COVID-19 mortality rate elevated in pregnant women
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Pregnant women with COVID-19 are more likely to die from the novel coronavirus than nonpregnant individuals similar in age, according to research published in the American Journal of Obstetrics and Gynecology.
“This study represents another strong piece of evidence that pregnant women are more vulnerable to SARS-CoV-2 infections, as well as other highly pathogenic respiratory infections,” Kristina M. Adams Waldorf, MD, FACOG, professor of obstetrics and gynecology at the University of Washington, told Healio Primary Care. “As women represent a large part of the essential workforce, we still have a large group at risk for a more severe course of COVID-19 and death.”
Adams Waldorf and colleagues conducted a statewide multi-center retrospective cohort study in Washington. They identified pregnant women with confirmed SARS-CoV-2 infection based on polymerase chain reaction testing from March 1, 2020, through June 30, 2020, at 35 cities across the state.
A total of 240 pregnant women were included in the study. Among these women, 10% were hospitalized for COVID-19 concerns and 3.3% received care in the ICU.
Among all pregnant women with COVID-19, 56.3% were diagnosed during the third trimester, 27.9% were diagnosed during the second trimester and 15.8% were diagnosed during the first trimester. Most (77.1%) were symptomatic at the time of testing.
Adams Waldorf and colleagues found that 90.8% of women who tested positive had mild disease, 7.5% had severe disease and 1.7% had critical disease.
The researchers determined that, overall, the hospitalization rate for COVID-19 was 3.5-fold higher among pregnant women (10%) compared with nonpregnant adults aged 20 to 39 years (2.8%; RR = 3.5; 95%CI 2.3-5.3) in Washington.
Among hospitalized patients, 40.9% delivered while hospitalized for COVID-19, 79.1% received oxygen support and 16.7% underwent mechanical ventilation.
Three pregnant women with COVID-19 died, yielding a maternal mortality rate of 1,250 out of 100,000 pregnancies (95% CI, 258-3,653). The researchers noted that this COVID-19 mortality rate was 13.6-fold higher than the rate in similarly aged nonpregnant adults in the state, which was 91.7 per 100,000 pregnancies, with an absolute rate difference of 1.2% between the groups (95% CI; -0.26-2.57).
The deaths among pregnant women accounted for 9.4% of COVID-19-related deaths for the age group in Washington, according to the researchers.
Based on the findings, Adams Waldorf said that pregnant women should “absolutely” be prioritized for COVID-19 vaccination.
“Pregnancy is a finite condition and delaying the vaccine would withhold clear benefit from pregnant individuals who face increasing risk with advancing gestational age,” she said.
She added that additional research is needed to further assess the effects of COVID-19 in pregnant women.
“The immune response in pregnancy is altered to protect the fetus from a ‘rejection response’ akin to transplanted organ with a different genetic makeup,” Adams Waldorf said. “Although this shift in immune profile benefits the fetus, it may be at the mother’s expense in fighting a severe respiratory infection like SARS-CoV-2 or influenza virus.”
She also said that more information is needed to determine why pregnant women have increased vulnerability to respiratory infections and how they can be treated.
“These questions need our attention urgently,” she said.
Perspective
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This is an interesting study that, unfortunately, reinforces the reports of increased severity of COVID-19 infection in pregnant women that have emerged since the beginning of the pandemic here in the U.S., from last March onward. An extremely concerning finding in this report is the higher mortality rate seen in pregnant women with COVID-19 infection in this study from Washington State. The researchers specifically compared a cohort of pregnant women to one of nonpregnant women of a similar age group, and showed a substantially higher risk of mortality associated with COVID-19 infection in the setting of pregnancy. It is a bit limited by the fact that even though there were 240 patients who were identified as being COVID-19-infected, there were only 24 women who were admitted with a concern for a COVID-19 diagnosis. The others were all diagnosed, essentially, incidentally with a universal screening policy, so the actual comparison cohort is smaller than the entire group of women with COVID-19 infection. Still, there were significantly higher rates of maternal death, and as other studies over the last 6 to 9 months have shown, pregnant women in this study who had underlying medical conditions were at significantly higher risk of COVID-19-releated complications.
This and other recent related studies are underscoring the fact that pregnancy appears to be an independent risk factor for more severe COVID-19-related disease, and pregnant women with underlying medical conditions are at an even higher risk than pregnant women with no preexisting conditions. Last week was the annual scientific meeting of the Society of Maternal Fetal Medicine (SMFM) and maternal and neonatal outcomes from larger cohorts were reported. The largest report was from the National Institute of Child Health and Human’s Maternal Fetal Medicine Unit’s network, which is a collaborative multi-center, multi-state network of high-risk OB units across the country. They looked retrospectively at over 1,200 women who were diagnosed with COVID-19 infection during pregnancy in a similar time period to this study — from the beginning of March through the end of July last year. This group of researchers showed that there were higher rates of adverse perinatal outcomes with increased severity of maternal COVID-19 disease. They also demonstrated a significantly higher rate of thromboembolic events in women with more severe disease, as well as that more severe infection was associated with higher rates of preterm birth, cesarean delivery and postpartum hemorrhage compared with pregnant women who had less severe or asymptomatic disease.
I feel strongly that this study from Washington state, as well as the larger studies that were presented but not yet published from last week’s SMFM meeting, clearly show the importance of pregnant women being vaccinated against COVID-19. This is despite the fact that there was recently conflicting patient-directed information disseminated between the WHO and the organizations here in the U.S. about the appropriateness of pregnant women to be vaccinated. ACOG, SMFM and the CDC all reinforce that pregnancy should not be a barrier for pregnant women to be vaccinated. Those of us working closely with these agencies in the U.S. continue to voice our frustration that pregnant women are excluded from trials of vaccines like the COVID-19 vaccine, under the assumption that pregnant women are somehow a fragile or vulnerable population, and that adult pregnant women are unable to make informed consent decisions. The data that show that pregnant women are at a higher risk for more severe disease just reinforces the fact that they are a population for whom vaccination against SARS-CoV-2 is particularly important. This is especially true for pregnant health care workers — with women making up a large percentage of the health care worker population — and hopefully the realities of this pandemic will help convince those who decide these issues that pregnant women are genuinely able to make informed choices about involvement in future clinical research trials.
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