Pandemic raises anxiety for expectant mothers amid higher intensive care risk
Like business owners across the country, Nichole Chakur has worried how her physical therapy practice will survive the coronavirus. But as a first-time pregnant mother, that's just one of her concerns.
For women who are pregnant, the pandemic can be particularly fraught with anxiety as they worry about the effects of COVID-19 on themselves and their babies, all while coping with potential job loss, child care issues and economic uncertainty.
"I had some depression and anxiety in the beginning, being a practice owner and dealing with that on top of pregnancy," said Chakur, whose baby is due on Oct. 18.
"It’s kind of scary, like, 'Am I going to make it through this? Is my business going to survive?" she said. "It adds this extra level of stress at a time when you really want to monitor your stress level and blood pressure, and make sure the baby’s not stressed either."
An evolving body of research — including a recent study by investigators at the Wayne State University Medical School and the National Institutes of Health Perinatology Research Branch in Detroit — has shown it's unlikely for the virus to pass from a pregnant woman to her fetus.
A data analysis of U.S. cases, published by the federal Centers for Disease Control and Prevention in July, concluded that pregnant women are at no greater risk of dying from the virus than non-pregnant women, though they are more likely to end up in intensive care and require a ventilator.
In February, when Chakur, 33, of Macomb Township learned she was pregnant, neither she nor her doctor knew any of that.
"It was very harrowing at the beginning of this because we didn’t know anything about it," said Dr. Brian Torok, chief of Obstetrics and Gynecology at Beaumont Hospital in Troy, and Chakur's doctor at Clinton Women's Healthcare.
"Initially we thought it was all being transmitted just by putting your hands in your mouth or any kind of mucus membrane — we didn’t think it could be transmitted just by respiratory particles," he said. "Our initial thought of what to do to protect ourselves was 100% different than right now, where mostly we feel it’s respiratory spread.
"And then we figured out how to treat it; we’re using treatments now that we never would have thought of using before, and medicines that we never would have thought would help."
Transmissions to babies?
With 24 million cases of COVID-19 worldwide, including about 6 million in the United States and more than 100,000 in Michigan, there has been no consistent evidence of pregnant mothers passing the infection to their newborns, what's called vertical transmission.
While other viral infections such as Zika, cytomegalovirus and rubella can be passed from mother to fetus, researchers led by Dr. Roberto Romero, chief of the Perinatology Research Branch at the National Institute of Child Health and Human Development at Wayne State, investigated why the same isn't true of SARS-CoV-2, the virus that causes COVID-19.
"The rate of vertical transmission is extremely low," Romero said. "The best estimates that we have are less than 2%, or less than 1%.
"There have been some reports of neonates testing positive after birth, but there is always the question: Was that virus acquired in utero, or was it acquired from a mother who is sick?"
For a virus to infect a cell, the cell surface needs to express a receptor for the virus. So Romero's team used cutting-edge molecular techniques, such as single-cell genomics, to determine if placental cells have that ability.
The main receptor for SARS-CoV-2 is something called ACE2, for angiotensin converting enzyme 2. And the spikes seen in images of the virus are activated to invade the cell by an enzyme called TMPRSS2.
Cells that expresses both ACE2 and TMPRSS2, such as those found in the lungs, are especially inviting to the new coronavirus. But the Detroit research team found that placental cells don't have the ability to create those receptors.
"In contrast, the receptors for other viruses known to cause fetal infection such as Zika and cytomegalovirus were found in placental cells," Romero said.
The Wayne State researcher noted the CDC study that found pregnant women with COVID-19 are more likely to end up in the intensive care unit or on a ventilator than are non-pregnant women, though their risk of dying from the virus is about the same.
Pregnancy places women at higher risk of severe illness with any kind of respiratory infection, said Dr. Stanley M. Berry, professor of obstetrics and gynecology at Wayne State University and a member of the Perinatal Research Branch.
"The flu or chicken pox, respiratory infections in general, aren’t dealt with really well by pregnant women," he said. "So it certainly it makes sense that they would be more prone to ending up in the ICU and a ventilator (with the coronavirus)."
Those risks are compounded for African American women, who are more likely to suffer from chronic health conditions such high blood pressure or asthma, Berry noted.
"One of the reasons Detroit got hit so hard with COVID is the underlying disease burden — of hypertension, diabetes, obesity — and all of those diseases are reflected in our pregnant population to a higher degree than in more affluent patients," he said.
"That makes our patients a set-up for a disease like COVID. You have polluted air, and that increases the risk of asthma, and if you have asthma going into COVID, that really ups the chances that the disease is going to be a killer, and that it’s going to leave long-lasting sequala (a condition resulting from a prior disease, injury, or attack)."
Reassuring track record
The growing body of knowledge about the virus, and how to prevent and treat it, has been reassuring to OBGYNs like Torok, and for expectant parents.
"It’s been very reassuring for us because, in the obstetrical world, we never stopped — the rest of the hospital shut down to treat COVID-19 patients, but we had pregnant women going in every day like they normally would to deliver their babies," he said.
Roxana and Florin Zaha of Shelby Township said they've been focusing on the positive while expecting a sibling to join their 7-year-old son and three-and-a-half-year-old daughter at home.
"We really wanted to get pregnant, and we found out in February," said Roxana, a 36-year-old attorney. "Soon thereafter, (the pandemic) got bad. And so I would say, of all of the pregnancies, this one has been the roughest.
"Those first three to four months were rough in many respects — not feeling well, being extremely worried about the virus, all of a sudden having to home-school and keeping up with a demanding (legal) practice all at once."
"I feel like we are on the other side of that at this point. You just have to kind of work through it."
The couple could no longer see Roxana's parents, whom they counted on for child care and moral support. But they leaned on their religious faith and each other, she said.
"I think he was the stronger one of the two of us. He was the one who gave hope and encouragement," Roxana said of her husband.
There were a lot of unknowns in the beginning, Florin said, but the couple's confidence has grown and their fears have diminished.
"I do believe that the medical community now has a better understanding of the virus. The recovery rate has increased tremendously from the beginning of the pandemic," he added.
"Of course we still follow the guidelines, we are acting in a safe manner — wash your hands as soon as you come home from shopping, or anywhere else, and wear the mask, stay socially distant. But it's not the same level of panic as in the beginning."
For now, the couple is focused on the happiness of bringing a new baby into their family.
"My husband said it pretty well the other day," Roxana said. "He said fear is not going to make the virus go away, but what it will do is it will take your joy away — and pregnancy’s a beautiful thing, it’s a joyous time."
"So we’ve got to be cautious, certainly, but we can’t live in fear."
Torok said couples don't need to postpone getting pregnant until after the pandemic is over. In fact, he's expecting an increase in births this winter — perhaps an unintended consequence of the governor's stay-at-home orders.
"If they’ve got the economic ability to have a baby and they’re at a point in their life where they want to bring a child into this world, I have no hesitation in telling them to do so," he said.
"I think I saw six women last week that were all early pregnancies, and they were all within six days of June 10 or June 16. So I think we’re going to start seeing the numbers bump," he added.