While the coronavirus pandemic spread across the world, information about the impact of COVID-19 and pregnant and breastfeeding women was continuously evolving. And now, with the development of a COVID-19 vaccine, there are many new questions and considerations for Ob/Gyns and healthcare providers to address as they continue to counsel their patients.
Jeannie Kelly, MD, MS, Washington University maternal-fetal medicine specialist at the Women & Infants Center, a partnership among Barnes-Jewish Hospital, St. Louis Children’s Hospital and Washington University Physicians joins the show to talk more about how COVID-19 affects women during pregnancy and during breastfeeding, and the recommendations for this population as they become eligible to receive the COVID-19 vaccine.
Navigating COVID-19 and the Vaccine in Pregnant and Breastfeeding Women
Featured Speaker:
Jeannie Kelly, MD, MS
Jeannie Kelly, MD, MS is an Assistant Professor, Obstetrics and Gynecology, Washington University School of Medicine Division of Maternal-Fetal Medicine, Director of Obstetrical Inpatient Services, Maternal Transport Services and C.A.R.E. in Pregnancy. Transcription:
Melanie Cole (Host): Welcome to Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. I'm Melanie Cole, and I invite you to listen as we discuss navigating COVID-19, the vaccine in pregnant and breastfeeding women. Joining me is Dr. Jeannie Kelly. She's an Assistant Professor of OBGYN in the Division of Maternal Fetal Medicine at Washington University School of Medicine. Dr. Kelly, it's a pleasure to have you join us today. So, what do we know as of now about how COVID-19 affects pregnancy, the mom and the fetus?
Jeannie Kelly, MD, MS (Guest): Thank you so much for having me today. So, our data is still limited since we only have kind of 10 months to a year of data. But what we are seeing pretty clearly coming through is that when a woman is pregnant and she gets COVID-19, she's at higher risk of having more severe disease. So, a pregnant woman is going to have higher risk of being hospitalized, needing a ventilator or going to the ICU and even death if she gets COVID-19 compared to someone who is not pregnant.
Host: Doctor, how has prenatal and postpartum care changed due to this pandemic? What have you learned? What challenges have you overcome? Have you been able to use Telemedicine for certain appointments or not in this case? Tell us what's changed and how your practice has evolved.
Dr. Kelly: Absolutely. I think challenge is the, is the right word to describe it all. In the beginning of the pandemic, back in the spring, we didn't know a whole lot about how this was going to affect pregnancy. We weren't a hundred percent clear about how this disease was spread. You know, I think all of us were still wiping down all of our groceries. You know, washing our fruits and vegetables with soap and water. We have learned a lot in the last 10 months since pandemic life sort of took over us here in Missouri. And so we have shifted a lot of our outpatient visits to Telemedicine and we have provided our patients with a lot of tools such as you know, blood pressure cuffs, so that they can take their own blood pressure at home, do their own weights and, you know, still have a pretty good visit from a Telemedicine point of view.
But sometimes in pregnancy, some of those assessments of the baby's health have to be done in person. So, for example, doing an ultrasound to make sure that the baby's growing well or doing the ultrasound to make sure that the baby doesn't have any birth defects. These are not things that we can do via Telemedicine. And so obstetrics, unlike many other specialties, still necessitates our patients coming into the hospital and doing these assessments and exams.
On the inpatient side, again, we've learned a lot since the beginning of this pandemic. We were really scared in the beginning and similar to kind of other labor and delivery units across the country, there were some pretty draconian and drastic measures being taken. For example, if a mom was positive for COVID-19, she was separated from her baby. We quickly realized that these practices did not make a whole lot of sense. And what I mean by that is a mom was diagnosed with COVID-19 and everyone's scared that she's going to pass COVID-19 to the baby, so, we separate them in the hospital, but then two days later, when mom is going home, you give them this newborn that they haven't even touched in the two days that they've been home and they're expected to care for this newborn and also do it while taking all of the precautions. It just logistically, logically, and also just from a humane point of view, what just felt awful. And so we quickly reversed these policies in the beginning. And, you know, as of right now, if my mom is positive for COVID-19, when she comes in for delivery we, you know, take a couple of extra precautions in terms of our protective equipment that we wear. We wear special gowns, gloves, special masks, but part of our policy now is that babies still remain with mom.
Our moms are still going to have their visitor because we think it's important for a support person for, for a mom to be there. And we teach our moms how to keep their babies and their support person safe during kind of that newborn neonatal period, because we think that's really important that moms know how to do it and feel confident and know, and knowing how to take care of their babies. Another thing that we've changed is that we've realized quite a significant number of our moms, actually more than any other surgical or procedural site in the hospital, have COVID-19 and don't have any symptoms. So, our asymptomatic COVID rate upon labor and delivery is somewhere from four to 8%. And so, for our own protection and to prevent us from, you know, taking the infection from one patient into other rooms, we've actually started universally testing everybody who comes in for delivery for COVID-19. And so that helps us remain safe from the staff and provider point and also to prevent us from spreading it around. But it also helps us teach our moms hey, you know, you, you have COVID-19 whether you have symptoms or not, and these are important precautions we need you to take with your baby, but also with grandmas and grandpas and friends and relatives potentially visiting you.
Host: So, tell us what extra precautions you're suggesting, your pregnant individuals and their families take during the pandemic. As you've said, some of them have to come in for certain appointments. That's for sure. But what about regular life, grocery shopping, other siblings, kids that might be in the house? What are you recommending that patients do? And how can other providers counsel their patients on these safety things since this is such a different situation?
Dr. Kelly: Absolutely. So, we are recommending that pregnant patients, especially cause they're at higher risk for that severe disease, take all of those precautions. So, those precautions include, you know, masking anytime that you're in public, hand washing and hand hygiene and you know, making sure that you're socially distanced. So, that might mean, you know, don't go to these parties. Don't go to these get togethers and really be careful of who you're letting into the house. This is really not the time to be hosting large baby showers in person. This is not really the time to be attending other you know, birthday parties or those sorts of things, because of the risk, not only to the mom, but also to the fetus. And of course the COVID-19 vaccine this is a topic that frequently comes up with our patients and potentially is a method to prevent infection as well.
Host: So, now let's talk about COVID-19, the vaccine. What are you recommending as far as the vaccine for your pregnant women, your postpartum women, the baby? Tell us about how this vaccine is changing your practice and what you're recommending as far as that goes.
Dr. Kelly: Great question and a really hot topic at the moment. So, as we all know, pregnant patients, were not allowed to be a part of the Pfizer or the Moderna trials. And this is pretty routine of vaccine trials and trials for medications in general. There's a sense of, we really need to protect pregnant women when they're designing these trials. So, they exclude them from inclusion. But the problem is on the flip side, suddenly when your results come out, you don't have any data in pregnancy. And so it's a frustrating place for us on the obstetrician side, but also certainly many of our patients who are pregnant.
So, in terms of how the vaccine works, there's this mRNA that encodes part of the protein that's on the outside of that Coronavirus and your body makes that protein. So, your body learns to recognize that outer shell of the Coronavirus and learns to attack it and form antibodies to it without you needing to become sick with Coronavirus. The way that that works, we don't think that really should increase any risk during the pregnancy or to your baby. We unfortunately just don't have the data to say that, you know, for sure, because pregnant women were not included, but understanding the mechanism of how this vaccine works, this should be low risk in pregnancy. Vaccines in general are considered safe in pregnancy, except for some live vaccines that are not given.
And this is not a live vaccine. And so, generally speaking, we believe that this vaccine should be safe in pregnancy. The flip side is that we know COVID-19 is dangerous in pregnancy and can make moms and their babies incredibly sick. And so it becomes this shared decision that we make with our patients. You know, what is going on in that patient's life? Do they live in a situation where they're exposed because they are a healthcare worker or they live with someone who's a healthcare worker or an essential worker that, you know, they have to be exposed and going into work all the time? Are they living in a community where the rates of COVID-19 are pretty high? For us here in St. Louis and Missouri, that answer is yes, we have widespread community rates right now. Do they potentially have another health condition that makes them even higher at risk for getting really sick, such as diabetes or high blood pressure or a BMI over 30? And you know, is the anxiety and the worry of getting COVID-19 scarier and worse for them than the unknowns of the vaccine, which are, should be relatively low.
I would say generally speaking with our patients who are pregnant, most of them have come to a conclusion that they should seriously consider or go ahead and get the vaccine. Because the risks of getting COVID are, are significantly higher for the vast majority of our patients right now compared to the theoretical, unknown risk of the vaccine itself, which again, should be low. We know from animal data from Pfizer and Moderna, that in rats, this was not, you know, associated with any big problems in pregnant rats or their offspring. And we also know from a handful of patients who got pregnant in the Moderna and Pfizer trials, you know, even though they weren't supposed to, still people get pregnant, that they have not had any issues with their pregnancies.
Generally speaking, most healthcare workers who are pregnant have gone ahead and gotten the vaccine because they know we see what COVID does to patients in the hospital all the time. And that risk is much too high for the vast majority of healthcare workers who are pregnant.
Host: So much information. Doctor you're speaking to other obstetricians, gynecologists and primary care providers, what would you like them to know about the questions you're getting the most, what your patients are most concerned about and how they can work with their patients in answering all these questions we've discussed here today.
Dr. Kelly: That's a really great question. I think the most important thing for all of us to remember is that all of our expert committees, so that's the American College of Obstetricians and Gynecologists. That's the Society for Maternal Fetal Medicine. That's the CDC and also the WHO, all of them say the same thing, which is that pregnant women should be offered the vaccine. There really should be no one out there saying you're pregnant, there is no reason that you should get the vaccine. That's actually not what the recommendation is. And I encourage our providers to you know, open this conversation up with their patients. And if the conversation is getting to a point where, you know, you need more help or advice, we are always willing to come talk to any, any patient about a consult regarding the COVID vaccine and help them make a choice. The other part is that whatever choice our patients make we should all support them, whether that's to get the vaccine or to wait for more information before they get it while they're pregnant. We should all be supportive of that choice.
Melanie Cole (Host): Absolutely great information. It's so important. And what a great episode this was. Thank you so much, Dr. Kelly for joining us today. For more information or to speak with a pediatric specialist at St. Louis Children's Hospital, please call the Children's Direct Physician Access Line at 1-800-678-HELP. Or you can visit Stlouischildren's.org. That concludes this episode of Radio Rounds, the podcast series from the Washington University Pediatric Specialists at St. Louis Children's Hospital. Please remember to subscribe, rate and review this podcast and all the other St. Louis Children's Hospital podcasts. I'm Melanie Cole.
Melanie Cole (Host): Welcome to Radio Rounds, the podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. I'm Melanie Cole, and I invite you to listen as we discuss navigating COVID-19, the vaccine in pregnant and breastfeeding women. Joining me is Dr. Jeannie Kelly. She's an Assistant Professor of OBGYN in the Division of Maternal Fetal Medicine at Washington University School of Medicine. Dr. Kelly, it's a pleasure to have you join us today. So, what do we know as of now about how COVID-19 affects pregnancy, the mom and the fetus?
Jeannie Kelly, MD, MS (Guest): Thank you so much for having me today. So, our data is still limited since we only have kind of 10 months to a year of data. But what we are seeing pretty clearly coming through is that when a woman is pregnant and she gets COVID-19, she's at higher risk of having more severe disease. So, a pregnant woman is going to have higher risk of being hospitalized, needing a ventilator or going to the ICU and even death if she gets COVID-19 compared to someone who is not pregnant.
Host: Doctor, how has prenatal and postpartum care changed due to this pandemic? What have you learned? What challenges have you overcome? Have you been able to use Telemedicine for certain appointments or not in this case? Tell us what's changed and how your practice has evolved.
Dr. Kelly: Absolutely. I think challenge is the, is the right word to describe it all. In the beginning of the pandemic, back in the spring, we didn't know a whole lot about how this was going to affect pregnancy. We weren't a hundred percent clear about how this disease was spread. You know, I think all of us were still wiping down all of our groceries. You know, washing our fruits and vegetables with soap and water. We have learned a lot in the last 10 months since pandemic life sort of took over us here in Missouri. And so we have shifted a lot of our outpatient visits to Telemedicine and we have provided our patients with a lot of tools such as you know, blood pressure cuffs, so that they can take their own blood pressure at home, do their own weights and, you know, still have a pretty good visit from a Telemedicine point of view.
But sometimes in pregnancy, some of those assessments of the baby's health have to be done in person. So, for example, doing an ultrasound to make sure that the baby's growing well or doing the ultrasound to make sure that the baby doesn't have any birth defects. These are not things that we can do via Telemedicine. And so obstetrics, unlike many other specialties, still necessitates our patients coming into the hospital and doing these assessments and exams.
On the inpatient side, again, we've learned a lot since the beginning of this pandemic. We were really scared in the beginning and similar to kind of other labor and delivery units across the country, there were some pretty draconian and drastic measures being taken. For example, if a mom was positive for COVID-19, she was separated from her baby. We quickly realized that these practices did not make a whole lot of sense. And what I mean by that is a mom was diagnosed with COVID-19 and everyone's scared that she's going to pass COVID-19 to the baby, so, we separate them in the hospital, but then two days later, when mom is going home, you give them this newborn that they haven't even touched in the two days that they've been home and they're expected to care for this newborn and also do it while taking all of the precautions. It just logistically, logically, and also just from a humane point of view, what just felt awful. And so we quickly reversed these policies in the beginning. And, you know, as of right now, if my mom is positive for COVID-19, when she comes in for delivery we, you know, take a couple of extra precautions in terms of our protective equipment that we wear. We wear special gowns, gloves, special masks, but part of our policy now is that babies still remain with mom.
Our moms are still going to have their visitor because we think it's important for a support person for, for a mom to be there. And we teach our moms how to keep their babies and their support person safe during kind of that newborn neonatal period, because we think that's really important that moms know how to do it and feel confident and know, and knowing how to take care of their babies. Another thing that we've changed is that we've realized quite a significant number of our moms, actually more than any other surgical or procedural site in the hospital, have COVID-19 and don't have any symptoms. So, our asymptomatic COVID rate upon labor and delivery is somewhere from four to 8%. And so, for our own protection and to prevent us from, you know, taking the infection from one patient into other rooms, we've actually started universally testing everybody who comes in for delivery for COVID-19. And so that helps us remain safe from the staff and provider point and also to prevent us from spreading it around. But it also helps us teach our moms hey, you know, you, you have COVID-19 whether you have symptoms or not, and these are important precautions we need you to take with your baby, but also with grandmas and grandpas and friends and relatives potentially visiting you.
Host: So, tell us what extra precautions you're suggesting, your pregnant individuals and their families take during the pandemic. As you've said, some of them have to come in for certain appointments. That's for sure. But what about regular life, grocery shopping, other siblings, kids that might be in the house? What are you recommending that patients do? And how can other providers counsel their patients on these safety things since this is such a different situation?
Dr. Kelly: Absolutely. So, we are recommending that pregnant patients, especially cause they're at higher risk for that severe disease, take all of those precautions. So, those precautions include, you know, masking anytime that you're in public, hand washing and hand hygiene and you know, making sure that you're socially distanced. So, that might mean, you know, don't go to these parties. Don't go to these get togethers and really be careful of who you're letting into the house. This is really not the time to be hosting large baby showers in person. This is not really the time to be attending other you know, birthday parties or those sorts of things, because of the risk, not only to the mom, but also to the fetus. And of course the COVID-19 vaccine this is a topic that frequently comes up with our patients and potentially is a method to prevent infection as well.
Host: So, now let's talk about COVID-19, the vaccine. What are you recommending as far as the vaccine for your pregnant women, your postpartum women, the baby? Tell us about how this vaccine is changing your practice and what you're recommending as far as that goes.
Dr. Kelly: Great question and a really hot topic at the moment. So, as we all know, pregnant patients, were not allowed to be a part of the Pfizer or the Moderna trials. And this is pretty routine of vaccine trials and trials for medications in general. There's a sense of, we really need to protect pregnant women when they're designing these trials. So, they exclude them from inclusion. But the problem is on the flip side, suddenly when your results come out, you don't have any data in pregnancy. And so it's a frustrating place for us on the obstetrician side, but also certainly many of our patients who are pregnant.
So, in terms of how the vaccine works, there's this mRNA that encodes part of the protein that's on the outside of that Coronavirus and your body makes that protein. So, your body learns to recognize that outer shell of the Coronavirus and learns to attack it and form antibodies to it without you needing to become sick with Coronavirus. The way that that works, we don't think that really should increase any risk during the pregnancy or to your baby. We unfortunately just don't have the data to say that, you know, for sure, because pregnant women were not included, but understanding the mechanism of how this vaccine works, this should be low risk in pregnancy. Vaccines in general are considered safe in pregnancy, except for some live vaccines that are not given.
And this is not a live vaccine. And so, generally speaking, we believe that this vaccine should be safe in pregnancy. The flip side is that we know COVID-19 is dangerous in pregnancy and can make moms and their babies incredibly sick. And so it becomes this shared decision that we make with our patients. You know, what is going on in that patient's life? Do they live in a situation where they're exposed because they are a healthcare worker or they live with someone who's a healthcare worker or an essential worker that, you know, they have to be exposed and going into work all the time? Are they living in a community where the rates of COVID-19 are pretty high? For us here in St. Louis and Missouri, that answer is yes, we have widespread community rates right now. Do they potentially have another health condition that makes them even higher at risk for getting really sick, such as diabetes or high blood pressure or a BMI over 30? And you know, is the anxiety and the worry of getting COVID-19 scarier and worse for them than the unknowns of the vaccine, which are, should be relatively low.
I would say generally speaking with our patients who are pregnant, most of them have come to a conclusion that they should seriously consider or go ahead and get the vaccine. Because the risks of getting COVID are, are significantly higher for the vast majority of our patients right now compared to the theoretical, unknown risk of the vaccine itself, which again, should be low. We know from animal data from Pfizer and Moderna, that in rats, this was not, you know, associated with any big problems in pregnant rats or their offspring. And we also know from a handful of patients who got pregnant in the Moderna and Pfizer trials, you know, even though they weren't supposed to, still people get pregnant, that they have not had any issues with their pregnancies.
Generally speaking, most healthcare workers who are pregnant have gone ahead and gotten the vaccine because they know we see what COVID does to patients in the hospital all the time. And that risk is much too high for the vast majority of healthcare workers who are pregnant.
Host: So much information. Doctor you're speaking to other obstetricians, gynecologists and primary care providers, what would you like them to know about the questions you're getting the most, what your patients are most concerned about and how they can work with their patients in answering all these questions we've discussed here today.
Dr. Kelly: That's a really great question. I think the most important thing for all of us to remember is that all of our expert committees, so that's the American College of Obstetricians and Gynecologists. That's the Society for Maternal Fetal Medicine. That's the CDC and also the WHO, all of them say the same thing, which is that pregnant women should be offered the vaccine. There really should be no one out there saying you're pregnant, there is no reason that you should get the vaccine. That's actually not what the recommendation is. And I encourage our providers to you know, open this conversation up with their patients. And if the conversation is getting to a point where, you know, you need more help or advice, we are always willing to come talk to any, any patient about a consult regarding the COVID vaccine and help them make a choice. The other part is that whatever choice our patients make we should all support them, whether that's to get the vaccine or to wait for more information before they get it while they're pregnant. We should all be supportive of that choice.
Melanie Cole (Host): Absolutely great information. It's so important. And what a great episode this was. Thank you so much, Dr. Kelly for joining us today. For more information or to speak with a pediatric specialist at St. Louis Children's Hospital, please call the Children's Direct Physician Access Line at 1-800-678-HELP. Or you can visit Stlouischildren's.org. That concludes this episode of Radio Rounds, the podcast series from the Washington University Pediatric Specialists at St. Louis Children's Hospital. Please remember to subscribe, rate and review this podcast and all the other St. Louis Children's Hospital podcasts. I'm Melanie Cole.