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888: Pregnancy and COVID-19
- Pregnant women should follow the same recommendations as non-pregnant persons to avoid exposure to the COVID virus.
- Pregnant health workers in the third trimester, especially those ≥36 weeks pregnant, must stop face-to-face contact with patients.
- Clinical manifestations of COVID-19 in pregnant women are similar to those in nonpregnant individuals.
- A positive test for SARS-CoV-2 generally confirms the diagnosis of COVID-19; however, false-positive and false-negative tests are possible.
- Pregnancy does not seem to make an individual more prone to infection or worsen the clinical course, and most infected mothers recover. However, severe disease can occur that may necessitate maternal intensive care unit admission and need for extracorporeal membrane oxygenation.
- Infected women, particularly those who develop pneumonia, may have an increased frequency of preterm birth and cesarean delivery. These complications are likely associated with severe maternal illness as intrauterine infection does not appear to occur, but this is still being investigated. A few possible early newborn infections and one possible placental infection have been reported thus far.
- The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have issued guidance regarding prenatal care during the COVID-19 pandemic.
- For the general population, the Centers for Disease Control and Prevention recommend that glucocorticoids must be avoided in COVID-19-positive persons owing to the potential for adverse effects on the course of the disease. There are clear benefits of antenatal betamethasone administration between 24+0 and 33+6 weeks of gestation in patients at risk of preterm birth within seven days. Therefore, ACOG recommends its use for standard indications to pregnant patients with suspected or confirmed COVID-19.
- For most women with preterm COVID-19 and nonsevere illness with no medical/obstetric indications for prompt delivery, delivery is not indicated and would ideally occur sometime after a negative test result is obtained or isolation status is lifted, thus limiting the risk of postnatal transmission to the neonate. Early delivery may be helpful in severely ill patients at least 32 to 34 weeks of gestation with COVID-19 pneumonia.
- In areas with active infection, testing all patients upon presentation to labor and delivery (or the day before if a scheduled admission) seems reasonable, if testing is available. In a city with a high infection prevalence, a high proportion of asymptomatic patients (13.5% in one study) admitted for delivery tested positive, which has clinical implications for triage, staff, and newborn care.
- Management of labor is generally not altered in women giving birth during the COVID-19 pandemic or in women with confirmed or suspected COVID-19. There has been no evidence of detection of SARS-CoV-2 in vaginal secretions or amniotic fluid, so rupture of fetal membranes and internal fetal heart rate monitoring may be performed for usual indications, though data are scarce. COVID-19 is not an indication to alter the route of delivery. The partner/support person should be screened in accordance with hospital policies and those with any symptoms consistent with COVID-19, exposure to a confirmed case within 14 days, or a positive test for COVID-19 within 14 days should not be attend the labor and birth.
- In patients with known or suspected COVID-19, neuraxial anesthetic is not contraindicated and has several advantages in laboring patients. The Society of Obstetric Anesthesia and Perinatology suggests that the use of nitrous oxide be suspended for labor analgesia in these patients on account of insufficient data about potential aerosolization of nitrous oxide systems.
- During delivery of patients with known or suspected COVID-19, some institutions choose to prohibit delayed cord clamping in term infants, in whom the benefits are modest, in order to minimize newborn exposure to any virus in the immediate environment and to limit the chances that the newborn will require phototherapy for jaundice.
- NSAIDs are commonly used for treatment of postpartum pain; however, anecdotal reports suggest possible negative effects of NSAIDs in patients with COVID-19. Considering the uncertainty, paracetamol (acetaminophen) should be used. If NSAIDs are needed, use the lowest effective dose.
- Infants born to mothers with known COVID-19 are COVID-19 suspects and should undergo testing, be isolated from other healthy infants, and cared for according to infection control precautions for patients with confirmed or suspected COVID-19.
- Whether a mother with known or suspected COVID-19 needs to be separated from her infant is determined on a case-by-case basis. If the infant tests positive, separation is not needed. If separation is indicated (mother is on transmission-based precautions) but not implemented, other measures may be put to use to limit potential mother-to-infant transmission, including physical barriers and ≥6 feet separation, personal protective equipment and hand hygiene, and utilization of other healthy adults for infant care (feeding, diapering, bathing).
- The virus has only been found in one sample of breast milk, but data are limited.
- Droplet transmission to the newborn could occur through close contact during feeding.
- In mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19, direct contact can be minimized if the infant is fed expressed breast milk by another caregiver until the mother recovers or has been proven uninfected, provided that the other caregiver is healthy and follows hygiene precautions. In these cases, the mother should wear a mask and thoroughly clean her hands and breasts before pumping; the pump parts, bottles, and artificial nipples should be cleaned as well. If she breastfeeds the infant directly, similar personal hygienic precautions should be followed.
- Remdesivir is the most promising drug and has been used without reported fetal toxicity in some severely ill pregnant women.
Dr KK Aggarwal
President CMAAO, HCFI, Past National President IMA, Chief Editor Medtalks