Covid-19, a pneumonia of unknown cause that was first reported in China on December 31, 2019, rapidly escalated in 2020 and became an International Public Health Emergency. Obstetricians and international obstetric agencies attempted to identify the effects of this unusual condition on pregnant women in a short period of time, whether parturients were at a higher risk of morbidity and mortality, and what effect, if any, this disease would have on the foetus.
After the arrival of a potential cure, pregnant and lactating women were not included in any of the COVID-19 vaccine trials, as is conventional in clinical trials. As health systems around the world began to vaccinate eligible adults, thousands of lactating mothers were kept in the dark.
Medically Speaking, thus spoke to several distinguished gynaecologists upon the risks of Covid-19 and precautions that should be followed up by women who are pregnant or planning to their pregnancy via IVF route, in case they catch the virus and whether lactating mothers should get vaccinated. The panel included Dr. Abha Majumdar, Senior Consultant, Sir Gangaram Hospital; Dr. Shivani Sachdev, Director, SCI; Dr Gursimran Khurana, Senior Consultant, Deep Hospital; Dr. Sandeep Chaddha, Gynaecologist, Motherhood Hospital.
Question: Dr Majumdar, the government has finally allowed vaccination for pregnant women. Please help us understand the significance of the vaccine for pregnant women. Why, perhaps, should they not hesitate to get vaccinated?
Dr. Abha Majumdar: The first wave of Covid-19 went over without affecting the pregnant women much. After the launch of vaccines, there was no sufficient data to establish the safety of jabs for pregnant women, as a result of which the government recommended them not to get vaccinated.
But the second wave hit badly and we witnessed the deaths of so many mothers and babies. In every hundred women, we were losing ten women, especially in their second and third trimesters. The Federation of Obs and Gynae wrote many pleas to the government and got the vaccine recommended for pregnant women.
However, I think it would be better if they avoid getting vaccinated during the first three months as it is a critical time for women. Otherwise, go ahead and take the vaccine as it is better than contracting Covid in pregnancy. So, I recommend vaccines for pregnant and to-be-pregnant women.
Qusestion: Dr Sachdev, if a pregnant woman is thinking of a vaccine, which vaccination would you suggest?
Dr. Shivani Sachdev: Right now in India, we have three options- Covishield, Covaxin and Sputnik. The largest study on vaccination in pregnancy is an American study of 90,000 women, where they have used the Pfizer vaccine. They have found it to be safe for pregnant women. The Covishield vaccine, which is a collaboration of Oxford vaccine and AstraZeneca and is manufactured in Pune, is not recommended in the UK. They prefer Pfizer or Moderna over the Oxford vaccine. Also, there is an increased risk of clot formation with the Oxford vaccine. Clots can form in the legs or other body parts of pregnant women and can migrate to the lungs or brain, causing complications like a stroke.
The government of India directive says that pregnant women who are diabetic, have high blood pressure or are immunocompromised, should be given Covaxin instead of Covishield because they would be at a higher risk of complications. However, the incidents of clot formation are just 0.6 per million population. It is really small because there are racial differences also. In the Indian population, you do not see so many cases of clot formation.
On the other hand, if a woman is a low-risk patient, then she can opt for either Covaxin or Covishield.
We have very little data to base any recommendation for the Sputnik vaccine in pregnancy.
Question: Dr Chaddha, what would you tell the pregnant women? Should they wait during their first trimester and get vaccinated in their second and third trimester, when the risk is considerably lower?
Dr. Sandeep Chaddha: I would suggest that they get vaccinated after 18 weeks. That is because till 18 weeks various organs are being formed and we do not know what effect it may have.
All the vaccines are still in the phase 3 trial. It is just Moderna that has had all the trials but it is not available in India. But, after 18 weeks, they should go ahead and take the vaccine because having the disease in pregnancy is worse than having any minor side effects of the vaccine.
Question: Dr. Gursimran Khurana, is there a misconception in smaller towns? Are there women who have misgivings about getting vaccinated? What is your advice to pregnant ladies who are your patients?
Dr. Gursimran Khurana: There are a lot of misconceptions that are prevalent among women regarding the vaccine. The first misconception was that they should not be taking the vaccine during menstruation. This is incorrect. You can take it on any day.
Secondly, they felt that it is unsafe to take the vaccine during pregnancy. I would say that yes, the vaccine should be given during pregnancy, but wait for the first trimester to get over and give it in the second and the third trimester.
The risk of getting Covid in pregnancy is high. Certain women come safely out of Covid, but certain women might require hospitalisation, ICU care, ventilation etc. So, the benefits of taking the vaccine are more than the risk of the disease per se. So, I would recommend the vaccine.
Question: Dr Majumdar, since you specialise in high-risk pregnancy, can you tell us a little about what can happen if a woman gets Covid during pregnancy?
Dr. Abha Majumdar: In February, March and April, people started flocking in for IVF treatment and a lot of them got pregnant. But, the vaccine was still not there for pregnant women. So we lost a lot of pregnancies during the first trimester. An amazing thing happened to a patient who got Covid in the sixteenth week. She lost control of her bladder and all four of her limbs got paralyzed. She is still coming to our neuro physicians and is in recovery now, three months post-Covid. Apart from miscarriages and preterm delivery, Covid can have bizarre symptoms in pregnant women. The third trimester is the worst.
Already, the gravid uterus has taken a large part of the abdomen during pregnancy, so there is compression of the lungs, oxygenation is less. In three cases, we lost both the baby and the mother. In the fourth case, we did a C-sec, took the baby out, but the mother had to be kept 18 hours prone and six hours with the ventilator ultimately we lost her also. These are just four cases. We treated around 400 Covid cases in those six weeks.
I would say that vaccine can be taken after organogenesis is complete in the first trimester. That is, mostly 12 weeks or maybe 14 weeks. We don’t need to delay it.
Talking about the blood clot, we are giving the vaccine in the fat of our upper arm if we are picking up the muscle. The fat is very rich in blood supply and there is a likelihood that any little minuscule of the vaccine goes into the vessel and leads to a blood clot. But that happens once in one lakh injections. So, there is new research about Covishield that the technique of giving the vaccine is very important. We need to stretch the skin and then give the injection so that it goes straight into the muscle, rather than the fat.
Question: Dr Chaddha, in Ganga Ram, they had converted the labour room into a Covid ward. They had about 400 pregnant women who caught Covid. When you go to a private maternity hospital, they have all the amenities. But the fear is that if you catch Covid, you would have to move to a govt hospital or a PPP model like Ganga Ram. So, what do you think. Should private hospitals also start accepting Covid patients? Perhaps, at least those who catch Covid in the middle of their pregnancy.
Dr. Sandeep Chaddha: The private hospitals should take care of their Covid patients because it becomes very difficult for the patient to suddenly leave and go to a new hospital. This is what happened in our hospital in April. We refused a few patients but then we changed our policy. We created a special Covid labour room and Covid OT for patients on separate floors. We have started accepting our patients who tested positive for Covid and we deliver them ourselves.
Question: Dr Sachdev, should people defer going for an IVF treatment as of now?
Dr. Shivani Sachdev: The IVF services were shut for two months last year, but resumed in June. They are now teleconsultations, home pickup of blood samples and minimised visits. The aim is to encourage more people to go in for IVF treatment at the right time.
Question: Dr Khurana, should pregnant women refrain from consuming any sort of Ayurvedic or any other alternative medicine for increasing their immunity against Covid?
Dr. Khurna: I do not have any personal experience with alternative medicines, be it homoeopathy or Ayurveda. I just advised my patients to follow the Covid protocols….to avoid going out as far as possible, taking a healthy diet rich in protein and taking Vit C supplements.
Question: Dr Chaddha, when we speak of medication, there are a lot of pregnant women and lactating mothers who cannot take a lot of medicines for Covid like Fabiflu. What are they supposed to do? What would be your suggestion to such women who are apprehensive about taking certain strong medications?
Dr. Sandeep Chaddha: As of now Fabiflu and Remdesivir have not been proven to be very beneficial. Generally, we avoid Fabiflu and Remdesivir during pregnancy.
So, ideally, you should follow strict Covid protocol and avoid getting the infection. If you do have an infection, you should consult the physician and follow accordingly.
Question: Dr Majumdar, what should breastfeeding mothers do when they get Covid? Should they use a breast pump and give the milk via the bottle or go with the WHO recommendation and feed the child?
Dr. Abha Majumdar: This depends on the condition of the patient. If you have someone to look after you in the postpartum period, it is best to express the milk and give it to them, so that they can feed the baby. It is very important to give breast milk. It is all the more important now because if you have Covid, then you will produce antibodies. You will pass these antibodies to the baby and the baby will be protected.
But in case you are alone, you can hold the baby close to yourself because skin contact does not cause Covid. Wear a double mask while feeding the baby and if possible, wear gloves. Wipe your breasts with water and cotton wool. Suckling doesn’t transmit Covid to the baby. Breast milk needs to go to the baby. Remember that after feeding, the child should be kept separate from the mother.
Question: Dr Chaddha, what about those breastfeeding mothers who have to take medication that is not breastfeeding compatible?
Dr Chaddha: I would recommend that you should keep expressing the milk if you cannot breastfeed the baby because of the medications or your condition. Keep expressing the milk and throwing it away. If you stop expressing the milk, the milk secretion would reduce after you have recovered. Once you recover, the secretion will continue and you will be able to transmit the antibodies to the child, as Dr Majumdar said.
Question: Dr Sachdev, what about breastfeeding and vaccination? Since there are a lot of breastfeeding mothers who are afraid about the side effects of the vaccine, what would you tell them?
Dr. Shivani Sachdev: I would advise them not to be afraid to get the immunisation because Covid is a potentially fatal disease. You cannot gamble with your life, especially if you have a young child. The recommendations for breastfeeding moms were issued by the Government of India long before the recommendations for pregnant women. You would be immune to Covid and might pass the antibodies on to the baby through breast milk. The immunisation will also safeguard your youngster.
Question: Dr Khurana, are you getting any patients who have misgivings about breastfeeding and vaccination?
Dr. Gursimran Khurana: Absolutely. We would just recommend all post-partum mothers take the vaccine because it is the best way to give antibodies to your child. Both you and your child will remain protected. So, all lactating women should get vaccinated.
According to our panel of doctors, prevention is key. The best thing to do is to protect yourself against Covid. If you are breastfeeding, go ahead and get vaccinated. It is not just you but also your baby who is going to benefit from the antibodies. Stay home, stay safe!