Since the coronavirus pandemic was first declared in March 2020, a lot of questions have swirled around whether or not the disease might be especially harmful to pregnant people or threaten the lives of their unborn children. A year and a half into the pandemic, expectant mothers, as well as people seeking to become pregnant, still have many questions about how COVID-19 might impact pregnancy, fertility and health outcomes for themselves and their children.
One of the first questions on the long list of queries is: Does being pregnant increase the severity of the disease?
In a word, yes.
Contracting COVID-19 while pregnant can result in more severe illness, increase risk of hospitalization and increase risk of death.
Initially, this wasn’t clear, says Dr. Mary Jane Minkin, clinical professor of obstetrics, gynecology and reproductive sciences at Yale University School of Medicine in New Haven, Connecticut. But as evidence has accumulated, “the body of information right now says that women who are pregnant who get COVID-19 do have the potential to get sicker than nonpregnant women. I think most folks are pretty comfortable saying that pregnancy is an extra burden.”
The Centers for Disease Control and Prevention agrees, noting that while the overall risk of severe illness from COVID-19 is low across the board, pregnant people and those who’ve recently been pregnant do appear to be at increased risk for severe illness when compared with non-pregnant people.
COVID-19 Increases Risk to Mom and Baby
Dr. Brian Keith Iriye, a maternal-fetal medicine specialist and founder and managing partner of High Risk Pregnancy Center in Las Vegas, Nevada, explains that COVID-19 infection in pregnancy increases risk of admission to an intensive care unit three times. It also carries “a 1.7 times increased risk of death, as well as increased risk of preterm birth, cesarean delivery and possible stillbirth.”
Delivering a pre-term baby means the baby arrives earlier than 37 weeks. When this happens, that increases the risk of poor health outcomes for the baby, which may include developmental disabilities and other issues with the lungs, eyes and other organs.
These complications have only gotten worse with the rise of the more infectious Delta variant of the coronavirus, Iriye says. “Clinicians have been seeing an increasing number of pregnant women with severe infections rise in the last two to three months with increased prevalence and circulation of the Delta variant. We have had multiple young pregnant women struggling to breathe, eventually becoming intubated, and in some cases, dying. The need for pregnant women to obtain vaccination against COVID-19 is urgently needed.”
Pregnancy Brings Risk Factors
Age of the pregnant person further increases risk for severe illness. In this context, being older than age 25 at the time of infection with COVID-19 is considered a risk factor.
In addition, there can be some logistical complications related to pregnancy in terms of severe illness. For example, Minkin notes that when you’re pregnant, “you’ve got this thing sitting in your belly. Having a pregnant uterus pushes up on the diaphragm,” which means less room for the lungs to expand to take in air. When you’re dealing with a severe lung infection, that compromised breathing can become a problem.
What’s more, during pregnancy, a woman’s blood volume “actually goes up almost 50%,” Minkin explains. “Her heart is basically working 50% extra during pregnancy,” even in a totally healthy person. Add a significant infection on top of that, and you’re adding a bigger burden to the heart. “So, a pregnant woman is set up for these other bad things to happen to her on top of the infectious issues. So, it really isn’t great to be pregnant and have COVID.” If you have underlying medical conditions, that can make everything more challenging.
If you do have a severe case of COVID, there can be some complications with treatment too. For example, the practice of “proning” or turning someone with severe COVID-19-related pneumonia on their stomach to help them breathe — as that helps open up the surface of the back of the lungs to process more oxygen — also poses some challenges for pregnant people. “Again, this is just a logistical issue” Minkin says, of having to work around the bulk of the belly where the baby is located in helping to treat the mother.
Studies into the long-term effects of infection are still underway for everyone who gets COVID-19, but the CDC notes that changes in the body that occur during pregnancy can make it easier to get very sick from respiratory viruses. These changes can continue after pregnancy for at least 42 days. This can potentially set the person up for worse health outcomes later.
COVID Increases Risk of Miscarriage and Birth Defects
Many people want to know whether infection with the coronavirus can increase the risk of miscarriage or birth defects. And again, the short answer is yes.
A review study published in the open access journal PLOS One in August 2021 found that pregnant people who contract COVID-19 are at higher risk of miscarrying and the risk appears to be highest during the first trimester. It’s thought the increased risk is related to placental inflammation during the viral infection, which can also result in fetal growth retardation and induce miscarriage.
In addition, running a high fever during pregnancy, such as may occur with severe illness from COVID-19 can be problematic, says Dr. Michael Cackovic, an obstetrician-gynecologist at the Ohio State University Wexner Medical Center in Columbus. “Case reports of fevers of greater than 101 degrees F for longer than 24 hours in the first trimester may be associated with congenital anomalies,” or birth defects. This finding is not limited to COVID-19. Any illness that creates a high fever for that period of time or longer could cause health problems.
Minkin notes that we’re too early in the course of the coronavirus to know for sure what the long-term effects of infection by a pregnant person during pregnancy might herald for their baby. “We don’t know. We just don’t have the years of data yet to tell people.”
Is Coronavirus a Sexually Transmitted Disease?
Some are wondering whether COVID-19 is a sexually transmitted virus, like HIV or Zika. But the CDC reports there’s currently no evidence that COVID-19 can be transmitted via semen or vaginal fluids.
However, the virus has been detected in the semen of people who have or are recovering from the virus. Whether that has any bearing on the development of the disease is still unknown. But it seems unlikely.
Still, because the virus is airborne, close contact, such as what typically occurs during sex, can pass the virus from one person to the other.
Can the Coronavirus Be Passed to an Infant During Pregnancy or Delivery?
Another area of concern is the potential for the transmission of the virus to the newborn during pregnancy or delivery. So far, there’s no evidence that a baby can contract COVID-19 from the mother while in utero.
The authors of that PLOS One study noted that “there has not been any consistent evidence of vertical transmission of the virus from mother to fetus,” but they and others are recommending further investigation.
While it’s not believed that the virus can be transmitted during delivery in the way that a disease like herpes can be, it’s still possible that the baby could become infected almost immediately after the birth if someone in the delivery room is infected. An infected person poses the risk of spreading the virus to the newborn as soon as it starts breathing.
To limit this route of potential infection, hospitals around the country have instituted strict protocols, and many safe and healthy deliveries have taken place during the pandemic with very few babies being infected.
And, if a woman is diagnosed with COVID-19 or is suspected of having it and delivers while infectious, she’ll typically be moved to a separate section of the maternity ward to reduce the risk of transmitting the virus to other women in the ward. Her baby will be tended by medical staff to prevent spread of the virus.
Restrictions have also extended to the labor and delivery room, where many hospitals have limited who can be in the room to critical medical staff and one support person, again in an effort to reduce the risk of viral transmission. Many hospitals have also instituted visitor limits and prescreening protocols to protect new moms and their babies.
Does Having COVID-19 Impact Fertility?
According to several studies, it appears that infection with COVID-19 could disrupt both male and female fertility. In men, sperm are susceptible to viral attack, and COVID-19 infection appears to have demonstrated adverse effects on the reproductive system, particularly in younger people who may still be developing.
However, vaccines can help prevent these issues, despite misinformation being peddled that it can decrease fertility. “There is absolutely no evidence that shows the vaccines decrease fertility in men or women,” says Dr. Nora Colburn, an infectious diseases physician, also at Wexner.
How Has COVID-19 Impacted Fertility Treatments?
Another aspect of fertility and COVID-19 relates to individuals who are pursuing fertility treatments. Dr. James A. Grifo, professor in the department of obstetrics and gynecology at NYU Langone Medical Center in New York City, says that because fertility treatments are often thought of as “elective” procedures, this has forced some families to put their efforts to have a child or children on hold until the pandemic is over.
Grifo, however, argues that infertility is a disease — a definition the World Health Organization agrees with — and “not treating a disease has an impact.”
Though some facilities have resumed administering fertility treatments, some have not. COVID-19 has also depressed birth rates around the world, according to an August 2021 United Nations report, for a variety of reasons, not just fertility treatments. Fertility levels aren’t expected to return to pre-pandemic levels until sometime between 2023 and 2025.
Vaccination Is the Best Defense
While all of these findings paint a bleak picture for pregnancy in the time of COVID, vaccination eliminates those risks, says Colburn. “There has been no risk observed in fetuses of mothers who are vaccinated. In fact, studies have shown that mothers who are vaccinated can pass protective antibodies against COVID-19 to their babies through the placenta.”
Iriye notes that “two studies have shown that protective antibodies produced due to vaccination cross the placenta and enter the fetal bloodstream.” These findings indicate there may be possible prevention of COVID-19 infection for the baby. What’s more, he adds, “COVID-19 vaccines do not cause infection in pregnant women or their babies.”
Vaccines against the coronavirus have been proven safe and effective, and Iriye notes that “the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Centers for Disease Control and other organizations recommend that pregnant, postpartum and breastfeeding women receive the COVID-19 vaccine.”
The Food and Drug Administration granted full approval to the Pfizer COVID-19 vaccine on Aug. 23. This full approval status means the vaccine has met the FDA’s threshold of safety and efficacy standards and is considered safe and effective. Full approval of the Moderna and Johnson & Johnson vaccines is expected to follow soon.
Still some people may hesitate. To that, Iriye says it’s true that “these medications are relatively new, and hence rare fetal complications are not readily apparent. Nonetheless, the same statement can be made about COVID-19 infection, its effect on the fetus and possible developmental concerns.” What we do know now is that “vaccination does decrease the risk of COVID-19 infection, hospitalization and death.”
And Minkin notes that “we understand anxiety” about the vaccine. “But the bottom line is, we strongly encourage people to get the vaccinations.” That’s because the safety and efficacy evidence for COVID-19 vaccines is strong. “We have certainly accumulated a good amount of data on getting the vaccine. And we’ve seen no adverse consequences to the mom or the baby in getting the vaccine. Mom has a much lower risk of getting an infection, and that’s terrific.”
If you’re immunocompromised and can’t be vaccinated, Minkin cautions you to “be as careful as humanly possible.” As much as you can, get someone who is vaccinated to help you with things like shopping and other chores that might bring you into contact with people who are sick. And “if you need to be somewhere, double mask.”
Colburn adds that a better understanding of the virus is on the horizon, but there’s no doubt that vaccination is the way to go. “We continue to learn more about SARS-CoV-2 every day, and the CDC has set up a robust registry of pregnant women volunteers to continue to follow their progress closely. There are also studies looking at protective antibodies passed from mother to child.”
Expect that the guidance related to COVID-19 infection and pregnancy will evolve as more studies are completed.
For the time being, Colburn says “we know that pregnant women are at high risk for severe disease if they catch COVID-19. Many of these deaths, both maternal and fetal, can be prevented by vaccination of the pregnant woman and her entire family.”
As an infectious disease physician and new mother herself, Colburn strongly urges “everyone, and most especially pregnant women, to get vaccinated as soon as possible. The safety profile in pregnant women has been examined extremely closely and these vaccines are incredibly safe and effective.”
“Please go out and get your shots,” Minkin says. “If you’re pregnant or thinking about getting pregnant, it’s the right thing to do to protect yourself and your kids.”
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Update 09/03/21: This story was published previously and has been updated with new information.