“As a pregnant after loss (PAL) mom [this pandemic is] really hard because the worst-case scenario has happened to us. When things like this happen and there are dilemmas or uncertainties or something that can affect the health of our families, especially our children, we’ve already been to that worst-case scenario. So, for me personally, my mind goes to worst-case scenario all the time.” -Dr. Kristen Sharp

Pregnancy After Loss and COVID-19: An Update on the Research with Dr. Sharp

If you’re anything like me, you’ve been gobbling up information on the coronavirus, the pandemic that’s gripped the world in 2020. I spend many late nights doing the “doom scroll” on my phone, and worrying about my own living children, all of whom were born after my stillborn daughter. I worry about their health, their safety, whether they should go to school, how much contact we should have with anyone outside our home. I see headlines about medical studies that show this, or new data that indicate that. I read stories about kids and babies who’ve died from the disease and feel that pit in my stomach that someone else is experiencing the worst pain a parent can endure. For a moment, while reading that article, I want to quarantine my kids for life.

Lately, COVID-19 and its impact on pregnancy has been in the news. From studies on how the coronavirus affects the placenta, to research into the link between COVID-19 and stillbirths, to maternal health during this pandemic, there’s so much information to digest. It can be overwhelming.

If I’m honest, I seem to take this on as a hobby. I read the articles. I try to read the studies.  But I am not a doctor. I’m not a scientist. Reading medical journals makes me feel like I’m reading a foreign language. I think I understand, but I’m not entirely certain I’m getting it. Still, I want to understand what this all means for me, my family, and my fellow pregnant and parenting after loss mamas.

We at PALS assume many of you are doing the same. Because of that, I sat down with Dr. Kristen Sharp, the obstetrician and fellow loss mom who founded the Hope After Loss Clinic in Madison, Wisconsin, to discuss COVID-19 and pregnancy, the impact of these new studies on miscarriage and stillbirths, and to find out just how concerned we should be about this disease affecting our pregnancies. We want you to have an accurate picture of what you’re facing – whether you’re currently pregnant, trying to conceive, or thinking about trying to conceive – based on what the medical community and science is telling us they know right now.

The following is a transcript of my conversation with Dr. Sharp.

Rebecca Markert (RM): Tell us about medical research studies – the majority of us are not doctors, not medical researchers or scientists, and get news from things like blogs, newspapers, and tv. Many studies seem to be written in a different language. Can you explain the process of medical studies to us laypeople?

Dr. Kristen Sharp (KS): The caveat with all of this is it is an evolving situation. It’s a constantly moving target. The information we have one week or one month may be different than what we have the next month. We’ve only been living with coronavirus for six months if you include the initial Chinese experience in December. Six months of data is really nothing – or a very minimal time frame – in the scheme of how typical research studies are done. That’s why you hear so many different things about what’s going on.

The research that has been done, that’s been primarily out there so far is a lot of observational studies. Just making observations of how women are doing with the virus, what is the transmissibility of the virus – is it transmissible in utero or post-birth? They’re looking at amniotic fluid samples, vaginal swabs, things like that to see if there’s evidence of the virus there. That’s really the bulk of the studies that have been done or published so far.

From what I can say from a preliminary, evolving situation, it doesn’t appear fetuses are infected in utero from what they can see so far. But there are some mixed results from that too.

What we can also say is that the majority of women who contract COVID are doing okay. Any viral illness, or any major bacterial illness, in pregnant women may pose a higher likelihood they’ll get more sick from that.  So pregnant women, for example, with the normal seasonal flu are in a high-risk group who can end up in the ICU.  Even though it’s a low likelihood that you would get seriously ill, in pregnancy it is still higher than if you were not pregnant.

We’re seeing similar effects of COVID with pregnant women. We know that pregnant women are at risk for more severe illness with COVID than nonpregnant women. But that being said, the vast majority of pregnant women who contract COVID will do okay. Some may be very minimally symptomatic, asymptomatic, it’s really a mix.

What I’ve been telling patients is just try to protect yourself as much as possible. Wear masks. Limit social exposures. All of those things.

But it’s not so desperate that the recommendation is to hole up in your home for the remainder of this, don’t go out at all; we are not at that point. Certainly, there may be some women at higher risk because maybe they have really bad asthma or have other major underlying health conditions, so there’s a lot of variability.

So that’s what we know so far about COVID and pregnancy.  There really aren’t any formal guidelines in place that once you have a woman who’s had COVID and recovered you need to do additional monitoring of her and baby. Again, this is still evolving.

In terms of some of the stillbirth data, in particular, the study that was linked on the Star Legacy Foundation Facebook page, I think it brings up a really interesting point or interesting question that needs to be looked at further on a larger scale: “is stillbirth increasing in the setting of this?” From that particular study, it didn’t look like there was any effect of COVID, but is COVID causing so much disruption of our routine care and routine practices, people’s comfort level of going into the hospital if there’s a concern, things like that. We just need more data to be able to say that. The study that was attached to that website was a single study, a short time period, so it’s really hard to make really generalized conclusions from that study alone. But again, I think it does point the need to look at this further.

I think what also is challenging with questions that were raised in the study is that there’ve been so much variability about the care people have gotten. Some practices shut down completely. Other practices continued with prenatal care and everything as normal and routine. Many in between did some variation of that. So there’s so much heterogeneity between medical institutions, states, countries, even just practices in the same community of how they have really handled prenatal obstetric care in the setting of all of this. So that makes it really challenging.

RM: When patients come to you with these studies, what do you tell them to keep in mind about the studies?

KS: I would say it’s a really narrow time frame and most of these studies are single institution, observational studies. The gold standard with research is to do double-blind, placebo-controlled trial. Obviously, you cannot do that with COVID and pregnant people. You can’t infect one pregnant women with COVID and the other not.

Observational studies get stronger with the more people you have in them and the longer time frame you have. When you have such a short time frame and overall a smaller pool of people you’re looking at, you can get a lot of confounding factors there.

The optimistic side of this is that there is a lot of people looking at this. As this evolves, we’ll have more and more data.

RM: Are you aware of any studies that show that the rate of miscarriage (and here I’m defining that as a first-trimester loss) because of coronavirus?

KS: I have not seen any studies that have shown that yet. Most of the studies that came out with the observational data about COVID have been people who’ve been infected in the second and third trimesters. So now that we’re a good six months in, I think there’s going to be more data coming out about what this looks like in early pregnancy. When you think about this, when it all began the people who were obviously pregnant, knew they were pregnant, or already established with a health care provider, those people were already a little bit further along in pregnancy than someone who didn’t know they were pregnant or very early in pregnancy and got infected with COVID so you have a little bit more of a lag time knowing what the outcomes are for those women.  If you think about it, someone who got pregnant in January is still pregnant right now. Their pregnancy isn’t completed, so if they had a COVID infection early on, we’re not seeing the full scope of the pregnancy to see how things are doing.  Again, I would not anticipate there would be some developmental effects for the baby because we similarly don’t see that with the flu or other respiratory viral illnesses. We’ll get more and more data each and every month.

RM: The scariest news for parents expecting again after loss are the reports that there’s an uptick in stillbirths during this pandemic.

No one wants lightning to strike twice. A baby dying again is, for some, the biggest fear. There are two studies that I’ve read about indicating there’s an increase – PHS – Scotland data shows increase in stillbirths; JAMA published a research letter – hospital in the UK shows increase in stillbirths. You answered this earlier, but again what can you tell us about these studies; what do they say; and is there a reason to be concerned? Is there anything you want to add?

KS: The other limitation with some of these studies is that I don’t know what care looked like at those places when this was all happening. I don’t know how they adjusted their prenatal visits. Also, too, the schedule of prenatal visits in the UK and Scotland is actually quite different than it is here in the US. There are so many variables at play that I don’t have a good grasp of whether this is truly stillbirth related to the COVID response or the COVID epidemic in general. What are those underlying causes? Or is this just the statistical uptick. In the Scotland study, they included a graph or table of their stillbirth rates and while it seemed like it did go up in this three-month block at the beginning of the year, it still was within the parameter. In January of 2017, they had a similar stillbirth rate. I just don’t know. It’s too soon to tell. But it raises the need for more research to be looking at this.

RM: There is a lot of anecdotal “evidence” out there.

At the very beginning of this in the US, I remember someone saying in the Northwest, like nearer to the Seattle outbreak, midwives are talking about how many more stillbirths they’ve seen. Even just here in Madison, our local support group has seen more late-term stillbirths; more so than in previous years. I don’t know what to make of that. Whether it’s coronavirus, or if that’s just the wave. In 2010, when I joined the group, it seemed like everyone had a second-trimester loss. Then suddenly there were infant losses. It feels like sometimes that’s just the wave of things.

KS: It’s hard to know. What would be interesting would be to look at each individual loss and see if there was an attributable underlying cause that we can flush out. Was it because you got a growth-restricted baby in this one or was it a placental abruption? You would need to look at those individual things. I think it definitely warrants a deeper dive into the data to figure out if there’s something going on.

RM: If there is a second or third-trimester loss right now, would they do testing to determine if coronavirus was present?

KS: That’s a good question. Anyone admitted to the hospital would get a COVID test to see if they are actively shedding COVID – that’s just hospital policy. In terms of stillbirth evaluation, to my knowledge, COVID antibody testing has not been included in that. In those routine tests that we give for every stillbirth to evaluate a cause especially a stillbirth when it’s unclear what the inciting event was. So I don’t think COVID antibody testing has been included in that to date.

RM: So that’s what they would do, they would test for the antibody?

KS: That would be able to tell if you had a previous infection. The nasal swab shows if you’re actively shedding the virus. An antibody test would show if you had an infection in the past.

RM: There also have been stories recently about fetuses contracting coronavirus through the placenta.

I also read about a study from Northwestern that indicated coronavirus can injure the placenta in women who’ve contracted COVID-19. Can you tell us anything about the coronavirus and the health of the placenta? Is there an increased risk for miscarriage and stillbirth because of that?

KS: I read that study. It was really interesting. I was waiting to see if that would change post-infection recommendations. Are they going to say we need to be doing growth ultrasounds on these babies. Or antenatal testing on these babies. There hasn’t been any recommendation change yet in response to that.  But I think that these are things that ACOG and other governing bodies of practice are looking at to see if we need to be doing monitoring afterwards.

RM: You mentioned this before as well, but the CDC released a study last month saying that pregnant women were more likely to get severely ill from COVID-19 than their nonpregnant counterparts. Are you familiar with that study and do you have any thoughts on that?

KS: I always compare it to the flu. And I don’t want to misstate that for saying it’s just like the flu where people get as sick as you do with the flu. Certainly, there is a higher risk of getting significantly ill or death with COVID versus the flu. But, how I think about it in terms of counseling patients in my mind is that I’ve counseled patients for years you should get the flu shot because flu in pregnancy is a different beast than when you’re not pregnant. Most pregnant women will do fine with the flu. But pregnant women are more likely to end up in the ICU or die of the flu. We had two flu deaths in Dane County in 2013 of either pregnant or postpartum women. So people are at increased risk for those adverse outcomes versus if they weren’t pregnant. We know that pregnancy alters the immune system and makes people more susceptible to severe illness. So I look at COVID the same way even though the severity of that illness has the potential to be much more severe than the flu. But if a pregnant woman contracts COVID, she most likely will do fine. But she is at higher risk for being significantly ill versus if she had COVID a year prior when she wasn’t pregnant.

So that’s how I’ve been thinking about that is thinking about that risk of severe illness similarly to any other respiratory illness a pregnant woman can get.

RM: PALS support group covers people who are currently pregnant, people who’ve had their babies, but also people who are trying to conceive.

I would say probably once a week there is someone who posts, “I’m thinking of getting pregnant again. Is this crazy to do right now in the middle of a global pandemic?”  If you have a patient who comes and says this, what are you counseling?

KS: I don’t think there’s a right or wrong answer to that. There are certainly factors that may turn somebody’s hand to not want to wait versus wait. The hard part about this is we don’t have an end in sight right now. So what does that look like for building your family? Is that something that waiting a year, eighteen months, two years, works for you? Or does that sound way too long and you want to start now?

From our experience so far, I would tell the vast majority of women it is probably okay to go ahead and get pregnant. There may be people who have severe underlying respiratory disease or other medical risk factors that we would say maybe this isn’t the best time for you. But, in general, I wouldn’t say, “Absolutely don’t try to get pregnant.”

We really, as a medical system, prioritized obstetric care to continue so even in the height of the shut down our institution, and most institutions, really prioritized OB care, so I wouldn’t expect major disruption to that. But again, it’s a really personal decision. If this were something where 10% of women were dying from COVID, which is not the case, but if there were some statistics like that, I would say maybe not. But, from what we have seen, I would say it’s probably okay for most people.

But again it all depends on what their family situation looks like. This is a time where maybe help that would come in to help with the baby may not be possible in the midst of all this. So I think taking all that–medical, social, emotional factors–into play and making the best decision for yourself is important.

RM: I really think the outside help that is the biggest factor for me.

When I think about what things will look like if one of us gets sick, and who can help, that’s the thing that probably keeps me at home most of the time, wearing a mask, social distancing, and all that, just because I don’t have help. So if one or both of us go down, I don’t know what to do.

KS: That’s a huge thing. I’ve had people say to me who are ready to deliver or have recently delivered, “Holy cow if I knew this was going to be the case, I would have waited because my mom who was going to come in can’t anymore, or she’s high risk medically.” There’s just so many of those factors that I think really get overlooked with a lot of the data. The data focuses a lot on the medical/clinical side of things, but I think the social disruption, the support disruption is pretty huge.

RM: The final question: what do you recommend a pregnant woman do to keep herself and her growing baby safe during this pandemic?

KS: That’s a really good question. I would say to do whatever you can to minimize the chance of infection. Wear a mask. Socially isolate when appropriate or when you’re able to. Really take all of those precautions. And additionally, I would have an open dialogue with your health care provider. If you’re someone who’s becoming pregnant and thinking about establishing yourself with someone. Call around to different practices and see what they’re doing with their prenatal care. Really just have an open dialogue with your provider and advocate for yourself to get the care that you need. Especially for PAL moms who maybe need some of that extra visits or touchpoints with their provider.

Don’t be afraid of going into the medical system if you need something. If you are feeling like your baby’s movements are off, having a hesitancy to call or to get checked because of a concern for COVID, I would say that health care institutions and hospitals are making every effort they can to minimize risks of infection there. I wouldn’t want the fear of contracting COVID to ever be a barrier for somebody going in and getting the care that they need, or getting the check in they need, or going to their antenatal testing appointments.

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Please note that Dr. Sharp’s answers and recommendations in this article are not a substitute for medical advice from your own obstetrician or midwife. Your care provider is most familiar with your personal situation, your region’s response to COVID-19, and is best equipped to answer your specific questions and address your concerns. These questions and answers are intended for informational purposes only. Please do not use this article as a substitute for medical advice, diagnosis, or treatment.

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