COVID exacerbated a health crisis in pregnant women

KOKOMO, Indiana – Tammy Cunningham does not remember the birth of her son. She was not quite seven months pregnant when she became acutely ill with COVID-19 in May 2021. When she was taken by helicopter to an Indianapolis hospital, she was coughing and gasping for air.

The baby wasn’t due for another 11 weeks, but Cunningham’s lungs failed. The medical team, concerned that neither she nor the fetus would survive while she was pregnant, asked her fiancé to authorize an emergency caesarean.

“I said, ‘Are they both going to make it?'” Matt Cunningham recalled. “And they said they couldn’t answer that.”

New government data suggests scenes like this were playing out with shocking frequency in 2021, the second year of the pandemic.

The National Center for Health Statistics reported Thursday that 1,205 pregnant women died in 2021, a 40% increase in maternal deaths from 2020’s 861 deaths and a 60% increase from 2019’s 754 deaths.

The census includes deaths of women who were pregnant or were pregnant within the last 42 days from causes related to or aggravated by pregnancy. A separate report by the Government Accountability Office has cited COVID as a contributing factor to at least 400 maternal deaths in 2021, accounting for much of the increase.

Even before the pandemic, the United States had the highest maternal mortality rate of any industrialized nation. The coronavirus worsened an already dire situation, raising the rate from 20.1 per 100,000 live births in 2019 to 32.9 per 100,000 births in 2021.

Even before the pandemic, the United States had the highest maternal mortality rate of any industrialized nation. The coronavirus has exacerbated an already dire situation.

Racial differences were particularly acute. The maternal mortality rate for black women rose to 69.9 deaths per 100,000 live births in 2021, 2.6 times the rate for white women. From 2020 to 2021, the death rate for Native American and Alaskan women who were pregnant or who had given birth in the previous year doubled, according to a study published Thursday in Obstetrics & Gynecology.

The deaths only tell part of the story. For every woman who died from a pregnancy-related complication, there were many others, like Tammy Cunningham, who suffered a serious illness that results in premature birth and can affect the long-term health of both mother and child. Loss of wages, medical bills and psychological trauma add to the stress.

Pregnancy makes women particularly vulnerable to infectious diseases like COVID. The heart, lungs and kidneys work harder during pregnancy. The immune system, while not exactly weakened, is recalibrated to accommodate the fetus.

Abdominal pressure reduces excess lung capacity. Blood clots more easily, a tendency exacerbated by COVID, increasing the risk of dangerous constipation. The infection also appears to damage the placenta, which supplies the fetus with oxygen and nutrients, and can increase the risk of a dangerous pregnancy complication called preeclampsia.

Pregnant women with COVID have a sevenfold risk of dying compared to uninfected pregnant women, according to a major meta-analysis tracking unvaccinated individuals. The infection also makes it more likely that a woman will give birth prematurely and the baby will require neonatal intensive care.

Fortunately, the current Omicron variant appears to be less virulent than the Delta variant that emerged in summer 2021, and more people have now acquired immunity to the coronavirus. Preliminary figures suggest that maternal mortality in 2022 has fallen to around pre-pandemic levels.

But pregnancy remains a factor that makes even young women particularly vulnerable to serious illnesses. Cunningham, now 39, who was slightly overweight when she was pregnant, had just been diagnosed with gestational diabetes when she fell ill.

“I talk about this with all my patients,” said Dr. Torri Metz, a maternal fetal medicine specialist at the University of Utah. “If they have some of these underlying medical conditions and are pregnant, both of which are high-risk categories, they need to be extra cautious about putting themselves at risk of exposure to any type of respiratory virus, because we know that pregnant people get sicker from these viruses.”

Delayed vaccinations

In the summer of 2021, scientists were somewhat unsure about the safety of mRNA vaccines during pregnancy; As is so often the case, pregnant women were excluded from the clinical studies. As recently as August 2021, the Centers for Disease Control and Prevention released clear guidance to support vaccination of pregnant women.

Most pregnant women who died from COVID had not been vaccinated. Today, more than 70% of pregnant women have received COVID vaccines, but only about 20% have received the bivalent booster shots.

“We definitely know that vaccination prevents serious illness and hospitalization and prevents poor maternal and infant outcomes,” said Dr. Dana Meaney-Delman, chief of the CDC’s Infant Outcome Surveillance, Research and Prevention Division. “We have to keep emphasizing that.”

We definitely know that vaccination prevents serious illnesses and hospitalizations and prevents poor maternal and child outcomes. We have to keep emphasizing that.”
– dr Dana Meaney-Delman, chief of the CDC’s Division of Surveillance, Research and Prevention of Infant Outcomes

Cunningham’s obstetrician had encouraged her to get the shots, but she hesitated. She was “almost there” when she suddenly began having unusually profuse nosebleeds that produced blood clots “the size of golf balls,” she said.

Cunningham also felt short of breath, but she attributed that to the advancing pregnancy. (Many COVID symptoms can be missed because they resemble those typically seen in pregnancy.)

A COVID test came back negative and Cunningham was happy to return to her job. She had already lost wages after previous pandemic furloughs at the auto parts plant where she worked. On May 3, 2021, shortly after clocking in, she turned to a friend at the factory and said, “I can’t breathe.”

When she arrived at the IU Health Methodist Hospital in Indianapolis, she was suffering from acute shortness of breath. Doctors diagnosed pneumonia and found patchy shadows on her lungs.

Her oxygen levels continued to drop even after she was given undiluted oxygen and even after the baby was born.

“It was clear that her lungs were extremely damaged and could no longer function independently,” said Dr. Omar Rahman, an intensive care physician who treated Cunningham. Already on a ventilator, Cunningham was hooked up to a specialized cardiopulmonary bypass machine.

Jennifer McGregor, a friend who visited Cunningham in hospital, was shocked at how quickly her condition had deteriorated. “I can’t tell you how many bags were hanging there and how many tubes went into her body,” she said.

But over the next 10 days, Cunningham began to recover. When she was weaned off the heart-lung machine, she found that under sedation she had missed an important life event: having a son.

He was born 29 weeks and two days into pregnancy and weighed 3 pounds.

Preterm births fell slightly in the first year of the pandemic. But they surged in 2021, the year of the delta rise, reaching the highest rate since 2007.

About 10.5% of all births that year were preterm, up from 10.1% in 2020 and 10.2% in 2019, the year before the pandemic.

Although the Cunninghams’ baby Calum never tested positive for COVID, he was hospitalized in the NICU at Riley Hospital for Children in Indianapolis. He was on a breathing tube and occasionally stopped breathing for seconds.

Doctors feared he wasn’t gaining weight fast enough – “failure to thrive,” they wrote on his chart. They worried about possible vision and hearing loss.

But after 66 days in the NICU, the Cunninghams were able to bring Calum home. They learned how to use his feeding tube by practicing on a mannequin and prepared for the worst.

“From what they told us, he would have developmental delays and be really behind,” said Matt Cunningham.

After being discharged from the hospital, Tammy Cunningham was given strict orders to have a caretaker with her at all times and to rest. She did not return to work for seven months after finally getting her doctors’ approval.

Cunningham has three teenage daughters and Matt Cunningham has another daughter from a previous relationship. Money was tight. Friends brought groceries and the landlord accepted late payments. But the Cunninghams received no government aid: they were even turned down for food stamps.

“We had never asked for help in our lives,” Tammy Cunningham said. “We were workers. We used to work seven days a week, eight hours a day, sometimes twelve. But when the whole world shut down in 2020, we used up a lot of our savings, and then I got sick. We were never caught.”

Despite returning to work at the plant, Cunningham has persistent symptoms, including migraines and short-term memory problems. She forgets doctor appointments and what she went to the store for. She recently left her card in an ATM.

Many patients are so traumatized by their stay in the intensive care unit that they develop what is known as post-intensive care syndrome. Cunningham has flashbacks and nightmares about being back in the hospital.

“I wake up feeling like I’m going to be suffocated in the hospital or like they’re going to kill my whole family,” she said. She was recently diagnosed with post-traumatic stress disorder.

However, Calum surprised everyone. Within months of returning home from the hospital, he was achieving developmental milestones on time. He started running shortly after his first birthday and likes to join in with “What’s up?” and “Oh oh!”

He was back in the hospital with viral infections, but his vocabulary and understanding are excellent, his father said. “If you ask him if he wants a bath, he’ll strip all his clothes off and meet you in the bathroom,” he said.

Louann Gross, who owns the daycare Calum attends, said he has a hearty appetite — often asks for “thirds” — and can more than keep up with his peers. She added, “I called him our ‘super baby.'”

COVID exacerbated a health crisis in pregnant women

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