Management of pregnant patients

Last updated: 19-03-2020

Management Pearls

  • Pregnant patients diagnosed with COVID-19 are currently being managed the same way as patients with COVID-19 that are not pregnant. Routine obstetric precautions and routine prenatal care should be continued.[1-2]

  • As with all COVID-19 patients, management includes prompt implementation of recommended infection prevention and control measures and supportive management of complications, including advanced organ support if indicated. Supportive management includes oxygen therapy if hypoxic, antibiotics for superimposed pneumonia, and so on.[1-3]

  • No anti-viral therapy has been proven to work for COVID-19 in humans yet.[3]

  • Corticosteroids should be avoided. [2-3]

  • Some medications used to treat COVID-19 are contraindicated in pregnancy

    • Certain medications that may be used to treat patients diagnosed with COVID-19 are contraindicated in pregnant patients. These include, but are not limited to, most nucleoside analogues and host-directed therapies like IFN-alpha. [4]

 

Antenatal Care

Given the risk of exposure to COVID-19 with outpatient appointments, altered antenatal care schedules are recommended to reduce the number of visits. All other questions or non-essential care should be done remotely. Also, it is recommended that the patient should come alone without being accompanied by children or partners to minimize viral exposure.

 

Boelig et al [6] created a COVID-19 guideline for suggested changes in practice titled ‘MFM Guidance for COVID-19’[6]. In the guideline they suggest the following antenatal care schedule:

<11 weeks: Initial Telephone OB intake

11-13 weeks: Initial in person OB visit, initial labs and dating ultrasound/NT

20 weeks: In person OB visit and Anatomy Scan

28 weeks: In person OB visit and OB labs/glucose test/vaccines

32 weeks: In person OB visit and ultrasound if indicated

36 weeks: In person OB visit with GBS screening. Ultrasound if indicated.

37 weeks till delivery: Weekly in person OB visits

 

Note: Routine appointments for women with suspected or confirmed COVID-19 (such as growth scans, antenatal or secondary care appointments) should be delayed until after the recommended period of isolation.[3]

PPE During Delivery

  • If a pregnant patient with COVID-19 ends up requiring mechanical ventilation or has severe deterioration, she may need an emergency caesarean section depending on the gestational age.[3]

  • Appropriate Personal Protective Equipment must be worn during a caesarean section of an individual with confirmed COVID-19. This includes a N95 respirator (fit-tested, seal-checked), isolation gown, gloves, and eye protection (goggles or face shield).[2-3]

  • Given that intubation is considered an aerosol-generating procedure, the surgical team should wear N95 respirators for caesarean delivery in case there is a need to convert from neuraxial to general anesthesia.3

  • Avoid general anesthesia if possible.[3]

  • There have been some case studies where asymptomatic women eventually requiring cesarean sections developed symptoms intrapartum and was confirmed to have COVID-19 postpartum [5]. Given this many centers are now wearing N95 masks and taking aerosol precautions for any cesarean section given the possibility of intubation.

 

 

How does the virus affect pregnant women and the newborn?

Data is currently indeterminate on the following questions:

1) Does COVID-19 cause problems during pregnancy? [1-3]

  • There have been a small number of reported problems with pregnancy or delivery, such as preterm birth, in babies born to mothers who tested positive for COVID-19 during their pregnancy1. However, it is not clear that these outcomes were related to the maternal infection.

2) Does COVID-19 affect the health of the baby after birth? 

  • As there is no clear evidence of intrauterine infection with COVID-19, it is not thought to cause congenital defects at this time.[1,4,7] 

3) Do pregnant women have a greater chance of catching COVID-19 than the general public? [1]

 

4) Pregnant women are more likely to have a serious illness as a result of COVID-19? [1-3]

  • Unlike influenza and other respiratory illnesses, based on a limited number of confirmed COVID-19 cases, pregnant women do not appear to be at increased risk for severe disease.[1]

 

Do pregnant women with COVID-19 can pass the virus that causes COVID-19 to their fetus or baby during pregnancy or delivery? [1,4]

  • No infants born to mothers with COVID-19 have tested positive for the COVID-19 virus yet. In these cases, which are a small number, the virus was not found in samples of amniotic fluid or breastmilk.[1-2]

  • However, all babies of women with suspected or confirmed COVID-19 need to also be tested for COVID-19.[3]

  • CDC recommends that a mother with flu should continue breastfeeding her infant while taking precautions to avoid spreading the virus to her infant, e.g. washing her hands before touching the infant and wearing a face mask while feeding at the breast.[1]

 

However, we do know that pregnant women experience multiple bodily changes that tend to increase their risk of infections. With viruses from the same family as COVID-19, and other viral respiratory infections like influenza, women have had a higher risk of developing severe illness if pregnant. [1-3]

 

 

References

  1. Centers for Disease Control and Prevention (CDC)

  2. The American College of Obstetricians and Gynecologists (ACOG)

  3. Royal College of Obstetricians & Gynaecologists

  4. Chen, Huijun, et al. “Clinical Characteristics and Intrauterine Vertical Transmission Potential of COVID-19 Infection in Nine Pregnant Women: a Retrospective Review of Medical Records.” The Lancet, vol. 395, no. 10226, 2020, pp. 809–815., doi:10.1016/s0140-6736(20)30360-3.

  5. Breslin, Noelle et al. “COVID-19 in Pregnancy: Early Lessons.” American Journal of Obstetrics and Gynecology MFM, 2020. https://doi.org/10.1016/j.ajogmf.2020.100111

  6. Boelig RC, Saccone G, Bellussi F, Berghella V, MFM Guidance for COVID-19, American Journal of Obstetrics & Gynecology MFM,2020, doi: https://doi.org/10.1016/ j.ajogmf.2020.100106. 

  7. RCOG Coronavirus (COVID-19) Infection in Pregnancy : Information for healthcare professionals Version 3 (Published March 18, 2020)

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