One of the major concerns in light of the coronavirus disease 2019 (COVID-19) pandemic is the prevention and control of the infection in pregnant women. Although a small number of cases have been analyzed and more follow-up studies are needed, pregnant women are likely to be more susceptible to COVID-19, especially if they have chronic diseases.1
In addition to individuals aged ≥65 years and patients with chronic conditions, such as diabetes or kidney disease, pregnant women with rheumatic diseases may have a risk of developing serious cases of COVID-19.2 Overall, pregnant women with rheumatic diseases have to be closely monitored because of the increased risk for both maternal complications and adverse neonatal outcomes.3
To get more insight into the risk for infection, preventive strategies, and effects of COVID-19 in pregnant women with rheumatic diseases, we spoke with Jane E Salmon, MD, rheumatologist at the Hospital for Special Surgery, New York City, New York.
Pregnant women with rheumatic diseases may have compromised immune systems because of the medications that they receive. What is known about the risk and severity of COVID-19 infection in this patient population, and can the infection be transmitted to the fetus?
Patients with rheumatic conditions, including lupus, rheumatoid arthritis, scleroderma, myositis, and vasculitis, may be at greater risk of developing many infections and tend to have more severe symptoms. While we do not have significant data on [severe acute respiratory syndrome coronavirus 2] (SARS-CoV-2) yet, we can assume that the same may be true in the case of this virus. A global registry to study this question has been established. The increased risk may be the result of the disease or the immunosuppressive medications used to treat [patients with rheumatic diseases]. Pregnant women might also be more vulnerable, although there is no specific information on this yet.
At this time, little is known about the effects of COVID-19 in pregnant women and infants, and there are currently no recommendations specific to pregnant women regarding its evaluation or management. Because pregnant women are known to be at greater risk for severe illness from other respiratory infections, such as influenza, they should be considered an at-risk population for infection with SARS-CoV-2.
We do not know what, if any, risk is posed to infants of pregnant women who have COVID-19. There have been a small number of reported problems with pregnancy or delivery (eg, preterm birth) in babies born to mothers who tested positive for COVID-19 during their pregnancy; however, it is not clear whether these outcomes are related to maternal infection.4 We also do not know if COVID-19 can cross the placenta; in the limited number of studies performed, few infants born to mothers infected with COVID-19 have tested positive for the disease, and none had malformations or serious consequences.5
What measures can clinicians take to minimize this risk? How can these patients safely be screened?
Clinicians can strongly encourage patients to adhere to local and Centers for Disease Control and Prevention (CDC) recommendations.6 Testing guidelines vary by region and are changing too rapidly to be able to comment on them. Because women going into labor may have symptoms including fatigue, shortness of breath, and diarrhea, which mimic COVID-19, some institutions are testing these individuals to protect other mothers, babies, and hospital staff.
What specific guidance can clinicians give pregnant women with rheumatic diseases to alleviate their fear of contracting the infection?
[Clinicians can advise] patients to practice the following to protect themselves against the virus:
- Avoid contact with people who are sick.
- Wash your hands often with soap and water for at least 20 seconds, covering every surface of your hands and under your fingernails.
- Use an alcohol-based hand sanitizer when soap and water are not available.
- Don’t touch your eyes, nose, or mouth with unwashed hands.
- Practice good respiratory hygiene by coughing or sneezing into a tissue and then immediately disposing of it, or if this is not possible, sneeze or cough into the crook of your arm. Clean your hands afterward.
- Clean and disinfect areas that you and other people touch often.
- There is no need to wear a face mask unless you have developed symptoms of the infection. The CDC does not recommend that healthy people wear face masks for protection.
Guidelines provided by local and state governments recommend social distancing and, in some states, sheltering-in-place (remaining at home). We strongly advise that patients with rheumatic disease remain at home and work from home, if possible. If patients must leave home, they need to avoid public transportation, crowded areas, and large gatherings, as mandated by the CDC and state governments.
What is known about COVID-19 risk in women with rheumatic diseases who are breastfeeding? What is the risk for their newborns?
Advice for women who are breastfeeding and have COVID-19 and rheumatic disease should be no different than that for healthy women. The infection is thought to spread from person to person through respiratory droplets (sneezing and coughing). Other coronaviruses have not been detected in breast milk, but we do not know whether mothers with COVID-19 can transmit the virus through breast milk.
According to guidance by the CDC, “Breast milk is the best source of nutrition for most infants. However, much is unknown about COVID-19. Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and healthcare providers. A mother with confirmed COVID-19 or who is a symptomatic person under investigation because of exposure should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while breastfeeding the infant. If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use. If possible, consider having someone who is well feed the expressed breast milk to the infant.”4
Disclosures: Dr Jane E Salmon is currently leading a clinical trial in lupus supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and UCB, Inc.
1. Qiao J. What are the risks of COVID-19 infection in pregnant women? Lancet. 2020;395(1022):760-762.
2. Hospital for Special Surgery. What to know about rheumatic disease and the COVID-19 coronavirus. Accessed March 24, 2020. https://www.hss.edu/conditions_rheumatic-disease-and-COVID-19-coronavirus.asp
3. Sugawara E, Kato M, Fujieda Y, et al. Pregnancy outcomes in women with rheumatic diseases: a real-world observational study in Japan. Lupus. 2019;28(12):1407-1416.
4. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): pregnancy & breastfeeding. Updated March 17, 2020. Accessed March 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html
5. Chen H, Guo J, Wang, C et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395:809-815.
6. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): how to protect yourself. Updated March 18, 2020. Accessed March 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html