COVID-19 in Pregnancy: Dotters-Katz Transcript

June 5, 2020

This is a transcript from our second installment of interviews with obstetricians and gynecologists who specialize in infectious diseases during the COVID-19 pandemic.

This is a transcript from our second installment of interviews with obstetricians and gynecologists who specialize in infectious diseases during the COVID-19 pandemic.

In this episode, we interviewed Dr. Sarah Dotters-Katz. She did share her expertise in our April print issue, along with Dr. Brenna Hughes, in a commentary entitled, “COVID-19: The pathogen that will define the decade.

A living document with comprehensive guidelines for treatment of COVID-19 has been released by the National Institutes of Health, and that was developed by a panel of experts, including physicians, statisticians, and other experts. It includes guidance for treating women who are pregnant. Both that, and the commentary from Dr. Dotters-Katz and Dr. Hughes, can be found on our site. Watch the full interview here.

DeRosa: This is Angie DeRosa, Senior Editor of Contemporary OB/GYN, and we are here today with Dr. Sarah Dotters-Katz, who is a Maternal-Fetal Medicine Specialist at Duke Health in Durham, North Carolina. Your research area is in clinical infectious diseases and how they impact pregnancy. We would like to hear from you about the impact of COVID-19.

Dotters-Katz: Thank you so much for having me. I'm really excited to be here. I think the impact of coronavirus on pregnancy is really an interesting one. It's been fun to watch the story evolve. I really want to be transparent. I think it's still evolving as we learn new things about the virus and how it impacts all sorts of people, including women.

What we know right now is, overall, very reassuring. Both from what we've seen in the published literature and what I can speak to about our patients in Durham is that many of the women that we see get a virus and do really well. As Dr. Riley noted last week, you feel crummy.

It's a bad virus. When you're pregnant, a lot of women don't feel awesome anyway. So that's sort of interplay between kind of not always feeling awesome and then getting a mix of feeling crummy.

We have a really cool outpatient clinic where we're managing all of our moms that have developed coronavirus. They've all done really well. None of them have needed to be hospitalized and they are continuing on in their pregnancies.

DeRosa: Do you get a lot of anxiety among your patients?

Dotters-Katz: Yes, I think one of the most challenging jobs for obstetricians right now is not only managing that anxiety and kind of helping to support our women who have the virus, but also helping to take care of women who don't have the virus, but who are really, really worried about what this means for them. If they were to get it, or how is their pregnancy going to look different because of the landscape that we're living in right now.

DeRosa: You and Dr. Hughes had really talked about this as the pathogen that will define the decade. Can you go more into detail about what exactly you meant by that?

 

Dotters-Katz: Yeah, of course. I think, for everyone, we live differently. Our lives day-to-day are affected in a way that we could have never imagined, you know, four or five months ago. Simple things: you wear a mask everywhere you go. When you meet people, you only see [half] of their face.

For a physician, what we're taught very early on in med school is that you go into a room and you shake someone's hand. It is so hard to not shake my patients’ hands when I meet them for the first time. I am an emoter and I like to physically connect with my patients. To not be able to like touch someone's leg or give them a hug after discussing something really hard is difficult.

The way we interact with people and even just electronically, the amount of interactions that we're having, both professionally and with patients through telehealth, is totally changing.

Even for people who don't contract the virus, everything is super different. And for pregnant women, the way they're living their pregnancy is really different.

DeRosa: When you say that they’re living their pregnancies differently, what do you mean?

[05:52]

Dotters-Katz: Their prenatal care, they're having sort of less visits, the end (of) some of their visits are happening electronically, as opposed to in person, which I don't think is unsafe in any way. I think it's actually probably safer in a lot of places to connect with your doctor this way than it is to go, especially if you live in a city to take the subway to go to your doctor's office.

When you do go to your doctor's office, there are much less people there. Our clinic’s doing a very cool telephone check in so the patient, instead of coming in and checking in at the front desk, pulls into the parking lot and calls the registration. We say, “Thank you, you're checked in,” and then they wait until it’s time for their visit.

They come in by themselves without a support person, get a mask and go directly back to their room. Their vital signs are all done (in) room, as opposed to kind of moving through our clinic in what I like to call the “BC” or, “before COVID era.” It's a different time to be experiencing pregnancy or really be working through our daily life.

DeRosa: How have your patients responded to the telehealth component, especially in the later stages of pregnancy?

Dotters-Katz: We're still seeing patients in clinic at the essential points in pregnancy. So for example, at 28 weeks, you need to get some lab work done in every pregnancy.

Around 20 weeks, everyone still comes to the clinic. Often at 32-33 weeks, you don’t necessarily need to do anything that would require an in-person visit.

A lot of visits at that time are happening via telehealth. I think patients like it. It's convenient, because you don't have to like take off work or get in your car and drive however far to the office. It’s time saving. It's safer; they aren't being worried about being exposed to other patients in the waiting room, to the healthcare workers, all of those things. And I think as more and more things become virtual and electronic, they're getting much more used to interacting with someone in this way.

DeRosa: How about the possibility of any vertical transmission?

Dotters-Katz: Oh, that is the million-dollar question. Right now, the evidence that we have is that it's unlikely, but it's possible.

DeRosa: Have you seen it in any of your patients? Are you treating for COVID-19?

Dotters-Katz: We haven't had any women with coronavirus give birth yet. The CDC has tempered its language about separating mom and baby after delivery and is recommending that it's done on a case-by-case basis. [They have recommended] giving the mom the information about the risks of transmitting the virus to her baby, and what that might look like, and then letting her make the decision on what’s best for her and her baby.

We've had a couple patients come through that have tested positive and they've had their babies without issue, and we haven't seen vertical transmission. Social distancing has been effective in our community.

DeRosa: That's what you identified in your recent paper as the most effective: social distancing as the best protective mechanism. Are people adhering to that in your area? Or are you seeing a mix?

Dotters-Katz: I think they are. A lot of it is forced. Our state just like many states has sort of a stay at home order. And, you know, this is a scary virus because you can't see it. It’s so unknown. And the news is powerful and the images are dramatic, and they're scary. And so I think that most of the community as they are able is really trying to stay home. You have to go to the grocery store … that there's certain things you just have to do but … and individuals are really doing their best to stay home as much as possible and when they do have to go out -  minimize those trips being not taking their whole family but going by themselves things like that.

DeRosa: We know that herd immunity exists. In your opinion, how long would it take before any type of herd immunity to take effect?

Dotters-Katz: This virus is pretty infective. What I mean by that is that, when one person gets it, you know, probably a couple of them are going to get it. We know that it's easy. If you're exposed, you're not unlikely to get the virus. I think herd immunity is going to develop faster in places that have a lot of virus. In a paradoxical way, say for example, individuals in New York City are going to have herd immunity faster than individuals in Durham, where our prevalence of diseases isn't very high.

DeRosa: When it does come to a mother being positive, in regard to mother-baby separation, it avoids transmission. Where do you identify that as the most effective and what has to be done?

Dotters-Katz: The issue of mother-baby separation is one of the hardest things that ob/gyns are having to deal with right now. Patients have grown this little baby inside of them for 9-10 months.

The first thing that every mom and every family wants to do is snuggle their baby, but we know it's respiratory. You're putting this little tiny human on your chest and all your respiratory droplets are potentially being transmitted to your baby.

The good news is, though we've seen neonatal infections, they don't seem to be very severe. Most of the babies have done really, really well and not had a lot of issues. You can mask mom and be thoughtful, and do really good hand hygiene and protect the infant from infection.

Again, think about it: when you’re breastfeeding every 2-3 hours with a newborn, that transmission potential is real. I think the question of whether to separate mom and baby is really a hard one.

We know that skin-to-skin contact right after delivery is better for mom and baby. We know that often feeding is better for mom and baby, and that breastfeeding is the best way to give infants nutrition. There are a lot of pros and a lot of cons to each one. Then the other question becomes, even if you separate for two days while mom's in the hospital, then they go home together.

Mom is still potentially infectious. So, was all that early separation emotionally traumatic or not, right?  I don't think there's a one-size-fits-all answer. I think it's really about educating mom and helping her understand the risk, giving her really good tools for masking and hand hygiene-especially when she goes home-and figure out what makes the most sense for her and her family.

DeRosa: What's fascinating is the immunity that I learned about that can be obtained through the breast milk. They don't even have that option, and there's thankfully no evidence of transmission from breast milk, but we know there is enhanced immunity. Would there be a way of encouraging or could you encourage more breastfeeding?

Dotters-Katz: In general, as obstetricians, we always encourage breastfeeding as the best mode of feeding for the neonate independent of the situation, in almost all cases. If it were me and it was my baby, I probably would pump breast milk and have someone who wasn't infected give it to my baby, which is an absolutely safe and viable option. That’s a choice I would make personally that might not be a feasible option for other people. It is a safe option that someone might choose.  

DeRosa: What is your perspective of what it's going to look like for all of you in 9 to 12 months?

Dotters-Katz: Believe it or not, this is a hot topic of discussion in Labor and Delivery. At first, we thought, “It's going to explode nine months from now,” but when we actually reflected on it, we thought, “People get tired of their partner.”

When you're together so much, maybe you're going to have less intercourse. Additionally, with all of the financial complications that are so real for so many families, they may decide that this is a horrible time to have kids. They may decide that they are going to use family planning in ways they haven't because it would be that they can't afford another kid.

Also, 50% of pregnancies in the United States are unplanned. Those happen in random unions when people are going out and maybe not making the best choices. If you're really social distancing, those unplanned, spontaneous pregnancies that happen because you're dating or you're out at a party and maybe don't make decisions you might make otherwise aren't really happening.  We're all social distancing. The boredom babies, if you will, might be evened out by the lack of the other spontaneous pregnancies.

[. . .]

DeRosa: Are you busier now, in L&D?

Dotters-Katz: It's been really interesting. What we're seeing is more progressive pathology. What I mean by that is, I think people are hesitant to come to the hospital because this is where coronavirus is, and they're being told to stay home. When they do come, they're a little bit sicker or a little bit further along in labor because they've waited longer than they would have in normal time.

We're seeing less visits to our triage, which is sort of like our mini obstetric emergency room, than we normally see. The patients that we're seeing have more progressed pathology.

DeRosa: What would you say you are learning during this experience, especially with your clinical research interest in infectious disease?

Dotters-Katz: I continue to be so inspired by the way that our different teams are working together to create ways for women to continue to receive prenatal care and have babies. The glass is always half full. Everyone is ready to pitch in and it's just really an inspiring time to be in healthcare, even in the setting of something so scary and potentially really dangerous. Seeing all of these individuals working together to do the best we can for our patients right now is really inspiring.

DeRosa: Are you satisfied with your PPE?

Dotters-Katz: We are, actually. We've been really fortunate. Our institution has been really thoughtful about how they obtain it, and they actually have developed cool ways to recycle it. I feel very safe when I go to work knowing there's adequate PPE.

We are definitely very fortunate and probably in the middle minority of centers as far as having enough PPE.

I think I'd love to emphasize that this is a really hard and stressful time, no matter who you are, no matter what you do, but especially ob/gyn providers. Know that you're not alone, we're all going through this. All of our societies are working really hard to put out very thoughtful guidelines about what to do and how to do it.

From a clinical perspective, there's support out there, and that we should all be taking time to be well in ourselves. Do things to keep ourselves healthy, so that when we do have to be clinical, you know, we have that energy.

 

For more information and additional expert perspectives, view the series below:

COVID-19 in Pregnancy: Dr. Laura Riley

COVID-19 in Pregnancy: Dr. Kristina Adams Waldorf

COVID-19 in Pregnancy: Dr. Emily S. Miller