As per UNICEF statistics, India faces the world’s largest burden of COVID-19 pregnancies as 20.1 million births are expected since the COVID-19 pandemic was declared. This is more than China, which comes second to India, with 13 million births expected. A much-neglected aspect of the COVID-19 pandemic is the psychological stress during pregnancy and its risk on the development of the baby (neurodevelopmental effects on the offspring - published in Journal of Psychosomatic Obstetrics and Gynaecology in May2020)

What are the physical and mental stress factors that pregnant women endure?

Physical discomforts such as nausea, vomiting, feeling tired, mood swings can cause stress in the beginning of the pregnancy, called the first trimester. They need to make changes in daily activities, work patterns. Planning for future finances and adjustments add to the stress.

Further on, pregnancy is associated with several changes in the physiology of the woman which can cause backache, difficulty in sleeping, heartburn, frequent urination, swelling in the feet, stretch marks, itching in the abdominal area and constipation. Additionally, fear of labour, risk of infection while being in the hospital and risk of infection to the baby, coping post-delivery with limited help from family members due to the pandemic can add to the stress.

It has been shown that elevated levels of cortisol, also known as “the stress hormone”, lead to a 2.7 times greater chance of miscarriage within the first 3 weeks after conception in comparison with women with low cortisol levels. This suggests that preventing / decreasing maternal stressors may have a positive outcome on pregnancy

(Published in Reprod Biology Endocrinology 2018)

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What should a pregnant woman do to alleviate stress?

Top 8 tips for pregnant women include:

1. Maintain a daily routine. Get up on time, get ready, have breakfast, work from home, check your e-mails, projects or do your daily activities if you are a homemaker.

2. Rest: Take a 45-minute nap during the day and get 8 hours of sleep in the night.

3. Diet and Exercise: An additional 300 calories per day is the requirement for pregnancy, the diet should be high in protein and low in sugar and refined and processed carbohydrates. Take your pregnancy vitamins and drink plenty of water; 3 litres per day. Avoid caffeine, tobacco, alcohol and harmful drugs. Exercise and yoga appropriate for the pregnancy should be done daily.

4. Take breaks from constant news updates on COVID-19

5. Keep in touch regularly with friends and family use video calling, messaging and stay connected

6. Maintain social distancing strictly. Avoid contact with maids and avoid going out for grocery shopping and using public transport

7. Diligently follow up with your doctor/ obstetrician as most hospitals are doing teleconsultations. For in person visits and scans, wear a mask and use sanitisers or wash your hands before and after leaving the clinic and carry minimal personal belongings which you can keep in a disposable bag to be discarded on reaching home. Only one attendant should be with you. The safest place for your relative accompanying you is in the car, waiting for you, during your appointment.

8. Pursuing a hobby like painting, cooking, karaoke singing, taking care of plants, cleaning up can be extremely stress relieving and are highly recommended

Ministry of Health and Family Welfare Government of India has issued 5 tips to cope with stress during COVID-19

Be Kind to Your Mind {MoHFW}

Tips to cope with stress during COVID-19

PAUSE. Breathe. Notice how you feel, TAKE BREAKS from COVID-19 content, MAKE TIME to sleep and exercise, REACH OUT and stay connected, SEEK HELP and call the helpline

WHO has given Guidelines on how to handle stress related to COVID-19:

Minimise watching, reading or listening to news about COVID-19 that causes you to feel anxious or distressed.  Seek information updates at specific times during the day, once or twice. Stress and the feelings associated with it are by no means a reflection that you cannot do your job or that you are weak. Try and use helpful coping strategies such as ensuring sufficient rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends. Avoid using unhelpful coping strategies such as use of tobacco, alcohol or other drugs. In the long term, these can worsen your mental and physical well-being.

Are pregnant women more susceptible to contracting COVID-19?

Pregnant women are “at risk population” as per the Royal College of Gynecologists UK and also the American College of Obstetricians and Gynecologists.  This is due to changes in the immune system of the pregnant women which is a natural part of pregnancy. Pregnant healthcare workers are considered at highest risk.  The Indian ICMR Guidelines state that: Pregnant women do not appear more likely to contract the infection than the general population. However, pregnancy itself alters the body’s immune system and response to viral infections in general, which can occasionally be related to more severe symptoms and this will be the same for COVID-19.

Reported cases of COVID-19 pneumonia in pregnancy are milder and with good recovery.

Pregnant women with heart disease are at highest risk (congenital or acquired).

In other types of coronavirus infection (SARS, MERS), the risks to the mother appear to increase in particular during the last trimester of pregnancy.

There are case reports of preterm birth in women with COVID-19, but it is unclear whether the preterm birth was always iatrogenic, or whether some were spontaneous.

The coronavirus epidemic increases the risk of perinatal anxiety and depression, as well as domestic violence. It is critically important that support for women and families is strengthened as far as possible; that women are asked about mental health at every contact

A meta-analysis was published by Mascio et al in the American Journal of Obstetrics and Gynaecology MFM in which 41 COVID positive pregnant women were studied and the following complications were noted:

Preterm birth <37 weeks (41.1 %),

PPROM (18.8 %),

Preeclampsia (13.6 %),

Caesarean delivery (91.1 %),

They warn that the data reflect small numbers and more studies are required

It is said that pregnant women should walk more, but is it fine if that activity is confined to inside the house?

Regular walking for 30 minutes in a day during pregnancy strengthens and tones muscles, keeps your cardiovascular system (heart) healthy and helps to release endorphins which are the stress relieving neurotransmitters in the brain. This gives a wonderful sense of wellbeing. You do not need to miss going out to a gym or out of your home. You can watch Youtube or Instagram videos to guide you in walking and stretching exercises and Yoga during pregnancy and practice these at home. You can walk about in your balcony during the time of day when the weather is cooler. Remember that during pregnancy you should avoid exercises which involve lying on your back or your stomach, avoid exercises in which you may lose your balance, especially in the third trimester. Pelvic floor exercise is perhaps the most important of all and can be done throughout pregnancy and even post-delivery for 2 months to reduce the chances of pelvic floor laxity and urinary incontinence. They are the easiest and can be done even while cooking or doing other activities

How can the stress level of mothers affect the baby?

Numerous studies have shown that maternal stress can have a profound effect on the baby. Stress can cause pregnancy and birth complications like high blood pressure, preeclampsia, diabetes, premature delivery and low-weight babies. Even low levels of stress can cause preterm births and low-weight babies who are more likely to experience asthma allergies and childhood infections

The greatest impact is seen when stress occurs early in pregnancy. An article published in Epidemiology Journal noted that major stress around conception resulted in increased risk of conotruncal heart defect, neural tube defects or isolated cleft lip in the baby.

(Carmichael SL, Shaw GM. Maternal life event stress and congenital anomalies. Epidemiology 2000; 11: 30–5)

A study published in The Journal of Obstetrics Medicine has shown that psychosocial stress and pregnancy-specific distress are both associated with increased levels of inflammatory cytokines (interleukin-6 and tumour necrosis factor-α) in the pregnant woman and prenatal stress is linked with difficult temperament and affective disorders in the child

Journal of Neurodeveolpmental Disorders has published studies suggesting trans-generational effects of gestational stress. The implications of these findings are important as they suggest that the effects of prenatal stress may affect several generations

How does one tackle post pregnancy tension or stress?

Post pregnancy, most new mothers will experience “baby blues”. There is a sharp decline in estrogen and progesterone hormones and the lack of sleep, mood swings and new responsibilities can all be very overwhelming. These are the top 7 tips to tackle the post pregnancy stress.

Do not neglect yourself: at regular intervals get sleep, eat a nutritious diet, high in proteins. An additional 600 calories per day are required for breast feeding mothers. Avoid caffeine, alcohol and smoking. Avoid indulging in junk food and do not miss meals

Try to avoid doing activities which cause you stress. “Don’t stress about stress”. 

Try to establish a routine as much as practically possible for daily activities: Take a bath, get dressed have breakfast, check your work updates or check on your household work for home makers.

Take a few minutes daily for some leisure activities like listening to relaxing music

Take time out to exercise or have a massage. There are many mediation techniques and breathing exercises in Yoga to keep the mind and body calm and relaxed

Do not hesitate to ask for help from your family and friends. Do not be withdrawn but keep in touch with your loved ones

If you experience severe problems that you cannot resolve like difficulty in sleep, excessive crying, feeling of guilt or sadness, then you must seek professional help and contact your doctor

What are the main difficulties faced by pregnant women during this period of COVID?

Due to the pandemic there is likely to be lack of social support and there could be difficulty in access to medical care in person with most of the follow up appointments being done on telephone or online.

Difficulties with breast feeding such as not getting enough breast milk, retraction of the nipple

Difficulties in looking after the newborn and handling issues such a colic or constipation in the newborn due to lack of knowledge for first time mothers, especially

Postpartum blues and coping with the feeling of depression

Stress related to maternity leave at work and resuming work with childcare issues

How adversely will coronavirus affect newborns and mothers?

This is currently a priority for research and the data is at an evolving stage. It will take several years to completely understand the implications for babies born in the COVID-19 pandemic. For now, what we know from various studies is summarised:

A meta-analysis published in the American Journal of Obstetrics and Gynaecology noted that in COVID-19 positive mothers the stillbirth rate was 2.4%, admission to intensive care unit for the baby was 10% and neonatal death rate was 2.4%

Evidence from China suggests that the virus may be transmitted vertically (from mother to the baby from the placenta - Dong L JAMA 2020). 3 out of 33 babies all born by C-Section, to COVID positive mothers, tested positive for coronavirus

Lancet has published a study from China where Chen et al have found no evidence of COVID-19 in the amniotic fluid or cord blood of 6 infants of infected women

According to the Indian Council of Medical Research, emerging evidence now suggests that vertical transmission is probable, although the proportion of pregnancies affected and the significance to the neonate is yet to be determined.

At present, there are no recorded cases of vaginal secretions being tested positive for COVID-19.

At present, there are no recorded cases of breast milk being tested positive for COVID-19.

There are currently no data suggesting an increased risk of miscarriage or early pregnancy loss in relation to COVID-19.

There is no evidence currently that the virus is teratogenic. Long term data is awaited.

COVID-19 infection is currently not an indication for Medical Termination of Pregnancy

A WHO report concluded that out of 147 pregnant women diagnosed with COVID-19, 8% had what the WHO classified as “severe disease” and 1% were “critical.”

It was determined that they weren’t more likely than non-pregnant people to develop a life-threatening illness.

A study published in The New England Journal of Medicine analysed data from pregnant women who delivered in New York City. They reported that out of 215 patients, 88% of women who tested positive for COVID-19 did not show any symptoms

A study of 43 pregnant women in New York with confirmed COVID-19 published in the American Journal of Obstetrics & Gynecology in April found that unlike SARS and H1N1, pregnant women do not seem to experience more severe illness from the coronavirus compared to the general population.

The National Institutes of Health has launched the largest study to date on COVID-19 and pregnancy to study the effects of COVID-19 pandemic during and after pregnancy. Researchers will analyse the medical records of up to 21,000 women to evaluate whether changes to healthcare delivery that were implemented as a result of the pandemic have led to higher rates of pregnancy-related complications and Caesarean delivery. They also seek to establish the risk of pregnant women with COVID-19 infection transmitting the virus to their foetus. Newborns will be monitored and assessed until they are discharged from the hospital.

In addition, the study will track more than 1,500 pregnant women confirmed with COVID-19 infection, monitoring their health for six weeks after childbirth. These results will help with useful insights on the impact of the pandemic on pregnancy and the babies born

(The answers to the questions are given by Dr Shivani Sachdev Gour, Director of SCI Healthcare, Gynaecologist & IVF Expert)