The cough could have been anything. Amanda Joyce didn’t even notice it while racing through busy days on the Labor and Delivery floor at Newton Wellesley Hospital, where she works as a nurse. It only registered when her sister asked during a phone call: “oh, you have a cough?”
That was Friday, March 20.
Joyce woke up the following morning feeling like she’d been slammed onto a wrestling mat, again and again. She reached for her phone and used an app to check her baby’s heart rate. Joyce was five and half months pregnant.
Now Joyce, who is 33, is living through a real-time experiment. What does COVID-19 look like in pregnant women? And how does it affect pregnancy?
Joyce suffered through three days of grinding aches and pains, headaches so bad she couldn’t sleep, and a fever she couldn’t control before calling her obstetrician. The doctor said Joyce should be tested for the coronavirus. But she’d been so careful, she says, not going out unless absolutely necessary, making family members shower first thing when they got home, disinfecting everything that came into the house.
“So I was like, I just don’t think so,” Joyce recalls telling her OB. “I was really convinced I had the flu.”
Their First COVID-Positive Pregnant Patient
By the time the lab confirmed she was positive, Joyce could no longer move. She lay in bed sobbing, she says. She couldn’t sleep or retain fluids - had no sense of taste or smell and no appetite. She took Tylenol for days on end, and still her temperature hovered just under 102 degrees. She lay awake nights, praying for anyone with a worse case of COVID-19.
“I don’t know how it could be worse, it’s so awful,” says Joyce, who has what would be considered a moderate case because she’s not in a hospital. She did go the hospital, twice.
When Joyce couldn’t take more than a few steps without gasping for air, her husband drove her to a hospital respiratory clinic. There, doctors ran some tests and decided it was best not to admit her. Joyce says she worried about being admitted. She didn’t want to end up on a ventilator. The survival rates for COVID-19 patients are not good.
But two days later Joyce returned to the hospital, this time to the emergency room. She had chest pains, that rattling breath that signals pneumonia and was dehydrated. With Joyce in an isolation room, hooked up to IV fluids and an EKG, a team of obstetricians and infectious disease specialists conferred. She was their first COVID-positive pregnant patient.
The doctors decided to put Joyce on a combination of an antibiotic, Zithromax, and hydroxychloroquine, also known as Plaquenil, the anti-malaria drug President Trump is promoting for COVID-19 patients.
“The data that supports treatment, whether pregnant or not, with that medication regime is not very robust,” says Dr. Daniel Katz, a maternal fetal medicine specialist who consulted on Joyce’s case. But “she was getting worse, I was trying to do whatever I can to help prevent her from being admitted to the hospital.”
There are no proven treatments for COVID-19. Joyce worries about taking these drugs as well as a blood thinner she had to add to prevent clots. But she trusts her doctors. And Joyce needs to breathe.
“It’s still a little anxiety provoking,” she says, “but if the mom’s not good, the baby’s not going to be good.”
Katz says many of his patients are unusually worried these days. He tries to reassure them. Right now, he says, there’s no reason to think pregnant women are more likely to get sick than the general population. But he knows that all the unanswered questions are difficult.
“The anxiety and the unknowns really goes hand in hand,” Katz says.
Joyce was able to go home with doctors monitoring her heart rate — the drug Plaquenil can disrupt heart rhythms. Her breathing got deeper and easier. Was it the medications or did COVID-19 just finish pummeling Amanda Joyce?
Seeking Clues To Pregnancy And COVID-19
That’s one of many unknowns she may help resolve. Joyce has agreed to answer surveys and send her medical records to researchers at the University of California San Francisco who’ve launched a nationwide study of pregnant women who have the disease.
“There are so many questions,” says Dr. Stephanie Gaw, a co-principal investigator on the study. “This is a new disease. We don’t know how to manage it.”
These researchers will try to determine if the coronavirus symptoms are different for different pregnant women, and whether the impact on the fetus is different in the first, second and third trimesters. They’ll look at the experience of patients, like Joyce, who are treated with experimental medications. And they’ll review early delivery rates, as well as cases of transmission to or immunity for the newborn baby, if they occur.
Gaw says her group will publish what they’re seeing as soon as possible.
“It’s really hard to say we don’t know,” says Gaw. “Most people understand there are certain risks, but not even being able to say what to look out for or what those risks are, it’s really hard to take care of patients due to the uncertainty of the whole pandemic.”
Boston-area hospitals are collaborating on research about COVID-19 and pregnancy as well, says Dr. Ilona Goldfarb, a maternal fetal medicine specialist. She’s the COVID-19 obstetrics lead at Massachusetts General Hospital.
Goldfarb says she’s paying special attention to postpartum depression during the pandemic.
And Goldfarb says the main concern she hears from patients is about how the surge in coronavirus cases will affect their delivery experience. She reassures them, labor and delivery is a haven within hospitals.
“When I’m in the delivery room with a patient, it’s still quite a beautiful experience,” Goldfarb says. “There’s a lot of joy, there’s a lot of excitement and optimism, which is amazing in the midst of this crisis.”
That doesn’t mean labor and delivery rooms are risk-free for patients or providers. Among 215 pregnant patients who delivered at two New York hospitals during the pandemic, 33 tested positive for the coronavirus. Only 4 showed symptoms at the time of the test.
Starting today, Goldfarb says all Partners HealthCare hospitals will be testing pregnant patients admitted for labor and delivery. Other Boston hospitals are doing this to some degree. Tufts Medical Center, for example, tests patients who are scheduled for C-sections but not those who arrive in active labor.
Joyce Inches Towards Recovery
One month after Joyce woke up feeling like she’d been hit by a train, she’s still having low-grade fevers. Her sister, Moriah Hill, who checks in at least once a day, is worried.
“It makes me feel like the infection is still there, which is just nuts at this point,” Hill tells Joyce during a phone call.
Hill and other family members and friends who’d normally stop by to help cook or clean or visit can’t do any of that for Joyce until she tests negative for the coronavirus. Joyce hopes that will happen next week.
Once she’s cleared to leave the house, Joyce will be able to see her OB for a check-up. Joyce says the baby’s been moving a lot, which doctors say is a good sign. Joyce isn’t sure when she’ll go back to work. She’s not certain she’ll be immune to the coronavirus or how long immunity might last.
“If I could be promised I wouldn’t get it again, I would obviously in a heart-beat go back to being right in there every day,” Joyce says. “But I just couldn’t do this again.”
And Joyce carries some guilt. On those days when she had a cough she didn’t even notice, Joyce may have infected some co-workers.
“The first day I found out I cried so hard, I was on the phone with my boss, and I was like, ‘I’m so sorry,’” she says. “I had not a clue, it didn’t even register for me. That was a tough one to come to terms with.”
There’s a lot to come to terms with now as Joyce thinks about re-entering a world turned upside down in the month she’s been sick, a world into which Joyce and her husband hope to bring a healthy baby girl.
Even when she’s feeling normal again, the world won’t be.
Correction: An earlier version of this article overstated the number of pregnant women in a New York study who tested positive for the coronavirus and showed symptoms. The correct number is 4. An additional 29 women in the study tested positive but showed no symptoms of COVID-19.
This article was originally published on April 17, 2020.
This segment aired on April 17, 2020.