Take a Pregnant Pause
Picture this. You’re grappling with COVID’s unfamiliar terrain while also navigating the complexities of pregnancy in ordinary times: this test or that, nutrition and exercise, raging hormones, birth plans and more. It all seems like too much, but thankfully these questions are no match for the expertise of Amanda Williams, MD, MPH, FACOG. After completing her education and training at Harvard, Emory and UCSF, Dr. Williams has worked in a large health care system for 16 years where she oversees the maternity experience for over 45 thousand births per year. In short, she’s what I call a bad-ass. I’ve known Amanda since high school and can vouch for her unstoppable advocacy work for women and racial equity in medicine—plus her humility, humor, and incredible strength of character. I asked her to help us ponder complex decision-making when it comes to COVID, pregnancy and vaccination. Here is what she shared.
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As a mom and an obstetrician who has cared for thousands of patients over 20 years of practice, I say from learned experience that pregnancy can be a trying time. So take the “regular” pressures of gestating a human being, add an unpredictable global pandemic featuring a novel virus, fluid rules and a new vaccine on the block, and you’ve got a formula for some serious hand-wringing.
In the ever-evolving COVID-19 state of play, the last few months have generally shape-shifted pregnancy fears from “I’m scared of getting COVID while pregnant,” to “Is the vaccine safe in pregnancy, and will it protect me from the new variants?” I’m a physician, a scientist, so I like clear-cut, evidence-based answers. And it’s maddening that at times, my only honest answer is that there are no easy answers to those questions.
Here’s what we know. Fundamentally, COVID and pregnancy don’t mix well; COVID makes pregnancy worse—it brings increased risk of preterm birth, c-section and possibly stillbirth—and pregnancy makes a COVID infection and associated risks worse. And despite understandable patient concerns, the vaccine data we have so far from pregnant patients is reassuring.
So what’s a doctor to do? I strive to meet patients where they are. Here’s where my answers tend to land based on where I find patients along the continuum.
Patient #1: The vaccine is a triumph of science! Right, doctor? Where do I sign up?
Amanda Williams (me): Go for it! More than 128,000 pregnant patients have received the vaccine with excellent safety data for both the person and the pregnancy. COVID has taken far too many lives, especially in brown and black communities. If you were my sister, I’d wholeheartedly endorse it.
Patient #2: I’m being careful about everything else—how do I know this is safe for my baby?
AW: We’ve seen no increased risk of miscarriage, stillbirth or birth defects among the more than 128,000 pregnant patients in the national vaccine registry compared with pregnant patients who have not received the vaccine. Additionally, there is some evidence that the antibodies cross the placenta, just as we see with the pertussis (AKA whooping cough) and flu vaccines, so newborns may have some protective benefits after receiving the vaccine in utero. That’s why we recommend patients receive the vaccine during pregnancy and while breastfeeding.
Patient #3: I need a bit more safety info before committing to this thing, myself.
AW: The side effects of COVID mRNA vaccines (Moderna and Pfizer) are minor and short-lived. Fever is no more likely in pregnant patients than non-pregnant patients. There is a slightly increased risk of arm soreness in pregnant patients but this, along with fatigue and muscle aches, generally resolves quickly—and Tylenol can help with all of the above. TTS (thrombosis and thrombocytopenia syndrome), associated with the Johnson & Johnson vaccine, is both more concerning and complicated, since pregnancy generally carries a higher risk of blood clots. Though the vaccine-associated risk is indeed highest in reproductive-age women, at 7 per million women, it’s still far lower than many everyday risks, such as driving a car. Still, since we have choices, I recommend mRNA vaccines for pregnant patients.
Patient #4: This vaccine was created overnight. I don’t want to be a science experiment.
AW: While this vaccine is new, the mRNA vaccine technology behind two of the available options has been in production for a decade. And it’s a marvel of science—no live or deactivated virus involved. It programs your body to recognize the virus, make the virus-like protein and then make antibodies to that...and then disappears once its work is done. When the cord blood of newborns is sampled, none of the virus proteins are seen, but antibodies are. That’s the same reason we recommend pertussis and flu vaccines to patients during pregnancy and while breastfeeding, because they also safely transfer antibodies to the fetus.
Patient #5: This untested vaccine feels like yet another reason not to trust the medical establishment and their talking points.
AW: Especially for brown and black people, the scientific community has an atrocious record of abusing and experimenting on individuals they view as less than human. From the syphilis experiments of Tuskegee in the 20th century to involuntary sterilizations of women at the Mexico border just last year, myriad instances of racism in medicine have caused suffering—even death. Of course, there’s also the implicit bias and systemic racism in our medical system, accountable for so many disparities in plain view when it comes to maternal health. These are true and valid concerns, but this vaccine is different. It’s been well-studied in populations that included, but were not limited to, people of color. I’m committed to your health and safety, just as I was when (insert other event in the patient’s life), and I’m here to answer your questions.
In short, there’s no shorthand for this pandemic. But knowing what we now know, I wholeheartedly endorse the mRNA vaccine for pregnant and breastfeeding patients. As with any decision-making in medicine, pregnancy or just life in general, risk must be calibrated and re-calibrated. We’ve seen both hundreds of thousands of pregnant and breastfeeding people safely vaccinated, and the severe consequences of COVID in pregnancy. Now we need to tailor our patient counseling to understand their “why,” avoid shaming them if they’re just not ready yet and, just as we do whenever there’s hand-wringing in pregnancy (early and often), walk with them on their decision-making journey.
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I will check in next week. Until then, be well.