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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?
In a major systematic review about COVID-19 in pregnant women, studies so far have shown that:
- Unvaccinated 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 variants, although so far most cases of serious illness have been with the delta variant.
- It is possible that a larger proportion of pregnant women infected with COVID-19 do not develop symptoms, but it may be because healthy pregnant women are being tested to a greater extent. The most common symptoms among pregnant women are coughing and difficulty breathing. It appears that fever and moderate general symptoms are not as common as in non-pregnant women.
- In a UK study it appears that 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 increased in unvaccinated pregnant women during the waves of infection with alpha and especially the delta variant of the virus.
- 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 r 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 places.
- COVID-19 has not been shown to increase the risk of miscarriage during pregnancy.
- There have been some cases of transmission from mother to child before or during birth but this is extremely rare. In the cases where this has occurred, all has gone well with the child.
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.
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 for all pregnant women who have not yet been vaccinated. This applies regardless of the trimester.
- Pregnant women are also recommended a booster vaccine. This is especially important for women who are pregnant in the 2nd and 3rd trimester if more than 20 weeks have passed since the 2nd dose, and the first trimester if the woman has an underlying disease.
There has traditionally been a general caution with medical treatment, including vaccination, of pregnant women in the first trimester. However, such a precautionary principle can prevent pregnant women from getting vaccinated and thus protecting themselves and the fetus from serious illness and complications. It is therefore important to emphasize that there is no knowledge that indicates that vaccination with the Covid-19 vaccine in the first trimester poses a risk to mother or child. Most other countries have chosen to recommend vaccination during pregnancy, regardless of trimester.
Primary vaccination with the Covid-19 vaccine is also recommended for women who are planning to become pregnant, to protect them from infection in the time before they become pregnant and throughout the pregnancy. It is not necessary to wait until after vaccination to become pregnant. Vaccines are also recommended for women who receive / plan IVF treatment. A recent study from the United States confirms that the Covid-19 vaccine does not affect the outcome of IVF.1
Vaccination during pregnancy can protect both mother and child from becoming ill with COVID-19. Women who are vaccinated during pregnancy will develop antibodies against the coronavirus, which are then transmitted to the baby - especially in the later stages of pregnancy (regardless of when the woman is vaccinated). Therefore, vaccination of pregnant women can help protect the baby in the first months after birth.
Data from countries where pregnant women have been vaccinated for longer, including a study in Norway, show that vaccination with non-live vaccines (such as mRNA vaccines and viral vector vaccines) does not have an adverse effect on the course of pregnancy, for either the mother or the foetus.
Much of the knowledge about vaccination of pregnant women against coronavirus disease comes mainly from countries that started vaccination earlier than Norway, due to higher infection rates, such as in the US, UK, Israel and Sweden. Pregnant women in Norway are offered two doses at 3-8 week intervals with one of the two mRNA vaccines available in Norway.
The mRNA vaccines from BioNTech / Pfizer (Comirnaty) and Moderna (Spikevax) are considered equivalent in terms of efficacy and safety for pregnant women.
A flexible interval is important so that those who are further along in their pregnancy can receive their primary vaccination before birth, while for those who begin vaccination earlier in the pregnancy, a longer interval may be allowed. The best protection is obtained after the second vaccine dose, and pregant women are also recommended a booster dose. If the vaccination course is not completed during pregnancy, the vaccine can also be given after birth when the woman is ready.
No other side effects have been observed in pregnant women after vaccination compared to non-pregnant women of the same age.
Follow-up studies of vaccinated pregnant women report that pregnant women may experience the same, common side effects as 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. Animal 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.
- Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons. N Engl J Med. 2021.
- Goldshtein I, Nevo D, Steinberg DM, et al. Association Between BNT162b2 Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women. JAMA. 2021
- Gray KJ, Bordt EA, Atyeo C, et al. COVID-19 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol.
- 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. 2021.
- 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.
- 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. BMJ. 2020;370:m3320.
- Engjom H, Aabakke AJ, Klungsøyr K, et al. COVID-19 in pregnancy – characteristics and outcomes of pregnant women admitted to hospital because of SARS-CoV-2 infection in the Nordic countries. medRxiv. 2021:2021.2002.2005.21250672.
There is no evidence that coronavirus vaccines affect women's fertility. Menstrual irregularities after vaccination have been reported, but not during pregnancy.
- Coronavirus vaccine for pregnant women (information letter)
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.
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.
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.
- Risk groups and their relatives
- Pregnancy and COVID-19 - Norwegian Medical Association (in Norwegian)
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.
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 pregant 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.
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).
Breasrfeeding women can be vaccinated.
What do we know about COVID-19 vaccination of breastfeeding women?
For most vaccines, there is little documentation of transmission to breast milk. There are still few studies on breastfeeding women who have been vaccinated with the coronavirus vaccines.
Breastfeeding women have a good immune response to the vaccine (1). When the mother is vaccinated, the baby will obtain antibodies from the mother through breast milk (2-4). Two studies did not find mRNA from the vaccines in breast milk (5, 6), while a non-peer-reviewed study using an even more sensitive method found extremely limited amounts of mRNA in breast milk (4). However, it is very unlikely that even tiny amounts of vaccine in breast milk could have any effect, as the vaccine does not contain live viruses and any small residues will be broken down in the digestive system.
The WHO does not recommend any restrictions on breastfeeding. Women who are vaccinated should continue to breastfeed.
- Collier A-rY, McMahan K, Yu J, Tostanoski LH, Aguayo R, Ansel J, et al. Immunogenicity of COVID-19 mRNA Vaccines in Pregnant and Lactating Women. JAMA. 2021;325(23):2370-80.
- Gray KJ, Bordt EA, Atyeo C, Deriso E, Akinwunmi B, Young N, et al. Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol.
- Jakuszko K, Kościelska-Kasprzak K, Żabińska M, Bartoszek D, Poznański P, Rukasz D, et al. Immune Response to Vaccination against COVID-19 in Breastfeeding Health Workers. Vaccines (Basel). 2021;9(6).
- Low JM, Gu Y, Ng MSF, Amin Z, Lee LY, Ng YPM, et al. BNT162b2 vaccination induces SARS-CoV-2 specific antibody secretion into human milk with minimal transfer of vaccine mRNA. medRxiv. 2021:2021.04.27.21256151.
- Mattar CN, Koh W, Seow Y, Hoon S, Venkatesh A, Dashraath P, et al. Addressing anti-syncytin antibody levels, and fertility and breastfeeding concerns, following BNT162B2 COVID-19 mRNA vaccination. medRxiv. 2021:2021.05.23.21257686.
- Golan Y, Prahl M, Cassidy A, Lin CY, Ahituv N, Flaherman VJ, et al. Evaluation of Messenger RNA From COVID-19 BTN162b2 and mRNA-1273 Vaccines in Human Milk. JAMA Pediatr. 2021.
Information for the general public
Information helpline for questions about coronavirus: 815 55 015 (weekdays 08-15.30)
The Norwegian Directorate of Immigration has answers to many frequently asked questions about travelling to Norway, and a helpline 23351600 that is open on weekdays from 10:00-14:00.
The Ministry of Foreign Affairs also has answers to many frequently asked questions.
If you need acute medical attention, contact your doctor. If you cannot reach your doctor, contact the emergency out-of-hours clinic on 116117. If life is in danger, call 113.