Mitra Afshari, MD, MPH, assistant professor in the movement disorders program at Rush University, was apprehensive. Twenty-one weeks into her first pregnancy, she was about to go to her OB-GYN's office for her ultrasound appointment, the "anatomy scan," alone. No visitors were allowed to accompany her due to the COVID-19 pandemic, not even her husband, who desperately wanted to be there.
Child neurologist Roha Khalid, MD, an epilepsy fellow at the Children's Mercy Hospital in Kansas City, MO, was 33 weeks into her pregnancy when the first news of the coronavirus broke out. "Pregnancy in general, was very anxiety-provoking for me," she said. "And when we began to realize the severity of the pandemic, I experienced added worries about whether I would get COVID-19 and pass it on to the baby," she said, especially because my due date coincided with the time we expected COVID-19 to peak in our area," said Dr. Khalid.
Neurologists caring for patients during the COVID-19 pandemic have experienced myriad sources of anxiety. Will there be enough personal protective equipment (PPE)? Will it be sufficiently effective? Will I bring this virus home to my family? But neurologists who are pregnant and seeing patients have all those concerns as well as another: Will my baby be healthy? While this question crosses the minds of all expectant mothers, little is known yet about the novel coronavirus and its effects on birth outcomes, and that uncertainty weighs heavily on the minds of women throughout pregnancy.
Differing Levels of Precautions
As Rush University Medical Center slowly opened up last week, Dr. Afshari—whose schedule is comprised of 60 percent clinical work and 40 percent research—has been seeing all her new patients in person. She performs deep brain stimulation programming on return patients and administers botulinum toxin injections to her dystonia patients.
"I've been very lucky to have all the PPE I need including N95 masks, gowns, and plastic face shields," she said, adding that she is taking precautions to a higher level with all her face-to-face visits. "As for COVID patients requiring neurologic consultation, my wonderful colleagues have volunteered to see them during my pregnancy," she said.
"The PPE being supplied at the hospital has improved over time; now, appropriate PPE is being given to everyone, and we wear N95 masks when going to the emergency department, so we are more protected," said Simona Nedelcu, MD, PhD, a PGY-3 neurology resident at the Brigham and Women's Hospital-Massachusetts General Hospital (BWH-MGH), who is currently 33 weeks pregnant and due in July.
All the new precautions may also have an effect on the labor and delivery process itself. When neuromuscular specialist Kathleen Thornton Pearson, MD, delivered her baby on April 3, PPE was still in short supply at Virginia Commonwealth University Medical Center. Health care professionals in the delivery room were wearing P100 masks and instructed to use them until they became soiled. The masks were uncomfortable and made it difficult to connect with the labor and delivery team.
"It was a completely different experience from when I delivered my first child," Dr. Pearson said. "But, I was also lucky, unlike some women at other hospitals, "Dr. Pearson said. "My husband was allowed to be with me during labor, and my doula could also be there."
Dealing with Uncertainty
All the women who spoke to Neurology Today pointed out the difficulties in considering a virus about which so little is known. "In the beginning, there was a lot of uncertainty," said Dr. Nedelcu. "We knew so little about this coronavirus and its effects, and I was unsure how to protect myself and the baby," she said, adding, "It make things more stressful."
Now in her third trimester, with a due date in late August, Dr. Afshari said, "We don't know the nuances of COVID during pregnancy quite yet, but we know that the body is under stress, so pregnant women like myself may not be able to mount a robust immune response," Dr. Afshari explained.
Sona Narula, MD, a pediatric neurologist in the division of neurology at Children's Hospital of Philadelphia, currently at 37 weeks, said a source of stress at times has been conflicting reports about the risks of being pregnant while infected with COVID-19.
"People are well-intentioned, and send me all kinds of information, but some of the case reports are alarming in the absence of long-term scientific data," she said. "We don't have answers now and simply don't know enough," she said.
"It was a difficult time because no one had any recommendations for pregnant women early on," said Dr. Khalid. When she joined a Facebook group for expecting mothers, it only added to her confusion. "It was helpful initially to know I was not alone, but their panic was infectious, and I had to stop," she said. "You wait your whole life to have this baby, and you try to find the perfect time, and I thought my fellowship would be that time," she explained, "but instead, I ended up smack in the middle of a pandemic."
The Safety of Telemedicine
For pregnant neurologists who have adopted telemedicine, the relative safety of isolation at home has been a welcome blessing. Dr. Nedelcu's third-year schedule was already front-loaded due to her pregnancy and she has been able to do some of her electives such as psychiatry by telehealth, and the Veterans Association Hospital clinic by telephone.
Dr. Afshari, who had been performing research in the field even before the pandemic, was excited about the rapid adoption of the technology amongst her colleagues. "When COVID started, I had already been piloting a telemedicine project in Parkinson's disease for two years, incorporating physical therapy and occupational therapy, and virtual home safety evaluations for falls prevention," she said. During the pandemic, she was able to continue her telemedicine research efforts and expand her project to recruit many more patients who were in need of this service while sheltering in-place.
Dr. Narula was entering her third trimester when the pandemic began. But she has been fortunate to do telemedicine the entire time, and with the support of her division chair, she has had no face-to-face visits since mid-March.
Dr. Khalid, who worked for nearly a month before the birth of her daughter on April 6, was able to read EEGs remotely from home and evaluate patients who needed to be seen by telemedicine. "I was lucky because my program director made those arrangements for me early on," she said.
Additional Child Care Challenges
Dr. Nedelcu, who has a 7-year old son, and a 5-year old daughter at home, said, "We have no family here in the United States, and when schools closed, we had to consider who will care for our children."
She has had to go to the hospital for overnight shifts about twice a week to cover services and had other, albeit limited, clinical responsibilities. But her family was able to manage because her husband's research lab also closed due to COVID and he was able to work from home.
In addition to her newborn, Dr. Pearson, has a 2-year old child, but has not yet decided how to handle the return of her nanny. "We have to consider potential exposure by bringing another person into our home, in addition to the risk I may pose to her by working in a health care setting."
"Everything we do involves weighing risks vs. benefits, she said.
Dr. Narula, who has a 4-year old, said, "Normally, my child would be in school and we would have a nanny helping with his care, but we have not had her return to the house yet."
"We are all testing the limits of being caregivers in the workplace and caregivers at home, and navigating the new complexities of our lives," said Dr. Afshari, who is expecting her first child.
"There are neurologists with aging and sick parents, and those with school age and young children, trying to adjust to new circumstances. We all have to be as empathetic as possible and understand that this is a very unique time for everyone," she said.
Compassion from Colleagues
Jenna Conway, MD, a PGY-4 resident in the department of neurology at NYU Langone Health was 18 weeks into her pregnancy when NYU instituted a travel ban, and she realized the gravity of the coronavirus pandemic. Her ten PGY-4 co-residents, a very close group, reached out to her soon thereafter and told her that they would arrange coverage for all her clinical responsibilities.
"I have been really lucky; we are very close as a class," Dr. Conway said, adding that her residency program director, Arielle M. Kurzweil, MD, reached out very early on, checked in frequently, and ensured that she was able to stay out of the hospital.
Dr. Conway has been working from home since that time doing telehealth, research, and arranging for weekly Grand Rounds.
"I feel conflicted between being unable to be there in-person to help on the front line, but at the same time having a duty to take care of my unborn child," she explained. The whole department, under the leadership of Steven L. Galetta, MD, works as a team, she said, adding, "that trickles down to the residents who go on annual retreats and get together frequently for regular social events."
"My colleagues were so protective of me," said Dr. Khalid. "Right off the bat, they cancelled all my patients, and blocked my clinic schedule."
"Our department is like a family, and this brought out the best in the people I work with," she continued. "I am extremely appreciative of them."
At the end of March, NYU instituted a policy for pregnant staff to be exempt from caring for COVID patients. Other institutions, including BWH-MGH, have elected to have health care workers stop seeing all patients after 37 weeks—so that a potential COVID infection which would require mother and newborn to be separated—would not be risked.
"I am also fortunate that leadership has been so supportive in our program, not just to me during my pregnancy, but to residents with children who had child care challenges during this pandemic," Dr. Nedelcu said. "At the end of the day, I never felt I was unsafe."
A similar policy at Penn is encouraged at the discretion of the division. Dr. Narula said, "I was very lucky in that I have a very supportive division and lots of people who were willing to cover me."
"The entire team has been very accommodating and found coverage for me for previously scheduled two weeks of inpatient service in April," Dr. Narula said. She considers herself fortunate to be part of a large division, and knows that if she had fewer colleagues, like in some places, it would have been more difficult to make accommodations for her.
Link Up for More Information:
Several organizations and universities are establishing registries to better understand how pregnant and postpartum women are affected by COVID-19.
The PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) is a nationwide study of pregnant women and those who have recently delivered who are either under investigation for Coronavirus infection (COVID-19) or have been confirmed to have COVID-19. Health care professionals can refer patients or patients can self-enroll on the website.
OTIS/MotherToBaby is currently enrolling women in the US and Canada in an observational COVID-19 and pregnancy study open to women with known or suspected COVID-19 infection at any point during a current or recent pregnancy or within 30 days of the last menstrual period before conception. The study is also recruiting breastfeeding women with known or suspected COVID-19 infection for a lactation study.
AAP Section on Neonatal Perinatal Medicine is inviting hospitals that take care of infants to participate in a National Perinatal COVID-19 Registry by submitting de-identified maternal and neonatal data.