In our preoccupation with managing the COVID-19 pandemic , we should not lose sight of special issues that may pose problems for women in the reproductive age group. The special issues are of two kinds: one that relates to medical management of pregnancy and newborn care. The World Health Organization (WHO) and the Indian Council of Medical Research (ICMR) have provided guidelines to address this issue.
The second relates to the advisability of deliberately delaying pregnancy until the epidemic wanes and the disease becomes endemic. All available guidelines are silent on this issue. Is there a need for exercising a choice of timing of pregnancy? What should be a wise policy for the Government of India, or for that matter any government, the ICMR and WHO on this matter?
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Need for protocols, follow-up
The SARS-CoV-2 virus that causes COVID-19 has a special predilection for the cells that form the inner lining of blood vessels. Therefore, organs that have a large number of blood vessels are particularly at risk. The placenta, a unique organ in pregnancy — the source of nourishment for the growing foetus — is highly vascular.
It has been clearly demonstrated that in mothers infected close to the time of delivery, the virus can infect the placenta. A small percentage of newborn babies (1.4%) of such mothers have neonatal infection acquired from the mother. While most newborn babies do not develop clinical disease, rare neurologic problems have been described in them. In this context, it is pertinent that in Indian maternity hospitals, routine reverse transcription polymerase chain reaction (RT-PCR) testing of pregnant mothers admitted for delivery reveal that about 8-10 % of mothers are indeed infected by SARS CoV-2. The ICMR along with the professional bodies concerned should ensure that the treating teams are aware of the potential for trans-placental transmission of the virus and establish protocols for careful periodic follow-up of the new-born of infected mothers.
If the virus can infect the placenta in term pregnancy, can it not affect the placenta in the first three months (first trimester) of pregnancy? The important question that comes to mind, therefore, is whether infection of the mother during the first trimester of pregnancy, the crucial period for the development of organ systems in the foetus, can cause congenital abnormalities. In the first trimester of pregnancy, many infections such as those caused by rubella and zika virus cause severe congenital abnormalities in the foetus. Recognition of this fact led to a WHO-approved government policy of routine rubella vaccination as part of the immunisation schedule of children.
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Issue of contraception
In the context of COVID-19, it is too early to say whether viral infection during the first trimester will cause congenital abnormalities but the potential for such an occurrence is real. If it is a florid abnormality it would be known by now, but if subtle, by the time the effects on the foetus are recognised, it may be too late. Therefore, there is a need to anticipate this eventuality and be prepared for it. In the epidemic context, it is wiser to be cautious and advise effective contraception to postpone pregnancies till the probability of maternal viral infection is minimal.
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Cutting infection threat
What are the advantages in adopting such a policy? If women adopt contraception, they will not need antenatal clinic visits which, during epidemic times, pose a risk of contracting infection in the clinic. Antenatal women constitute a large proportion of subjects who need to visit hospitals regularly and considerable proportions of health-care workers at the primary and secondary levels are occupied with their care. If this demand is less because women in reproductive age group practise contraception, there will be less pressure on the health-care system which is already struggling under the burden of this epidemic. These health-care workers can be deployed for the much-needed care of COVID-19 patients, non-COVID illness and, more importantly, the ensuing COVID-19 vaccination programme, a mammoth task in India.
The lower birth rate till the epidemic wanes will ensure that there will be fewer children in the post-epidemic phase for economically distressed families to care for and curtail disease transmission through children.
Every day about 748,000 babies are born in India. Since the outcome is unsuccessful in about half the pregnancies (embryo/foetal loss), the daily new pregnancies in India would be more than 15,00,000. With the widespread community transmission in India now, a large number of women who conceive are likely to be exposed to the virus.
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A proportion of those exposed will get infected and nearly 80% of those infected will be asymptomatic or have only trivial transient symptoms. They may not come to medical attention unless a family contact has RT-PCR positive symptomatic disease. At present, in city maternity hospitals, RT-PCR positivity in the first trimester is about 10% of all infected pregnant women and likely to increase rapidly as the epidemic in India approaches the peak. Infected women should have a more intensive follow-up during their ante-natal period to identify and document any fetal abnormality. Analysis of these results will be vital to state clearly whether any abnormality is attributable to the viral infection.
The risk of exposure of the developing foetus is not just in those who come to hospital but also in all those asymptomatic or minimally symptomatic pregnant women with the viral infection. It is important, therefore, to advise all women in the reproductive age group to practise effective contraception over the next several months in order to prevent coronavirus infection during pregnancy and its potential impact on the foetus. The ICMR and the professional bodies concerned will do well to formulate policy on this matter and inform the profession and the public. Women who happen to conceive in spite of the advice may have to cocoon (reverse quarantine) themselves at least for the first trimester of pregnancy in order to avoid infection.
On vaccination
It is predicted that this virus will not go away but will stay on as an endemic problem after the fury of the epidemic is over. When this occurs and when an effective and safe vaccine is available, women in the reproductive age group who have not already acquired the infection and those who do not have circulating IgG antibody to indicate that they may have had asymptomatic infection, will have to be considered for priority vaccination prior to conception.
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Finally, while this problem will be huge in countries with a high birth rate such as India and China, it will also be a public health problem in countries with a low birth rate, where governments are concerned about ‘population wealth’. The ICMR and governments globally would do well to assess the situation, review all available scientific evidence and formulate and circulate an appropriate health advisory. India has the challenge and opportunity of adopting this policy and voicing its opinion in WHO.
M.S. Seshadri is former Professor and HOD, Clinical Endocrinology Department, CMC Hospital, Vellore, and is currently Medical Director, Thirumalai Mission Hospital, Ranipet, Tamil Nadu. T. Jacob John is former Professor and HOD, Clinical Virology Department, CMC Hospital, Vellore and former President, Indian Academy of Pediatrics
