Reply

We thank Dr Norman for the call for precision in reporting results, particularly during the coronavirus disease 2019 (COVID-19) pandemic¹; we could not agree more. Pregnant women and clinicians need such data to make informed and evidence-based decisions during this stressful time. The objective of our case series of 46 pregnant patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections was to report the clinical outcomes of COVID-19 among these patients.² Our aim was not to provide population-health estimates on the rate of infection or severe disease among all pregnant patients during this time, as estimated by Dr Norman. Although a rigorous assessment of the population-based risk in pregnancy is important, a key estimate for obstetricians right now is the likelihood that a patient infected with SARS-CoV-2 will experience severe disease or adverse pregnancy outcomes. We believe that our report stating that 15% of pregnant patients with COVID-19 had severe disease is accurate (6 of 46 patients with COVID-19; 6 of 43 symptomatic patients). As obstetricians, we aimed to understand the effect of COVID-19 on our own patients to counsel them to the best of our ability.

Our case series reported all known cases from 6 large hospital systems contributing 40% of the annual deliveries in Washington State. This was a key strength of our manuscript because we captured confirmed infections in pregnancy across all trimesters, independent of severity. Our abstract and manuscript clearly reported outcomes on 46 pregnant women with SARS-CoV-2 infections with study results targeted to these patients. We did not attempt to make larger population-wide conclusions across Washington State. Although the rate of SARS-CoV-2 infections and severe COVID-19 disease among all pregnant women in Washington State is low, our case series indicates that we cannot discount the potential for severe disease among pregnant individuals who acquire SARS-CoV-2 infections. In particular, we highlight factors that may increase the risk of severe COVID-19 in pregnancy, such as obesity and asthma, which may affect counseling or medical management after SARS-CoV-2 diagnosis; these factors deserve further study.

There are many ways to leverage data to estimate the effects of a disease on individuals and on the population, each of which is appropriate for different purposes and audiences. For our manuscript, the goal was to provide obstetrical care providers with key clinical insights into disease outcomes among pregnancies affected by SARS-CoV-2 specifically to urgently inform clinical care.