Pregnancy and COVID-19 What You Need to Know
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The months leading up to the birth of your baby are supposed to be joyous ones. But COVID-19 has created anxiety and uncertainty. We’d like to share a message of hope by answering some questions you likely have during these unprecedented times.

Q: Are pregnant women more affected by the virus than non-pregnant women?
Dr. Rachael Overcash: Right now, the limited preliminary information we have suggests that pregnant women are not more adversely affected by it.

Still, it's an incredibly hard time to be pregnant. In fact, we expect women to experience more symptoms of depression and anxiety during pregnancy and following birth. Depressive symptoms or moods can be exacerbated by stressful situations like the pandemic. Providers and patients should anticipate an increase in depressive symptoms and anxiety and should be ready to provide resources and support.

Q: What precautions should pregnant women take to avoid contracting the virus?
Dr. Sara Iqbal: Observe social distancing and stay home as much as possible, wash your hands often with soap for at least 20 seconds. Use MedStar Health Video Visits instead of in-person appointments, unless it's absolutely necessary. Please check out all of the prevention tips from the Centers for Disease Control and Prevention (CDC).

Dr. Overcash: Also, follow the recommendations from the CDC to wear a mask. It doesn’t have to be a medical-grade mask—just something that covers your mouth and nose.

Q: Which pregnant women should take extra precautions? Dr. Overcash: There are certain subpopulations of pregnant women who have complicated medical conditions and should take extra precautions. That includes women who have Type 1 or Type 2 diabetes, lupus, kidney disease, or other autoimmune conditions that require them to be on immune suppressant medications. They should really try to stay home as much as possible. Limit trips to the grocery store or other essential businesses.

Q: Is it possible for a pregnant woman to have the virus without showing symptoms? Dr. Overcash: Yes, it is possible, although published information from New York shows that about 70% of asymptomatic women who have tested positive for coronavirus will eventually develop symptoms.

Dr. Iqbal: Asymptomatic carriers do not have any symptoms; however, they are infectious, shedding the virus, and potentially transmitting it to other people. That’s why it's so important that pregnant women—and everyone—take precautions such as social distancing, hand hygiene, staying at home, and wearing masks when you must go out.

Q: What symptoms of the virus should pregnant women be aware of?
Dr. Iqbal: They should watch for any signs and symptoms that range from cough, shortness of breath, sore throat, fever/chills, headache, and body aches.

Some patients can have gastrointestinal (GI) and neurological symptoms such as nausea, diarrhea, confusion, loss of appetite, and even loss of smell or taste. If they have a fever, cough, or other symptoms, they should call their Ob/Gyn or MFM physician for advice. Mild symptoms can be managed at home with isolation, adequate hydration, rest, healthy sleep patterns, and nutritious food.

However, they should go to the hospital right away or call 911 if symptoms intensify, such as persistent or worsening shortness of breath, chest pain, dizziness, and sudden confusion. If you go to the hospital, try to call ahead to let them know you are coming so they can prepare.

Q: Should pregnant women be tested even if they have no symptoms?
Dr. Overcash: We are performing universal COVID-19 testing for women who are admitted to our labor and delivery, those who have not delivered yet but are admitted due to complications with their pregnancy, and of course to women with symptoms. They will get the nasopharyngeal swab (the test for the virus).

@MedStarWHC provides universal #COVID19 testing for women who are admitted to the labor and delivery unit. @RachaelOvercash
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Q: Are there other virus-screening procedures at MedStar Washington Hospital Center?
Dr. Overcash: Anyone entering the hospital is screened by security. Screeners at every hospital entrance check for symptoms. They also perform a temperature check with a monitor near the forehead. If that's normal, the patient can enter; if not, they are moved to an isolation clinic, where we screen patients and staff.

Q: How does the virus affect the health of a pregnant woman and her child before she gives birth?
Dr. Iqbal: So far, we know that severe acute respiratory syndrome coronavirus (SARS-CoV) in 2003, Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, and influenza during pregnancy are associated with adverse maternal and neonatal outcomes including miscarriage, growth restriction, and preterm birth. However, limited data of pregnant women with COVID-19 show no intrauterine transmission and no clinical differences in severity of respiratory symptoms. Though these results are promising, they must be interpreted with caution given minimal data.

Q: How many people are permitted in the labor and delivery room right now?
Dr. Overcash: We limit visitors to the labor and delivery room to one person. And once that visitor has been with the patient, they may not leave the hospital, and must stay with her for the duration of her hospitalization. If they do leave, they're not allowed back. Pregnant moms envision a certain type of birth experience—having family members, grandparents, other children visiting them in the hospital after their child is born. Unfortunately, this is not the experience they can have right now, so that can be really hard. By limiting the number of visitors, we limit potential exposure of our patients and staff.

Q: Are there potential complications during birth for women confirmed with the virus?
Dr. Overcash: Women can potentially experience complications during birth and after delivery, similar to someone who is not pregnant.

Traditionally, when a woman is in labor, we give her extra intravenous (IV) fluid hydration, especially before administering an epidural. Now, we're judicious about giving that IV fluid to a woman with the virus because we want to avoid potential pulmonary issues that may be caused by COVID-19 infection. So, traditional management of these women has changed.

Dr. Iqbal: We know that, theoretically, pregnant women may be at increased risk of severe disease because of their immunocompromised state. However, with this virus, the incidence of severe disease in pregnancy is unclear.

And possibly due to increased oxygen consumption and decreased functional residual capacity (the amount of air remaining in the lungs after normal exhalation is decreased by approximately 20% in pregnancy), the mom may be more vulnerable to respiratory issues.

Q: If a pregnant patient tests positive for COVID-19, how should the baby be delivered?
Dr. Iqbal: The data on mode of delivery is limited. COVID-19 is not an indication for a cesarean delivery and mode of delivery should be determined by the clinical circumstances and obstetrical factors.

We were able to report a successful vaginal delivery of a woman with confirmed COVID-19. To our knowledge, this is the first published U.S. case of a COVID-19 patient with an uncomplicated vaginal delivery and the efforts of our multi-disciplinary team were documented in the New England Journal of Medicine. This was a message of hope! A safe vaginal delivery for all involved. The baby was tested at 24 hours, 48 hours, and 10 days of life and remained negative for COVID-19.

Q: Are there complications for either the mother or the baby after a mother with the virus delivers her child?
Dr. Iqbal: The baby is at risk for contracting the virus after birth through maternal respiratory secretions. The baby must have a physical exam and a baseline workup, including a complete blood count (CBC) test and COVID-19 testing after delivery. At our hospital, the newborn COVID-19 testing is done by the neonatology team at 24 hours and 48 hours after birth to make sure the baby remains asymptomatic and negative for the virus.

So far, we are not aware of any delivery-related complications in the mother. However, COVID-19-related symptoms can worsen during the second week, which is when some patients can quickly decompensate. Therefore, it's very important to monitor Mom's serial labs and symptoms clinically, to ensure that she remains afebrile and asymptomatic prior to discharge.

Q: Does the virus affect breast milk?
Dr. Overcash: Although it’s not known for sure, the limited information about this subject suggests that the virus is not transmitted through breast milk. Current guidelines recommend that women who have tested positive should be separated from their infant for least seven days after symptoms started or three days of normal temperatures without Tylenol, whichever is the longest.

If the mom and the infant are not physically together, the mom can pump her breast milk and then have a healthy caregiver provide it to the baby. If the mom and the infant are together and the mom is breastfeeding, the CDC recommends she wash her hands before and after the feeding, and wear a face mask during feeding, to minimize transmission through respiratory secretions. Any breast pump supplies should be thoroughly cleaned and sterilized between feedings.

Dr. Iqbal: Breast milk is highly recommended, as it provides optimal nutrition and protection against many illnesses; however, transmission of the virus after birth via contact with infectious respiratory secretions is a concern. To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, the CDC recommends temporarily separating (e.g., separate rooms) the mother from her baby until the mother’s transmission-based precautions are discontinued. Separation between a mother with COVID-19 and her infant is a mutual decision that is made by a healthcare team based on the mother’s wishes and her health status.

Per CDC guidelines, during temporary separation, mothers who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply. The expressed breast milk should be fed to the newborn by a healthy caregiver.*

Q: Are there procedures in place if a mom is confirmed to be positive for the virus after the birth?
Dr. Overcash: We've designated a wing in the hospital for patients found to be positive for COVID-19, to limit exposure to other patients and staff.

If patients are meeting all their postpartum goals—they're walking, going to the bathroom, their pain is well controlled, their virus symptoms and vital signs are stable (meaning they are not on supplemental oxygen), and they don't have any signs that their respiratory condition has worsened—our goal is to have them go home and self-isolate. It’s not necessary to keep them in the hospital that entire time.

Q: Are preventive measures realistic in all cases?
Dr. Overcash: Sometimes, it’s just not possible to follow the precautions. There may be situations when you are pregnant, live in close quarters with a person who is starting to have symptoms, and share one bathroom. Social isolation and mask-wearing can be hard for a lot of families.

Dr. Iqbal: It’s hard to say, given so much uncertainty with the COVID-19 virus. Despite of all the recommended preventative measures there is going to be a vulnerable population who could potentially be severely affected, such as the elderly population, people with underlying lung diseases such as asthma, COPD, chronic heart disease, renal failure, and those who are immunocompromised.

Q: How should patients talk with their obstetricians or pediatricians about the virus?
Dr. Overcash: Many patients schedule telehealth or electronic visits over video chat where they can discuss their situation.

I've spoken individually to several patients about precautions they can take. Many patients are quite anxious, but we talk through their uncertainties and anxieties and try to help them manage the unknowns.

Q: How can patients help reduce exposure during this pandemic?
Dr. Iqbal: Telehealth is an effective option, especially since we are trying to reduce the spread of coronavirus. There are, however, certain things that need to be done in person—for example, physical examination including vital signs such as blood pressure checks and pelvic exam if necessary, labs, obstetric ultrasound and fetal monitoring to evaluate fetal well-being during pregnancy.

Otherwise, everything else can be discussed through telehealth. If there is an issue, the mom-to-be should call the OB provider and can always come to the hospital for evaluation if needed.

Dr. Overcash: One of the strengths of MedStar Washington Hospital Center being part of a large hospital system is that we have the resources and expertise to tackle major strategic planning events of this kind. I've used telehealth and find it easy to use. It allows you to see the patient and offers a great connection. Patients have been incredibly happy with it. It's helped us to consult with our patients while still allowing for social distancing.

Q: What can you tell expectant moms to ease the anxiety around this whole pandemic?
Dr. Iqbal: I understand the challenges this virus is bringing to our lives. However, I advise my patients to stay positive, adapt, be creative, and limit news and social media to reduce anxiety. I suggest spending quality time with their family, daily light exercise, and maybe getting a meditation app such as Calm and using that to help with relaxation.

Dr. Overcash: We have to focus on the present and what we can be grateful for. We need to remember that social distancing does not necessarily mean social isolation. You and your baby can still have that positive emotional connection with your loved ones and do it safely. As this becomes the new normal, people have become more accepting of that and have found ways to engage. It helps us deal with the stress and anxiety we all have right now.

Dr. Iqbal: Right. We can still engage with each other—have video conversations with the grandparents, connect through Skype and FaceTime. Stay positive, be creative, and connect. We all should support the fight against COVID-19 together!

*Reference: Centers for Disease Control and Prevention. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, March 2020.

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