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Coronavirus - facts, advice and measures

Advice and information for women who are pregnant or breastfeeding

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The COVID-19 vaccine is recommended for pregnant and breastfeeding women. Vaccination during pregnancy will also protect the baby after birth.

The COVID-19 vaccine is recommended for pregnant and breastfeeding women. Vaccination during pregnancy will also protect the baby after birth.

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Pregnant women and their risk for severe COVID-19 disease course

The risk of serious illness among pregnant women who become infected with coronavirus is low. However, international studies show that pregnant women are somewhat more likely to have a severe COVID-19 disease course than non-pregnant women, and that the risk is highest in the later stages of pregnancy. This may be because pregnant women have a greater strain on their heart and lungs as the foetus grows, and are therefore more prone to a severe disease course if they first become ill.

It is recommended that pregnant women follow advice for at-risk groups.

What do we know about COVID-19 and the risk for pregnant women?

  • Pregnant women have a slightly higher risk of admission to hospital due to COVID-19 than women who are not pregnant, although the risk for both groups is very low. This applies to all virus variants, although most cases of a severe disease course so far have been with the delta variant.
  • The most common symptoms among pregnant women are coughing and difficulty breathing. It appears that fever and moderate general symptoms are less common than in non-pregnant women.
  • Pregnant women with COVID-19 who develop symptoms have a slightly greater risk of needing treatment in hospital, intensive care units and with a respirator. 
  • The risk groups for severe course of COVID-19 are the same as for others: underlying conditions such as diabetes, cardiovascular disease and / or obesity. See Risk groups and their relatives
  • The proportion of pregnant women with a migrant or minority background is higher than other pregnant women.
  • Some studies suggest that the risk of premature birth is somewhat higher if the mother has COVID-19. However, this does not apply to spontaneous births, and may be related to how pregnant COVID-19 patients have been treated in different countries.
  • COVID-19 has not been shown to increase the risk of miscarriage during pregnancy.

In the studies, the incidence and risk of a severe disease course among pregnant women with COVID-19 is partly compared with the risk among pregnant women without COVID-19, partly with the risk among non-pregnant women in the same age group, and partly only observed and described. We emphasise that the figures are uncertain, because many countries to a large degree test pregnant women for coronavirus regardless of symptoms. Some countries have had routines for delivering babies from pregnant women with confirmed COVID-19 infection by Caesarean section and also in treating them differently than other pregnant women. The uncertainty is great, which is reflected in the researchers' conclusions.

Sources

  1. Engjom HM, Ramakrishnan R, Vousden N, et al Severity of maternal SARS-CoV-2 infection and perinatal outcomes of women admitted to hospital during the omicron variant dominant period using UK Obstetric Surveillance System data: prospective, national cohort study BMJ Medicine 2022;1:e000190. doi: 10.1136/bmjmed-2022-000190
  2. Vousden N, Ramakrishnan R, Bunch K, Morris E, Simpson N, Gale C, O'Brien P, Quigley M, Brocklehurst P, Kurinczuk JJ, Knight M. Management and implications of severe COVID-19 in pregnancy in the UK: data from the UK Obstetric Surveillance System national cohort. Acta Obstet Gynecol Scand. 2022 Feb 25. doi: 10.1111/aogs.14329. Epub ahead of print. PMID: 35213734.

Vaccination of pregnant women

Most pregnant women who become infected with the coronavirus get only a mild disease course. Nevertheless, Norwegian and international data show that pregnant women have an increased risk of a severe disease course compared with non-pregnant women of the same age. The risk of serious illness increases throughout pregnancy and is greatest in the 2nd and 3rd trimesters. If the pregnant woman also has other risk factors, such as multiple births or underlying illness, the risk increases further. This also applies in the first trimester.

The NIPH recommends:

 

Primary vaccination series

Booster dose*

Pregnant and previously healthy

Recommended regardless of trimester

Recommended in each pregnancy in 2nd or 3rd trimester for best protection of mother and child.

Pregnant with underlying conditions that give increased risk

Recommended regardless of trimester

Recommended in each pregnancy in 2nd or 3rd trimester for best protection of mother and child. Vaccination in 1st trimester can be considered depending on mother's risk.

*Booster dose given with an interval of at least 6 months after previous dose.
 
Traditionally, there is a general caution with medical treatment, including vaccination, of pregnant women in the first trimester. However, being cautious can prevent pregnant women from being vaccinated and protecting themselves and the foetus against a severe disease course and complications. There is no knowledge to indicate that vaccination with COVID-19 vaccine in the first trimester poses any risk to mother or child. Furthermore, large reviews have shown that the vaccines have a good effect against a severe disease course (1). Most other countries have chosen to recommend vaccination during pregnancy, regardless of trimester. Newborns receive protection in the first period after birth if the mother is vaccinated in the second or third trimester of pregnancy.
 
Women who are vaccinated during pregnancy will form antibodies against the coronavirus which are then transferred to the child - especially in the latter part of pregnancy (regardless of when the woman was vaccinated) (2). Vaccination of pregnant women can therefore help protect the child in the first months after birth (3).
 
Data from countries where pregnant women have been vaccinated for a long time, also in Norway(4;5), show that COVID-19 vaccination with non-live vaccines such as mRNA vaccines and virus vector vaccines has no adverse effect on the course of pregnancy, for either the mother or the foetus.
 
Primary vaccination with COVID-19 vaccine is also recommended for women if they plan to conceive. It is not necessary to wait to conceive until after vaccination. Women who are receiving/planning fertility treatment (e.g. IVF) are also recommended the vaccine(6).

Side effects

No other side effects have been observed in pregnant women after vaccination compared to non-pregnant women of the same age.

This means that they can experience pain in the arm, lethargy, body aches and fever. The side effects are short-lived and pass in one to two days.

What do we know about COVID-19 vaccination of pregnant women?

Vaccination during pregnancy requires special considerations, because the woman and the foetus are in a vulnerable phase in life. Previously, there has been a somewhat restrictive attitude to all vaccination during pregnancy, but in recent decades there is more knowledge that it is both important, has a good effect, and is safe for both mother and foetus. Globally, there is an immunisation programme for pregnant women against influenza (WHO recommendation from 2005), against tetanus in low- and middle-income countries (WHO recommendation from 2006) and against pertussis (WHO recommendation from 2015). In addition, several other vaccines, both inactivated and some live, attenuated vaccines, are recommended for pregnant women if they are exposed to infection.

The mRNA vaccines are non-live vaccines and cannot replicate so neither the mother nor the foetus can be infected by the vaccine. Large studies of the mRNA vaccines indicate no direct or indirect harmful effects with respect to pregnancy, foetal development, childbirth or postnatal development.

There is limited knowledge from the manufacturers, as pregnant women were not included in the initial phase III studies that led to the marketing authorisation. However, there is increasing experience from countries that offer vaccination to pregnant women, especially with the mRNA vaccines. Data from vaccinated pregnant women in the USA and Israel have not shown any signs of adverse side effects1,2. There is also no increased risk of miscarriage, congenital deformities or premature birth among pregnant women who have been vaccinated against coronavirus.

Studies also show that pregnant women have the same vaccine response as non-pregnant women3, and that antibodies are transmitted to the child by vaccination in the third trimester4. In this way, vaccination of pregnant women will help to protect the child against COVID-19 after birth. It has been shown that COVID-19 vaccination of women during pregnancy results in lower admission of newborns with COVID-195.

More and more countries are recommending pregnant women to take vaccines. From 18 August 2021, the NIPH also recommends that pregnant women in Norway should also be vaccinated.

The risk of a severe COVID-19 disease course increases if the pregnant woman has underlying conditions such as diabetes, cardiovascular disease and / or obesity6. Nordic studies support this, and have shown an increased risk for women with obesity or who had an immigrant background7.

References

  1. Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons. N Engl J Med. 
  2. Goldshtein I, Nevo D, Steinberg DM, et al. Association Between BNT162b2
  3. Magnus MC, Örtqvist AK, Dahlqwist E,et.al. Association of SARS-CoV-2 Vaccination During Pregnancy With Pregnancy Outcomes. 2022 Apr 19;327(15):1469-1477. doi: 10.1001/jama.2022.3271. PMID: 35323851; PMCID: PMC8949721.
  4. Magnus MC, Gjessing HK, Eide HN, et al. Covid-19 Vaccination during Pregnancy and First-Trimester Miscarriage. N Engl J Med. 2021 Nov 18;385(21):2008-2010. doi: 10.1056/NEJMc2114466. Epub 2021 Oct 20. PMID: 34670062; PMCID: PMC8552533. Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women. JAMA. 202
  5. Gray KJ, Bordt EA, Atyeo C, et al. COVID-19 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol.
  6. Rottenstreich A, Zarbiv G, Oiknine-Djian E, Zigron R, Wolf DG, Porat S. Efficient maternofetal transplacental transfer of anti- SARS-CoV-2 spike antibodies after antenatal SARS-CoV-2 BNT162b2 mRNA vaccination. Clin Infect Dis. 
  7. Halasa NB, Olson SM, Staat MA, et al. Effectiveness of Maternal Vaccination with mRNA COVID-19 Vaccine During Pregnancy Against COVID-19–Associated Hospitalization in Infants Aged <6 Months — 17 States, July 2021–January 2022. MMWR Morb Mortal Wkly Rep 2022;71:264–270. DOI: http://dx.doi.org/10.15585/mmwr.mm7107e3external icon
  8. Allotey J, Stallings E, Bonet M, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. 2020;370:m3320.

There is no evidence that coronavirus vaccines affect women's fertility. Menstrual irregularities after vaccination have been reported, but not during pregnancy.

Influenza vaccine

Pregnant women in their second and third trimester, and pregnant women in their first trimester who have risk factors, are recommended to take the seasonal influenza vaccine. This advice applies regardless of the coronavirus vaccine.

Preventing infection

To prevent infection in pregnant women, the same advice applies as for the general population: good hand hygiene and limited physical contact with others than your closest contacts (you decide who your closest contacts are, but they are usually the ones you live with). Primary vaccinated people are considered to be well protected against a severe disease course. Unvaccinated people can discuss the possibility of working from home with their employer.

If any of the closest contacts have symptoms of a respiratory tract infection, the pregnant woman should limit contact with them if possible, and otherwise have good hand hygiene and follow other basic infection control advice.

Healthcare professionals who are pregnant

The recommended personal protective equipment should be used by all healthcare professionals during contact with a patient with suspected, probable or confirmed COVID-19 disease, regardless of the healthcare professional's vaccination status.

As a precaution for unvaccinated or partially vaccinated healthcare professionals who are pregnant, it is recommended that other healthcare professionals should take samples and treat people with probable, suspected or confirmed COVID-19 disease where possible. Primary vaccinated healthcare professionals will have effective protection from vaccination, especially if they have had a booster vaccine. If they also use recommended protective equipment, most healthcare professionals can work as normal.

For healthcare professionals who are pregnant and who have pregnancy complications or chronic diseases with an increased risk of severe COVID-19 progression (see section on pregnant women and risk factors above), work adjustment or remote working should be assessed based on individual risk. This applies regardless of vaccination status.

Pregnancy check-ups

All pregnancy check-ups should follow normal guidelines for healthcare.

Unvaccinated pregnant women with chronic diseases or pregnancy complications should discuss with their doctor whether or not there is reason to exercise extra care and if workplace adjustment is necessary. In the event of an increased risk of transmission in society and in work where it is not possible to follow advice on the recommended distance to others, transfer to other tasks should be considered.

If the pregnant woman is concerned about her own or the fetus' health, additional examinations will be performed according to usual criteria. The Norwegian Gynecological Association has prepared advice on pregnancy follow-up for women in connection with the COVID-19 outbreak.

Confirmatory tests

It is recommended that pregnant women contact the health service if they have a positive COVID-19 test. Since the professional communities have prepared advice on follow-up during pregnancy, it is recommended that the pregnant woman takes a confirmatory test with PCR in a positive self-test. If you are pregnant and have a negative self-test, but have symptoms from the upper respiratory tract, you should also contact your regular doctor to assess whether or not you should be tested for other respiratory viruses.

Birth and maternity 

There is uncertainty about whether coronavirus can be transmitted from mother to child before or during birth. Babies born to mothers with COVID-19 that have been infected after birth have had mild or no symptoms. Severe fetal/neonatal events were reported more frequently with the delta variant of the virus. There has been detected virus in umbilical cord blood, which indicates that there is a possibility the child has been affected by the virus in the womb. The virus is mainly spread by droplet and contact transmission. Mothers who are sick may infect their child after birth and shall follow the infection control advice given by the healthcare personnel. 

Women who give birth and who had confirmed COVID-19 just before birth can be together with their newborn after the birth, unless the mother is seriously ill or the child is very premature or sick.

Hospitals must arrange for a partner / next of kin (defined by the mother herself) to be able to be present before and during the birth, and while in the maternity unit.

Maternity and neonatal departments in Norway are prepared to handle women with confirmed COVID-19 giving birth and her baby and procedures have been issued in collaboration with the Norwegian Institute of Public Health. 

After returning home from the hospital, it is important to remember that new mothers may be vulnerable and need support from those around them, even during the corona pandemic. Anyone who visits newborns should be healthy and without symptoms.

Breastfeeding

Coronavirus has not been detected in breast milk from women with COVID-19 infection, where this has been studied. Women with COVID-19 infection can therefore breastfeed normally. This is also the advice of the World Health Organization (WHO).

A large summary of documentation on the effect on breastfeeding after COVID-19 vaccination has been made. There is nothing to suggest that breastfeeding after vaccination is harmful to the child. Antibodies (both IgA and IgG) against COVID-19 have been detected in breast milk 1-2 weeks after vaccination among breastfeeding mothers(11)

  1. Ciapponi A, Berrueta M, P.K. Parker E, Bardach A, Mazzoni A, Anderson SA, et al. Safety of COVID-19 vaccines during pregnancy: A systematic review and meta-analysis. Vaccine 2023;41(25):3688-700. DOI: https://doi.org/10.1016/j.vaccine.2023.03.038
  2. Badell ML, Dude CM, Rasmussen SA, Jamieson DJ. Covid-19 vaccination in pregnancy. BMJ 2022;378:e069741. DOI: 10.1136/bmj-2021-069741
  3. Carlsen E, Magnus MC, Oakley L, Fell DB, Greve-Isdahl M, Kinge JM, et al. Association of COVID-19 Vaccination During Pregnancy With Incidence of SARS-CoV-2 Infection in Infants. JAMA Intern Med 2022. DOI: 10.1001/jamainternmed.2022.2442
  4. Magnus MC, Örtqvist AK, Dahlqwist E, Ljung R, Skår F, Oakley L, et al. Association of SARS-CoV-2 Vaccination During Pregnancy With Pregnancy Outcomes. JAMA 2022;327(15):1469-77. DOI: 10.1001/jama.2022.3271
  5. Fell DB, Dimanlig-Cruz S, Regan AK, Håberg SE, Gravel CA, Oakley L, et al. Risk of preterm birth, small for gestational age at birth, and stillbirth after covid-19 vaccination during pregnancy: population based retrospective cohort study. BMJ 2022;378:e071416. DOI: 10.1136/bmj-2022-071416
  6. Aharon D, Lederman M, Ghofranian A, Hernandez-Nieto C, Canon C, Hanley W, et al. In Vitro Fertilization and Early Pregnancy Outcomes After Coronavirus Disease 2019 (COVID-19) Vaccination. Obstet Gynecol 2022;139(4):490-7. DOI: 10.1097/aog.0000000000004713
  7. DeSilva M, Haapala J, Vazquez-Benitez G, Vesco KK, Daley MF, Getahun D, et al. Evaluation of Acute Adverse Events after Covid-19 Vaccination during Pregnancy. New England Journal of Medicine 2022. DOI: 10.1056/NEJMc2205276
  8. Ellington S, Olson CK. Safety of mRNA COVID-19 vaccines during pregnancy. The Lancet Infectious Diseases 2022;22(11):1514-5. DOI: 10.1016/S1473-3099(22)00443-1
  9. Nicola V, Rema R, Kathryn B, Eddie M, Nigel ABS, Christopher G, et al. Severity of maternal infection and perinatal outcomes during periods of SARS-CoV-2 wildtype, alpha, and delta variant dominance in the UK: prospective cohort study. BMJ Medicine 2022;1(1):e000053. DOI: 10.1136/bmjmed-2021-000053
  10. IFE-Core Group U, WHO, COVID-19 Infant Feeding Working Group. FREQUENTLY ASKED QUESTIONS: COVID-19 vaccines and breastfeeding based on WHO interim recommendations. I: World Health Organization, red. Geneva2021.
  11. Development BMNIoCHaH. COVID-19 Vaccines: National Institute of Child Health and Human Development; 2023. Tilgjengelig fra: https://www.ncbi.nlm.nih.gov/books/NBK565969/

 

References

1. Aharon, Devora MD; Lederman, Matthew MD; Ghofranian, Atoosa MD; Hernandez-Nieto, Carlos MD; Canon, Chelsea MD; Hanley, William BA; Gounko, Dmitry MA; Lee, Joseph A. BA; Stein, Daniel MD; Buyuk, Erkan MD; Copperman, Alan B. MD In Vitro Fertilization and Early Pregnancy Outcomes After Coronavirus Disease 2019 (COVID-19) Vaccination, Obstetrics & Gynecology: January 25, 2022 - Volume - Issue - 10.1097/AOG.0000000000004713 doi: 10.1097/AOG.0000000000004713

History

02.06.2023: Updated references and text about vaccines

25.03.2022: Updated throughout with the latest studies/scientific knowledge in this field.

31.01.2022: Amended vaccination recommendations to apply to all pregnant women regardless of trimester.

25.11.2021: Clarification of advice that women do not need to wait to conceive after vaccination.

23.11.2021: Clarification about vaccination of pregnant women.

09.09.2021: A new recommendation that healthcare professionals who are pregnant and have pregnancy complications or chronic diseases that may be associated with an increased risk of severe covid-19 disease course are recommended for relocation to other work tasks or home office assessed on the basis of individual risk, regardless of vaccination status. Inserted link to Risk groups for severe covid-19 disease course.

03.09.2021: Changed the order of paragraphs and simplified the text. It is specified that for unvaccinated and partially vaccinated healthcare professionals who are pregnant, it is recommended that other healthcare professionals take samples and treat patients with COVID-19, as far as possible.

18.08.2021: Changed text: pregnant women are recommended to be vaccinated against COVID-19 with mRNA vaccine. Vaccination is recommended in the 2nd and 3rd trimesters unless there are risk factors in the mother or a high risk of infection to indicate vaccination in the 1st trimester. Women planning to conceive can be vaccinated.

26.07.2021: Updated with collapse box with information about vaccination of breastfeeding women in English, as per Norwegian version.

21.05.2021: Added supporting information about vaccination of pregnant women

29.04.2021: Updated text based on new knowledge. Changed advice about vaccination of pregnant women so that it can be considered if the benefits outweigh the disadvantages, also for pregnant women in areas with widespread transmission and who do not have other underlying diseases.

04.03.2021 Added that some studies may indicate that it is possible that the child can be infected before birth, although this is rare, and that the presence of partners during birth and during childbirth is important.

22.01.2021 Updated information about coronavirus vaccine

23.12.2020 Added information about coronavirus vaccine

22.09.2020: Changed "...it is recommended that other healthcare professionals should take samples and treat people with probable, suspected or confirmed COVID-19 disease where possible." 

18.09.2020: Added information from a major systematic review among pregnant women

08.06.2020
Updated knowledge basis, removed information about SARS and MERS that is no longer relevant, moved and shortened paragraph about "do some pregnant women have an increased risk" to a bullet list at the start.

23.03.2020 
Section about children and adolescents moved to a separate article, as per Norwegian version. 

20.03.2020 

Updated advice about pregnancy and birth, according to Norwegian text