O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 2 | 1 O&G Forum 2021; 31: 01 - 02 EDITORIAL It is now clear that there are increased risks of maternal and fetal morbidity and mortality when COVID-19 is contracted during pregnancy. Preventing severe COVID-19 in this population must be a priority. Risks of COVID-19 during pregnancy Pregnancy has been identified as an independent risk factor for severe COVID-19 disease. Pregnant women are more likely than their non-pregnant counterparts to die, require invasive ventilation or require ICU admission if infected. 1-3 This is in contrast to early reports in the pandemic which showed no increased risk of severity in pregnant populations. 4 A large analysis from the USA, including over 400,000 women of childbearing age, of which more than 30,000 were pregnant, showed a 2.5-fold increase in ICU admissions and a 70% greater risk of mortality in pregnant women. 5 COVID-19 not only poses a risk to the mother but also poses a risk to the pregnancy itself as well as the neonate. The risk of preeclampsia and thromboembolic events is increased 2, 6, 7 , as are the rates of preterm birth and stillbirth. 7 Iatrogenic preterm delivery and an increased rate of Caesarean section are seen in pregnant women with COVID-19 showing that the preterm births are likely related to maternal factors as opposed to neonatal or pregnancy-specific factors. 2 Severe disease is associated with an increased risk of gestational diabetes, preterm birth and small for gestational age birth, and a fourfold increased risk of preeclampsia when compared to mild COVID-19. 7 Safety and efficacy of the vaccines Initial vaccine regulatory approvals named pregnancy as a contraindication to vaccination, mainly due to a lack of safety data because of the exclusion of pregnant and lactating women from phase 3 vaccine efficacy trials. Initial advice from public health, governmental and professional authorities were therefore inconsistent, leading to confusion amongst patients and healthcare providers alike. Due to these events, we still have only observational data to motivate for vaccine safety during pregnancy. 8 Four classes of COVID-19 vaccines are currently available: mRNA (Pfizer-BioNTech, Moderna); viral vector (Oxford- AstraZeneca, Johnson & Johnson); whole virus (Sinovac, Sinopharm) and protein subunit vaccines (Novavax). The Johnson & Johnson and Pfizer/BioNtech vaccines are currently available in South Africa, and the Sinovac vaccine is set to arrive later this year. Even though women enrolled in vaccine trials were advised against pregnancy, 53 pregnancies occurred during the trials of three vaccines in the UK. Neither mRNA, nor viral vector vaccines showed a significant difference in rates of accidental pregnancies or miscarriages between the vaccine and control groups, arguing vaccines neither prevent pregnancy, nor increase the risk for miscarriage. 9 There is no theoretical reason and currently no evidence that any of the COVID-19 vaccines should affect fertility in women or in men. 10 A short term observational study recorded 35691 pregnant women who received an mRNA vaccine in the USA.(11) There was no significant difference reported in spontaneous abortion, still birth, pre-term birth, small for gestational age, congenital anomalies or neonatal death, when compared to published incidence. An observational retrospective cohort study performed in Israel compared 7530 vaccinated pregnant women with 7530 unvaccinated pregnant women and reported a hazard ratio of 0.22 (95% CI, 0.11-0.43) demonstrating a significant reduction in the incidence of COVID-19. 12 Long term follow up and larger numbers of women vaccinated early in pregnancy are required. Pfizer and BioNTech announced in February they have initiated a phase 2/3 trial which will enrol approximately 4,000 healthy pregnant women during their second and third trimester from various parts of the world, including South Africa. 13 Current advice based on best evidence A number of societies and organisations including the American Centre for Disease Control and Prevention (CDC), American College of Obstetricians and Gynaecologists and the Society for Maternal and Fetal Medicine recommend vaccination in pregnancy, irrespective of gestational age. 14-15 The Royal College of Obstetricians and Gynaecologists recommend vaccination with the Pfizer or Moderna vaccines at any gestation but advise that women in low risk categories could consider delaying vaccination until after 12 weeks gestation. 16-17 Considering the significantly increased risk of severe disease in pregnancy, the authors’ opinion is consistent with the South African National Department of Health, South African College of Obstetricians and Gynaecologists and the South African Society for Obstetricians and Gynaecologists - that all pregnant women in their second and third trimesters of pregnancy, lactating or women considering pregnancy be encouraged to receive the COVID-19 vaccine. References 1. Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of L Wium 1 , J Zamparini 2 , P Soma-Pillay 3 1 Department of Internal Medicine, Kalafong Hospital and the University of Pretoria 2 Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and the University of the Witwatersrand, Johannesburg 3 Department of Obstetrics and Gynaecology, Steve Biko Academic Hospital and the University of the Pretoria Vaccinate: Protecting Pregnant Patients from COVID-19