COVID-19 is caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Based on several studies, the epidemiology, virology, transmission, and symptoms and signs of COVID-19 in pregnant women are similar to those in nonpregnant patients. Data from the Centers for Disease Control and Prevention (CDC) and other publications indicate an increased risk of intensive care unit admission, mechanical ventilation, and death in pregnant patients with symptomatic COVID-19, particularly in those with underlying health conditions such as diabetes and cardiovascular disease (1). However, the overall risk of severe illness and death due to COVID-19 remains low for pregnant women.
Risk of obstetric complications (eg, preterm labor, preterm birth, preeclampsia, cesarean delivery, stillbirth) is increased in patients with moderate and severe infection (usually including pneumonia) (2, 3, 4).
Vertical transmission appears to be infrequent, with studies reporting rates from 0 to 3.6% (5, 6).
(See also Infectious Disease in Pregnancy.)
General references
1. Khan DSA, Pirzada AN, Ali A, et al: The Differences in Clinical Presentation, Management, and Prognosis of Laboratory-Confirmed COVID-19 between Pregnant and Non-Pregnant Women: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health18(11):5613, 2021. doi:10.3390/ijerph18115613
2. Metz TD, Clifton RG, Hughes BL, et al: Association of SARS-CoV-2 Infection With Serious Maternal Morbidity and Mortality From Obstetric Complications. JAMA 327(8):748-759, 2022. doi:10.1001/jama.2022.1190
3. Lyu T, Liang C, Liu J, et al: Risk for stillbirth among pregnant individuals with SARS-CoV-2 infection varied by gestational age [published online ahead of print, 2023 Feb 28]. Am J Obstet Gynecol S0002-9378(23)00132-1, 2023. doi:10.1016/j.ajog.2023.02.022
4. DeSisto CL, Wallace B, Simeone RM, et al: Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization — United States, March 2020–September 2021. MMWR Morb Mortal Wkly Rep 70:1640–1645, 2021. DOI: http://dx.doi.org/10.15585/mmwr.mm7047e1external icon.
5. Olsen EO, Roth NM, Aveni K, et al: SARS-CoV-2 infections among neonates born to pregnant people with SARS-CoV-2 infection: Maternal, pregnancy and birth characteristics. Paediatr Perinat Epidemiol 36(4):476-484, 2022. doi:10.1111/ppe.12883
6. Musa SS, Bello UM, Zhao S, et al: Vertical Transmission of SARS-CoV-2: A Systematic Review of Systematic Reviews. Viruses 13(9):1877, 2021. doi:10.3390/v13091877
Diagnosis of COVID-19 During Pregnancy
Real-time reverse transcriptase–polymerase chain reaction (RT-PCR) or other nucleic acid amplification test (NAAT) of upper and lower respiratory secretions
Antigen testing of upper respiratory secretions
Diagnosis of COVID-19 is the same in pregnant and nonpregnant patients. (See also Centers for Disease Control and Prevention (CDC): Overview of Testing for SARS-CoV-2, the virus that causes COVID-19.)
Chest x-ray and/or CT, if indicated, may be done because the fetal radiation doses are low.
Treatment of COVID-19 During Pregnancy
Supportive
General medical treatment for COVID-191).
Oxygen saturation should be kept > 95% or a PaO2 of > 70 mm Hg.
Management of symptomatic hospitalized pregnant patients with COVID-19 should involve a multidisciplinary team, including respiratory or infectious disease specialists as needed.
Treatment reference
1. Garneau WM, Jones-Beatty K, Ufua MO, et al: Analysis of Clinical Outcomes of Pregnant Patients Treated With Nirmatrelvir and Ritonavir for Acute SARS-CoV-2 Infection. JAMA Netw Open 5(11):e2244141, 2022. doi:10.1001/jamanetworkopen.2022.44141
Prevention of COVID-19 During Pregnancy
Pregnant women should follow general good-health practices to avoid exposure to infections, including regular handwashing and avoiding other people with contagious infections, if possible.
COVID-19 vaccine
The Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) recommend COVID-19 vaccination for all eligible people who are pregnant, breastfeeding, trying to get pregnant, or who might become pregnant in the future (see CDC: COVID-19 Vaccines While Pregnant or Breastfeeding and ACOG: COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care). Evidence supports the safety and effectiveness of COVID-19 vaccination during pregnancy (1). These data suggest that the benefits of receiving a COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy.
A National Institutes of Health (NIH)-supported study found that when a pregnant person has antibodies against SARS-CoV-2 after being vaccinated or having COVID-19, those antibodies may be transferred to the infant through breast milk (2). The antibodies help infants gain immunity that can protect them from COVID-19.
Breastfeeding
Risk of transmitting the virus in breast milk is low or absent. If a woman with known SARS-CoV-2 infection chooses to breastfeed directly, she should wear a face mask and maintain proper hand hygiene. If bottle feeding breast milk, the woman should put on a mask and thoroughly wash hands and any pump parts, bottles, and artificial nipples prior to expressing milk (3).
Prevention references
1. Ciapponi A, Berrueta M, P K Parker E, et al: Safety of COVID-19 vaccines during pregnancy: A systematic review and meta-analysis. Vaccine 41(25):3688-3700, 2023. doi:10.1016/j.vaccine.2023.03.038
2. Gray KJ, Bordt EA, Atyeo C, et al: Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol 225(3):303.e1-303.e17, 2021. doi:10.1016/j.ajog.2021.03.023
3. American Academy of Pediatrics (AAP): Post-Hospital Discharge Guidance for Breastfeeding Parents or Newborn Infants With Suspected or Confirmed SARS-CoV-2 Infection. Last updated August 2, 2022.
Key Points
Manifestations, diagnosis, and treatment of COVID-19 are similar in pregnant and nonpregnant patients.
Risks of obstetric complications are increased.
Vertical transmission is rare, and transmission in breast milk is unlikely.
Counsel pregnant women about COVID-19 vaccination.
