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Warner Huh, MD (Host): Hello, this is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama in Birmingham. I'd like to welcome you to another monthly episode of Women's Health with Dr. Huh.

Today, we're going to actually have a followup podcast on the topic of COVID in pregnancy. And some of our listeners probably recall that one of the very first podcast of the series was on the topic of COVID in pregnancy, which was obviously a timely topic, given the COVID pandemic. And at that time, it was clear that the pandemic wasn't going away anytime soon.

But since then, we've obviously had had two additional surges, the Delta surge and the Omicron surge. And I felt that it was a timely update to give our listeners a better understanding of what we know about COVID and pregnancy.

And so with me today is Dr. Akila Subramaniam, who is an Associate Professor in the Division of Maternal Fetal Medicine at UAB. Of note, Dr. Subramaniam is the only board-certified MFM and geneticists in the state of Alabama. And she's a true legitimate expert in infectious diseases in pregnancy. Welcome, Dr. Subramaniam.

Dr. Akila Subramaniam: Thank you, Dr. Huh, for having me this afternoon.

Warner Huh, MD (Host): So obviously, as I mentioned earlier, Dr. Audra Williams and Dr. Rachel Sinkey last year gave us a really great update in terms of what we knew at that time about COVID infection in pregnancy. And when you look back, it was the first half of the epidemic. It was obviously becoming very clear that both the morbidity and mortality was higher in pregnant women. And since that time, we've had two major surges. I thought maybe you could just update us in terms of the listener's better understanding of what we know about COVID in pregnancy and has things changed and, if they have, how they've changed.

Dr. Akila Subramaniam: Yeah. So I think, you know, the last time you guys had this podcast, it was like you said very early in the pandemic and really the data that we had and the evidence that we had about what COVID was doing to pregnant patients was really small. At this point now over a year after that point in time, after the Delta surge and now the Omicron surge, we just have plenty of data from across the world that has shown and demonstrated repeatedly the effects of COVID-19 in pregnancy. And what we're seeing more or less conclusively is that women who are pregnant with COVID are delivering their babies earlier, so having preterm births. They're three times more likely to need an ICU admission. They are at least two to three times more likely to even die from COVID. So even though the majority of these women are going to have mild disease or asymptomatic, they are more likely to get severe illness than their non-pregnant counterparts and they're more likely to have really adverse outcomes, like I said, ICU admission and possibly even death.

And I think with other things that have sort of come to light since the Delta variant is that we're seeing this very palpable increase in stillbirths. And stillbirth is something really hard to look at, because it's rare in a general population. And so when you're seeing this increase, we can't really ignore that that's what we're seeing amongst individuals who are pregnant and then get COVID.

Warner Huh, MD (Host): So, let me see if I can just summarize that for the listeners. So what we know definitively over the last year or so is, A, that the morbidity and the mortality of women who are pregnant and have COVID is definitively higher; B, that the rate of preterm labor is higher; and then C, we're seeing an uptick in terms of the rate of stillbirths, is that correct?

Dr. Akila Subramaniam: That's correct.

Warner Huh, MD (Host): Okay. Yeah. I mean, I think we were just starting to really appreciate the impact and I think that it sounds like we have much greater clarity on the specificity of the impact of COVID on pregnancy.

Dr. Akila Subramaniam: Yeah, absolutely. I think, you know, you can always get some clarity on situations after some time and more cases. And so I think that you're seeing this is, you know, data and results that are being replicated around the world. So we finally have enough cases to be able to detect some of these things that are in general pretty rare.

Warner Huh, MD (Host): Great. So I thought maybe you can comment on the role and the potential benefit of vaccination during pregnancy.

Dr. Akila Subramaniam: Yeah. I think, you know, along with what we just talked about, it's really quite conclusive that pregnant women are at risk for more severe disease than their non-pregnant counterparts. And there's no better way to protect both moms and their babies than vaccination. And so a lot of the bodies that sort of govern what we do, so if you think about ACOG, which is the American College of Obstetricians and Gynecologists, as well as SMFM, which is the Maternal-Fetal Medicine organization, they just unanimously recommend vaccination to pregnant women. And so they actually recommend vaccination to all persons, but including those who are thinking of getting pregnant; those who are pregnant, regardless of when they're pregnant; those who are breastfeeding and those postpartum. So really, there's no preference as to when to get vaccinations. And it's really so protective that they recommend vaccination as early as possible. And we have data to suggest and that has shown really the benefits of early vaccination protects mom. And now we have data that suggests that even if you're later in pregnancy and you decided to get vaccinated, you get some protection to moms, but you may get some protection to the babies as well. And so the data looking at vaccination is really quite robust. There've been no safety signals associated with vaccination. So now, they have, you know, thousands and thousands of individuals in the United States who are pregnant and who had been vaccinated and self-reported their outcomes and no increase in risk of things like birth defects as well as early miscarriages from vaccination. And so really the benefits far outweigh any of the risks and those risks just haven't been demonstrated.

Warner Huh, MD (Host): Yeah. I mean, I think what's interesting for our listeners that when we first did this podcast, you know, vaccination was just coming from. It was not FDA approved. It is FDA approved now. And I think the biggest question at that time was not so much about of its efficacy, but really about its safety, as you've mentioned. And there was a bunch of reports about whether or not there were some certain clinical signals that were concerning for safety. But I just want to make sure that the listeners understand this and they're very clear on this. From your perspective and your expertise, you don't see any untoward or negative adverse events that are related to the vaccination and pregnancy specifically.

Dr. Akila Subramaniam: Yeah, that is correct. And I think one thing for the listeners to bear in mind is that there are three available vaccines for COVID-19. None of them use live virus. So you can't actually get infected with COVID-19 by getting these vaccines because they just don't work that way. Some people may say they feel terrible, like as if they have an illness, but that's really the immune system kicking in to fight the virus. So the risk of them getting the virus, the risk of them passing on the virus-- well, the virus is not shown to be in the placenta. So there's very rare reports of the actual virus passing from mom to baby in the pregnancy. So we do see infants that are infected, but that usually happens through other forms of contact, not through the uterus and just being pregnant.

So I think there's just a lot of robust data that suggests that vaccination is safe. And for those who are concerned about long-term effects, if you look at vaccinations and all vaccinations, so not just that limited to COVID, vaccines, really, if they're going to cause any issues are short term. They don't cause long-term problems. So looking at effects 20 years down the road, 40 years down the road for these pregnant women who might be really worried about their children, that's just not what vaccines do, is cause those long-term effects. If you see anything, it's going to be in the very short period after they receive the vaccine dose.

Warner Huh, MD (Host): So you touched upon this just before and I want to make sure that I ask this question just for our listeners. Could you just comment on the benefits of vaccination to the fetus or the newborn specifically?

Dr. Akila Subramaniam: Yeah. So I think when you look at the benefits of the vaccination to the infant, we have to actually look at it in two ways. One is maternal health. So if you're talking about the vaccine decreasing the risk of severe illness, well, a healthy mom leads to a healthy baby. So you're hopefully avoiding things like preterm birth, a really sick mom that ends up with a very small baby that might need to be in the ICU.

When we're talking about protecting babies after birth, well, what we're seeing is that when moms receive vaccination, they develop an immune response. And those antibodies, those protective antibodies, which is why we encourage breastfeeding, can transfer to the baby. So vaccine doesn't transfer to the baby, virus doesn't transfer to the baby in these ways, but the antibodies do. So this is what we call passive immunity. And this is really important for all infants when they're born to protect them from all environmental exposures. And so we have seen, and it's demonstrated, that those antibodies do cross both the placenta, so while the baby's inside, as well as through the breast milk. So you're protecting that infant as well, and really what they're showing and what they've shown in some studies is that moms who have gotten vaccinated, there is a decreased risk of those babies needing to be hospitalized within the first six months of life for moms who have gotten COVID vaccination. So really a decreased risk of illness to those infants. How robust that immune responses to those infants? We don't know, but there is actually, you know, signs that it does affect severe disease in those infants as well.

Warner Huh, MD (Host): Okay. And so I think also the listeners might be interested in learning like what do we know about actual treatment options, not prevention options like vaccination, but treatment options and how we manage COVID infection in pregnancy? I mean, what do you think would be important to share with our listeners?

Dr. Akila Subramaniam: Yeah, I think what's really, probably most important is that, you know, while a lot of these things are new treatments we're using. Some of them have been developed just for COVID. Some of them have been around for other indications. So remdesivir has been around before, dexamethazone is a steroid that has been around before.

The cornerstone of treatment for COVID in pregnancy is that we should be able to treat our pregnant patients in very similar ways to the way we treat our non-pregnant patients. So pregnancy is not an indication to not treat individuals. And so a lot of what you see, whether it's remdesivir or steroids or those monoclonal antibodies, or even the newest oral agents, so paxlovid, those are all acceptable treatment options for pregnant persons. And so, really the cornerstone of treatment is treating those patients just like everybody else who happened to have COVID.

The one caveat I would say is that because pregnant women do just have some certain changes that go along with pregnancy, there's a higher risk that you might get some of that treatment while you're in the hospital, just to make sure that, you know, you're doing okay and the baby is doing okay as well.

Warner Huh, MD (Host): Okay. I just thought maybe we just have some closing comments from you, but I just wanted to make maybe a comment and a question to you which is, you know, when we went through the Delta surge, at least for me as an observer, the morbidity and the striking mortality of pregnant women who had COVID at that time, it was surprising and it was sobering. And I think that the important thing for our listeners to recognize is the vast majority of these women who had severe COVID-related disease, including women who died and women who had to be delivered early were not vaccinated, right? And I think that we're seeing this over and over again, and it's a very common theme in terms of severe illness. But I think for the listeners, I don't think that we've ever seen the rate of morbidity and mortality in our pregnant population that we have ever, you know, with COVID. I don't know if that's something that you would agree with or you want to add more to that?

Dr. Akila Subramaniam: Yeah. No, I would totally agree. I mean, I have been around doing this for a number of years. And I will say the closest thing that maybe we thought we saw was back in the H1N1 pandemic where pregnant women were sort of universally having more severe disease than others, which is what instigated the recommendations for vaccination for flu in pregnancy. And I think what we saw, you know, at least in Alabama in July and August with the Delta surge, really just on multiple orders was exponential compared to what we saw back then. And I don't think any of us had ever expected anything like that to happen. We hope we don't ever see that again in our lifetimes, because it was really, like you said, sobering.

And so I think that, you know, the important thing to keep in mind is that, yes, the Delta variant was very severe and very sobering, but we're still seeing cases of COVID affecting pregnant women. So even with Omicron, which is even more transmissible and maybe less severe, we're still seeing that. And so it's not quite over yet. And I know everyone wants it to be over, but it's really not.

Warner Huh, MD (Host): You know, I think that's a great point. I mean, I think our listeners have to understand that we're still very much dealing with COVID-related disease and its impact on pregnancy. So even though the Omicron surge is on its tail end, I think we don't want this to be out of sight, out of mind.

Dr. Akila Subramaniam: Exactly. I couldn't agree more.

Warner Huh, MD (Host): Yeah. Well, again, I really want to thank Dr. Subramaniam for updating us on pregnancy and COVID I fully suspect that we'll probably have another update on this topic in the future, because I think there are a lot of questions about, again, what we know and perhaps, you know, women who have been pregnant who have had COVID and who are long-haulers, but I suspect that we'll definitely have another update on this in the upcoming months.

And as always, please rate this podcast and we welcome any comments and suggestions that you have. And if there are other topics that you would like to listen to, please definitely forward them to us. And for more information on our obstetrical services and expertise, particularly in the area of maternal-fetal medicine and other clinical services that UAB provides, please check out uabmedicine.org. And until next time, hope you all have a great day and thank you. Peace out.