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CME

COVID-19 and Pregnant Patients

Overview

  • COVID-19 infection (coronavirus disease 2019) is an acute respiratory disease caused by novel coronavirus SARS-CoV-2 (CDC 2020 Mar 22)
  • many physiologic and anatomic changes of pregnancy affect the respiratory system and increase susceptibility to infections in general, which may complicate or delay the diagnosis of COVID-19 and/or the clinical course of the disease in infected women
  • respiratory illnesses during pregnancy may be associated with increased infectious morbidity and high maternal mortality rates but it is currently unknown if pregnant women have more severe disease as a result of COVID-19 infection
  • Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) recommend priority COVID-19 testing for pregnant women admitted to hospital with suspected COVID-19 infection or who develop symptoms associated with COVID-19 infection during admission
  • screening for COVID-19 in pregnant patients is similar to that in the general population
  • follow general recommendations for infection prevention in the management of pregnant women with suspected or confirmed COVID-19
  • outpatient, inpatient, or intensive care for management of COVID-19 infection in pregnant women
  • antenatal, intrapartum, and postpartum considerations during COVID-19 pandemic
    • consider mental health needs of pregnant women during COVID-19 pandemic
    • considerations for routine prenatal care during COVID-19 pandemic
      • unless directed otherwise by local clinic policies, women should be advised to attend routine antenatal care unless they meet criteria for self-isolation, in which case, appointments should be deferred for 14 days
      • screen for COVID-19 symptoms and possible exposure prior to having patient report for in-person appointments
      • patients with certain high-risk obstetric conditions and/or comorbidities should be provided appropriate and necessary prenatal care and antenatal surveillance when indicated
      • consider alternate prenatal care approaches to help control the spread of COVID-19, including
        • patient assessments via phone or telehealth
        • alternate prenatal care schedules
    • women with suspected or confirmed COVID-19 infection should notify the obstetric unit prior to arrival to allow for appropriate infection control procedures (CDC 2020 Apr 4)
    • antenatal considerations
      • antenatal fetal surveillance
        • during acute illness, fetal management should be similar to that provided to any critically ill pregnant person
        • ultrasound
          • elective ultrasound exams should not be performed
          • if risk of exposure and infection within the community is greater than benefit of testing, consider postponing or canceling some testing or exams
          • detailed mid-trimester anatomy ultrasound examination may be considered following first trimester maternal COVID-19 infection
          • ultrasound assessment of fetal growth is indicated in pregnant women with COVID-19 infection due to risk of fetal growth restriction
      • all pregnant women with suspected or confirmed COVID-19 infection should receive prophylactic low molecular weight heparin upon admission to reduce risk of venous thromboembolism unless birth is expected within 12 hours2
      • antenatal corticosteroids for fetal maturation
        • for pregnancies with suspected or confirmed COVID-19 between 24 0/7 weeks and 33 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should continue to be offered as recommended
        • for pregnancies between 34 0/7 and 36 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should not be offered
        • modifications to care should be individualized, weighing neonatal benefits of antenatal corticosteroids with risk of potential harm from possible immunosuppression in infected patients
      • benefits of magnesium sulfate for fetal neuroprotection should be weighed against potential risks of maternal respiratory depression in patients with symptomatic infection while also taking gestational age into account
    • labor and delivery
    • postpartum management
      • tubal sterilization (other than that performed during cesarean delivery) is an elective procedure, therefore postpartum tubal ligations should be deferred in patients who are COVID-19 positive and alternative forms of contraception can be offered1
      • infants born to mothers with confirmed COVID-19 should be considered persons under investigation and should be isolated per United States Centers for Disease Control and Prevention (CDC) guidance
      • mother-infant contact
        • decision whether to separate a mother with suspected or confirmed COVID-19 and her infant should be made on a case-by-case basis using shared-decision making between the mother and the clinical team
        • if rooming-in of mother and newborn occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, consider implementing measures to reduce exposure of the newborn to COVID-19
      • expedited discharge from the hospital may be considered when both mother and infant are healthy to limit risk of exposure and infection to COVID-19
      • all women with confirmed COVID-19 should be given prophylactic low molecular weight heparin for ≥ 10 days upon hospital discharge regardless of mode of birth2
      • consider modifying or reducing postpartum follow-up appointments to decrease risk of COVID-19 spread and exposure
      • breastfeeding for women with suspected or confirmed COVID-19
        • for mother/infant pairs who are rooming-in, breastfeeding can be considered with use of proper hand washing and other preventative measures to decrease risk of exposure for infant
        • for mother/infant pairs who are temporarily separated, mothers who wish to breastfeed should be encouraged to express their breastmilk to establish and maintain milk supply and expressed milk should be fed to newborn by a healthy caregiver

General Information

Description

  • COVID-19 infection (coronavirus disease 2019 ) is an acute respiratory disease caused by novel coronavirus SARS-CoV-2 (CDC 2020 Mar 22)
  • patients with existing conditions may be more susceptible to COVID-19 and may experience more severe illness, including pregnant women (Am J Obstet Gynecol 2020 Mar 23 early online)

Physiologic changes during pregnancy that increase susceptibility to COVID-19

  • many physiological and anatomical changes of pregnancy affect the respiratory system and increase susceptibility to infections in general, which may complicate diagnosis of COVID-19 and/or the clinical course of the disease in infected pregnant women
    • PubMed27066123Breathe (Sheffield, England)Breathe (Sheff)20151201114297-301297diagnosis of COVID-19 may be delayed in pregnant women due to pregnancy-associated rhinitis and physiologic dyspnea, which is common in pregnancy (Breathe (Sheff) 2015 Dec;11(4):297full-text)
    • pregnant women are not necessarily more susceptible to viral illness; however, immunosuppression during pregnancy may impact severity of symptoms, particularly towards the end of pregnancy2,3
    • PubMed27066123Breathe (Sheffield, England)Breathe (Sheff)20151201114297-301297pregnant women have decreased lung functional residual capacity and have a relative inability to clear respiratory secretions (Breathe (Sheff) 2015 Dec;11(4):297full-text)
    • PubMed32227760The New England journal of medicineN Engl J Med20200330SARS-CoV-2 is proposed to interact with the renin-angiotensin-aldosterone system (RAAS) through angiotensin-converting enzyme 2 (ACE2), an enzyme that physiologically counters RAAS activation but also acts as a receptor for SARS-CoV-2 (N Engl J Med 2020 Mar 30 early online)
      • PubMed15273828Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicasBraz J Med Biol Res200408013781255-621255during normal pregnancy, estrogen and progesterone increase levels of angiotensinogen and renin, leading to an increase in ACE-2 levels (Braz J Med Biol Res 2004 Aug;37(8):1255full-text)
      • PubMed32171062The Lancet. Respiratory medicineLancet Respir Med20200311increased expression of ACE2 may facilitate infection with COVID-19 (Lancet Respir Med 2020 Mar 11 early online)

Complications of COVID-19 infection during pregnancy

  • respiratory illnesses during pregnancy may be associated with increased infectious morbidity and high maternal mortality rates (Am J Obstet Gynecol 2020 Mar 23 early online)
  • currently unknown if pregnant women have more severe disease as a result of COVID-19 infection (CDC 2020 May 13)
  • PubMed16933304Birth defects research. Part A, Clinical and molecular teratologyBirth Defects Res A Clin Mol Teratol20060701767507-16507fever is a prevailing symptom of COVID-19 infection; maternal pyrexia in early pregnancy may be associated with craniofacial and cardiac defects and adverse neurological outcomes (Birth Defects Res A Clin Mol Teratol 2006 Jul;76(7):507)
  • maternal, obstetric, and neonatal outcomes of coronavirus infections in pregnancy
    • based on pooled data from case studies and case reports
    • 84 women who had coronavirus infections during pregnancy were included
      • COVID-19 in 55 women
      • severe acute respiratory syndrome (SARS) in 17 women
      • Middle East respiratory syndrome (MERS) in 12 women
    • comparing COVID-19 vs. SARS vs. MERS (no p values reported)
      • maternal mortality in 0% vs. 18% vs. 25%
      • mechanical ventilation in 2% vs. 35% vs. 41%
      • miscarriage/stillbirth in 2% vs. 25% vs. 18%
      • intrauterine growth restricted fetus in 9% vs. 13% vs. 9%
      • preterm birth in 43% vs. 25% vs. 27%
      • neonatal death in 2% vs. 0% vs. 9%
    • Reference - Am J Obstet Gynecol 2020 Mar 23 early online

Evaluation, Diagnosis, and Screening

Clinical presentation

  • COVID-19 may range from mild disease to severe illness (CDC 2020 May 13)
  • common symptoms in nonpregnant patients include
    • fever
    • cough
    • shortness of breath or difficult breathing
    • chills
    • repeated shaking with chills
    • muscle pain
    • headache
    • sore throat
    • new loss of taste or smell
    • Reference - CDC 2020 May 13
  • see also COVID-19 (Novel Coronavirus) topic
  • clinical presentation of COVID-19 in case series of 43 pregnant women (median gestational age 37 0/7 weeks) in New York City, New York, United States between March 13, 2020 to March 27, 2020
    • no COVID-19-specific symptoms in 14 women (32.6%)
      • 10 out of 14 (71.4%) identified as COVID-19 positive after developing symptoms during admission for obstetric reasons or early after postpartum discharge
      • 4 out of 14 (28.6%) identified as COVID-19 positive after implementation of universal testing for all obstetrical admissions
    • symptomatic infection in 29 women (67.4%)
      • dry cough in 19 women (65.5%)
      • fever in 14 women (48.3%)
      • myalgia in 11 women (37.9%)
      • headache in 8 women (27.6%)
      • shortness of breath in 7 women (24.1%)
      • chest pain in 5 women (17.2%)
      • any combination of above symptoms in 26 women (89.7%)
    • Reference - Am J Obstet Gynecol MFM 2020 Apr 9 early online
  • clinical presentation of COVID-19 pneumonia in case series of 9 pregnant women in Wuhan, China
    • fever in 7 women (77.8%)
    • cough in 4 women (44.4%)
    • myalgia in 3 women (33.3%)
    • sore throat in 2 women (22.2%)
    • malaise in 2 women (22.2%)
    • PubMed32151335Lancet (London, England)Lancet2020030739510226809-815809Reference - Lancet 2020 Mar 7;395(10226):809

Initial evaluation and management

  • Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) recommend priority COVID-19 testing for pregnant women
    • admitted to hospital with suspected COVID-19 infection
    • who develop symptoms associated with COVID-19 infection during admission
    • References -
  • American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) recommendations for outpatient assessment for pregnant women with suspected or confirmed COVID-19
    • assess symptoms, which typically include fever ≥ 38 degrees C (100.4 degrees F) or ≥ 1 of the following
      • cough
      • difficulty breathing or shortness of breath
      • gastrointestinal symptoms
    • if absent, proceed with routine prenatal care
    • if present, conduct illness severity assessment including presence of any
      • difficulty breathing or shortness of breath
      • difficulty completing a sentence without gasping for air or needing to stop to catch breath frequently when walking short distances
      • coughing ≥ 1 teaspoon of blood
      • new pain or pressure in chest other than pain with coughing
      • inability to keep liquids down
      • signs of dehydration such as dizziness when standing
      • confusion or decreased responsiveness
    • if yes to any questions on illness severity assessment (above), patient is considered to be at elevated risk of severe disease
      • recommend immediate care in emergency department or equivalent unit that treats pregnant women, preferably in a setting where patient can be isolated
      • notify the facility that a person under investigation is being referred to minimize chance of spreading infection
      • adhere to local infection control practices including personal protective equipment
    • if no to all symptoms and signs in illness severity assessment (above), assess clinical and social risks for COVID-19 infection including
      • comorbidities, such as hypertension, diabetes, asthma, HIV, chronic heart disease, chronic liver disease, chronic lung disease, chronic kidney disease, blood dyscrasia, and immunosuppressive therapy
      • obstetric complications, such as preterm labor
      • an inability to care for self or arrange follow-up if necessary
    • if yes to any answers on clinical or social risk assessment
      • examine patient as soon as possible in an ambulatory setting with resources to determine severity of illness, preferably in a setting where patient can be isolated
      • clinical assessment for respiratory compromise includes
        • physical exam
        • pulse oximetry
        • chest x-ray
        • arterial blood gas as clinically indicated
        • chest computed tomography with abdominal shielding if clinically recommended
    • if patient is determined to have respiratory compromise or complications, admit for further evaluation and testing and review policies on isolation, negative pressure, and other infection control measures to minimize patient and provider exposure
    • if patient does not have any identified clinical or social risks or if it is determined that patient does not have respiratory compromise or complications
      • refer for symptomatic care at home, including hydration and rest
      • monitor for development of any new symptoms and revisit algorithm if new symptoms present
      • take routine obstetric precautions
    • Reference - ACOG/SMFM 2020 Apr 24 PDF
  • Study Summary
    ultrasound reported to be helpful for assessment and monitoring of COVID-19 pneumonia in pregnant women
    DynaMed Level3
    Details
    Emergency_Medicine Obstetric_and_Gynecologic_Conditions Radiologyultrasound reported to be helpful for assessment and monitoring of COVID-19 pneumonia in pregnant women (Ultrasound Obstet Gynecol 2020 Apr 26 early online)05/22/2020 08:16:50 AMstudySummary
    • Case Series based on case series
    • 4 pregnant women (median age 37 years, gestational age 24-35 weeks) admitted to hospital with suspected (and later confirmed) COVID-19 infection had lung ultrasound on admission, at 72-96 hours, and > 96 hours
    • ultrasound features indicative of COVID-19 pneumonia
      • irregular pleural lines and vertical artifacts (B-lines) in 4 women
      • patchy areas of white lung in 2 women
      • pleural line abnormalities and multiple subpleural consolidations in all lung areas in woman admitted to intensive care unit (ICU)
    • outcomes based on lung ultrasound during disease course
      • 3 women had resolution of lung pathology assessed by ultrasound at > 96 hours of admission
      • 1 woman admitted to ICU showed progressive improvement of lung pathology by reduction of number of lung areas with pathological findings
    • PubMed32337795Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and GynecologyUltrasound Obstet Gynecol20200426Reference - Ultrasound Obstet Gynecol 2020 Apr 26 early online

Screening

  • screening for COVID-19 in pregnant patients is similar to that in the general population - see COVID-19 (Novel Coronavirus) for additional information

Management

ManagementManagement

Management overview

  • outpatient, inpatient, or intensive care for management of COVID-19 infection in pregnant women
  • antenatal, intrapartum, and postpartum considerations during COVID-19 pandemic
    • consider mental health needs of pregnant women during COVID-19 pandemic
    • considerations for routine prenatal care
      • unless directed otherwise by local clinic policies, women should be advised to attend routine antenatal care unless they meet criteria for self-isolation, in which case, appointments should be deferred for 14 days
      • consider screening for COVID-19 symptoms and possible exposure prior to having patient report for in-person appointments
      • patients with certain high-risk obstetric conditions and/or comorbidities should be provided appropriate and necessary prenatal care and antenatal surveillance when indicated
      • consider alternate prenatal care approaches to help control the spread of COVID-19, including
        • patient assessments via phone or telehealth
        • alternate prenatal care schedules
    • women with suspected or confirmed COVID-19 infection should notify the obstetric unit prior to arrival to allow for appropriate infection control procedures (CDC 2020 May 20)
    • antenatal considerations
      • antenatal fetal surveillance
        • during acute illness, fetal management should be similar to that provided to any critically ill pregnant person
        • ultrasound
          • elective ultrasound exams should not be performed
          • if risk of exposure and infection within the community is greater than benefit of testing, consider postponing or canceling some testing or exams
          • detailed midtrimester anatomy ultrasound examination may be considered following first trimester maternal COVID-19 infection
          • ultrasound assessment of fetal growth is indicated in pregnant women with COVID-19 infection due to risk of fetal growth restriction
      • antenatal corticosteroids for fetal maturation
        • for pregnancies with suspected or confirmed COVID-19 between 24 0/7 weeks and 33 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should continue to be offered as recommended
        • for pregnancies between 34 0/7 and 36 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should not be offered
      • benefits of magnesium sulfate for fetal neuroprotection at any given gestational age should be weighed against potential risks of maternal respiratory depression in symptomatic patients
    • labor and delivery
    • postpartum management
      • tubal sterilization (other than that performed during cesarean delivery) is an elective procedure, therefore postpartum tubal ligations should be deferred in patients who are COVID-19 positive and alternative forms of contraception can be offered1
      • infants born to mothers with confirmed COVID-19 should be considered persons under investigation and should be isolated per United States Centers for Disease Control and Prevention (CDC) guidance
      • mother-infant contact
        • decision whether to separate a mother with suspected or confirmed COVID-19 and her infant should be made on a case-by-case basis using shared-decision making between the mother and the clinical team
        • if rooming-in of mother and newborn occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, consider implementing measures to reduce exposure of the newborn to COVID-19
      • expedited discharge from the hospital may be considered when both mother and infant are healthy to limit risk of exposure and infection to COVID-19
      • all women with confirmed COVID-19 should be given prophylactic low molecular weight heparin for ≥ 10 days upon hospital discharge regardless of mode of birth2
      • consider modifying or reducing postpartum follow-up appointments to decrease risk of COVID-19 spread and exposure
      • breastfeeding can be considered for women with suspected or confirmed COVID-19 with use of proper hand washing and other preventative measures to decrease risk of exposure for infant

General infection prevention measures

  • see COVID-19 (Novel Coronavirus) for United States Centers for Disease Control and Prevention (CDC) general recommendations for infection prevention in the management of COVID-19
  • Queensland Health general recommendations for infection prevention in the management of COVID-19 (Queensland Health 2020 Apr 24)

Considerations for management of COVID-19 infection in pregnant women

Determination of outpatient, inpatient, or intensive care management of COVID-19 infection in pregnant women

  • inpatient monitoring indicated for pregnant women
  • criteria for admission to intensive care unit for hospitalized pregnant woman with COVID-19
    • consult intensivist/critical care physician if any of the following
      • inability to maintain oxygen saturation ≥ 95% (pulse oximetry) with supplemental oxygen or if rapidly escalating need for supplemental oxygen
      • hypotension (mean arterial pressure ≤ 65) despite appropriate fluid resuscitation (about 500-1,000 mL bolus of crystalloid fluids)
        • for patients with COVID-19 in acute resuscitation, consider a conservative fluid strategy to avoid concomitant fluid overload and worsening pulmonary edema
        • in the setting of clear hypovolemia and nothing per mouth status, conservative fluid administration and IV fluid administration is recommended
      • evidence of new end-organ dysfunction, such as altered mental status, renal insufficiency, hepatic insufficiency, cardiac dysfunction
    • if none of the above signs and symptoms are present, continue with current inpatient care with frequent reassessment; admit to intensive care unit if any of the following
      • persistence of above symptoms despite interventions
      • inability to increase frequency of assessments, such as a need to transfer to a higher level of care
      • intubation or mechanical ventilation
      • need for other end-organ support
    • if none of the above, conninue advanced management in intermediate acuity setting with low threshold for higher level of care as needed
    • Reference - SMFM 2020 Apr 30 PDF

Outpatient and inpatient monitoring and management of COVID-19 infection in pregnant women

  • outpatient management of mild or asymptomatic COVID-19 infection in pregnant women
    • women should be monitored closely by obstetric care provider for worsening symptoms
    • women should perform daily self-assessments and should contact healthcare provider for any of the following
      • worsening shortness of breath
      • tachypnea
      • persistent fever ≥ 39 degrees C (102.2 degrees F) despite appropriate use of acetaminophen
      • inability to tolerate oral hydration or needed medications
      • oxygen saturation ≤ 95% either at rest or on exertion via home pulse oximetry, if available
      • persistent pleuritic chest pain
      • new onset confusion or lethargy
      • cyanotic lips, face, or fingertips
      • obstetric complaints, such as preterm contractions, vaginal bleeding, or decreased fetal movement
    • consider follow-up visits at least once within 2 weeks of COVID-19 diagnosis (either through telehealth or at a specialized COVID-19 clinic where available)
    • Reference - SMFM 2020 Apr 30 PDF
  • inpatient management of COVID-19 infection in pregnant women
    • frequency of vital sign assessment depends upon severity of disease and corresponding level of nursing care needed
      • for mild disease, vital signs should be monitored every 4-8 hours as needed and should include
        • temperature
        • heart rate
        • respiratory rate
        • blood pressure
        • pulse oximetry
      • for severe disease, vital signs should be monitored every 2-4 hours; consider continuous pulse oximetry and/or telemetry to decrease patient contact and exposure risk
      • for critical disease
        • continuous pulse oximetry and telemetry should be used
        • noninvasive and invasive cardiovascular monitoring may be considered as needed
        • vital signs, including respiratory support, should be monitored every 1-2 hours
    • timing of intubation in hospitalized pregnant woman with COVID-19 infection
      • timing of intubation should be individualized; considerations for placing a definitive airway include
        • maternal status
        • preexisting comorbidities
        • presence of multi-organ failure
        • required oxygen supplementation
        • need for transport to a facility with a higher level of care
      • intubation is generally considered
        • with any of the following oxygen requirements
          • ≥ 15 L per minute by common nasal cannula or mask
          • ≥ 40-50 L per minute by high-flow nasal cannula
          • ≥ 60% of fraction of inspired oxygen by Venturi mask to maintain oxygen saturation of > 95% by transcutaneous pulse oximeter
        • if patient is unable to protect the airway due to an altered mental status (Glasgow coma scale < 8)
    • alternatives to intubation for safe oxygen delivery
      • common nasal cannula (maximum of 15 L per minute deliverable)
      • face mask
        • non-rebreather type
        • maximum dependent on source, typically up to 15 L per minute from wall supply but may be increased to about 50 L per minute with an additional source
      • Venturi mask, which supplies support via fraction of inspired oxygen at a maximum of 60% oxygen delivery
      • noninvasive positive-pressure ventilation, which are controversial due to concern for aerosolizing infectious particles
    • prone positioning can be considered for pregnant and postpartum women (including those who recently delivered)
      • padding or support devices may be needed to position pregnant woman properly
      • ensure the endotracheal tube remains in place throughout rotation and positioning and that it is remains secured
      • passive prone positioning where the patient is not intubated and positions herself in the lateral decubitus or fully prone position (for about 2 hours in each position) may be more comfortable for the patient and may help avoid intubation

Treatment of COVID-19 disease and co-infections in pregnancy

  • there is no specific antiviral treatment for COVID-19, but supportive care may help to relieve symptoms and should include support of vital organ functions in severe cases; see COVID-19 (Novel Coronavirus) for guidance on supportive management and investigational therapies in nonpregnant patients
  • investigational therapies for COVID-19 include
    • use of remdesivir appears safe in human pregnancies
    • hydroxychloroquine (with or without azithromycin) and chloroquine phosphate
      • chloroquine phosphate and its metabolites cross the placenta, but its use appears safe in all trimesters of pregnancy with no increased risk of adverse perinatal outcomes
      • higher doses may be needed in pregnancy (≥ 500 mg twice daily) due to lower plasma drug concentrations in pregnancy
      • high-dose chloroquine may cause systolic hypotension, which may exacerbate hemodynamic changes from supine aortocaval compression by a gravid uterus
    • lopinavir-ritonavir (LPV/r) is known to be safe in pregnancy based on population-based data of LPV/r exposure in HIV-positive pregnancies
    • ribavirin is teratogenic and should be avoided
    • baricitinib is contraindicated in pregnancy based on evidence of embryotoxicity in animal studies
    • PubMed32217113American journal of obstetrics and gynecologyAm J Obstet Gynecol20200323References -
  • consider empiric antibiotic therapy for superimposed bacterial pneumonia in women with confirmed COVID-19 infection or severe respiratory disease; first-line antibiotics are oral amoxicillin for stable patients and ceftriaxone for severe disease, based on general recommendations for the management of pneumonia3,4 - see also Streptococcus pneumoniae Pneumonia

Perinatal mental health considerations

  • mental health considerations for pregnant women during COVID-19 pandemic
    • pregnant women and their partners may experience heightened anxiety and stress related to the COVID-19 pandemic, irrespective of personal COVID-19 status (negative, suspected, or confirmed)
    • provide consistent information about the COVID-19 pandemic to women and their families
    • maintain awareness that domestic and family violence situations may increase with social isolation
    • offer referral to mental health services
    • References -

Considerations for routine prenatal care

  • unless directed otherwise by local clinic policies, women should be advised to attend routine prenatal care unless they meet criteria for self-isolation, in which case, appointments should be deferred for 14 days2,3,4
  • considerations for screening prior to reporting for in-person appointments1
    • screen for COVID-19 symptoms and potential exposure via telehealth (including telephonic and other remote services) prior to in-person appointments
    • instruct patients to call ahead and discuss the need to reschedule their appointment if they develop any respiratory symptoms on the day of their scheduled appointment
    • confirm whether any patient scheduled for an in-person appointment has been tested for COVID-19
    • if patient reports exposure to a person with COVID-19 during screening process, patient should not attend scheduled appointment
  • patients with certain high-risk obstetric conditions and/or comorbidities should be provided the appropriate and necessary prenatal care and antenatal surveillance when indicated (SMFM 2020 Apr 11 PDF)
  • consider alternate prenatal care approaches to help control the spread of COVID-19; options may include1,4
    • promoting access to online antenatal education, such as group/individual sessions via online platforms, email contact, support groups, telehealth appointments, or text messaging
    • assessing the individual circumstances of each women and tailoring the number and schedule of antenatal appointments to the absolute minimum
    • spacing out in-person routine prenatal care appointments to reduce the number of patients in the office at one time, which may be achieved by
      • postponing nonemergent gynecological or well-woman appointments
      • conducting appointments via telehealth when possible
      • grouping components of prenatal care together to reduce the number of in-person visits; examples of alternate or reduced prenatal care schedules include
        • OB Nest care consisting of
          • 8 onsite appointments with an obstetric provider
          • 6 virtual visits consisting of phone or online communication with an assigned nurse, supplemented with fetal Doppler and sphygmomanometer home monitoring devices
          • access to an online community of pregnant women
          • PubMed31228414American journal of obstetrics and gynecologyAm J Obstet Gynecol201912012216638.e1-638.e8638.e1Reference - Am J Obstet Gynecol 2019 Dec;221(6):638.e1
        • antenatal visit timing in setting of COVID-19 pandemic
          • initial obstetric intake by telehealth at < 11 weeks gestation
          • in-person visits to be conducted at
            • 11-13 weeks gestation for ultrasound (pregnancy dating and nuchal translucency screening) and initial obstetric labs
            • 20 weeks gestation for detailed anatomical ultrasound
            • 28 weeks gestation for routine labs and vaccinations
            • 32 weeks gestation for ultrasound if clinically indicated
            • 36 weeks gestation for ultrasound if clinically indicated and group-B streptococcus and HIV screening
            • 37 weeks gestation until delivery for weekly assessments
          • Reference - MFM Guidance for COVID-19
        • modified antenatal care schedule for women at low risk of COVID-19 and gestational diabetes mellitus (GDM) screening/oral glucose tolerance test (OGTT) recommended by Queensland Health
          • general principles of antenatal care during COVID-19 pandemic
            • reduce number and duration of face-to-face contacts to reduce risk of virus transmission
              • limit face-to-face appointment to < 15 minutes
              • conduct face-to-face appointment with minimum number of people present (preferably patient only)
              • minimize time spent in waiting areas
              • consider hybrid face-to-face and telehealth models for care
            • schedule face-to-face appointments around care that requires physical interaction/care, such as vaccination
            • during every face-to-face appointment
              • perform usual clinical assessments, including blood pressure, fundal height, fetal heart, weight, and urinalysis
              • ask about fetal movements, mental well-being, and screen for domestic violence
            • for all women regardless of COVID-19 status, if clinical features of gestational diabetes mellitus (GDM) emerge during pregnancy, recommend usual screening and management for GDM as indicated
          • proposed antenatal schedule
            • < 12 weeks gestation (or first visit) - face-to-face appointment
              • recommend influenza vaccination
              • if high risk for GDM, measure hemoglobin A1c (HbA1c) instead of OGTT
                • if HbA1c > 41 mmol/mol (5.9%), proceed with GDM management
                • if HbA1c < 41 mmol/mol (5.9%)
                  • check fasting blood glucose at 24-28 weeks gestation or after first trimester based on clinical concern
                    • if fasting blood glucose ≤ 4.6 mmol/L - OGTT not required and proceed with routine prenatal care
                    • if fasting blood glucose 4.7-5 mmol/L - OGTT recommended (if COVID-19 suspected or confirmed, seek expert clinical advise)
                      • if OGTT normal - proceed with routine prenatal care
                      • if OGTT not normal - proceed with GDM management
                    • if fasting blood glucose ≥ 5.1 mmol/L - OGTT not required and proceed with GDM management
                  • Reference - Queensland Health 2020 Apr 14 PDF
              • consider dating scan (6-8 weeks) for gestational age, viability, and location
              • recommend nuchal scan (11-13 weeks) with or without noninvasive prenatal testing (≥ 10 weeks)
              • refer for routine antenatal blood tests, including ferritin with hemoglobin assessment
            • 12-18 weeks gestation - telehealth appointment
              • discuss assess to online/virtual antenatal classes
              • follow-up results of tests from previous appointment
              • recommend fetal anatomy scan (18-20 weeks)
            • 20-22 weeks gestation - face-to-face appointment
              • recommend pertussis vaccination
              • give referral for 26-28 week blood tests
            • 24-26 weeks gestation - routine prenatal care via telehealth appointment
            • 28 weeks gestation - face-to-face appointment
              • RhD immunoglobulin (anti-D), if indicated
              • give referral for 36 week gestation blood tests
            • 31 weeks gestation - routine prenatal care via telehealth appointment
            • 34-37 weeks gestation
              • 1 face-to-face appointment
                • RhD immunoglobulin (anti-D), if indicated
                • consider ultrasound for assessment of fetal growth
              • routine prenatal care via telehealth
            • 38 weeks gestation - routine prenatal care via telehealth appointment
            • 41 weeks gestation - face-to-face appointment (if needed) to discuss usual considerations for fetal well-being and birth planning
  • American College of Obstetricians and Gynecologists (ACOG) recommends that low-dose aspirin continue to be offered to pregnant and postpartum women with suspected or confirmed COVID-19 as medically indicated for preeclampsia prevention1

Considerations for pregnancy termination

  • pregnancy termination/delivery may be considered for
    • maternal hypoxia as risks of prolonged fetal hypoxia include neurologic injury and/or stillbirth
    • fetal compromise
    • rapid maternal deterioration as the gravid uterus can interfere with mechanical ventilation
  • American College of Obstetricians and Gynecologists and the American Board of Obstetrics & Gynecology, together with the American Association of Gynecologic Laparoscopists, the American Gynecological & Obstetrical Society, the American Society for Reproductive Medicine, the Society for Academic Specialists in General Obstetrics and Gynecology, the Society of Family Planning, and the Society for Maternal-Fetal Medicine do not support COVID-19 responses that cancel or delay abortion procedures (ACOG/ABOG 2020 Mar 18 PDF)

Antepartum considerations

Antenatal surveillance

  • during acute illness, fetal management should be similar to that provided to any critically ill pregnant person1
  • ultrasound
    • elective ultrasound exams should not be performed1
    • if risk of exposure and infection within the community is greater than benefit of testing, consider postponing or canceling some testing or exams1
    • perform ultrasound scan for fetal well-being as indicated and after resolution of acute symptoms in women with COVID-194
    • detailed midtrimester anatomy ultrasound examination may be considered following first trimester maternal COVID-19 infection4,SMFM 2020 Apr 11 PDF
    • ultrasound assessment of fetal growth is indicated in pregnant women with COVID-19 infection due to risk of fetal growth restriction (SOGC 2020 Mar 13; SMFM 2020 Apr 11 PDF)
  • continuous fetal monitoring in the setting of severe illness should be considered only when delivery would not compromise maternal health or as another noninvasive measure of maternal status (SMFM 2020 Apr 11 PDF)

Medications

  • venous thromboembolism prophylaxis
    • Royal College of Obstetricians and Gynaecologists recommend all pregnant women with suspected or confirmed COVID-19 infection receive prophylactic low molecular weight heparin upon admission to reduce risk of venous thromboembolism unless birth is expected within 12 hours2
    • Queensland Health states that antenatal venous thromboembolism prophylaxis should be considered in all women with suspected or confirmed COVID-19 infection even in the absence of other risk factors4
  • tocolytics4
    • either nifedipine or indomethacin may be considered in the setting of COVID-19
    • betamimetics should be avoided in women with COVID-19 due to potential for exacerbation of maternal hypotension, tachycardia, and pulmonary edema
  • use of antenatal corticosteroids for fetal maturation in pregnancy with suspected or confirmed COVID-19
    • in nonpregnant patients with COVID-19, the United States Centers for Disease Control and Prevention (CDC) recommends that corticosteroids be avoided because of potential for prolonging viral replication as observed in MERS-CoV patients (CDC 2020 May 20)
    • American College of Obstetricians and Gynecologists (ACOG) is unaware of any evidence regarding use of antenatal corticosteroid use for fetal maturation in pregnancy with suspected or confirmed COVID-19 but makes the following recommendations1
      • for pregnancies between 24 0/7 weeks and 33 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should continue to be offered as recommended - see Preterm Labor for additional information
      • for pregnancies between 34 0/7 and 36 6/7 weeks gestation at risk of preterm birth within 7 days, antenatal corticosteroids should not be offered
      • modifications to care should be individualized, weighing neonatal benefits of antenatal corticosteroids with risk of potential harm from possible immunosuppression in infected patients
    • Royal College of Obstetricians and Gynaecologists (RCOG) recommends that antenatal corticosteroids for fetal maturation be given as indicated2
    • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that antenatal corticosteroids for fetal maturation be given as indicated3
    • Queensland Health recommendations for antenatal corticosteroids for fetal lung maturity4
      • currently insufficient evidence to alter usual indications/recommendations when considering antenatal corticosteroids for fetal lung maturity
      • for women with severe COVID-19 disease requiring intensive care unit admission or ventilation, consider individual circumstances and consult with multidisciplinary team
  • magnesium sulfate for fetal neuroprotection in pregnancy with suspected or confirmed COVID-19
    • Society of Maternal and Fetal Medicine (SMFM)/Society for Obstetric Anesthesia and Perinatology (SOAP) recommendations
      • benefits of magnesium sulfate for fetal neuroprotection at any given gestational age should be weighed against potential risks of maternal respiratory depression in symptomatic patients
      • per routine clinical practice, normal renal function should be assured before initiating magnesium therapy, and for patients with renal dysfunction, dosage and fluid administration should be adjusted accordingly
      • a single 4-g bolus dose of magnesium sulfate may be considered as an alternative to usual dosing in the setting of mild respiratory distress
      • Reference - SMFM/SOAP 2020 Apr 14 PDF
    • Queensland Health recommends magnesium sulfate for fetal neuroprotection as indicated and that fluid administration be adjusted accordingly4

Labor and delivery

General considerations

  • all medical staff caring for potential or confirmed COVID-19 patients should use personal protective equipment, including N95 respirators, eye protection, gloves, and gown when available1 - see also COVID-19 (Novel Coronavirus) for extended guidelines
  • analgesia/anesthesia
    • general anesthesia should be avoided unless necessary for standard indications
    • early epidural should be considered to minimize potential of general anesthesia, which may be associated with increased risk of infection as intubation is considered an aerosolizing procedure
    • neuraxial blockage recommended before or early in labor to minimize need for general anesthesia if urgent birth is necessary
    • considerations for use of nitrous oxide in the setting of COVID-19
      • insufficient information about cleaning, filtering, and potential aerosolization with the use of nitrous oxide labor analgesia systems in the setting of COVID-19
      • individual labor and delivery units should discuss the relative risks and benefits and consider suspending use
      • consider the possibility that asymptomatic women not known to be COVID-19 positive may request use during labor
      • if nitrous oxide is offered, use of face mask rather than mouthpiece and use of the following nitrous oxide circuits are recommended by Queensland Health
        • if scavenger system is available, Equinox Advantage Analgesia Circuit–MC/4003
        • if scavenger system is not available, Equinox Advantage Analgesia Circuit–MC/4001
    • References -
  • delayed cord clamping
    • there is insufficient evidence to determine whether delayed cord clamping increases the risk of infection to the newborn via direct contact
    • World Health Organization (WHO) states that delayed umbilical cord clamping is unlikely to increase the risk of vertical transmission of pathogens in the case of maternal infection (WHO 2014 PDF)
    • American College of Obstetricians and Gynecologists (ACOG) state that delayed cord clamping may still be considered in the setting of suspected or confirmed COVID-19 infection with use of appropriate personal protective equipment1
    • PubMed32160345Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and GynecologyUltrasound Obstet Gynecol20200311International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) recommends immediate clamping of the umbilical cord and immediate transfer of the neonate to an assessment area (Ultrasound Obstet Gynecol 2020 Mar 11 early online)
    • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends delayed cord clamping in the setting of maternal COVID-19 infection3
    • Queensland Health states that there is no evidence that delayed cord clamping increases risk of infection to the newborn4
  • scheduled inductions of labor and cesarean deliveries should continue to be performed as indicated with considerations made to availability of healthcare personnel and access to readily available resources1
  • number of visitors should be limited during in-hospital maternity care to minimize risk of infection
    • visitors with suspected or confirmed COVID-19 should not visit
    • recommend 1 constant support person during labor and delivery
    • References -
    • see also United States Centers for Disease Control and Prevention (CDC) interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings for guidance on managing visitor access and movement within the facility (CDC 2020 May 18)

Setting, timing, and mode of delivery

  • in general, a positive COVID-19 result without other indications is not an indication for immediate delivery1,4
  • elective induction is associated with increased hospital time and, therefore, may not be advisable in patients with confirmed COVID-19 infection due to increased risk of transmission
  • considerations for elective cesarean delivery
    • Society of Obstetricians and Gynaecologists of Canada (SOGC) states that elective cesarean delivery should be delayed if possible until a woman is no longer considered infectious3
    • Queensland Health recommends assessment of urgency if elective cesarean delivery has been planned4
  • setting of labor and delivery in women with suspected or confirmed COVID-19
    • labor and delivery should take place in an isolation room
    • airborne infection isolation rooms (single-patient negative-pressure rooms with a minimum of 6 air changes per hour) can be used if performance of aerosolizing procedures is anticipated
    • References -
  • considerations for home birth
    • American College of Obstetricians and Gynecologists (ACOG) recommends following existing guidance regarding home birth, including counseling about risks and benefits and absolute contraindications to home birth1 - see also Prenatal Patient Support and Delivery Considerations
    • Society of Obstetricians and Gynaecologists of Canada (SOGC) states that hospital birth is preferred to home birth for women who have been or are being testing for COVID-193
  • considerations for water immersion during labor and delivery4
    • no evidence that water immersion during labor in woman with suspected or confirmed COVID-19 is contraindicated
    • water birth is not recommended as SARS-CoV-2 has been detected in stools and may pose risk to neonate
    • consider potential loss of personal protective equipment integrity during emergency procedures or evacuation from water
  • timing of delivery
    • timing of delivery should not be affected by COVID-19 infection in most cases
    • for women with suspected or confirmed COVID-19
      • in early pregnancy who recover, delivery should proceed as planned
      • in third trimester who recover or who have asymptomatic or mild infection, consider postponing delivery in absence of other medical indications
        • until a negative test result is obtained or
        • quarantine status is lifted
      • References -
    • for asymptomatic or mildly symptomatic patients at ≥ 39 weeks gestation, consider delivery to decrease risk of worsening maternal status (SMFM 2020 Apr 30 PDF)
    • for critically ill patients, timing of delivery should be individualized
      • mechanical ventilation alone is not an indication for delivery
      • decisions should be based on
        • maternal status
        • concurrent pulmonary disease
        • critical illness
        • ability to wean off the ventilator and ventilator mechanics
        • gestational age at time of delivery
        • shared decision making with the patient or healthcare proxy
      • requires careful weighing of risks and benefits for mother and fetus
      • consideration of delivery in setting of worsening critical illness is reasonable
      • maternal-fetal medicine and critical care teams should discuss individualized delivery criteria in the setting of
        • worsening maternal status
        • worsening fetal status
        • limited or no improvement in maternal status
      • if delivery is being considered based on severe hypoxemia, the following options should also be considered before proceeding with delivery
        • prone positioning
        • extracorporeal membrane oxygenation
        • use of other advanced ventilatory methods, particularly if ≤ 30-32 weeks gestation
      • Reference - SMFM 2020 Apr 30 PDF
  • mode of delivery
    • COVID-19 is not considered an indication for cesarean delivery or operative delivery for patients with suspected or confirmed infection1,4
    • cesarean delivery should be based on obstetric (fetal or maternal) indications1,3
    • all medical personnel involved in the delivery (both cesarean and vaginal) of a patient with suspected or confirmed COVID-19 should wear personal protective equipment, including N95 respirators, eye protection, gloves, and gown1
    • PubMed30575678Obstetrics and gynecologyObstet Gynecol201901011331e73-e77e73maternal request for cesarean delivery because of COVID-19 concerns should be handled as in nonpandemic times based on American College of Obstetricians and Gynecologists Committee Opinion 761 Cesarean delivery on maternal request (Obstet Gynecol 2019 Jan;133(1):e73)
    • mode of delivery and perinatal outcomes in case series of 18 pregnant women with COVID-19 (median gestational age 37 0/7 weeks) in New York City, New York, United States between March 13, 2020 to March 27, 2020
      • 4 women presented with symptomatic infection, 14 women initially asymptomatic and identified as COVID-19 positive after development of symptoms upon admission or early in postpartum or via universal testing for SARS-CoV-2 for all obstetric admissions
      • all women had neuraxial (epidural) anesthesia
      • uncomplicated vaginal delivery in 10 women (55.5%)
      • cesarean delivery in 8 women (44.4%); reasons for cesarean delivery included
        • nonreassuring fetal heart tones in 3 women
        • repeat cesarean section in 2 women
        • arrest of descent in 1 woman
        • arrest of dilation in 1 woman
        • failed labor induction in 1 woman
      • Reference - Am J Obstet Gynecol MFM 2020 Apr 9 early online
  • Study Summary
    vaginal delivery does not appear to increase risk of obstetric or neonatal complications or SARS-CoV-2 infection in neonate in women with COVID-19 infection
    Details
    Infectious_Diseases Obstetric_and_Gynecologic_Conditionsvaginal delivery does not appear to increase risk of obstetric or neonatal complications or SARS-CoV-2 infection in neonate in women with COVID-19 infection (Int J Gynaecol Obstet 2020 Apr 29 early online)05/11/2020 06:49:23 AMstudySummary
    • Cohort Study based on retrospective cohort study
    • 63 pregnant women who had vaginal delivery in Wuhan, China were included
      • COVID-19 infection in 10 women (15.9%)
      • absence of COVID-19 infection in 53 women (84.1%)
    • no significant differences between groups for
      • gestational age, postpartum hemorrhage, or perineal resection
      • birth weight of neonates and neonatal asphyxia rates
    • among 7 neonates born to COVID-19-positive mothers who remained in hospital per standard protocols, 100% tested negative for SARS-CoV-2 infection 24-48 hours after birth
    • PubMed32350871International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and ObstetricsInt J Gynaecol Obstet20200429Reference - Int J Gynaecol Obstet 2020 Apr 29 early online
  • Study Summary
    no intrauterine infection by vertical transmission upon cesarean delivery reported in women with COVID-19 in late pregnancy
    Details
    Family_Medicine Hospital_Medicine Infectious_Diseases Internal_Medicine Obstetric_and_Gynecologic_Conditions Primary_Careno intrauterine infection by vertical transmission reported in women with COVID-19 in late pregnancy (Lancet 2020 Mar 7)03/20/2020 11:38:54 AMstudySummary
    • Case Report based on review of case reports
    • 9 pregnant women in China with laboratory-confirmed COVID-19 pneumonia during third trimester were evaluated
    • common symptoms were fever (7 women), cough (4 women), myalgia (3 women), sore throat (2 women), and malaise (2 women)
    • all neonates delivered by cesarean section with 100% live birth
      • 0% neonatal asphyxia
      • 5-minute Apgar score 9-10 in all neonates
    • amniotic fluid, cord blood, neonatal throat swab samples, and breast milk samples from 6 mothers and infants were tested for SARS-CoV-2 to determine intrauterine vertical transmission
    • 100% of samples tested were negative for SARS-CoV-2
    • PubMed32151335Lancet (London, England)Lancet2020030739510226809-815809Reference - Lancet 2020 Mar 7;395(10226):809
  • Study Summary
    rates of cesarean and preterm delivery reported to be high in women with COVID-19 at time of delivery
    Details
    Family_Medicine Obstetric_and_Gynecologic_Conditionsrates of cesarean and preterm delivery reported to be high in women with COVID-19 at time of delivery (Am J Obstet Gynecol 2020 Apr 17 early online)04/28/2020 03:30:15 PMstudySummary
    • Systematic Review based on systematic review of case series and case report
    • systematic review of 5 case series and 1 case report including 51 pregnant women (median age 30 years) with COVID-19
    • median gestational age at maternal diagnosis of COVID-19 was 36 weeks
    • most common symptoms of COVID-19 at time of hospital admission were fever, dry cough, dyspnea, and myalgia
    • 48 fetuses were delivered (3 pregnancies ongoing at time of publication)
      • 96% delivered by cesarean section
      • 39% delivered prior to 37 weeks gestational age
      • 1 stillbirth reported during delivery in critically ill woman
      • 1 neonatal death reported
    • reasons for cesarean section were reported for 34 cases
      • COVID-19 pneumonia in 55.9%
      • premature rupture of membranes in 26.5%
      • fetal distress in 17.6%
      • preterm labor in 1.8%
    • PubMed32311350American journal of obstetrics and gynecologyAm J Obstet Gynecol20200417Reference - Am J Obstet Gynecol 2020 Apr 17 early onlinefull-text

Maternal and fetal monitoring

  • delay investigations and procedures that require a woman with suspected or confirmed COVID-19 to be transported out of isolation to when it is clinically safe to do so4
  • maternal monitoring
    • maternal observations and assessment should be continued per standard practice, with the addition of hourly oxygen saturations2,4; see also Management of Routine Labor
    • for patients with confirmed COVID-19 and moderate/severe symptoms2
      • perform hourly oxygen saturation assessments; oxygen should be titrated to keep saturations > 94%
      • perform hourly respiratory rate assessments
      • perform radiographic investigations as indicated for nonpregnant patients, including chest x-ray and computed tomography with use of abdominal shielding to protect the fetus per normal protocols
      • individualized assessment of maternal well-being should be made by multidisciplinary team to decide whether elective birth is indicated to assist in maternal resuscitation or for serious fetal concerns
    • intrapartum oxygen
    • diagnosis of pulmonary embolism should be considered in women with chest pain, worsening hypoxia (particularly if sudden increase in oxygen requirements), or in women whose breathlessness persists or worsens after expected recovery from COVID-192
    • maintain suspicion for bacterial pneumonia in pregnant women with suspected or confirmed COVID-194
  • fetal monitoring
    • fetal surveillance should proceed as clinically indicated in pregnant woman with suspected or confirmed COVID-194
    • electronic fetal monitoring using cardiotocograph (CTG) should be initiated upon admission to maternity unit2,3,4
    • internal monitors
      • Society of Maternal and Fetal Medicine (SMFM)/Society for Obstetric Anesthesia and Perinatology (SOAP) recommends that internal monitors, such as intrauterine pressure catheter or fetal scalp electrode, are safe and may be necessary to optimize fetal monitoring (SMFM/SOAP 2020 Apr 14 PDF)
      • Queensland Health recommends against the use of fetal scalp electrode and fetal blood sampling in women with suspected or confirmed COVID-19 and if either of these approaches are considered, the possible risks of fetal transmission should be weighed against known benefits of improved assessment of fetal well-being4
    • for patients with confirmed COVID-19 and moderate/severe symptoms, frequency and necessity of fetal heart rate monitoring should be considered on an individual basis, taking into consideration gestational age and maternal condition2
    • routine use of intrapartum oxygen for fetal indications is not recommended (SMFM/SOAP 2020 Apr 14 PDF)
  • amniotomy is safe and may be considered for labor management as clinically indicated (SMFM/SOAP 2020 Apr 14 PDF)

Initial neonatal assessment and management

  • consider all neonates born to mothers with confirmed or suspected COVID-19 as having suspected COVID-19 when testing results are not available
  • neonates with suspected COVID-19 should be isolated from other healthy infants and cared for per United States Centers for Disease Control and Prevention (CDC) guidance (CDC 2020 May 20)
  • see COVID-19 and Pediatric Patients topic for information on management of neonates born to mothers with COVID-19

Postpartum management

Mother/infant contact

  • recommendations for immediate postpartum maternal/infant contact for suspected or confirmed maternal COVID-19
    • United States Centers for Disease Control and Prevention (CDC)
      • decision whether to separate a mother with suspected or confirmed COVID-19 and her infant should be made on a case-by-case basis using shared-decision making between the mother and the clinical team; considerations include
        • clinical condition of mother and infant
        • SARS-CoV-2 testing results of mother and infant (positive infant test negates need to separate)
        • desire to breastfeed
        • capability of the facility to accommodate separation or colocation
        • ability to maintain separation upon discharge
      • discuss risks and benefits of temporary separation with mother
      • if the decision is made to temporarily separate mother with suspected or known COVID-19 and infant, provide a separate isolation room for infant, away from other healthy infants, while they remain a person under investigation
        • consider limiting visitors
        • visitors, including caregivers present to provide newborn care, should be instructed to wear personal protective equipment
      • if rooming-in of mother and newborn occurs in accordance with the mother’s wishes or is unavoidable due to facility limitations, consider implementing measures to reduce exposure of the newborn to COVID-19, including
        • use of physical barriers, such as a curtain, between mother and newborn
        • keep ≥ 6 feet distance between mother and newborn
        • use of face mask and proper hand washing before feedings and other close contact if no other healthy adult is present to care for newborn
      • Reference - CDC interim infection prevention and control recommendations for coronavirus disease (COVID-19) in inpatient obstetric healthcare settings (CDC 2020 May 20)
    • Royal College of Obstetricians and Gynaecologists (RCOG) advises that in the setting of confirmed maternal COVID-19 infection, women and healthy infants, not requiring additional neonatal care for other indications, be kept together in the immediate postpartum period2
    • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations on postpartum and newborn care3
      • universal isolation of the infant born to mother with suspected or confirmed COVID-19 infection is not recommended
      • skin-to-skin contact and other infant care is recommended with mother wearing a mask and after practicing good handwashing
    • Queensland Health recommends colocation of well mother with suspected or confirmed COVID-19 and well infant while supporting risk minimization strategies such as hand washing and use of face mask, during feeding and other close mother-infant interactions4
  • consider weighing risks and benefits of mother/infant contact in immediate postpartum period together with a neonatologist for infants who may be more susceptible to infection2

Hospital discharge

  • consider postpartum venous thromboembolism prophylaxis for all pregnant women with suspected or confirmed COVID-19 even in the absence of other risk factors; Royal College of Obstetricians and Gynaecologists (RCOG) recommends prophylactic low molecular weight heparin for ≥ 10 days upon hospital discharge regardless of mode of birth2,4
  • United States Centers for Disease Control and Prevention (CDC) recommendations for hospital discharge
    • for postpartum women with suspected or confirmed COVID-19, discharge procedures for nonpostpartum hospitalized patients with COVID-19 should be followed (CDC 2020 Apr 30)
    • for infants with pending test results or who test negative for COVID-19 upon discharge, caregivers should follow steps to minimize risk of transmission to the infant at home (CDC 2020 May 24)
  • American College of Obstetricians and Gynecologists (ACOG) recommends considering expedited discharge from the hospital when both mother and infant are healthy to limit risk of exposure and infection to COVID-19; discharge may be considered1
    • after 1 day for uncomplicated vaginal delivery
    • after 2 days for women with cesarean births depending on status
  • Queensland Health recommends usual discharge criteria in the setting of suspected or confirmed COVID-19; discuss requirements for completing self-isolation/quarantine4
  • patients with early discharge should be monitored via telehealth visits for both mother and infant1

Postpartum follow-up

  • consider modifying or reducing postpartum follow-up appointments to decrease risk of COVID-19 spread and exposure1
    • American College of Obstetricians and Gynecologists (ACOG) recommendations1
      • perform initial follow-up appointment for general assessment, wound checks, and blood pressure checks within 3 weeks of discharge via phone or telehealth if possible
      • comprehensive postpartum visit
        • delay in-person visit to 12 weeks postpartum
        • consider conducting appointment via phone or telehealth if needed prior to 12 weeks or if risk of losing insurance before in-person appointment can be conducted
    • Queensland Health recommendations for postpartum follow-up in women at low risk of COVID-194
      • 0-6 weeks postpartum - consider either face-to-face or telehealth appointment
        • perform perinatal mental health check
        • ask about domestic violence
        • perform routine postnatal care
      • 6 weeks postpartum - face-to-face appointment
        • perform newborn assessment, including vaccinations
        • confirm completion of routine newborn follow-up, including neonatal screening test and hearing screen
      • postpartum screening for women with gestational diabetes mellitus (GDM)
        • delay oral glucose tolerance test for 6-12 months postpartum
        • screening is recommended before infant is 12 months old or if woman is pregnant again
        • if woman is high-risk for type 2 diabetes
          • continuous self-monitoring may be indicated
          • perform HbA1c at 4-6 months postpartum
        • Reference - Queensland Health 2020 Apr 14 PDF

Breastfeeding

  • risk of transmitting COVID-19 from mother to infant is not due to transmission via breastmilk because virus is not present in breastmilk; risk of transmission to infant is associated with exposure to virus via respiratory droplets while in close contact with mother or other caregiver with suspected or confirmed COVID-19 during feeding
  • United States Centers for Disease Control and Prevention (CDC) recommendations for breastfeeding in women with suspected or confirmed COVID-19
    • considerations during temporary separation
      • mothers who wish to breastfeed should be encouraged to express their breastmilk to establish and maintain milk supply
      • proper hand washing techniques should be used prior to expressing milk and a face covering should be used
      • after pumping, all parts of the breast pump that come into contact with breast milk should be washed thoroughly and the entire pump should be disinfected
      • expressed milk should be fed to newborn by a healthy caregiver
    • if mother and newborn are rooming-in and mother wishes to breastfeed, face mask and proper hand washing techniques should be used
    • References -
      • CDC interim guidance on brestfeeding and breast milk feeds in the context of COVID-19 (CDC 2020 May 5)
      • CDC fact sheet on how to keep breast pump kit clean (CDC 2020 May 20)
  • Royal College of Obstetricians and Gynaecologists (RCOG) advise that the benefits of breastfeeding outweigh any potential risks of transmission of COVID-19 through breastmilk but the following should be considered2
    • discuss risks and benefits of breastfeeding, including risk of holding baby in close proximity to mother or other caregiver with suspected or confirmed COVID-19
    • proper precautions, including
      • hand washing prior to contact with baby, breast pump, or bottles
      • avoiding coughing or sneezing on the baby while feeding
      • wearing a face mask if available while caring for or feeding the baby
      • following recommendations for cleaning breast pump
      • asking someone who is well to feed the baby
  • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends use of face mask and proper hand washing techniques for women who choose to breastfeed3
  • Queensland Health recommendations for breastfeeding and milk expression in the setting of suspected or confirmed COVID-194
    • provide usual support for maternal feeding preferences
    • breastfeeding is not contraindicated
    • support and encourage mother to express breastmilk if it is her desired feeding choice
    • instruct and support adherence to infection prevention and control measures, including
      • hand hygiene
      • equipment cleaning and sterilization
      • use of face mask
      • use of disinfectant wipe on outside of container of expressed breast milk
  • 33% of breastmilk samples (1 of 3 samples) reported to contain SARS-CoV-2 virus among 5 women with COVID-19 infection who delivered in Wuhan, China (BJOG 2020 May 5 early online)

Guidelines and Resources

Guidelines and Resources

Guidelines

International guidelines

  • World Health Organization (WHO) technical documents for coronavirus disease (COVID-19) can be found at WHO Coronavirus Disease (COVID-19)
  • PubMed32248521International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and ObstetricsInt J Gynaecol Obstet20200404International Federation of Gynecology and Obstetrics (FIGO) global interim guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium can be found in Int J Gynaecol Obstet 2020 Apr 4 early online
  • PubMed32160345Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and GynecologyUltrasound Obstet Gynecol20200311International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) interim guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals can be found in Ultrasound Obstet Gynecol 2020 Mar 11 early online
  • PubMed32338645Diagnostics (Basel, Switzerland)Diagnostics (Basel)20200422104International Society of Infectious Disease in Obstetrics and Gynecology (ISIDOG) guideline on COVID-19 and pregnancy can be found in Diagnostics (Basel) 2020 Apr 22;10(4)full-text

United States guidelines

  • American College of Obstetricians and Gynecologists (ACOG) practice advisory on novel coronavirus 2019 (COVID-19) can be found at ACOG 2020 May 19
  • Infectious_Diseases Obstetric_and_Gynecologic_ConditionsSociety for Maternal-Fetal Medicine (SMFM) management considerations for pregnant patients with COVID-19 (SMFM 2020 Apr 30 PDF)05/11/2020 06:48:44 AMSociety for Maternal-Fetal Medicine (SMFM)
  • ACOG and SMFM outpatient assessment and management for pregnant women with suspected or confirmed novel coronavirus (COVID-19) can be found at ACOG/SMFM 2020 Apr 22 PDF
  • SMFM and the Society for Obstetric Anesthesia and Perinatology (SOAP) labor and delivery COVID-19 considerations can be found at SMFM/SOAP 2020 Apr 14 PDF
  • Centers for Disease Control and Prevention (CDC)
    • interim infection prevention and control recommendations for coronavirus disease (COVID-19) in inpatient obstetric healthcare settings can be found at CDC 2020 May 20
    • CDC interim guidance on brestfeeding and breast milk feeds in the context of COVID-19 can be found at CDC 2020 May 5
    • overall interim guidance on coronavirus (COVID-19) can be found at CDC Coronavirus (COVID-19) or in Chinese, Korean, Spanish, Vietnamese
    • evaluation and management
      • interim guidance on evaluating and testing persons for coronavirus disease (COVID-19) can be found at CDC 2020 May 5
      • interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19) can be found at CDC 2020 May 20
      • interim guidance for implementing home care of people not requiring hospitalization for coronavirus disease (COVID-19) can be found at CDC 2020 Feb 12
      • interim considerations for discontinuation of transmission-based precautions and disposition of hospitalized patients with COVID-19 can be found at CDC 2020 May 2
      • interim guidance for pediatric healthcare providers can be found at CDC 2020 May 20
      • guidance for evaluation and management considerations for neonates at risk for COVID-19 can be found at CDC 2020 May 20
    • infection prevention and control
      • interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings can be found at CDC 2020 May 18
      • interim guidance for preventing the spread of coronavirus disease (COVID-19) in homes and residential communities can be found at CDC 2020 May 24 or in Chinese or in Spanish
  • American Academy of Pediatrics (AAP) initial guidance on management of infants born to mothers with confirmed or suspected COVID-19 can be found at AAP 2020 May 21
  • National Institutes of Health (NIH) COVID-19 treatment guideline can be found at NIH 2020 May 12

United Kingdom guidelines

  • Royal College of Obstetricians and Gynecologists/Royal College of Midwives/Royal College of Paediatrics and Child Health/Public Health England/Health Protection Scotland (RCOG/RCM/RCPCH/PHE/HPS)
    • guidance for healthcare professionals on coronavirus (COVID-19) infection in pregnancy can be found at RCOG 2020 May 13
    • guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic can be found at RCOG 2020 May 22 PDF
  • Royal College of Obstetricians and Gynecologists (RCOG)
    • guidance for antenatal and postnatal services in the evolving coronavirus (COVID-19) pandemic can be found at RCOG 2020 May 22 PDF
    • guidance for antenatal screening and ultrasound in pregnancy in the evolving coronavirus (COVID-19) pandemic can be found at RCOG 2020 Mar 23 PDF
    • guidance for fetal medicine units in the evolving coronavirus (COVID-19) pandemic can be found at RCOG 2020 Mar 23 PDF
    • guidance for maternal medicine services in the evolving coronavirus (COVID-19) pandemic can be found at RCOG 2020 May 13 PDF
    • guidance on self-monitoring of blood pressure in pregnancy can be found at RCOG 2020 Mar 30 PDF
  • National Health Service (NHS)
    • guidance for maternity and antenatal services on service organisation during the COVID-19 pandemic can be found at NHS 2020 Apr 9 PDF
    • guidance on fetal growth surveillance during the COVID-19 pandemic can be found at NHS 2020 Apr 3 PDF
    • guidance on COVID-19 and CO monitoring in pregnancy can be found at NHS 2020 Apr 3 PDF
  • Royal College of Psychiatrists (RCPsych) advice on perinatal mental health during the COVID-19 pandemic can be found at RCPsych 2020

Canadian guidelines

  • Society of Obstetricians and Gynaecologists of Canada (SOGC) committee opinion on COVID-19 in pregnancy can be found at SOGC 2020 Mar 13

European guidelines

  • PubMed31270848Journal of cellular biochemistryJ Cell Biochem201912011201219229-1924419229Polish Society of Gynecology and Obstetrics statement on safety measures and performance of ultrasound examinations in obstetrics and gynecology during the SARS-CoV-2 pandemic can be found in J Cell Biochem 2019 Dec;120(12):19229

Australian and New Zealand guidelines

  • Infectious_Diseases Obstetric_and_Gynecologic_ConditionsQueensland Health COVID-19 clinical guidance on maternity care for mothers and babies during the COVID-19 pandemic (Queensland Health 2020 Apr 29 PDF)05/11/2020 06:47:37 AMQueensland Health COVID-19 clinical guidance on maternity care for mothers and babies during the COVID-19 pandemic can be found at Queensland Health 2020 Apr 29 PDF, guideline supplement on maternity care for mothers and babies during the COVID-19 pandemic can be found at Queensland Heath 2020 Apr 29 PDF

Review articles

  • PubMed32366505BMJ (Clinical research ed.)BMJ20200504369m1672m1672review can be found in BMJ 2020 May 4;369:m1672
  • PubMed32385225Medical science monitor : international medical journal of experimental and clinical researchMed Sci Monit2020050926e924725e924725review of SARS-CoV-2 and COVID-19 disease in pregnancy can be found in Med Sci Monit 2020 May 9;26:e924725
  • review of COVID-19 pandemic in pregnancy can be found in Am J Obstet Gynecol 2020 Mar 23 early online
  • PubMed32398569The Pediatric infectious disease journalPediatr Infect Dis J20200601396469-477469review of epidemiologic and clinical features of COVID-19 in children, pregnancy and neonates can be found in Pediatr Infect Dis J 2020 Jun;39(6):469
  • PubMed32396948American journal of perinatologyAm J Perinatol20200512review of telehealth for high-risk pregnancies in the setting of the COVID-19 pandemic can be found at Am J Perinatol 2020 May 12 early online
  • PubMed32396947American journal of perinatologyAm J Perinatol20200512review of prenatal care to minimize risks of COVID-19 in patients with hypertensive disorders of pregnancy can be found in Am J Perinatol 2020 May 12 early online
  • PubMed32396397Diabetes technology & therapeuticsDiabetes Technol Ther20200512review on managing diabetes in pregnancy before, during, and after COVID-19 can be found in Diabetes Technol Ther 2020 May 12 early online
  • PubMed32393973Inflammatory bowel diseasesInflamm Bowel Dis20200512review of management of acute severe ulcerative colitis in pregnancy during COVID-19 can be found in Inflamm Bowel Dis 2020 May 12 early online

Patient Information

References

General References Used

  1. American College of Obstetricians and Gynecologists (ACOG). COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics. ACOG Physician FAQ COVID-19 2020
  2. Royal College of Obstetricians and Gynaecologists (RCOG) and The Royal College of Midwives. Coronavirus (COVID-19) Infection in Pregnancy. RCOG 2020 May 13 PDF
  3. Society of Obstetricians and Gynaecologists of Canada (SOGC). Committee Opinion on COVID-19 in Pregnancy. SOGC 2020 Mar 13
  4. Queensland Health Clinical Guidance on Maternity Care for Mothers and Babies During the COVID-19 Pandemic. Queensland Health 2020 Apr 29 PDF

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