Next Generation is a Brigham Clinical & Research News column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email us. This month’s column is written by Alice Abernathy, MD, a resident in Obstetrics and Gynecology.
Since the first cases of COVID-19 were reported out of Wuhan, China, more than 26 million people in the United States alone have been infected with the novel coronavirus. Among these are more than 64,000 pregnant women. I’m in my last year of residency in Obstetrics and Gynecology, and I take care of patients with COVID-19 infection every day. I see firsthand how the virus alters everything about childbirth, both because of my field of practice and because I am pregnant.
As a resident, I carefully monitor our pregnant patients, and not uncommonly I gown up, put on my N95 mask and wheel a patient to the intensive care unit for respiratory support. The data, reports and articles informing their care buzz constantly through my brain. I can recount in excruciating detail each patient’s clinical decline to intubation and all the steps that lead to delivery by Caesarean section while the mother remains passive, sedated on a ventilator.
As a pregnant person, I look closely at these future parents — their bellies often similar in size to my own — and I fear for them and for myself. Their faces remain with me. I wonder, could I too be a patient for whom pregnancy ends with unknowingly experiencing the birth of my first child? With each shift, I watch patients’ vital signs and wonder could this be me, my sister, my friend?
I am intimately aware of the known risks associated with pregnancy and coronavirus infection. Yet, like many women who are considering becoming pregnant, already pregnant or are breastfeeding, I was unsure of my next steps when I was offered the COVID-19 vaccine at Mass General Brigham. I was relieved that so many of those who work tirelessly beside me would now be able to protect themselves and, by reducing their risk of infection, their loved ones at home as well. I felt a deep sense of gratitude toward those responsible for bringing the vaccine through phase 3 clinical trial so quickly. At the same time, I still felt nervous about getting the vaccine while pregnant.
Pregnant and lactating women were not included in the trials for COVID-19 vaccines and are generally excluded from participating in most clinical trials. Excluding pregnant women is thought to protect the pregnant person and their fetus from unknown risk. Yet I did not feel protected. I felt very much at risk. Like all pregnant women, I belong to a population at high risk for severe infection. Pregnant patients with the coronavirus are at increased risk for severe illness compared with their non-pregnant peers. Coronavirus infection also increases risk of preterm birth, and we are only just beginning to understand the impact of infection on how the placenta develops, transmission to the fetus and on fetal growth and development. Guidance from the Centers for Disease Control and Prevention states that “people who are pregnant and part of a group recommended to receive the COVID-19 vaccine may choose to be vaccinated.” The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine recommend that pregnant and lactating women discuss the COVID-19 vaccine with their OB/GYNs and be offered the vaccine.
Fortunately, most days I work directly with experts at the Brigham in maternal fetal medicine, reproductive infectious disease and intensive care of both mother and baby. I diligently began polling my colleagues. I confided in my pregnant peers and felt safeguarded by their understanding of my trepidation surrounding the unknowns of the vaccine in pregnancy. After these informal conversations with the experts, my own research and knowing many of my pregnant peers had arrived at the same conclusion, I felt reassured. To me, the theoretical risks of receiving the vaccine seemed minimal in comparison to the known risks of contracting the coronavirus in pregnancy.
When I was around 24 weeks, I received the vaccine. A nurse who recently gave birth at the Brigham efficiently administered the vaccine to me. I promptly felt tears well up in my eyes. I suddenly realized that the weight of the fear I was carrying, and diligently ignoring, was slowly receding. I felt overwhelmingly privileged to be offered the vaccine and to have the opinion of my colleagues to help guide my decision to take the vaccine.
The individual variables that put patients at risk for severe infection play out in a complex realm of structural factors such as access to care, systemic racism and the historic and continued inequities in the health care system. These issues affect health outcomes for all patients, but dramatically so for pregnant women — especially when the information to guide critical decisions regarding reproductive health is limited. Until pregnant and lactating women are included in all phases of vaccine campaigns, each of us must engage in well-informed decision-making while we wait for more information.
In the meantime, I will remember the faces, stories and data that ground the clinical course of the patients I care for. I will continue to advocate for my patients to have access to the vaccine. Most of all, I will work to provide my patients the same option I had: to discuss the vaccine with their provider and determine if receiving it during pregnancy is the best choice for them and their baby.