Obstetricians call for pregnant women to be vaccinated as stillbirths linked to Covid
Seven foetal deaths from Sars-CoV-2 placentitis recorded in State, five connected to variant
Obstetricians have called for the Covid-19 vaccination to be offered to all pregnant women as a priority group due to an up to one-in-100 risk posed by the B117 variant of the virus.
The call comes as new data shows that stillbirths linked to Covid-19 reported in Ireland this year occurred just one to three weeks after the pregnant women’s positive Covid-19 tests.
Postmortems have so far revealed that the babies who died were normally-formed and grown, meaning that the virus, in the cases seen to date, rapidly attacked the placenta only.
Eleven cases recorded of Sars-CoV-2 placentitis so far, including 10 this year, have led to seven foetal deaths, as well as three emergency deliveries due to concerns about foetal distress, where the outcome for mother and baby was good.
Five deaths have been confirmed as being linked to the B117 variant of the coronavirus. Analysis determining the variant in the other two deaths is continuing.
Six deaths are classified as stillbirths, where the foetus is lost after 24 weeks, and one death occurred in the second trimester of pregnancy, at 20 weeks, according to the figures.
Saying that it is difficult to establish the true risk of a stillbirth caused by Sars-CoV-2 placentitis, Prof Keelin O’Donoghue said it ranges from one in 100 to one in 200.
Mortality data for 2019 shows that the chance of stillbirth for a normally-formed baby, without any risk posed by Covid-19, is estimated at one in 350, said Prof O’Donoghue.
‘Opportunity to save babies’
Calling for solutions to protect mothers and babies, Prof O’Donoghue said: “There is an opportunity here to save babies as these cases have shown that the virus attacks the placenta, while the babies are not affected.”
It was judged that pregnant woman faced a small increased risk from Covid-19, but this has changed since the B117 variant emerged late last year, the Cork-based obstetrician said.
“Last year pregnant women with Covid-19 were often advised to isolate at home for 10-14 days and then to visit their healthcare provider, unless they became very unwell,” she said.
“But now if a pregnant women has the Covid-19 infection, we need to know about it straight away as they will require extra surveillance and monitoring.
“A concern regarding these cases is that the women were mostly mildly symptomatic, yet the foetal deaths occurred within one to three weeks, meaning the damage to the placenta was acute and caused harm rapidly.”
Most placentas from pregnant women diagnosed with Covid-19 show no evidence of injury, or no consistent changes caused by the virus, but in a small number the placenta is attacked aggressively, she said.
“With so much damage to the placenta, we are clear this it is not an association, but a cause of stillbirth,” she said, adding that while it is “uncommon”, it has “the potential to cause significant placental injury”.
Dr Brendan Fitzgerald, consultant histopathologist at Cork University Hospital, who first described Sars-CoV-2 placentitis, said “consistent terminology” is needed to identify cases where placenta damage occurs.
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Prof O’Donoghue and Dr Fitzgerald noted that these type of stillbirths are now being seen in other countries and similar cases are under investigation in the UK.
Vaccine cohort system
This week, the Oireachtas Health Committee was told by National Immunisation Office director Dr Lucy Jessop that pregnant women are eligible for the vaccine, but are currently being vaccinated in line with the wider cohort system.
This means that pregnant healthcare workers have been vaccinated, and as more vulnerable pregnant women in medically susceptible categories become eligible for vaccination, they will too.
Meanwhile, the chairwoman of the Institute of Obstetricians and Gynaecologists at the Royal College of Physicians of Ireland, Dr Cliona Murphy, agreed that pregnant women should be offered vaccination.
The number of pregnant women needing intensive care has risen this year, compared with last: “While absolute numbers remain small, they are higher than expected in women of reproductive age,” she said.
Data from the UK showed that the number admitted to critical care with Covid-19 increased after the B117 variant emerged. From current evidence, the same appears true in Ireland.
“Therefore, we can see that pregnant women run additional risks to the rest of the population, which needs to be acknowledged. Cocooning can help reduce these risks but is not practical or feasible for many,” Prof O’Donoghue said.
In the US, more than 86,000 pregnant women had been vaccinated up to mid-April, without any evidence of problems caused by mRNA vaccines.
Regarding vaccination, Dr Murphy said: “My experience clinically is that pregnant women are well informed and weigh up their personal risk and circumstances very well.”
Many healthcare professionals, despite growing evidence about the risks to pregnant woman and their babies, have stopped short of calling for priority vaccine allocation.
However, a change could be in the offing. Prof Karina Butler, the chairwoman of the National Immunisation Advisory Committee (Niac) told the Oireachtas Health Committee that pregnant women “are at increased risk of adverse outcomes”.
While pregnant women were excluded from clinical trials, Prof Butler said the evidence from the US was “very reassuring” and Niac “will be preparing some advices” for the Department of Health.
“If the issue comes that it is recommended in pregnancy, it’s not so much that they require a specific prioritisation as such, but if pregnancy is time-limited, it may be that giving it to them might need to be facilitated in some way.”
She said Niac’s work on the issue is “ongoing at the moment”, and will be coming out “very soon”.
“We’re just finalising what will be coming from that.”
Pregnant women are advised to:
- consider all measures to avoid getting Covid-19
- consider vaccination if offered
- attend routine clinical appointments
- notify their healthcare providers if they test positive for Covid-19 to ensure surveillance is arranged
- present early to a healthcare provider if they have tested positive for Covid-19 and experience reduced foetal movements
‘Pregnant women are being ignored by policymakers’
Sarah Murphy has been “keeping her head down” since becoming pregnant with her second child.
Like all expectant mothers, she is acutely aware of the risks to her and her baby should she contract Covid-19.
The mother of one is 26 weeks pregnant, but at 38 may not be offered a vaccine until mid to late summer.
Pregnant women are being ignored by policymakers, she said.
“I am feeling frustrated that this is not being recognised as a significant risk for pregnant women. There is still not enough attention being paid to the risks.
“There is more and more evidence emerging that the vaccine is safe for pregnant women and that Covid-19 is more and more dangerous for pregnant women, and yet there is a gap. I’m not hearing anything from Cabinet on this.”
Declaring that the State is showing an “institutional, almost patriarchal view” towards pregnant women, Ms Murphy added: “Give us the information and let us choose whether or not to take the vaccine. I’m not saying everyone should or must have it, but I would like to have it available to me.”
She said she can “accept the risks and can [give] informed consent” and that she would “absolutely take the vaccine tomorrow” if offered it and does not believe there is any significant risk from taking it.
“The biggest concern I have is time,” she said. “Everyone carries different risks but with pregnancy there is a time factor there that is beyond our control. If I contract Covid any time in the next three months, then the risks to baby and me are significant.”
Currently pregnant women are vaccinated between 14 and 36 weeks only. Vaccination has to date been limited to women considered at high risk of severe illness and death from the virus.
For now the Blarney resident says she is trying to be “as cautious as possible”. But like most, she has responsibilities which mean she cannot fully protect herself at all times.
“I am trying to be sensible. My husband does the weekly shop but I have a 2½ year old that goes to creche. I am working from home full-time. My mum is in her late 70s and I try to check on her when I can. I am being as cautious as I can but there are responsibilities I have to continue with.”