COVID-19 Early Pregnancy Guidance – April 2020 guidance
Obstetricians-gynecologists believe strongly in providing the best advice and care to assist women in the many choices they face as they plan a pregnancy. Timing pregnancy in order to optimise woman’s health before conception improves the likelihood of an optimal perinatal outcome.
Investing in the health of women is an investment in the health of this and future generations. Yet, COVID-19 has made planning for pregnancy even more challenging. Ideally, women are counseled to take pre-conception folic acid for three months, make sure underlying medical problems are well-controlled, and achieve an ideal body weight before attempting to conceive.
This means effective use of contraception allows women to time pregnancies. Despite such recommendations, 50% of pregnancies are unplanned, or surprises. During COVID-19, easy access to contraception has become a barrier in several regions. Women may be balancing personal economic dilemmas, the concern of a biological clock, and the unknown impact of a COVID-19 infection on pregnancy. Each woman makes a decision about conception that reflects her personal needs and desires. Historically, the relationship between high mortality events such as this pandemic and the prediction of future fertility is complicated. Events like hurricanes, earthquakes and famines have been associated with decreased number of births nine months later.
COVID-19 is a novel virus, which means we have no experience with its effect on health, or on pregnancy. The first cases were reported in China in late 2019 and it has swept the globe in a matter of months. Given that a pregnancy lasts for 9 months, women who conceived during or even shortly before the pandemic began, have no evidence-based guidance on what to expect during the current pregnancy, and no knowledge of the impact that this virus has on fetal health.
The studies that are coming out as the pandemic unfolds are so far reassuring for women delivering at term with COVID-19 infections, with little fetal impact and no clear evidence of transplacental transmission, at this time. The full story will unfold as antibody testing takes place, and as women with early pregnancy exposure are tracked for nine months and their results are shared. It is clear that pregnancy registries to track women during and after pregnancy will be crucial.
Physicians must now rely on shared observations as the pandemic unfolds, and on pregnancy outcomes from other Coronavirus outbreaks. In 2002-2003, a novel Coronavirus known as Severe Acute Respiratory Syndrome (SARS) spread rapidly, causing over 8000 infections worldwide, and 800 deaths.
A study in Hong Kong followed 11 pregnancies where infections occurred in early pregnancy with high grade fever – known to be associated with pregnancy loss – documented in all cases. These pregnancies were associated with adverse pregnancy outcomes including miscarriages, stillbirths and intrauterine growth restriction. However, in the SARS series, the mortality rate was much higher than what has been observed in COVID-19, and the SARS maternal outcomes at term were worse. Just like COVID-19, SARS was not associated with vertical transmission from mother to fetus. Middle East Respiratory Syndrome (MERS) emerged in 2012, but only a small number of pregnancies were tracked. Again, 91% of the pregnancies had adverse outcomes with prematurity, neonatal hospitalization and neonatal mortality
The next year is one of uncertainty, yet optimism. Optimism because COVID-19 in pregnancy in the few case series has not been consistently associated with adverse maternal or fetal outcomes. Uncertainty, because we have 6-12 months before we see the effect of COVID-19 in early pregnancy and only then can we guide women in a process of shared decision-making in determining if or when to conceive.
Our advice at this point is clear: plan for pregnancy, use contraception until maternal health is optimised, take vitamins pre-conception, and make sure mental, physical and emotional health is where it should be. Then women must balance the considerations that are important to them, and their families. Managing pregnancies complicated by COVID-19 may require closer fetal monitoring to detect complications, so close supervision by a physician is indicated.