PREGNANCY AND COVID-19 . Pregnant women, beware of Covid-19

* Doctors stress that pregnant women need to be extra careful in these Covid-19 times.

* Tamil Nadu’s state health department reported twice the number of deaths of pregnant women in April-May as compared to March-December

* Doctors in some states have urged the government to speed up the vaccination process, and also allow pregnant women to get vaccinated

* Several medicines prescribed by physicians in Covid-19 are not recommended for pregnant women.

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Her last words tugged at every viewer’s heartstrings. “I am an active person, but my body is giving up,” Delhi-based Dr Dimple Arora Chawla said in Hindi in a video that was shared widely on social media. She was seven months pregnant when she tested positive for Covid-19 on April 11. She died on April 26 after losing her still-to-be-born baby on April 25.

She had trouble breathing, she said in the video, but wanted to leave behind a message. Wear a mask, Dr Arora Chawla said. “I am speaking with great difficulty. For your near and dear ones’ safety, please take care, for you might have pregnant women, elderly and children at home.”

Covid-19, the world has known from the first phase of the infection that spread last year, is especially dangerous for people with diseases such as diabetes or hypertension. In the second surge this summer, it became clear that the young were being severely affected by the infection. But a vulnerable group that has largely gone under the radar is that of pregnant women. Doctors now stress that pregnant women need to be extra careful in these Covid-19 times.

India has 25 million children born every year, and its maternal mortality rate recently saw a steep decline — dipping in 2018 to 113 per 100,000 deaths from double the figure a decade ago. Covid-19, however, has shaken the maternal healthcare system. In the first wave, women suffered due to lack of access to timely healthcare; this time around, Covid-19 is seen as a major risk factor leading to hospitalisation and invasive ventilation — and often death.

Tamil Nadu’s state health department reported twice the number of deaths of pregnant women in April-May as compared to March-December. Doctors in Tamil Nadu and some other states have urged the government to speed up the vaccination process, and allow pregnant women to also get vaccinated. Currently, the Indian government does not recommend vaccination for pregnant women although globally many countries do.

However, severe cases of Covid-19 are on the rise as reported from different states. Dr Aparna Hegde, urogynaecologist at Cama Hospital, Mumbai, says doctors have seen many more cases of Covid-19 in recent months. “It can be put down to the virulent strain called B.1.617 that has hit the second wave. We are seeing more women who need to be hospitalised as well as need oxygen support in this wave.”

Many pregnant women are not aware of the dangers of Covid-19. But Priyanka Robinson, a primary school teacher in Udaipur, knew she was going down with the disease when her son, complaining of a throat ache, clung to her and cried for hours. Soon, she had a high fever.

“After my fever went, I felt a heaviness in my chest for the next couple of days. At first I was unable to understand what was happening to me. Then it hit me — I couldn’t breathe. I told my husband we must rush to the hospital — I think I am going to die if we stay here.”

When she was admitted to the hospital her lungs were working at 60 per cent of their capacity. She was in the Intensive Care Unit for 12 days before her condition started to improve. “Even after I recovered, I was so weak. Thankfully, I got a really healthy diet in the recovery period, and that is the sole reason I feel that I have survived the disease,” Robinson says.

Double dilemma

Pregnant women are faced with a dilemma when it comes to the treatment of Covid-19. Several medicines prescribed by physicians in Covid-19 are not recommended for pregnant women. Even a CT scan, used to see the extent of damage in the lungs, is not advised because of radiation that may hurt the foetus.

“Steroids such as Methylprednisolone which are recommended in moderate cases of Covid-19 are not recommended in pregnant women,” says Dr Meenal Chugh, a practising obstetrician and gynaecologist in Rajasthan. According to some studies, steroids may lead to premature deliveries or congenital abnormalities and is classified as a Class D drug.

Stressed out: Many of the medicines prescribed to Covid-19 patients cannot be given to pregnant women

The other problem, she adds, is that the maximum stress on cardio-respiratory system is at around 32 weeks. “The diaphragm is also pushed up as the baby grows in the womb, reducing vital capacity of the lungs,” Dr Chugh says.

Special care

Doctors stress the need for special care to tackle this virulent strain. Dr Hegde points out that the circumstances of the first and second wave are vastly different. “While in the first wave we saw deaths as a result of a lack of access to the hospital, with sudden lockdowns and disruption of public transport, we didn’t hear of women dying because of a pregnancy-related emergency... This time around, it was the fast spreading mutant that caused havoc. Hospitals were overwhelmed. By the time people were reaching the hospital it was often too late.”

Maternal mortality figures have climbed up ever since the second wave hit home, though there are no official figures yet, and doctors say it is still too early to determine its full impact. But deliveries might affect a severe Covid-19 patient’s chances of survival as it strains their cardio-respiratory system. And unlike in other patients, the doctors reiterate, many of the drugs cannot be given to pregnant women for the harm that they might do to the foetus. Further, unlike the fairly regimented medicine courses for Covid-19 patients, there are no such guidelines for pregnant women.

“Many drugs such as Remdesivir, Favipiravir and steroids such as Methylprednisolone can’t be given to pregnant women, especially those in the first trimester as organogenesis (development of organs) of the foetus happens in the first trimester (initial 12 weeks) of the pregnancy.” Dr Chugh points out.

Indeed, the effect of Covid-19 on pregnant women and foetuses is still largely unknown. Some countries such as Brazil have asked women to delay pregnancies if possible because of concerns over the impact of the new coronavirus variant. The US Centre for Disease Control and Prevention (CDC) and American College of Gynaecologists and Obstetricians (ACOG) have listed Covid-19 as a potential risk factor and concluded that pregnant women were at an increased risk by 70 per cent of dying of Covid-19.

Dr Chugh explains why. “Pregnant women are in an immunocompromised state due to the nature of their condition. Pregnancy suppresses the immune system for the welfare of the foetus, allowing it to grow in the mother’s womb. This makes them at risk for contracting several diseases and Covid-19 isn’t different.”

Several countries have already pushed for prioritisation of vaccination for pregnant women, citing that the Covid-19 vaccines have no known side-effects on pregnancy. In India, it is still not permitted by the Central government. However, Dr Chugh says, “Pregnant women already receive flu vaccines which help both the mother and the baby. Since we aren’t administering a live vaccine to pregnant women, pregnant women may go ahead with vaccination.”

The Federation of Gynaecologists and Obstetricians in India (FOGSI) put out a statement last week regarding the vaccination of pregnant and breastfeeding women. It acknowledged that pregnant women were at a higher risk of complications if they contracted Covid-19. “...compared to non-pregnant women and pregnant women who are not infected with COVID-19, pregnant women who are infected with COVID are more likely to need hospitalization, critical care and (face) mortality. This checks out with data coming in from different hospitals.”

FOGSI makes a case for the vaccination for pregnant women. “In pregnancy, there could be concerns regarding transmission of infection to the foetus if a woman is vaccinated in pregnancy with a live attenuated vaccine. There are no live attenuated vaccines in the market in India or globally. Therefore, there is no mechanism for such an event.”

Concerns about vaccinating pregnant women resulting in adverse occurrences such as miscarriage, pre-term births, stillbirths and congenital anomalies have also been negated. FOGSI quotes data from the US based V-Safe registry (a vaccine-related app launched by the CDC) in this regard. “There is no increase in maternal side effects with vaccine administration in pregnancy as compared to non-pregnant women. Women who have delivered after receiving the vaccine in pregnancy do not show any increased risk of the above-mentioned events.”

Going online

Apart from vaccination, many doctors now advise pregnant women to opt for virtual consultations whenever possible, as pregnancy requires regular checkups.

Dr Hegde of Cama Hospital has founded an organisation called Armman, which has been running a virtual OPD for pregnant women in the Covid-19 pandemic. “Maternal health was adversely affected due to lack of access to healthcare services in the pandemic which led to a lot of adverse outcomes that could have been prevented in normal circumstances.”

Armman has tied up with 15 state governments to provide virtual OPD services and regular checkups to rural women who can opt to receive information via text messages and scheduled teleconsultations. The organisation also runs a helpline on which women could dial in to talk to a doctor with or without concerns regarding Covid-19 infection. Armman’s pan-India free virtual OPD (clinic) has provided over 14,000 pregnant women and children with free consultations with obstetricians and paediatricians via a toll-free number. Other interventions include training healthcare workers in rural and urban India — ASHA workers and ANM (Auxiliary Nursing Midwives) on Covid-19 protocols, as they are the point of contact in most villages for pregnant women.

Dr Hegde states that the situation is much worse in rural India because of lack of access to healthcare. “The problem is that they might or might not have sufficient oxygen cylinders at the village primary health centre. If they do, the staff might or might not be equipped to operate it. Since timely intervention is crucial to stop the spread of the disease and rescue a person, it is important that healthcare workers understand when to contact the chief medical officer, and how to manage symptoms for those who have a mild version of it.

Armman also sent critical information through calls/text messages to 800,000 health workers, in partnership with the government. “Through our large database, we also use AI to better help keep track of all the pregnant women who seek help from us, and ensure that they get tailored information that would be of help to them,” she adds.

Missing figures

There is no official database yet that keeps track of pregnant women who have died of Covid-19 related complications.

Even though FOGSI has recommended the vaccine for pregnant women in view of the complications, the government has played it safe and has not recommended it for the subset as of now, even though in countries such as Israel and the US, the vaccine has been taken by large sections of pregnant women, reportedly with no side effects.

Brazil banned Covishield for pregnant women after a woman died soon after taking the shot. No studies have been conducted on pregnant women taking Covishield and Covaxin yet, the two vaccines available in India.

Yashasvi Singhvi, an employee with the Delhi branch of a private bank, says she had mixed feelings about the news when she heard in March that she was pregnant. “While I’m elated about the news itself, I feel under-confident about remaining safe in the pandemic, given the situation. There is so much uncertainty all around, and I wish to get vaccinated as soon as possible. Even my doctor thinks that it would be best if it were opened up for pregnant women as soon as possible.”

Robinson feels that her case definitely got more complicated because of lack of specific guidelines on how to treat Covid-19 patients who are pregnant. “Ultimately, my doctor put a lens shield over my abdomen before conducting a CT scan to find out how severely my lungs were damaged even though CT scans are not recommended in pregnancy,” she says.

“Having survived Covid-19, I would recommend each pregnant woman to get help as soon as possible. It is better to get help earlier than later, as proved true in my case. It is important to ensure that the doctor you consult is not just a gynaecologist but also someone who has experience handling Covid-19 patients.”

The Udaipur teacher knows of pregnant women who were put on the ventilator and succumbed to the virus. “I am lucky to be alive,” says Robinson. As is the baby she is carrying.

Payel Majumdar Upreti