Expert weighs in on impact of COVID-19 in pregnancy

Even as she recovers from what she qualified as a “mild” case of COVID-19, Dr. Laura Riley, MD, shares her expert perspective on the impact the coronavirus is having in pregnant patients and steps to be taken by their OB/GYNs. Dr. Riley is a renowned obstetrician who specializes in obstetric diseases. She is chair of the department of Obstetrics and Gynecology at Weill Cornell Medicine and obstetrician and gynecologist-in-chief at New York Presbyterian/Weill Cornell Medical Center.

Hello, I’m Angie DeRosa, Senior Editor of Contemporary OB/GYN, a journal for practicing obstetricians and gynecologists across the United States. The coronavirus pandemic is causing anxiety for many, but especially those who are pregnant.

As we published in our April issue, doctors are calling this the pathogen that will define the decade. Dr. Catherine Spong-our new Editor in chief-and two other doctors, Dr. Brenda Hughes and Dr. Sarah Dotters-Katz, weigh in in our April print issue and online.

[0:48] Background

A World Health Organization report from China, which included a study on 150 women, found that 8% had severe infection and only 1% required ventilation; however, other coronaviruses such as SARS and MERS, as well as other respiratory viruses such as the flu are associated with more severe disease, as well as increased maternal morbidity and mortality.

The virus, as well as other respiratory viruses, have not been associated with miscarriage or congenial anomalies. Although the data are mixed, any fever in the first trimester may be associated with congenital malformations. Preterm delivery was reported from some of the early cases from China, although it may have been iatrogenic and not related to spontaneous preterm birth.

In these studies, no virus was found in the amniotic fluid, the cord blood, or breast milk; however, we do caution that the studies are small, and more data are needed. There currently is no evidence of vertical transmission; however, there are reports of positive tests on newborns hours after delivery following negative tests that were obtained at delivery.

Please visit Contemporary OB/GYN for more information on this topic and more coverage from us. Thank you.

[2:38] Dr. Riley Introduction

We are here with Dr. Laura Riley, a renowned doctor who specializes in infectious diseases in pregnancy. She is chair of the Department of Obstetrics and Gynecology at Weill Cornell Medicine and obstetrician and gynecologist-in-chief at New York Presbyterian/Weill Cornell Medical Center.

She is in the hot zone for COVID-19. Her hospital system is one of New York City's busiest labor and delivery units. She is here to answer questions about the impact to pregnant patients and give her expert perspective on how to navigate this tricky time. Hello, Dr. Riley and thank you for providing us with your expertise.

DeRosa: You have been in the trenches now in one of the most affected hot zones for COVID-19. What guidance would you give to practicing OB/GYN now when dealing with the anxiety of pregnant patients?

[3:41]

Dr. Riley: So far, what we've seen is what had been reported in China in very small numbers. From our perspective anyway, pregnant women are going to get sick with COVID-19. It doesn't appear that once they get COVID-19, they do any worse than the general population but that does mean some women are going to get sick. We’ve seen different groups of women who are literally asymptomatic because we've been testing women in our system when they come in for labor and delivery.

Then there are women who have [classic] symptoms-whether it be sore throat, cough, congestion, fever, [and] some GI symptoms-we have seen them and many of them are positive.

Then we have patients who come in with known exposures saying, ‘My husband had it; My sister had it,’ and that kind of thing. When we first got started, one of the hard things was that we know it's a bad disease and we know that it acts differently in different people.

I was sharing with you earlier that I got COVID-19. I had a mild case, thankfully, but I still was kind of down for the count for about seven to eight days. We do see that there are people who get it and recover-no big deal-then we do see people who get it, and unfortunately, land in the ICU on a ventilator.

As a health care worker, it's incredibly terrifying. Your whole profession is to help people so you know that's what you need to do when you go to work, and you do it.

You know that there's some level of protection with the PPE, but that wasn’t always clear, whether or not we had the appropriate PPE or enough PPE.

Then you have the guilt of being a healthcare worker and taking care of patients, and then taking it home to your family. It’s been challenging. Taking care of patients, taking care of pregnant women, [and] trying to reassure patients, while trying to reassure yourself. It’s been a challenge.

[6:30]

DeRosa: I know that there have been a very limited amount of data for pregnant women. Is there anything that indicates vertical transmission?

Dr. Riley: Interestingly, and this is not a study, so I just have to go on record saying that, but we've had several COVID-positive mothers and we have not had any COVID-positive babies. Do we have thousands? No. Do we have, you know, 50-60? Yeah, we've got some of those numbers. So far, it doesn't seem to be a particularly efficient mechanism of transmission, which is great for babies.

What’s interesting that I'm seeing with my patients is that, because we're testing everybody, we do have women who then know that they're COVID-positive and that their babies are negative.

We're trying to do our best to inform women that when they go home, they need to be really careful with their baby. [They need to] wear a mask, and their family needs to wear mask, and to try and keep the social distancing, even with a baby. Keep the isolette far away until it's time to breastfeed. I think it’s hard. We’re asking them to do quarantine after a delivery, and that’s tough. None of that is easy.

[7:56] 

DeRosa: No, not at all. There is no indication yet either that it will be transmitted via breast milk, is that correct?

Dr. Riley: No, there's no indication of that at the moment, although I think those studies have not truly been done and vetted. But it doesn't appear to be the case. I do know that there are reports of babies who have been readmitted to the hospital, you know, two weeks later, four weeks later, with infection, so clearly, they can get it in the community just like anybody else can.

[8:33] 

DeRosa: Are you seeing or advising your patients in their own birth plans? Are you seeing any changes that are being made, or able to advise patients on making any changes?

Dr. Riley: In terms of the birth plan, not really. A couple things that change that are happening across the country are-which I have to say, the first few times it was really quite challenging-is this whole idea of video visits. When is the appropriate time to do them in pregnancy? How many visits can you avoid? Because it's twofold, right? We want to decrease the number of people who are traipsing in the hospital because we want to decrease the number of asymptomatic exposures that will happen to everybody-both the patients as well as the healthcare teams.

In addition, for New York City, it became, ‘Do you really want to get on the subway?’ Patients don’t want to get into Ubers. Many, many patients wanted to get out of New York City right away, not recognizing that running to Boston was probably not ideal because then Boston was looking like an epicenter shortly after we were. Connecticut, you know. It didn’t go far.

I think the whole video visit era is interesting because that's not been something we've really embraced for pregnancy. I think other areas of medicine have embraced it significantly. We were kind of lagging behind there, but I think we figured out how to do it now. I think patients are pretty savvy to some extent.

In some ways, unfortunately, I think COVID-19 makes all those racial, ethnic, socioeconomic disparities really come to the forefront. The ability to even quarantine yourself, or self-isolate, kind of depends on your means. The ability to do the telehealth visits and not traipse in on the bus, in the subway, etc. depends on certain socioeconomic status and things like that.

I think that that's been quite challenging, but that is a difference that all of us have had to get used to: feeling comfortable with it and feeling comfortable with women basically taking care of themselves with some direction from me via a camera. So far, so good, but it's nerve racking.

In terms of their birth plan, most people really haven't had to do too much differently. Labor’s come in when it's coming. I think patients are getting used to the fact that they're going to be tested when they come in the door; that you have to wear masks the whole time. That's not really a crowd pleaser, but it's to decrease the risk to them as well as to ourselves.

I think we had a short period of time where we were trying to diminish the number of people that would come in, just because we didn't have enough protective gear and garb and all of that. We were worried about these asymptomatic exposures.

So, we had a short week where we were trying to discourage partners from coming in for labor support. They're now coming in. Patients seem to be fine with it. It's interesting how many patients said, ‘Why did you do that? We don't feel safe.’ There was no winning on that one. But it's all good.

[12:22] 

DeRosa: Do you mean having somebody there in labor support?

Dr. Riley: Yeah, having labor support. It's funny because there was a huge outcry of, ‘How could you do that, you know, no labor support?’ and we were like, ‘We're trying to prevent the influx of COVID-19.’ It’s interesting.

Then we reversed back because the governor asked us to, and the number of patients who were like, ‘I was fine with it,’ it's just very funny. People are fearful in different ways and it’s understandable.

[13:02]

DeRosa: It is because it's such a mysterious virus, right?

Dr. Riley: It’s a mysterious virus with no treatment on top of everything, right? A mysterious virus and there’s no treatment. There is not very much testing and there’s not a ton of protection. It’s difficult to protect yourself from something you can’t see, smell or hear. So much of this is out of our control. That’s the other thing, from a society standpoint, that I think is difficult for all of us. You don’t even have control to go to the grocery store when you want to because we’re all on lockdown.

[13:49]DeRosa: How is it at your hospital now? Is it better or worse than you had expected at this point in the virus’s impact?

Dr. Riley: What the modeling showed was that there was going to be this surge of cases. We’ve seen that. The surge of cases goes up several fold every day. It's terrifying because there are people who are coming in the hospital and getting on a ventilator, and some live and some don't. That part is devastating, just by the sheer numbers. You have faculty who get sick. You have friends who get sick. You have parents of people you knew who were in the hospital or died. It affects everybody. That’s what’s difficult.

[15:00]

DeRosa: Is there any other information you'd like to include and make sure you say as part of this interview? You and I were talking [earlier] about your expertise and the fact that you were in an HIV clinic that ran in Boston, and seeing the evolution of that virus, and comparing it to now? Can you give our audience a little bit of insight on that?

Dr. Riley: In my career, I started with the whole HIV epidemic in women and that was really scary and devastating in those first few years; we didn’t have the tests, then we got the tests; we didn’t have treatment and we didn’t understand transmission. It was a really tough time, but that’s a huge medical success story. Then there had been infections after that.

[COVID-19] is devastating on many, many levels, but I am optimistic because I’m a huge vaccine advocate. I am convinced that once the appropriate vaccine comes and is administered, we'll be able to prevent further illness whether that be in pregnancy or not. I'm hopeful that some of these antivirals and other medications that become available are actually effective.

Also, one really good thing that's happened with COVID-19 is, very early on, OB researchers got together and said, ‘Let’s have a registry.’ We have a registry in New York. There’s a national registry out of UCSF called The Priority Study. There’s an international effort to study pregnant women.

The fact that researchers have come together and really understood that pregnancies are really important, but different time period and different patients, and that it deserves real consideration and well-done studies is really good. It’s great.

It’s going to help us move the field and the knowledge base along faster, and in a much more scientific way, which I think is really important and it’s important for our patients as we go forward.

[17:53]

DeRosa: Okay, that's excellent. Thank you so much. Good luck to you and to your patients. Thank you for the work you do and for what you’re doing out there now. All I can say is good luck. My family is in healthcare too, and I feel helpless. That’s the only way I can describe how I feel. One of my dearest friends just went on to the coronavirus ward at University Hospitals here in Cleveland as of Sunday night. You all really, really are heroes. I have to make sure I say thank you for everything you’re doing.

[18:46]

Dr. Riley: We appreciate that. I have to say, people in New York have been amazing. At seven o’clock, people go out onto their porches and clap for the healthcare workers. I think it’s really, really appreciated. As I told my husband early on in this whole process [when] he asked, ‘What can I do for you?’ and I said, ‘Just stay healthy. Just stay in, don’t spread anything.’

Stay healthy and I look forward to talking with you again. Take care.