COMMENTARY

COVID-19 and Pregnancy: Is Miscarriage a Risk?

Barbara Levy, MD, and Jane van Dis, MD

Disclosures

May 14, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Two experts discuss feedback from the field suggesting a risk for miscarriage in pregnant women with COVID-19, and they encourage colleagues to use a new registry for women who have, or are suspected of having, COVID-19.

Dr Barbara Levy

Barbara Levy, MD: We are living through unprecedented times. It's an amazing experience to be trying to practice women's healthcare right now. There are so many unknowns, and so much going on, creating a huge amount of anxiety among patients and healthcare providers. There's so much focus on the emergency departments and ICUs, but very little about labor and delivery and pregnancy — what to say and what to do and how to manage.

We've heard about how to manage women coming into labor and delivery who are COVID positive, but there is also a vast group of women who might be positive, or might not, but they have been exposed. That anxiety and our inability to answer questions is really harming healthcare for women. The lack of direction about the impact of the disease on pregnancy is something that Jane and I began a conversation about a couple of weeks ago.

Concern has been expressed about women at 36 weeks and beyond who have been exposed to SARS-CoV-2 and what that might mean for pregnancy, but we really haven't thought much about first and second trimesters. What's the potential impact on growing fetuses being exposed to this virus? The need for data is huge. The challenge that we've had with testing has made data acquisition really difficult.

Jane is a guru of social media, and I'm going to turn it over to her to talk about what she has been reading on various Facebook groups, and what that prompted us to do.

Dr Jane van Dis

Jane van Dis, MD: The anxiety that many practitioners feel is related to being asked some very specific questions by our patients about what COVID means for pregnancy. The answers that we've been able to provide in the first few weeks were based on studies coming out of China. Now we have some US data. We are offering guidance and advice based on case series with numbers less than 200 that are influenced by demographics, geography, and other factors. At times I'm taking the information that I have available and extrapolating it, but that doesn't always feel scientifically accurate. It actually feels a little bit scary as the person who is supposed to be an authority, and yet having minimal data to operate on.

I am an OB hospitalist, and I also co-administer a group of obstetrician-gynecologists on Facebook. There are over 4300 of us, and it's my favorite place on the internet. These are the people who get me, and to whom, hopefully, I provide support as well. I started to notice that there were conversations about miscarriages. Someone had started a thread about the fact that they were noticing increased numbers of first and second and even term intrauterine fetal demises.

I thought to myself (as I'm simultaneously reading in the mainstream COVID literature about the increased risk for micro- and macrothrombi) that the placenta is an organ that is fundamentally affected by hypercoagulable states. We know that IL-6 plays a strong role in the placenta. We know that there are ACE2 receptors on the placenta. What does COVID really mean for the placenta? Is it possible that there are some increased risks for embryonic or fetal demise due to COVID on the placenta?

I started collating the anecdotal data that practitioners talked about. I'll share an example. One practitioner, in 2 weeks, had two 16-week demises, one 29-week demise, two spontaneous abortions, and two missed abortions. That is a huge number. She shared that this was more miscarriages than she'd seen all year. Another practitioner said, "I've had five spontaneous abortions in 2 weeks." Another practitioner had a "10-week COVID-positive patient had bilateral pulmonary emboli and miscarried."

Another practitioner has also noticed increased numbers of term demises. My next question was: Are these patients being enrolled in a registry, such as PRIORITY? Because that's the only way that we'll understand the science around pregnancy, the placenta, and COVID.

Levy: PRIORITY is a national study put up by the University of California at Los Angeles and San Francisco in an effort to track the data on COVID-positives or persons under investigation who are pregnant.

van Dis: It's our nation's registry — the place where practitioners can enroll patients or patients can enroll themselves. This allows our researchers to obtain all their demographic data and find out what complications of pregnancy they might have. They can then follow these women, hopefully through a successful birth. We need to know what's happening in terms of pregnancy loss as well.

Levy: We also put up a survey for OB-GYNs to find out more about what they are seeing and to direct them to the PRIORITY registry to report those cases. It was interesting that more than 60% of the survey responses were from people who didn't know about PRIORITY. They didn't know what it was or how to engage their patients and get their patients to enroll. The other thing that was so compelling about the data was how unavailable testing has been. People are not recognizing complications of pregnancy as potential complications of COVID, and these women aren't being tested.

For the future, as antibody tests become more available, it may be helpful and useful to go back to the patients who have had pregnancy losses and test them for antibodies because we'll get much more data, and it'll be more robust if we can say whether they were exposed to the virus or not.

van Dis: Anecdotally, we learned through the survey that some practitioners recognized that it would be helpful to obtain a COVID test on a patient (especially with a second- or third-trimester demise), but the only way they can get a patient tested at their institution is if the patient has respiratory symptoms.

I hope that the NewYork-Presbyterian/Columbia data, showing that 88% of their COVID-positive patients who presented to the hospital were asymptomatic, will change some of the policies around who gets tested. The testing parameters change every week — but in the spirit of collecting as much data as we can, as fast as we can, so that we can provide the right guidance and advice to our patients, we have to be able to expand that testing capacity to include women who have embryonic and fetal demises.

Levy: We also need to know if they were negative. I was on a call last night with folks from the University of Washington. They've been testing every pregnant woman who comes in. They have their own laboratory and are able to get a result in 15 minutes. They are not seeing an increase in losses and demises in their population, at least so far.

The bottom line is, data are critical. We cannot relieve the anxiety of our providers or of our patients unless we have more knowledge, and we can't get that knowledge without data. Thank you to UCSF and UCLA for so rapidly putting up the PRIORITY data set, but everybody needs to know about it and we need to engage everyone to participate, and to encourage their patients to participate, so that 6 months or a year from now, we'll know what the obstetrical impact of COVID really is.

This article originally appeared in OBG Management on the MDedge Network.

Barbara Levy, MD, is clinical professor, obstetrics and gynecology, at George Washington University of Medicine and Health Sciences and principal at The Levy Group LLC, Washington, DC. Jane van Dis, MD, is an OB hospitalist and volunteer clinical faculty at USC Keck School of Medicine, Los Angeles, California. She is CEO of Equity Quotient, co-founder of OB Best Practice, and a founder of TIMES UP Healthcare. Levy and van Dis have disclosed no relevant financial relationships.

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