenol for low fevers or for frequent use during pregnancy, for fevers ≥ 102.2°F, especially in the first trimester, short-term use during flu or COVID-19 Tylenol is recommended.
Mom-to-Baby in Utero Transmission
According to preliminary studies, it does not appear that pregnant moms can pass COVID-19 to their babies in utero (called vertical transmission). Babies born to moms with COVID-19 have not tested positive for the virus at birth, and there has been no detectable COVID-19 in the amniotic fluid or umbilical cord blood of these newborns.
There’s also no evidence that a mother can infect her baby during labor or birth. Further, while babies can and have become infected by exposure to COVID-19, which I talk more about under breastfeeding, one preliminary study suggested that babies are not likely to be severely affected. For example, none of the nine babies exposed to COVID-19 in China, as reported in a study published in JAMA, had severe complications nor required intensive care.
However, in a different report on 10 babies born to 9 mothers in China (there was one set of twins) with active, symptomatic COVID-19 infection, there was a higher rate of respiratory distress and other complications in the babies, including one neonatal death. In this study all of the babies tested negative for COVID-19 infection, so the authors could not definitively say that these complications were all due to maternal COVID-19. Nonetheless, it's important to remain aware of possible risks, vigilant to signs of distress or COVID-19 infection in newborns, do our best to prevent their exposure in the first place, and expand screening for COVID-19 to pregnant women.
Should You Go to the Clinic for Prenatal Visits?
Most midwifery, Family Medicine, and OB practices are rapidly changing their practices to bring more prenatal care online via telemedicine, however, there's no ‘one standard' for how often prenatal visits are being done remotely. I recommend consolidating visits to a limited number of in-person appointments, without skipping any of the essentials that help identify possible problems, while maintaining enough virtual connection to help you feel truly supported and have your questions answered.
Certain aspects of prenatal care can't be done online, so I recommend ‘grouping' elements together that require in-person appointments, for example, combine an early prenatal visit with your prenatal labs, and if you're planning to have an early ultrasound, get that done at the same time. You may be able to have your prenatal labs drawn at home, including your NIPT/NIPS if you're having that done. If you're choosing to have an anatomy scan, which is usually done between 18 and 20 weeks gestation, you can combine this with other routine prenatal visit concerns in person.
If you are high-risk, you may need to be seen more often in person, but there's still a great deal you can do from home, from blood pressure checks to blood sugar checks, with your Midwife's, OB's, or Family Physician's guidance.
Before you go into the office for any exams, ask them what precautions they're following for prevention, and also, if you are otherwise healthy and low risk, should you do a telemedicine check in and postpone your scheduled visit for a couple of weeks right now. If you are high-risk, it's likely you'll need to keep your appointment, but do call ahead to see how the office will be protecting your health.
If you have COVID-19, or cold or flu symptoms and aren't sure, call the office before you go in for your regularly scheduled appointment and let them know you are sick – they will give you instructions on what to do to prevent possibly infecting other patients/clients in the office.
If you are working with a provider in an at-home setting, please recognize that it may be much more difficult for your provider to provide the level of attention to infection prevention able to be achieved in a formal medical setting, and you're not necessarily at less risk of exposure if you're getting an exam on a midwife's sofa, bed, or other comfy place to stretch out if all the other people she's examining are doing the same. I know, because as a home birth midwife for 25 years, my sofa was my exam table, and it wasn't covered with paper that I changed after each successive client had her exam. Ask how she's keeping the space sanitized, preventing infection spread, and make sure she's washing hands between each visit, wiping down the fetoscope or doppler, etc, as you would ask a doctor or hospital-based midwife. We often assume a natural approach means we can let go of basic public health measures – but that's not smart thinking if we're really trying to protect ourselves from infection.
Also, as health care workers – all of us – MDs and midwives alike – we're trained to work when we're sick. It's perfectly fair to ask your health-care provider if she has symptoms or has been sick before you go to the office or get examined.
Having Your Baby in the Hospital vs Home Birth
Pregnant mamas should be aware that hospitals have started to limit the number of people that can come into the birth room with you–this includes doulas, whom many hospitals have defined as a visitor, rather than an integral part of the birthing team. You may be forced with the difficult decision to choose who you want in your birth room, and you may only be allowed one person. It’s worth calling your hospital to see what their policy is so you can make that choice ahead of time. If you are limited, you can consider having a doula or other members of your support team connect with you in the delivery room on a device (Skype, FaceTime). Though I've heard at least one report of this being prohibited, please know that no law prevents you from having a device in the room, and if the goal is preventing infection, the device can be sanitized with a good wipe-down!
One concern recently brought to my attention is whether the risk of going to the hospital to birth due to possible COVID-19 exposure there would warrant switching to a home birth. As this point, hospitals are being instructed to implement protocols that should protect women in labor and after birth, and there’s no reason to switch to a home birth just because of COVID-19 exposure risk.
In the UK, women with low-risk pregnancies are being advised to remain at home as long as possible in early labor to mitigate exposure risk. For women who do have COVID-19 when they enter labor, a hospital birth is advisable were mom or baby to develop COVID-19 related complications (i.e., respiratory distress) during labor or birth.
Also, as mentioned above about health care workers working when we're sick, your home birth midwife must have a back-up plan should she or her assistant(s) get sick; ditto that for your doula! Just last year a neighbor who is a doula called me to ask if she could attend a birth in hospital even though she and her son were sick. The answer, “No.” Have a back up, especially in a time of COVID-19 and flu!
Breastfeeding with COVID-19
Bottom line: with rare exception of severe infection in mom, breastfeeding is recommended even if mom has COVID-19. COVID-19 has not been detected in breastmilk. Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.
If you have confirmed COVID-19 or you’re symptomatic, the most important thing you can do is take all possible precautions to avoid spreading the virus to baby. This can be done by washing your hands before touching your baby, and wearing a face mask, if possible, while you’re feeding your baby. If you express your breast milk manually or with a breast-pump, you should wash your hands before touching any pump or bottle parts, follow recommendations for proper pump cleaning after each use, and if you have COVID-19, consider having someone who is uninfected feed the baby expressed milk with a bottle – though this is not considered a strict recommendation.
If you're well now and are able to pump, I do recommend ‘stockpiling' some breastmilk in the freezer, so that if you do get COVID-19 while breastfeeding, feel exhausted, or want to distance yourself from baby for your own peace of mind, then you have milk on hand for someone to feed baby from a bottle. Rest-assured, the age-old worries about nipple confusion from bottle to breast have been put to rest – babies can nimbly switch back to breast after a few days of bottle feeding.
If you do get sick, it's really important to stay well-hydrated, have someone who can help you with baby so you can get the sleep you need, and also during convalescence because you could feel weak for awhile. But breastfeeding itself is not dangerous for you if you're sick. You do have to be willing to ask for help, take it, and really do a lot of resting. Echinacea, ginger tea, Vitamin C, and zinc, are all considered safe while breastfeeding; I also talk more about herbs in pregnancy and breastfeeding in my classic book The Natural Pregnancy Book, but keep in mind, COVID-19 is new; herbs can be supportive in colds and mild flu, but are not adequate for severe infection or complications, and there's no proof that any help specifically with COVID-19.
What About Travel? Should I Avoid It If I’m Pregnant?
My recommendation is simple: until this is well under control, avoid all unnecessary travel.
What If I’m Trying to Conceive?
Whether to try to conceive in this immediate moment is a completely personal decision. At this time there appears to be no reason to avoid trying to conceive naturally, other than how you feel about the sheer stressfulness of the times we're in, and potential challenges accessing medical care should it be needed.
Practicing commonsense is important when it comes to avoiding intimate contact if you or your partner is actively sick or positive for COVID-19, and I recommended that you not try to conceive if there is active COVID-19 infection in either partner.
In light of the current COVID-19 pandemic, as of March 17th, 2020, the American Society for Reproductive Medicine, issued new guidelines that change assisted reproduction (fertility treatments) as follows:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilization (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers whether fresh or frozen.
- Continue to care for patients who are currently “in-cycle” or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and non-urgent diagnostic procedures, such as hysterosalpingograms.
- Minimize in-person interactions and increase utilization of telehealth.
These guidelines are intended to safeguard the health and safety of women seeking fertility treatment, as well as fertility health care workers, but the implications for this can feel enormous, particularly if you've been trying for some time or feel ‘time is running out' for getting pregnant, and of course, in addition to the enormous emotional investment you've made, no doubt you've invested substantial financial resources into becoming pregnant.
Should I Get the Flu Vaccine? What About DTaP?
Wow – vaccination is such a hot, controversial topic that I barely want to bring it up for fear of unleashing a storm. But the reality is, the risk of contracting flu remains greater than contracting COVID-19 and has been for months. Each year numerous pregnant women experience flu complications. and having one less infection to worry about this season is a sensible choice, and for my pregnant patients at high risk, I've been encouraging it – killed virus from single preloaded injection to avoid thimerosal.
That brings me to a rumor going around on the internet that getting the flu vaccine increases risk of contracting Coronavirus. This is based on a recent (2020) article published in a journal called Vaccine. The authors describe a phenomenon called viral interference in which receiving the influenza vaccine purportedly increases the risk of developing other respiratory infections. They concluded that “receipt of influenza vaccination was not associated with virus interference among our population” and that while there may be some increase in coronavirus, there was overall protection against respiratory infections. A 2013 study found no association between receiving the flu vaccine and increased risk of coronavirus.
Based on my read, I do not consider the limited data we have on viral interference enough to consider that getting a flu vaccine is a risk factor for developing coronavirus. Further, each year, the flu vaccine contains different strains, and the coronavirus we’re now facing is entirely new – so these studies aren’t really relevant, and the current official recommendation remains to receive the flu vaccine to reduce your risk of that infection.
Should I Take Herbs or Supplements to Boost My Immune System?
During pregnancy, I always recommend pregnant women take a prenatal vitamin with ample folic acid (400 to 800 mcg) daily, as well as fish oil for essential fatty acids important for baby’s brain health, and I recommend continuing to do so now. While there are no herbs or supplements at this time that are known to prevent or treat COVID-19, the amount of zinc and other nutrients in your prenatal vitamin should provide the core nutrients that also support immunity. While there’s no harm in taking up to 30 mg zinc daily or up to 2000 mg of vitamin C daily, loading up on these during pregnancy is not recommended. Small studies have suggested that taking a daily probiotic could help prevent colds; of course, that’s not the same as COVID-19, and the evidence is weak – but it’s not harmful to take a probiotic in pregnancy. Adequate Vitamin D levels, which can safely be achieved in most pregnant women by taking 2000 iu of Vitamin D3 daily, may also help support healthy immunity.
Herbal medicines including ginger and echinacea, for example, are considered safe during pregnancy, but shouldn’t be used in place of medication to reduce fever if you do have COVID-19 (or the flu) and shouldn’t take the place of medical care if needed. Teas such as chamomile, lemon balm, and ginger can help with aches and pains, as well as some digestive symptoms. For more information on herbs in pregnancy see my article here; just keep in mind there are no studies on herbs for COVID-19, and there are no proven traditional therapies as this is a brand-new virus.
What Should I Do If I Think I’m Infected?
First, don’t panic. Remember, yours and baby’s risks, based on all we know right now, are still low. If you have mild or moderate symptoms of COVID-19, call your primary pregnancy care provider (Midwife, OB-GYN, Family Physician) and let them know. Just like you would anytime, stay home, rest, stay well-hydrated, and take all of the steps you’d take if you had a cold or flu.
If you have underlying medical conditions that increase your risk of complications from COVID-19, or any respiratory infection, it’s important to work with a medical doctor skilled in higher-risk prenatal care, ask what you should do to mitigate your personal risks, and inform her or him right away should you feel unwell or have a known or suspected COVID-19 exposure, so you can get instructions on what to do.
Should you need to be seen by a health care provider, call ahead before you go to the clinic, office, or hospital and let them know you’re sick and might have COVID-19 so they can direct you to the right place, while protecting other pregnant women and staff. If you do experience any severe symptoms or complications, seek medical help immediately.
Where Can I Go for Updated Information on Pregnancy and COVID-19?
The Centers for Disease Control and Prevention (CDC) is the most reliable sources for medical information on COVID-19, pregnancy, and breastfeeding. OB/GYNs, Family Physicians, and CNM's should be staying apprised of recommendations as they evolve; if you’re working with an unlicensed birth provider who might therefore not be receiving official recommendations, make sure to ask her what resources she’s using to keep up-to-date. You should feel absolutely entitled to ask any care provider what precautions they are taking to prevent infection spreading to you, and insist on hand-washing and basic hygiene before examining you. I will also keep this article updated as available information evolves.
My overall sense is that in retrospect, most of us will simply be breathing a sigh of relief when this is over. There’s a good chance that this virus will become a new part of our seasonal viral landscape. Knowledge is power, and you now have in your hands the basic summary of what is known to date. I hope this has helped you to feel more at ease, with tools you can use to support your health and enjoy your pregnancy and birth as fearlessly as possible!