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\title{Commentary on Donati et al. SARS-CoV-2 infection among hospitalized
pregnant women and impact of different viral strains on COVID-19 disease
severity in Italy}



\author[1]{James Thornton}%
\affil[1]{Nottingham City Hospital }%


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  \date{May 21, 2024}


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Unlike many viral infections such as influenza, and the two previous
incarnations of the coronavirus, SARS and MERS, Covid-19 originally
appeared to be of similar severity, after adjusting for age, BMI and
other co-morbidities, in the pregnant as in the non-pregnant population.
Worryingly the paper from the Italian Obstetric Surveillance System
COVID-19 Working Group (p \ldots{}), suggests that, in pregnancy, the
virus may be getting more virulent with the advent of newer variants.
Specifically the need for ventilation or ICU admission was significantly
increased during the second wave (alpha variant predominant) compared to
the first (wild-type predominant), albeit with no maternal deaths during
the first wave and only one during the second. If real, this is both
unexpected and concerning. Unexpected, because viruses tend to mutate in
the direction of reduced severity; it is not in the interests of the
virus that the host dies. Concerning, because it suggest that the newer
variants are behaving more like other viral diseases; causing more
severe disease in pregnancy.

The evidence from Italy is supported by at least three other sources. In
August a preprint from the UK Obstetric Surveillance Service (Vousden et
al. MedRxiv 2021.07.22.21261000; doi:
https://doi.org/10.1101/2021.07.22.21261000 accessed 30 September)
reported disease severity in pregnancy when wild type predominated, when
alpha predominated and when delta predominated. In each succeeding phase
disease severity in increased. On 24 September the UK Intensive Care
National Audit \& Research Centre reported (ICNARC 17 September 2021
https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports accessed 30
September) that the absolute numbers of pregnant women admitted to
critical care with Covid were significantly higher in the second (alpha)
wave than the first (wild type), and looked set to be significantly
higher again in the third (delta) wave. Finally a large series from Nair
Hospital, the largest hospital caring for Covid in Mumbai (Mahajan et
al. Obstet Gynecol: July 7, 2021 doi: 10.1097/AOG.0000000000004529),
reported significantly higher maternal mortality during the second
(alpha predominant) wave than the first (wild type).

The lesson for women is simple, get vaccinated. Vaccines are safe and if
the disease is really getting more severe, the balance of risks and
benefits will be moving overwhelmingly in favour of vaccination. The
lesson for obstetricians is more complicated. Encourage women to get
vaccinated and take the disease seriously. Keep women with Covid out of
hospital if possible, but monitor them with saturation monitors
reliably, so those who deteriorate can be picked up quickly. When they
need admission follow evidence-based treatment guidelines, and keep
using personal protective equipment. We're not yet done with Covid.

Jim Thornton MD FRCOG

Emeritus Professor of Obstetrics \& Gynaecology, University of
Nottingham.

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