Ontario added pregnancy to the category of “high-risk” health conditions eligible for COVID-19 vaccination in Phase 2 of its its rollout on April 22, joining Alberta, Saskatchewan and New Brunswick in immediately prioritizing distribution of vaccines to expectant persons. This followed a widespread call from physicians across the province in the face of unprecedented numbers of intensive care admissions among the pregnant population.
OB/GYNs in Toronto, where the third wave has struck particularly hard, have found themselves in a new, urgent phase of advocacy for their patients. What began as phone calls and text messages among our cohort across the city asking, “Are you seeing what we’re seeing?” has become a veritable outcry in the news and over social media as alarm has turned into terror. What began as a trickle of admissions of pregnant persons with severe disease had become a tidal wave by mid-April, when half of patients in the Mount Sinai Hospital Intensive Care Unit were pregnant or postpartum.
In spite of this, we still frequently encounter physicians and health-care providers concerned over the administration of the COVID-19 vaccine to pregnant patients. To better unify our response and empower our patients, we present the following five things to know about COVID-19 and pregnancy.
Pregnant patients are more at risk of severe infection from COVID-19.
Although pregnancy is not thought to be an independent risk factor for acquiring COVID-19 infection, patients who develop severe infection are at heightened risk for a worsened clinical course. The Centers for Disease Control and Prevention (CDC) released an updated report in October 2020 that included data from more than 23,000 symptomatic pregnant patients with laboratory-confirmed infection through a national surveillance database. When compared to their non-pregnant counterparts, patients with severe COVID-19 infection in pregnancy had approximately 2-3 times the risk of admission to an ICU, need for intubation/ventilation and need for ECMO. Higher overall rates of death were also recorded in the pregnant group. It is hard to predict whether these numbers accurately reflect the new variants of concern (VOC) or whether they now underestimate these risks.
Pregnant people of colour and those with comorbidities may be even more likely to require invasive treatment.
As cases climb, there is increasing evidence that pregnant patients with comorbidities and those from racial and ethnic minorities have higher rates of COVID-19.
Equally, these patients experience associated severe outcomes and increased likelihood of hospitalization. A recently published systematic review and meta-analysis of more than 67,000 pregnant patients from 73 studies demonstrates that patients of increased age, high body mass index, chronic hypertension, diabetes and preeclampsia are all at increased risk of severe COVID-19 in pregnancy. We are cognizant, however, that in this third wave, patients with none of these risk factors are now contracting severe infection.
In Toronto, in particular, visible minorities have been even more dramatically affected.
The impact of systemic racism on the spread of COVID-19 variants has been well reported; racialized communities have incurred disproportionately increased infection rates and hospitalizations, while immunization sites in some neighbourhoods continue to face accessibility challenges. The provincial government has only recently offered any indication that it will consider widespread demands for a paid sick leave program for essential employees in large businesses and factories where much of the community spread has occurred. This has put expectant persons in such communities in an even more precarious position.
Severe infection in pregnancy confers an increased risk of prematurity, caesarean section and neonatal ICU (NICU) admission.
Patients who have contracted severe COVID-19 in their pregnancy are at an increased risk for a number of complications. This is most stark when considering rates of prematurity, and caesarean section, which have been found to be elevated in the literature approximately 2.5-3 fold in comparison to pregnancies unaffected by COVID-19.
Some of these deliveries may have been intentionally hastened due to concern for the patient’s life in cases of severe COVID-19 infection.
Similarly, infants born to carriers with severe COVID-19 are more likely to require admission to NICU. This is primarily due to prematurity, although occasionally for sequelae of COVID-19 itself. There continues to be debate on the extent to which vertical transmission – or transmission to baby while in utero – may be occurring.
All four COVID-19 vaccines approved in Canada (Pfizer, Moderna, AstraZeneca and Janssen) appear to be safe and effective in pregnancy and may actually offer protective benefits to babies.
As is traditionally the case with randomized controlled trials, pregnant patients were initially excluded from COVID-19 vaccine studies. The four vaccines have now been administered to more than 90,000 expectant patients. No evidence has been found of increased rates of miscarriage, infertility or fetal abnormalities. While all of these events have been reported, they are occurring at the same frequency as in pre-pandemic populations. Furthermore, no associated risk of blood clots in pregnant patients has been noted from administration of the vaccine, including AstraZeneca. These findings have similarly been replicated across animal models. The vaccine does not pass through breast milk, and there are no known risks of receiving non-live vaccines when breastfeeding. However, there is preliminary evidence that COVID-19 antibodies may be conferred through breast milk to an infant from a vaccinated individual, and emerging evidence to suggest that this protection may even begin in utero.
Provincial governments across the country should prioritize pregnant people in their vaccine rollout plans.
As VOC continue to spread across Canada, our experience in Toronto should serve as a warning to the rest of the nation that our pregnant population is in continued need of prioritization for the vaccine. With record numbers of pregnant patients admitted to ICUs and placed on ventilators, now is the time to initiate preventive action in provinces that have yet to see the magnitude of this third wave. Given the volume of COVID-19 ICU beds occupied by those who are pregnant or postpartum in Toronto, vaccinating expectant persons is more than a matter of altruism or morality, it is a necessity in our continued efforts to conserve equipment.
The Society of Obstetricians and Gynecologists of Canada has called for nation-wide prioritization of pregnant patients in the face of the third wave and spread of variants across the country. The Toronto experience has demonstrated that continued deprioritization and exclusion of expectant individuals in vaccine campaigns across Canada will result in more severe maternal infections, more strain on our intensive care system and, ultimately, potentially preventable deaths in this otherwise healthy young cohort. This risk disproportionately affects people of colour and those in marginalized communities. The evidence is in support of immediately expediting vaccination of all pregnant persons across the country.