Pregnant Women at Greater Risk for Severe COVID-19, CDC Says

Diana Swift

June 25, 2020

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

Pregnant women may be at increased risk for severe COVID-19 illness, according to a new report published online today in Morbidity and Mortality Weekly Report.

Among reproductive-aged women (15 to 44 years) infected with SARS-CoV-2, pregnancy was associated with a greater likelihood of hospitalization, admission to the intensive care unit (ICU), and mechanical ventilation, but not death. Pregnant women were 5.4 times more likely to be hospitalized, 1.5 times more likely to be admitted to the ICU, and 1.7 times more likely to need mechanical ventilation, after adjusting for age,  underlying conditions, and race/ethnicity.  

Furthermore, Hispanic and non-Hispanic Black pregnant women appear to be disproportionately impacted by the infection. 

Sascha Ellington, PhD, of the CDC's COVID-19 Response Pregnancy and Infant Linked Outcomes Team, and colleagues say preventing COVID-19 infection in pregnant women should be a priority and any potential barriers to compliance with preventive measures need to be removed.

"During pregnancy, women experience immunologic and physiologic changes that could increase their risk for more severe illness from respiratory infections," they write.

As of June 7, a total of 8207 cases of COVID-19 in pregnant women were reported to CDC, approximately 9% of COVID-19 cases among reproductive-aged women with known pregnancy status. The authors compared outcomes in these pregnant patients with those in 83,205 nonpregnant women with COVID-19. There was a substantially greater proportion of hospital admissions among pregnant patients (2587; 31.5%) compared with nonpregnant patients (4840; 5.8%) with COVID-19.

The authors caution there were no data to differentiate between hospitalizations for COVID-19–related problems as opposed to those arising from pregnancy, including delivery.

For other severity measures, ICU admissions were reported for 1.5% of pregnant women compared with 0.9% for their nonpregnant counterparts, whereas mechanical ventilation was required for 0.5% compared with 0.3%, respectively. Mortality was identical, affecting 0.2% in both groups, with 16 deaths in pregnant patients with COVID-19 and 208 in nonpregnant patients.

Age had an impact as well, with hospitalization more frequent in the age 35 to 44 years category than the age 15 to 24 category regardless of pregnancy status. When stratified by race/ethnicity, ICU admission was most frequently reported among pregnant women who were of non-Hispanic Asian lineage: 3.5% compared with 1.5% in all pregnant women.

Among pregnant women with laboratory-confirmed SARS-CoV-2 infection reporting race/ethnicity, 46% were Hispanic, 22% were Black, and 23% were white, whereas among women who gave birth in 2019, 24% were Hispanic, 15% were Black, and 51% were white. "Although data on race/ethnicity were missing for 20% of pregnant women in this study, these findings suggest that pregnant women who are Hispanic and black might be disproportionately affected by SARS-CoV-2 infection during pregnancy," the authors write.

They note that in a recent meta-analysis of influenza, pregnancy was similarly associated with a sevenfold risk for hospitalization, but a lower risk for ICU admission and no increased risk for death. A recent study reported by Medscape Medical News suggested that COVID-19 severity during pregnancy may be lower than in other respiratory infections such as H1N1.

ACOG Responds

In a response to the CDC findings, the American College of Obstetricians and Gynecologists (ACOG) advises calm, noting that the risk of needing the severity-associated interventions in the CDC report remains low and pregnant COVID-19 patients do not appear to have a greater risk for mortality.

Nevertheless, ACOG is reviewing all its COVID-19–related clinical and patient materials and "will make any necessary revisions to recommendations."

In the meantime, the college advises clinicians to alert patients to the potential increased risk for severe COVID-19 illness during pregnancy. They should also stress to pregnant women and their families the need for precautions to prevent infection, paying particular attention to measures to protect those with greater occupational exposure to the virus.

ACOG also criticizes the exclusion of pregnant and lactating women from clinical trials of potential coronavirus vaccines, noting that the new CDC findings underscore the importance of prioritizing pregnant patients to receive coronavirus vaccination when it becomes available, according to Medscape Medical News.

"ACOG again urges the federal government to use its resources to ensure the safe inclusion of pregnant and lactating patients, including patients of color, in trials for vaccines and therapeutics to ensure that all populations are included in the search for ways to prevent and treat COVID-19," the response reads.

The CDC authors say their report also highlights the need for more complete data to fully understand the risk for severe illness in pregnant women. To address these gaps, the CDC is collaborating with health departments in COVID-19 pregnancy surveillance for the reporting of outcomes in pregnant women with laboratory-confirmed SARS-CoV-2 infection.

MMWR. Published online June 25, 2020. Full text  

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