How to help patients contemplating a pregnancy this year

A NEWLY pregnant patient of mine with pre-existing mental health issues recently told me she was considering a termination. Despite previously wanting a baby, she was feeling distressed and ambivalent due to the coronavirus disease 2019 (COVID-19) pandemic.

Her fears were real, understandable and sufficient to destabilise her condition. How would she protect herself from COVID-19? Would she and her baby be safe? How would she be cared for in a health system obsessed with the virus? And what would happen if she and her partner lost their jobs? How would she cope if physical distancing continued until after the baby was born?

Similar concerns have been expressed by my patients without pre-existing mental health issues. Despite jokes about an expected baby boom following months of isolation, many people may be rethinking their plans for a pregnancy due to COVID-19. So, what can we tell patients contemplating a pregnancy if they ask for our advice?

Research to date

Due to the recency of COVID-19, there is a dearth of information about how it affects both male and female fertility, pregnant women, fetuses, and babies. However, a summary of what is known so far was published on 16 April in the journal Fertility and Sterility. Here are some of the key points:

• The limited existing evidence shows that the fever associated with COVID-19 can affect the quality of a man’s sperm for about 3 months, so may reduce fertility.
• Pregnant women are not more likely to get infected by the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) than other women, nor are they at higher risk for severe illness.
• Women who become seriously ill in late pregnancy are more likely than other pregnant women to deliver their babies prematurely.
• Postpartum neonatal transmission from mother to child has been reported, but there has been no indication that infants born to COVID-19-positive mothers experience any significant morbidity or mortality.

The researchers conclude that while data are limited and incomplete, “there is justifiable concern that reproductive consequences of the novel coronavirus may have lasting effects for male reproduction and for some pregnant women and children”.

In Australia, no authorities, including the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), have told women to put off pregnancy, but there is still a cautious feeling in the air. The latest RANZCOG advice for pregnant women, issued on 29 April 2020, states that pregnant women should be considered a vulnerable group; however, this is based on limited knowledge of COVID-19 outcomes in pregnancy and is based on our knowledge of the 2003 outbreak of severe acute respiratory syndrome (SARS) and of influenza in pregnancy.

Other considerations

If patients are keen to start trying for a baby, it may be worth asking a few extra questions in addition the usual pre-conception health discussion to prepare them for what may be ahead. While Australia has successfully “flattened the curve” for the moment, infection rates may still rise and may continue to fluctuate for some time. Some patients’ age may determine their decision, and that is a very important consideration for women aged over 35 years. I suggest asking patients the following questions:

• Is your mental health robust at the moment?
• Are you comfortable seeking care, including emergency care, in a hospital environment that will be very focused on COVID-19 during your pregnancy?
• Are you confident you will have the support you need throughout a pregnancy and with a newborn while maintaining physical distancing from relatives and friends?
• Have you discussed pre-natal testing and learned how to improve your health prior to pregnancy?

For patients wanting to delay pregnancy

If people want to delay their plans to conceive, seize the moment to discuss evidence-based ways they can improve their fertility and chance of a healthy pregnancy and child. With most people working from home and cutting out commutes, it’s a great time to encourage lifestyle changes that will improve pre-conception health. Here are my top five recommendations:

1. Exercise more. Getting off the couch to sweat has many benefits and it may help men and women maintain a healthy weight or get closer to a healthy weight for conception. Research shows that even losing a few kilos can improve pregnancy rates for people who are overweight. Exercise will also help women reduce their chance of complications such as gestational diabetes during pregnancy.
2. Eat well. Women and men can improve their chance of a pregnancy and give their baby the best start in life by having a healthy diet well before a baby is conceived. Encourage men and women to aim for the five food groups every day, with plenty of fruit and vegetables and to limit their intake of fast food and sugary drinks.
3. Limit alcohol intake. Drinking alcohol can reduce both men’s and women’s fertility and heavy drinking increases the time it takes to get pregnant. Alcohol can also reduce the chance of a healthy baby, so for women planning a pregnancy, not drinking alcohol is the safest option.
4. Quit smoking. Men and women who smoke take longer to conceive than non-smokers, and the chemicals in cigarettes can damage eggs and sperm, affecting a future child’s health. Men wanting to conceive should quit smoking at least 3 months before trying to conceive to ensure their sperm is healthy.
5. Take your supplements. Make sure women are taking at least 400 μg of folic acid and 150 μg of iodine each day to support a future baby’s brain, spinal cord and nervous system. Both supplements should be started at least a month before conception.
6. Where there are no contraindications, influenza vaccination is recommended.

If patients want more practical tips to improve their pre-conception health, they can visit the government-funded website yourfertility.org.au.

Dr Magdalena Simonis is a GP and Senior Research Fellow at the University of Melbourne, and the Royal Australian College of General Practitioners Representative to the Victorian Assisted Reproductive Treatment Authority and Your Fertility with a special interest in reproductive health.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.