944: IMA-CMAAO Webinar on COVID-19 in pregnancy

6th June, 2020, 4-5 pm

Participants: Dr KK Aggarwal, President CMAAO; Dr RV Asokan, Secretary General IMA; Dr Jayakrishnan Alapat; Dr Sanchita Sharma

Faculty: Dr Raina Chawla Bhatia, Associate Professor, Dept. of Obs & Gyn, ESIC Medical College, Faridabad

• COVID status of the pregnant woman is important as this has huge implications for the mother as well as the fetus and the neonate. There is also the risk of spread of infection to the healthcare providers. They should be segregated to prevent spread of infection.
• FOGSI has issued good clinical practice recommendations for pregnant women to prevent COVID-19 infection: Social distancing and Do the Five: Stay at home, hand hygiene, respiratory hygiene, avoid touching the face and keeping distance. Wearing a mask is recommended.
• Healthcare workers should observe precautions as they are at high risk of getting the infection: Distancing, PPE, chemoprophylaxis (hydroxychloroquine for HCW with known contact with COVID-19 positive patients).
• Always ask history (travel abroad, contact with COVID confirmed case, respiratory symptoms). A COVID check list at the initial point of contact will help to better segregate the suspected cases. A triage area in OPD is very important.
• Most pregnant women present with mild illness or are asymptomatic. But, comorbidities or obstetric risk factors, such as pre-eclampsia, gestational diabetes, will aggravate the severity of the disease. COVID-19 can exaggerate the hypercoagulable state also.
• There is now emerging evidence that in utero transplacental infection to the fetus may occur. There have been single reports of vertical transmission from UK, Belgium. The virus has not been isolated in amniotic fluid or vaginal secretions. There is not enough evidence to say that there is no effect on the fetus, but the effects seem to be minimal or are less in incidence.
• Testing:Although there is no recommendation for testing every pregnant woman, we test all pregnant women: more than 39 gestational weeks, from containment/cluster areas and those who are likely to deliver in next 5 days or who are in labor. Faridabad is a hot spot. Nasopharyngeal swab is done.
• COVID and non-COVID set ups should be defined to avoid intermingling of patients; three areas: clean area, suspected area and confirmed area. COVID-positive mothers should be delivered in separate and dedicated labor rooms or OTs. If these facilities are not available, then the LR and OT should be properly fumigated. There should be separate COVID-positive area.
• Optimize antenatal visits and time them as per need; encourage teleconsultations – first visit at 12 weeks can be timed with USG, 2^ndvisit at 20 weeks to time with level 2 USG at 20 weeks, then we call at 32 weeks and then at delivery for low risk women to reduce transmission. This frequency may be higher in high risk patients.
• USG:Avoid unnecessary USGs; do at 11-14 weeks, 18-20 weeks and then only if necessary; disinfect the USG machine and probes (fomite); the room should be fumigated.
• Management: Keep doctors ready, immediately initiate infection control measures (allow 30 minutes for this); if immediate obstetric intervention is required, admit directly to designated labor room or OT. If the woman is not in labor, if mild/asymptomatic with no high risk obstetric factors and good fetal status: Home isolation. Admit in COVID ward if moderate to severe symptoms or high risk pregnancy.
• Medical management:FOGSI has suggested two approaches: HCQ 600 mg/day + azithromycin (500 mg od) x 10 days or antiviral therapy with lopinavir + ritonavir (400mg+100mg) bd x 14 days. The decision of which line of management is to be given should be in consultation with medicine team.
• Antipyretic treatment is important as hyperpyrexia can lead to IUD; look for other infections, consider empiric antibiotics and also thromboprophylaxis as there may be prolonged admission and immobilization.
• Indications of ICU management:oxygen saturation <93% at rest, tachypnea (>30/min), qSOFA score can be used to aid decision making.
• Obstetric management:Counseling of mother (and attendants), neonatal corner should be at a distance of 2 m away from the delivery table; during labor monitor respiratory status. All suspected/confirmed COVID women should be provided with a 3-layer surgical mask at all times. Till now, all pregnant women with COVID have been delivered via cesarean section, but there is no proven rationale for this, so treatment should be individualized. Obstetric intervention should not be delayed because of lack of testing.
• Newborn care:Testing if mother has COVID or if baby is asymptomatic. Breastfeeding is encouraged with good hygiene practices. Rooming-in with direct breastfeeding (if mother is asymptomatic or mildly symptomatic) is practiced in India, whereas in the US or China, the mother and baby are kept in separate rooms. Viral RNA has not been found in breast milk. If mother has cough, fever, dyspnea or newborn needs ICU care, separate the baby and the mother; the infant is given expressed breast milk from the mother. The newborn of a COVID-positive woman is tested (RT PCR) on the day of birth and then after 48 hours and then repeated ever week till the baby is 28 days old.
• Training (donning and doffing PPE) and managing the healthcare cadre is very important to prevent them from getting infected. It is also important to keep up their morale.

Dr Chawla also shared the experience of COVID-19 at the Dept. of Obs & Gyn, ESIC Medical College & Hospital and shared a month’s data.

• A total of 225 women (data collected from 22.4.20 to 28.5.20 from ARI Clinic) were tested; of these, 10 tested positive. Only 2 were symptomatic.
• 24 patients were admitted till 5^thJune; 17 were diagnosed antenatally and 7 were diagnosed postnatally. Two out of 24 were symptomatic; almost 90% were asymptomatic.
• 7 of the 13 patients detected at term underwent LSCS for obstetric reasons; 2 delivered vaginally; of these, one baby tested positive on Day 0, had fever on Day 2, developed respiratory distress and died on day 3 (this could have been a case of vertical transmission). Three of the other babies tested positive between Day 5-14 but are asymptomatic.
• Patients are being monitored by daily NST, if available. If not, check daily fetal heart rate.
• HCQ started for all as per institutional protocol.
• Amniotic fluid and placental swab are now being tested by RT PCR.
• The incidence of cesarean section is high as it is not easy to monitor patients for prolonged time while wearing PPE.
• Challenges:Separating COVID and non-COVID areas, getting PPE for non-COVID areas, delay in reporting, motivating HCW, and working in PPE with no air conditioning.
• What can we do? Checklists, appropriate PPEs in all areas, audit donning and doffing procedures, conduct mock drills with new team members, 2 surgeons during cesarean is a must, develop institution SOP based on the present guidelines.

Dr KK Aggarwal

President CMAAO