“You think you’re gonna get the COVID shot, doc?” my patient asked, her eyes wide above her mask. They had just announced the sign-ups for the COVID-19 vaccine for healthcare workers at my hospital system. It felt like the first glimmer of hope for return to normalcy. The last thing I wanted was to dissuade her from signing up for her own shot, but I hesitated. I had a secret — I was in my first trimester of pregnancy. Since pregnant women were not included in the COVID-19 vaccine clinical trials, I wasn’t entirely sure if I could or should get the vaccine. A quick Google search was largely unhelpful in giving me the yes or no answer I wanted. The forums on my pregnancy tracking app were filled with post after post debating the decision to vaccinate. It appeared I wasn’t the only one struggling with the initial lack of evidence.
Had I truly been a “frontline” worker like my colleagues in the ER, ICU or anesthesia, the benefits of vaccination wouldn’t have been debatable. They care for the sickest patients on ventilators and breathing treatments, so their exposure was unquestionably high. My own risk as an outpatient physician was moderate, and I fall somewhere in the category with teachers, childcare workers and delivery workers who can’t maintain social distance in their homes. I frequently see patients in the office that test positive shortly after our visit. Though I wear PPE, my patients sometimes need me to examine their mouths or simply forget and take off their masks as they speak. I do not have an office and need to eat unmasked in a break room where 6 feet of distance isn’t manageable. Outside of work, we do not socialize, but my toddler goes to daycare and is just under the cutoff to wear a mask. The rates of infection in my city are high. I could be exposed to COVID-19 while grocery shopping or at the pharmacy. Each day feels like a ticking time bomb until I catch the virus.
That pregnant women weren’t included in these trials was unsurprising; they have historically been excluded from research due to ethical reasons, noting the potential risk to mother and developing fetus. The absence of rigorous testing means that pregnant women often find themselves reluctant to take even necessary medications due to lack of data regarding fetal harm. I have had many patients stop medications such as antidepressants or inhalers while trying to conceive, not realizing that a healthy baby is dependent on a healthy mother and that the risks of the untreated disease may be greater than the minor risk of the medication.
During my first pregnancy, I agonized over the use of steroid ointment for my psoriasis. Though data are consistent with safe use with appropriate dosage, I was frightened by the small handful of studies that showed potential growth restriction in high potency topicals, despite reassurance from my ob and dermatologist. The thought that my actions could cause even the slightest harm to this vulnerable creature led me to obsess over the choice in a way that I would have found laughable before motherhood. I ultimately used the steroids and delivered a healthy, thriving baby, as expected.
In the absence of any such data, I turned to guidance from the experts. In the US, the two advisory bodies on pregnancy (the American College of Obstetrics and Gynecology and Society of Maternal Fetal Medicine) released a joint statement in response to the initial WHO recommendations regarding avoidance of COVID-19 vaccination for pregnant individuals. They advocated for inclusion in clinical trials and for a woman’s right to make a decision with her provider regarding immunization. The WHO quickly retracted its message after outcry. It all felt rather patriarchal, these experts in their ivory towers graciously allowing women to chat with their doctors and have the autonomy to vaccinate when there was no evidence that this posed a threat to mother or baby.
So I approached my decision in the same way that I discuss routine vaccination with my patients — a risk versus benefit analysis of the vaccine versus the risks of the disease itself. My obstetrician encouraged vaccination without hesitation, and said simply that the risk of COVID-19 would be much higher than any potential risk of the vaccine. Data from the CDC shows that pregnant women are at significantly higher risk than non-pregnant women for outcomes such as ICU admission, ventilation and death. Some studies have shown an increased risk of preterm delivery and cesarean births due to COVID-19. Furthermore, 80% of clinical trials for COVID-19 treatment excluded pregnant women, although the treatments being evaluated have little or no safety concerns during pregnancy; this means that women who contract COVID-19 still face uncharted waters.
Evaluating the risks of the vaccine requires a review of how mRNA vaccines work. Both the Moderna and Pfizer vaccines use a molecule called mRNA to instruct our immune system to make the spike protein found on the outside of the coronavirus. Our bodies already use mRNA; the genetic code of our DNA is made into a single stranded copy (RNA) which travels from the cell’s nucleus to protein making factories known as ribosomes. The messenger RNA does not incorporate into the host cell’s genetic material, but rather acts as a sort of instruction manual. Once the proteins are made, enzymes destroy the genetic copy.
Our own mRNA survives only a matter of minutes, but the vaccine produces mRNA that can withstand these forces for a few days to incite a robust immune response before it’s destroyed. Because the mRNA never incorporates into the genetic host material and is destroyed quickly, the theoretical risk of fetal harm is incredibly low. The mRNA is thought to stay in the local lymph nodes, which makes crossing the placenta even less likely. Similarly, a closer look at the underlying science debunked the myth that similarity of the placental proteins and the spike proteins on the coronavirus can lead to infertility (they actually aren’t similar at all). Animal studies on the Moderna vaccine have not shown safety concerns for fetal development. The 18 women who inadvertently became pregnant during the trials have yet to report ill effects.
I would have loved the luxury to wait for clinical trial results, but the pandemic is here now. In medicine we often find ourselves facing scenarios that have no precedent, and after all, science is about making inferences based on existing principles. We do this already; although influenza vaccination is recommended routinely for pregnant individuals, the vaccine insert states that “available data are insufficient to inform vaccine associated risk of adverse developmental outcomes.” Other pregnant physicians have written about the dilemma of making this decision, and I can empathize. There is something inherently more reassuring about an error of omission than an error of commission; I understand how avoiding a new vaccine feels like a safer choice than rolling the dice on catching COVID-19.
Yet, I could not rationalize giving into fear of the unknown given the known harm that COVID-19 could do to my baby. I have read harrowing accounts about patients and the obstetricians who treated them. Would I be strong enough to make a rational decision about my baby’s health versus my own if my delivery was complicated by a preventable virus? Even if I had relatively mild symptoms, would I be prepared for months of shortness of breath, increased risk of blood clots and the post-COVID “brain fog” that plagued many of my young, relatively healthy patients?
Ultimately, I put my faith in science. I received both doses of the vaccine with only mild aches and fatigue. Visits to my ob continue to show a reassuring heartbeat. The CDC has created V-safe, a vaccine monitoring program to collect data on side effects, and I was happy that one of the questions included my pregnancy status. I also entered my data into a University of Washington registry on COVID-19 vaccination in pregnancy and lactation. Even if I could not sign up as a participant in a clinical vaccine trial, it felt like this counted for something. I got the vaccine to protect myself, my family, my vulnerable patients, my community and for overlooked pregnant patients everywhere. In a country where many high-risk patients have yet to receive their vaccine, I am immensely grateful for this privilege.
Although it is still too early to feel my baby kick, I wake up in the middle of the night to place my hands over my growing belly and wonder if all is well. But alongside this worry, I now feel immense hope — hope that my baby will be protected by maternal antibodies, can be held by his or her grandparents and will be born into a country where science is again taken as fact rather than politicized and vilified. Or maybe this roller coaster of emotion — this apprehension mixed with hope for the future — has nothing to do with the vaccine and is just another part of motherhood.