Pregnancy and COVID-19 vax: Talking about the evidence

Probably one of the most common questions pregnant patients ask doctors is, 'Is COVID-19 vaccination safe?' Evidence keeps coming that vaccination is indeed safe during pregnancy. In fact, because of that evidence, numerous medical associations strongly encourage pregnant women who have not been vaccinated to get the jab. The SOGC released a statement in May saying, “Pregnant individuals should be offered vaccination at any time during pregnancy or while breastfeeding if no contraindications exist.” More recently, in September the American College of Obstetricians and Gynaecologists (ACOG) along with 21 other U.S.-based medical and health associations released the “Statement of Strong Medical Consensus for Vaccination of Pregnant Individuals Against COVID-19." Read: Depression, SSRIs independently associated with preterm birth, low Apgar scores Vaccination during pregnancy is also supported by the well-known social-media figure Dr. Jen Gunter, a practicing Canadian-American obstetrician-gynaecologist in a related blog entitled “How Can We Be Sure Vaccination against COVID-19 Doesn’t Cause Infertility?” The blog, aiming to be easily understood by patients, addresses myths about COVID vaccines as they relate to fertility, describes how the vaccines work and why they can’t change your DNA. She told the Medical Post: “I absolutely recommend that pregnant people and people who may get pregnant be vaccinated. Everyone should be vaccinated unless they have one of the two medical exemptions, but even then for those with allergies (one of the exemptions) an allergist can help them get vaccinated.” Read: ‘It's really scary:' Alberta physicians face more aggressive, misinformed patients What clues are there that the vaccines are safe during pregnancy? A statement from the American Society for Reproductive Medicine (ASRM) clarifies several issues. “None of the currently available COVID-19 vaccines reach or cross the placenta. The intramuscularly administered vaccine mRNA remains in the deltoid muscle cell cytoplasm for just a few days before it is destroyed. However, protective antibodies to COVID19 have been shown to cross the placenta and confer protection to the baby after delivery,” it said. It also stated “COVID-19 vaccination does not induce antibodies against the placenta.” It further noted that, “existing data suggest COVID19 vaccination during pregnancy does not increase risk of miscarriage.” A recent prospective cohort study in JAMA of over 17,000 women who were either pregnant, lactating or planning pregnancy at the time of COVID-19 vaccination found the vaccines were well-tolerated in all three groups. As well, an epidemiologic study in the American Journal of Obstetrics and Gynaecology reported that COVID-19 illness during pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes, which is primarily driven by disease severity. While early pandemic reports suggested pregnant women were not at increased risk of severe COVID-19 infection, “data from the third wave is alarming, with higher rates of hospitalization and ICU admission noted in pregnant individuals,” said Dr. Kinga Malinowski, a maternal-fetal medicine specialist and co-author of a recent Journal of Obstetrics and Gynaecology of Canada (JOGC) commentary on COVID-19 vaccination in pregnancy. In fact, first and second wave pandemic data from the Canadian Surveillance of COVID-19 in Pregnancy (CANCOVID-Preg—which tracks epidemiology, maternal and infant outcomes) “had already demonstrated a five-fold increased risk of hospitalization and intensive care unit (ICU) admission for pregnant women with COVID-19 compared with the equivalent non-pregnant female population, a risk that also included higher rates of preterm birth (12%) and small for gestational age (9%) and a four-fold (1.2%) excess risk of stillbirth,” the authors said. Read: Pregnant patients should be screened for iron deficiency, study suggests Now, new variants are proving to be even more virulent, as described in the CMAJ which reports variants of concern are more transmissible and deadly putting even more people in hospital and the ICU. The hightened risk of severe illness from COVID-19 infection during pregnancy is not entirely surprising, given other respiratory viruses are known to increase pregnancy-related morbidity, said Dr. Malinowski, adding that the third wave is proving to be far more challenging among pregnant women whose rates of respiratory compromise, hospitalization, and ICU admission from SARS-CoV-2 infection are now even more pronounced. It is estimated that one in ten pregnant women with COVID-19 will be hospitalized, and one in 100 will require ICU admission. When it comes to concerns about vaccine-induced thrombosis with thrombocytopenia (VITT), “the condition has not been observed with the two mRNA vaccines available in Canada,” said Dr. Malinowski, while cases associated with the AstraZeneca-Oxford vaccine are rare, with overall estimates of 0.73 per 100,000. It noted that because VITT has autoimmune rather than hypercoagulable state origins, pregnancy is not considered a contraindication to the AstraZeneca-Oxford vaccine if other vaccines are not available. Cardiology Magazine, published by the American College of Cardiology, concurs with the low numbers and stated the rates of vaccine-induced VITT are about 3.6 per million people after the AstraZeneca COVID-19 vaccine and 0.9 per million people after Johnson & Johnson vaccine. “For comparison, the rate of cerebral vein thrombosis is estimated at 207 per million in patients hospitalized with COVID-19 and 2.4 per million in the general population. The risk of death and serious outcomes of COVID-19 (including thrombosis) far outweigh the small risk of VITT,” it said. What can pregnant women expect from a COVID-19 vaccine? First of all, Dr. Malinowski stated that the side effects of vaccination in both pregnant and non-pregnant people are similar, most commonly including tenderness at the injection site, and in the minority transient mild fatigue, myalgias, and low-grade fever, which can be safely treated with acetaminophen. Studies looking for indicators of increased risk in the pregnant and neonate population are ongoing, such as the Centers for Disease Control (CDC) and Prevention’s v-safe COVID-19 Vaccine Pregnancy Registry which is conducting ongoing surveillance. By the end of September nearly 162,000 participants who were pregnant when they received COVID19 vaccination were in the registry. The CDC released a statement stating vaccination is safe during pregnancy. Additional sources: 1. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: A systematic review and meta-analysis 2. V-safe COVID-19 Vaccine Pregnancy Registry from the Center for Disease Control

Pregnancy and COVID-19 vax: Talking about the evidence

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