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In some of the states hardest hit by the Covid-19 pandemic, doctors are sounding the alarm about a devastating impact the virus could have on pregnant women: stillbirths.
Nationally, the total number of stillbirths among pregnant women with Covid appears to be very low. According to the Centers for Disease Control and Prevention, 266 pregnancies have ended in loss since the start of the pandemic.
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But although reports remain anecdotal, there are new signs of an increase in stillbirths in some states with low vaccination rates, and many appear to be concentrated in the Deep South.
In Mississippi, for example, the state’s health department has identified 72 stillbirths among women with Covid-19 since the start of the pandemic – more than double what the state would normally expect over the course of from the same period, Dr Thomas Dobbs, the state’s health official, said this week at a press conference.
“It’s a number of tragedies that would unfortunately be preventable,” Dobbs said. Almost all of these mothers, he said, had not been vaccinated against Covid-19.
Mississippi has one of the lowest vaccination rates in the country, with just 39% of residents fully vaccinated. Even before the pandemic, the state had the highest infant mortality rate in the United States, at more than 9 per 1,000 births.
It remains to be seen whether the apparent trend in Mississippi illustrates what is happening in other parts of the country.
But doctors in neighboring Alabama, where the vaccination rate is just as low, have also noticed stillbirths associated with Covid among pregnant women.
At the University of Alabama at Birmingham, the stillbirth rate associated with Covid has ranged from 3% to 6% during the pandemic, said Dr Akila Subramaniam, associate professor in the Maternal and Fetal Medicine division of the UAB.
That’s higher than the usual stillbirth rate seen at his facility, said Subramaniam, which is around 2%. (Nationally, the stillbirth rate is less than 1%, but UAB treats high-risk pregnancies.)
Still, Subramaniam said the total number of stillbirths is far too low to draw any cause-and-effect conclusions.
“Everything we see with stillbirths is really anecdotal. We don’t have the numbers to confirm what we perceive we are seeing,” she said.
Doctors may see an increase in stillbirths just because there are more pregnant women sick with Covid-19, said Dr Brenna Hughes, chief of the maternal and fetal medicine division at Duke University Medical Center in Durham, North Carolina.
The super contagious delta variant of Covid-19 has led to an increase in the number of infected young adults, including women of childbearing age.
According to the CDC, 118,267 cases of Covid-19 have been reported in pregnant women during the pandemic. In recent weeks, ICU doctors have reported an increase in severe cases among unvaccinated pregnant women.
“Since we’re seeing more pregnant women getting sick, it’s no surprise to me that we unfortunately see a higher rate of fetal loss and stillbirth,” said Hughes.
What is the link ?
The mechanism behind any apparent link between Covid-19 in pregnant women and fetal death remains unclear. But it’s not uncommon for infections, like the flu or syphilis, to affect pregnancies.
“Anytime you have a mother who is really, really sick, the baby is also at risk of getting very, very sick,” said Dr. Marc Incerpi, chief of maternal and fetal medicine at Keck Medicine at the University of California. South.
Incerpi has not seen an increase in stillbirths similar to those in Mississippi and Alabama, but has seen an increase in premature births in mothers too sick to carry the baby to term.
Sometimes, said Incerpi, “we have no choice but to deliver them prematurely.”
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There are several aspects of Covid-19 in particular that could explain a possible link between infection in mothers and poor outcomes in babies.
Covid-19 is known to affect the supply of oxygen. “If you can’t give the baby enough oxygen, it increases the risk of bad things happening to babies,” Hughes said.
Dr Cindy Celnik, chief medical officer at Woman’s Hospital of Texas, Houston, has also seen how Covid-19 can affect a woman’s air supply.
“I have never seen healthy young women having to go through this,” she said. “It destroys their lungs.”
Additionally, the overwhelming inflammation that can occur with severe Covid-19 causes the body to produce nitric oxide, which in turn dilates blood vessels, resulting in dangerously low blood pressure in some patients.
And when the blood pressure drops too much, “they can’t get enough blood to circulate to the baby. It can also cause stillbirth,” said Hughes.
There is also emerging evidence that inflammation could affect pregnancies in other ways.
Subramaniam, of UAB, said his team had detected elevated levels of white blood cells in the placentas of women who were Covid-19 positive. These cells are part of the immune system and are associated with inflammation – although she added that much more research is needed to understand the link between the virus, white blood cells and the placenta.
Other research has also observed a link between Covid and inflammation in the placenta. A small study of 50 women, published this month in the American Journal of Obstetrics & Gynecology, found placental inflammation in women with the virus.
One of the study’s authors, Dr Christopher Golden, a neonatologist at Johns Hopkins Medicine, said it appeared the risk of Covid-related complications was higher later in pregnancy.
“If you are infected when you were about to give birth, there is an increased risk of multiple perinatal complications,” Golden said. “Stillbirth is one of them.”
Experts have pointed out that the Covid-19 vaccine can prevent these complications; almost all of the Covid-positive pregnant women who experienced complications had not been vaccinated.
Covid vaccines have been shown to be safe in pregnant women and their babies, and do not increase the risk of miscarriage or stillbirth.
The CDC, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine all recommend that pregnant women get the Covid-19 vaccine.
“The vaccine could actually save your baby,” Hughes said.
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