Monday, June 1, 2020

Waging the Covid-19 War on the Pregnancy Front

By on April 3, 2020

Frontline OB-GYN Specialists Strategize to Care for Patients Amid Outbreak

SAN JUAN — In the sour alphabet-soup world of pandemics—MERS-CoV, SARS, H1N1, and now, Covid-19—there are some members of the world population who are more vulnerable than others. These include pregnant women, for whom precise protocols are still under debate. Pregnant women, say reports from the College of American Pathologists, are more susceptible to complications from Covid-19 due to the physiologic changes they undergo during their pregnancy.

“Yes, that is correct. The domino component of the dependent patient, which is compromised somewhat by the fetus—and the further along in the pregnancy, the more compromised are the lungs in order to expand,” explained Dr. Nabal José Bracero, an obstetrician-gynecologist who is the medical director of the GENES Fertility Institute and founding president of PROGyn, a nonprofit entity dedicated to the education of the OB-GYN specialty. “So, we are very careful right now, around the time of delivery [of children], looking at how far [terms] can go. If [pregnant women] become infected by Covid-19, we have to be very watchful of how they are doing. Also, we don’t know a lot about the virus. So far, we haven’t seen that it has any negative impact on the malformation of the fetus. A high fever is something that can be a problem and we are also looking at what is happening with the mother’s lungs when they are in the third trimester.”

Dr. Nabal José Bracero

The obstetrics expert explained that the immune system of a pregnant patient has to allow some development of the placental tissue and in order to do that, the immune system will shut down partially—“so that is another thing that makes pregnant patients more vulnerable in these situations.”

“The data that we have from MERS [Middle East Respiratory Syndrome] and from SARS [Severe acute respiratory syndrome], which are cousins of Covid-19, are very concerning because those viruses showed 25 percent presenting complications for pregnant patients. So, one in four patients with MERS or SARS did not do so well when they were pregnant,” the doctor said.

Data from pandemics past are presenting OB-GYN specialists with a conundrum of a gestation threshold that allows for the development of fetuses without putting mothers at risk associated with late gestation.

“We were discussing, as early as yesterday, what to do with a patient who was as early as 36 or 37 weeks along—not to extend it to 39 weeks—because we were concerned that a Covid-19-positive patient could become very ill,” Bracero told Caribbean Business during an interview earlier this week. “Therefore, we are evaluating, at the national and local level, whether those patients would benefit from labor induction once we reach 37 weeks. Those are major words, because for the longest time we have been reducing our C-section [caesarean section, or delivery] rates. So, we are between a rock and a hard place because we know so little about this virus,” added the doctor, who liaises with health specialists around the world. Bracero, who is also the president of the Puerto Rico Section of the American College of Obstetricians and Gynecologists, recalls the importance of sharing empirical data and best practices with practitioners globally back in 2015, as they attempted to stem the tide of microcephaly attributed to the Zika virus. 

“Even with the nonprofit that we represent, which started as an educational organization when Zika came around, the Centers for Disease Control (CDC) reached out with meetings including all the OB-GYNs—so we banded together,” the doctor recalled. “At that time in 2015, we had a crash course—that was an outbreak, so we had to deal with outbreak containment and infectious [disease] catastrophe. We had to handle good data, not-so-great data in real time, to learn what was going on in other areas and what to do.”

Although the level of collaboration is not the same this time around “with the CDC—ironically, as I would have expected it—they have tools that can help to contain the outbreak,” the doctor added. 

The health expert believes that you either contain the outbreak, you mitigate or you introduce measures to suppress the outbreak. As pertains to this most recent pandemic, Bracero sees everyone around the globe working on both fronts—mitigating and trying to suppress the outbreak.

“Very few people on this side of the ocean, the Western Hemisphere, have nailed it in terms of suppression—to actually have a vaccine, to actually do full-fledged isolation…. Although it is happening, it is not happening at the speed it should happen,” the doctor told Caribbean Business.

“When it comes to the mitigation realm, it takes a lockdown and social distancing. So, that is one of the biggest frustrations in the Western Hemisphere because we will follow the lead of the CDC—historically, to the letter. And, I don’t know, if to the letter, the present change of the guard has to do with the sense of urgency and how early the panic button had to be pressed. So, we are somewhat lagging behind in that response.” 

The lessons learned with the Zika crisis had to do with a mosquito. Now that the human component is involved in the response, was Puerto Rico swifter in the way the administration reacted?

“We have been swift with the components that we have available—meaning that what we could do was done. In Puerto Rico, as you know, we went into lockdown. But, ideally, and this is the more complex problem because we have to deal with the industry—the diversion of resources towards specific goals outlined by the federal government. The law that President Trump set in motion about a week ago is a wartime mandate that moves toward providing the industry with all the essential items. So, that comes from the upper level. But, the complexity that happens at that upper level where you are dealing with the financial component and the economic part—those two issues have historically gone into conflict along the way. 

But a lot depends on how clearly the message from the public health officials is heard by the government,” the doctor concluded. 

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