Since first identified in early December 2019 in Wuhan, China, the Coronavirus disease (COVID-19) caused by the novel coronavirus SARS-CoV-2 has infected more than 7.5 million individuals to date. Although the pandemic has reached nearly every country in the world, certain populations are at heightened risk for infection with SARS-CoV-2. Pregnant women and their children may be vulnerable to infection due to physiological changes associated with pregnancy. Pregnant women are believed to be disproportionately affected by respiratory illnesses, of which the novel coronavirus is one, particularly during the second and third trimesters of pregnancy due to changes in lung volume, oxygen consumption, cell-mediated immunity, and inflammation levels. In conjunction with evidence from prior coronavirus disease outbreaks such as SARS-CoV and MERS-CoV, these physiological factors suggest that both pregnant women and their children may be at heightened risk for COVID-19. Despite this hypothesis, maternal risk of severe disease outcomes remains relatively low. However, recent reports theorize that outcomes of maternal infection with COVID-19 are affected by the healthcare system’s ability to provide respiratory therapy. Analysis of cases of COVID-19 among pregnant women according to the Brazilian Ministry of Health’s Acute Respiratory Distress Syndrome (ARDS) Surveillance System indicates that less well-equipped healthcare systems are seeing rises in adverse maternal outcomes.
In pregnant women, infection with COVID-19 is marked by fever, cough, and shortness of breath among other symptoms; however, current research does not indicate that symptom severity is greater for pregnant women compared to age-matched controls. Once infected, development of COVID-19 pneumonia may be indicated by radiologic findings such as patchy ground-glass shadows in the lungs evident on chest CT scans. Clinical presentations of those with pneumonia most often include fever, cough, and lymphopenia. Adverse disease outcomes resulting from COVID-19 infection in pregnant women are generally uncommon. Preterm birth before 37 weeks gestation has been observed in multiple cases, but it is unclear whether this is attributable to spontaneous preterm delivery or clinical management of pregnancy. Some women also report experiencing miscarriage of their pregnancies, preeclampsia, and preterm pre-labor rupture of membranes; however, epidemiological studies have not shown that COVID-19 has directly increased risks for these outcomes. Severe cases of COVID-19 may also develop a preeclampsia-like syndrome. An association exists between COVID-19 and the occurrence of placental injury among pregnant women; however, these pregnancies appeared unaffected and still delivered healthy babies at term.
In addition to the physiologic impacts, maternal mental health may be worsened by the COVID-19 pandemic. Pregnant women face increased susceptibility to developing mental health issues such as depression, anxiety, and PTSD; a rise in maternal depression and anxiety resulting from the uncertainty of the pandemic has been suggested by preliminary studies. The COVID-19 crisis could worsen a pregnant woman’s mental health during the intrapartum and postpartum periods by restricting access to necessary care resources, leaving her isolated or quarantined without interaction with other people, and removing her from social situations. Beyond worries regarding isolation, fears of infection or economic loss are possible factors contributing to the development of these adverse mental health outcomes. This is particularly concerning as maternal mental health issues can impact maternal physiological health and wellbeing as well as child development and functioning both in the short- and long-term.
The immature immune systems of infants may increase their susceptibility to infection; when born to mothers with confirmed cases of COVID-19, this lack of immune protection may place them at a greater risk of becoming infected with the virus. While the main mode of transmission responsible for infant infection with the virus remains unknown, postnatal environmental exposure to contaminated droplets is suspected to be the primary cause. Vertical transmission has been proposed as an additional transmission pathway for the virus. SARS-CoV-2 RNA is detectable in placental and membrane samples and the mixing of maternal and fetal fluid and tissue frequently occurs during delivery. However, the absence of viral isolates in other maternal and fetal areas of contact reduces the plausibility of the theory of vertical transmission as a major source. Understanding of the clinical presentation and potential outcomes resulting from infection with COVID-19 in infants is more ambiguous than that of pregnant women due to the lack of research involving infants. From the limited studies that have been performed thus far, common clinical presentations that have been observed include transient respiratory distress, low birth weight, pneumonia, fever, asphyxia, and respiratory distress syndrome. Additional symptoms that infants have demonstrated include lethargy, rhinorrhea, cough, tachypnea, vomiting, diarrhea, and feeding intolerance/decreased consumption. However, many of these symptoms are also complications of other diseases common in infancy, so it is possible that they are a result of these diseases and not COVID-19.
Progression to adverse disease outcomes in infants with COVID-19 is rare. Of the few cases of COVID-19 that have been reported in infants, it was noted that fetuses born to pregnant women who developed COVID-19 during their third trimester of pregnancy did not have altered cellular or humoral immunity as a result of their mother’s infection status. In severe cases, COVID-19 may result in a cytokine-storm in a pregnant woman; during the first and third trimesters, pregnant women are in a pro-inflammatory state and this cytokine storm may further increase inflammation. It is a theoretical possibility that this increased inflammation could affect fetal brain development and contribute to neuronal dysfunctions and behavioral phenotypes only recognizable later in postnatal life. Likewise, maternal fevers, which are a common symptom of COVID-19 in both pregnant and non-pregnant women, may be associated with increased attention-deficit/hyperactivity disorder in infants if untreated, but without follow-up studies this remains speculative.
As SARS-CoV-2 is a newly emerging virus and the COVID-19 pandemic is still ongoing, research remains limited. Specifically concerning maternal and child health, there is a significant void in the literature surrounding the clinical presentation of the virus, the risk of vertical transmission, and the potential adverse outcomes of infection with the virus for pregnant women and their children. The majority of research that exists focuses on the third trimester of pregnancy, and little is known about the potential impact of the virus during the first or second trimesters.
Leading public health organizations have made recommendations for several perinatal care practices; however, they are widely debated and subject to change as more research becomes available. There is currently no evidence that there is a greater risk of viral exposure or transmission for vaginal birth compared to Cesarean section delivery. When considering the most appropriate mode of delivery for a pregnancy, the decision should be made based on obstetric considerations rather than infection status. Despite concerns about close contact between a mother with confirmed COVID-19 and her infant while breastfeeding, the practice is still recommended. Breastmilk contains important biologic and immunologic components for neonates and the virus is undiscoverable in breastmilk so the likelihood of viral transmission is low. There is also the possibility of antibody transmission through breastmilk, which is an additional benefit. Visitors should be limited to emotional support persons (individuals deemed necessary to ensure good health and wellness of a pregnant woman during delivery) to reduce contact between the vulnerable maternal-neonate dyad and environmental contaminants carried by visitors. Given that no viral particles have been found in umbilical cord blood of pregnant women with confirmed COVID-19 thus far, delayed umbilical cord clamping is still recommended as well. Although infection control measures such as quarantine, isolation, and social distancing may be effective for reducing viral transmission in the general population, maternal-child separation after delivery is not recommended. The period immediately following birth is crucial bonding time for the new maternal-neonate dyad. The separation of a neonate from their mother can be detrimental to the developing infant as it disrupts breastfeeding and reduces the opportunity for skin-to-skin contact. Further, maternal bonding appears to be safe in neonates born to mothers that are SARS-CoV-2 positive.
While expectant mothers and newborns do not face more severe symptoms of COVID-19 than the general population, recent research reveals significantly higher stillbirth and neonatal mortality incidence during the pandemic period than during the pre-pandemic period. The mothers experiencing stillbirth and infant mortality did not show symptoms of COVID, suggesting these outcomes may instead be due to the reallocation of medical resources towards COVID-19 patients and the subsequent reduction in hospitalisation for labor management and perinatal care visits.
Impact of COVID-19 mitigation measures on the incidence of preterm birth: a national quasi-experimental study (The Lancet | October 2020)
Perinatal Distress During COVID-19: Thematic Analysis of an Online Parenting Forum (Journal of Medical Internet Research | September 2020)
Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study (The Lancet Global Health | August 2020)
Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic (The Journal of the American Medical Association | July 2020)
SARS‐CoV2 and pregnancy: An invisible enemy? (American Journal of Reproductive Immunology | July 2020)
Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies (Obstetrics & Gynecology | July 2020)
Maternal death due to COVID-19 (Obstetrics & Gynecology | July 2020)
The tragedy of COVID-19 in Brazil: 124 maternal deaths and counting (Obstetrics & Gynecology | pre-print)
Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis (Obstetrics & Gynecology | May 2020)
Pre-eclampsia-like syndrome induced by severe COVID-19: a prospective observational study (Obstetrics & Gynecology | pre-print)
Analysis of complement deposition and viral RNA in placentas of COVID-19 patients (Annals of Diagnostic Pathology | June 2020)
Maternal mental health in the time of the COVID-19 pandemic (Obstetrics & Gynecology | July 2020)
Perinatal depressive and anxiety symptoms of pregnant women during the coronavirus disease 2019 outbreak in China (Obstetrics & Gynecology | August 2020)
Detection of severe acute respiratory syndrome coronavirus 2 in placental and fetal membrane samples (Obstetrics & Gynecology | pre-print)
Coronavirus disease 2019 among pregnant Chinese women: case series data on the safety of vaginal birth and breastfeeding (Obstetrics & Gynecology | August 2020)
COVID-19 and newborn health: systematic review (Pan American Journal of Public Health | April 2020)
The immunologic status of newborns born to SARS-CoV-2-infected mothers in Wuhan, China (Journal of Allergy & Clinical Immunology | July 2020)
Why are pregnant women susceptible to COVID-19? An immunologic viewpoint (Journal of Reproductive Immunology | June 2020)
Coronavirus Covid-19 infection and breastfeeding: an exploratory review (Revista Española de Salud Pública | May 2020)
Breastfeeding and coronavirus disease‐2019: Ad interim indications of the Italian Society of Neonatology endorsed by the Union of European Neonatal & Perinatal Societies (Maternal & Child Nutrition | July 2020)
When separation is not the answer: Breastfeeding mothers and infants affected by COVID-19 (Maternal & Child Nutrition | pre-print)
Documents & Reports
The Role of the MHTF
As SARS-CoV-2 is a newly emerging virus and the COVID-19 pandemic is still ongoing, research remains limited. The MHTF is actively synthesizing and disseminating information on COVID-19 and maternal health as it becomes available.
COVID-19 Special Edition (Week of May 11, 2020)