How does COVID-19 affect pregnancy?

Summary

The following is a summary of evidence sources that provide high quality information on the impact of COVID-19 on pregnancy including guidance for health care professionals. For additional information about each of the sources, see the Table below.

The authors of two reviews, two guidance documents (from the United Kingdom and Canada), and one study all state that there have been no conclusively documented cases of vertical transmission from mother to infant, however suggests that mothers with COVID-19 should have their infants tested for the virus. [1,2,3,9] Three systematic reviews found an increased risk of obstetric complications documented in COVID-19 patients, which may include spontaneous prematurity resulting in preterm caesarean delivery, low birth weight and perinatal death. [1,3,4,5] 
  
The Centers for Disease Control and Prevention (CDC) in the United States, the Society of Obstetricians and Gynaecologists of Canada (SOCG) in the UK, and Health Canada advise that universal isolation of infants from mothers with suspected or confirmed COVID-19 is not indicated, but can be done according to the patient’s values and resources. [6,9] The CDC states that it is unknown whether mothers with COVID-19 can transmit the virus via breast milk, but the limited data available suggest this is not likely. [3,5,6] Health Canada, the CDC, and one review note that breastfeeding is safe if hand hygiene is followed and a face mask is worn by the mother. [2,5,6] In its Updated Committee Opinion – COVID-19 in Pregnancy, the SOGC recommended that elective caesarean sections should be postponed until the patient is not infectious. [9] 
  
Professional associations in the UK and Canada offer guidance on best practices for active health care professionals who are pregnant. According to the Royal College of Obstetricians and Gynaecologists (RCOG), in their guidance on Occupational Health Advice for Employers and Pregnant Women, they suggest that pregnancy does not impact the likelihood of health care professionals contracting a COVID-19 infection, but if infected, they may experience an increased severity of disease symptoms in the third trimester (i.e., more than 28 weeks). [8] In their SOGC Statement of Pregnant Workers during the COVID-19 Pandemic, the SOGC advises that pregnant women who work in essential industries and do not have COVID-19, can continue to work, but additional personal protective equipment (PPE) should be worn if they are in contact with people with suspected or confirmed COVID-19. [10] 
 
Health Canada and the CDC suggest that pregnant and postpartum women are at a higher risk of mental health issues due to COVID-19 social distancing measures, and that providers should share resources with their patients about coping with stress and isolation during the pandemic. [5,6] Lastly, the CDC also recommends that mothers should attend all prenatal care appointments or postpartum appointments even while social distancing measures are still in place. [7] 

Evidence

What‘s Trending on Social Media and Media

In China, a study assessing information needs of pregnant women found that more than 75% of pregnant women who responded to the survey reported using prenatal care information on hospital’s WeChat and Weibo social media accounts. Access to care through these media platforms significantly lowered the risk of stress, anxiety and depression in expecting mothers.
 
A Twitter review reflects a focus on mental well-being tips for expecting mothers during quarantine.
 
According to Google Search Analytics, interest in this topic peaked in Canada from March 15-21.

Organizational Scan

Several hospitals across Ontario (i.e., the Ottawa Hospital, North York General Hospital, Grand River Hospital) have policies that allow a single designated visitor to support pregnant patients going into labour. The designated support person must be identified by the hospital and cleared (i.e., deemed healthy) before entering the hospital. Further, the designated support person cannot change during the patient’s hospital stay. [11] [12] [13] 
 
Toronto’s Mount Sinai Hospital has developed an algorithm of Suspected/Confirmed COVID-19 Infection in Pregnancy to assist in outpatient settings. The algorithm aids in assessing when pregnant patients will require inpatient management. [14] 
 

Review of Evidence

Resource	Type/Source of Evidence	Last Updated
A systematic scoping review of COVID-19 during pregnancy and childbirth — Elshafeey et al.	Systematic Review	The review found that clinical presentation and severity of COVID-19 infection during pregnancy is like non-pregnant adults. In four infants with COVID-19, neither the amniotic fluid nor cord blood contained the virus, which is evidence against vertical transmission. Samples of breast milk from 26 women with COVID-19 tested negative for the virus. Last Updated: April 23, 2020
Maternal and perinatal outcomes with COVID-19: a systematic review of 108 pregnancies — Zaigham and Andersson	Systematic Review	The review found a possibility for more severe maternal morbidity and perinatal death with a COVID-19 infection during pregnancy.   One newborn tested positive 36 hours after birth despite isolation from mother. Therefore, even though maternal-fetal transmission was not detected in the majority of cases, the reviewers concluded it could not be completely ruled out. Last Updated: April 6, 2020
COVID-19 during pregnancy: a systematic review of reported cases — Della Gatta et al.	Systematic Review	The review found no evidence of vertical transmission of COVID-19 from mother to newborn.   There was a higher rate of preterm caesarean delivery in pregnant patients with COVID-19 infections. However, since these interventions are typically elective, it remains unclear if these interventions were warranted. A trend towards spontaneous prematurity is present. Last Updated: April 17, 2020
Maternal and neonatal outcomes associated with COVID-19 infection: A systematic review — Smith et al.	Systematic Review	The review found that the incidence of preterm births, low birth weight, C-section, NICU admission appear higher than the general population for pregnant women with COVID-19.   Last Updated: June 3, 2020
Pregnancy, childbirth and caring for newborns: Advice for mothers during COVID-19 — Health Canada	National Guidance	Health Canada advises that it is not necessary for mothers with COVID-19 to isolate from their baby, but they should wash hands frequently and wear a mask when in close contact. Breastfeeding should continue, as there is no evidence of COVID-19 being found in breast milk. This resource suggests that pregnant/postpartum women are at a higher risk of mental health issues and may not have access to the support and resources they normally would. Parents are encouraged to reach out to friends, family, community support and their healthcare providers to discuss their mental health.   Last Updated: May 31, 2020
Considerations for Inpatient Obstetric Healthcare Settings — CDC: Centers for Disease Control and Prevention	National Guidance	The CDC advises that deciding whether to separate a mother with known or suspected COVID-19 from her newborn should be done on a case-by-case basis depending on the clinical condition of the mother and newborn, testing results, desire to breastfeed, and ability to accommodate separation.     Data reported in the review suggests that breastmilk is likely not a form of transmission for COVID-19. Breastfeeding may occur for a mother with confirmed/suspected COVID-19, if the mother uses a face mask and practices safe hand hygiene.    Postpartum depression symptoms may worsen due to the COVID-19 social distancing measures. Providers should share more resources with patients about coping with stress and isolation during the pandemic.   Last Updated: May 19, 2020
If you are Pregnant, Breastfeeding or Caring for Young Children — CDC: Centers for Disease Control and Prevention	National Guidance	This report notes that pregnant women should attend all their prenatal care appointments or postpartum appointments. Pregnant women should get recommended vaccines like influenza vaccine due to symptom overlap and unknown interaction between COVID-19 and influenza. If patients are concerned about attending any appointments due to COVID-19, they should talk to their healthcare provider.     This report indicates that pregnant women may be at increased risk for severe illness from COVID-19. Newborns have tested positive for the virus, but period of transmission is unclear (before, during or after birth).   Last Updated: October 22, 2020
Occupational health advice for employers and pregnant women — RCOG: Royal College of Obstetricians and Gynaecologists	Professional Organization	The RCOG advises that women above 28 weeks' gestation should emphasize social distancing. While being pregnant does not increase the likelihood of contracting COVID-19, there may be increased risks of having more severe symptoms of the disease.   Last Updated: September 8, 2020
Updated SOGC Committee Opinion – COVID-19 in Pregnancy — SOGC: Society of Obstetricians and Gynaecologists of Canada	Professional Organization	The SOGC advises that elective caesarean sections that can be delayed should do so until the patient is not infectious. All mothers with COVID-19 should have their infants tested for COVID-19. Isolation of infants from mothers with suspected or confirmed COVID-19 is not indicated unless it is in line with the patient's values and resources. Last Updated: March 12, 2020
SOGC Statement of Pregnant Workers during the COVID-19 Pandemic — SOGC: Society of Obstetricians and Gynaecologists of Canada	Professional Organization	The SOGC advises that pregnant women without COVID-19 in essential industries can continue to work. If in contact with people with suspected or confirmed COVID-19, health care workers should use additional PPE. Last Updated: May 20, 2020
North York General Hospital Obstetrical Information — North York General Hospital	Organizational Scan	Last Updated: April 1, 2020
Visitor Restrictions and FACs during COVID-19 — Grand River Hospital	Organizational Scan	Last Updated: February 15, 2021
Patient & Visitor Restrictions at The Ottawa Hospital during the COVID-19 Pandemic — The Ottawa Hospital	Organizational Scan	Last Updated: July 30, 2020
Suspected or Confirmed COVID-19 Infection in Pregnancy — Mount Sinai Hospital	Organizational Scan	Last Updated: April 28, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.