COVID-19 in Pregnancy

A summary for health professionals and patients based on the RCOG Guidelines, Version 6: Published Friday 3 April 2020¹

by Amelie Hofmann-Werther

(4.9)

125 reviews

Dr. Amelie Hofmann-Werther

Specialist Obstetrics & Gynecology, Psychosomatics & Verbal Intervention Counselor, Cervical Dysplasia Colposcopist
Novomed Surgical Hospital

In times of COVID-19 with the current situation changing rapidly, reconfiguration of antenatal and postnatal services is vital. Pregnant women will continue to need as much support, advice, care and guidance in relation to pregnancy, childbirth and early parenthood as before the COVID-19 pandemic. But on top of that, much more patient education and mental support is needed. It is essential that care remains available and accessible to ensure continued support for women with their complex needs. Isolation, financial difficulties, insecurity, inability to access support systems are recognized factors putting mental wellbeing at risk. The corona virus epidemic increases the risk of perinatal anxiety, endogene depression, sleep deprivation and malnutrition. It is crucial that support for women and families is strengthened as far as possible.

General advice for continued provision of antenatal and postnatal services for midwifery and obstetric services caring for pregnant women has just been released by the RCOG in a guideline paper published on 3 April 2020¹ . Evidence to date shows that pregnant women are not more likely to contract COVID-19 infection compared to the general population¹. Whilst pregnant women are not per se more susceptible to viral disease, their individual immune responses can differ from women to women, from trimester to trimester and for different virus types. Changes in the immune system throughout pregnancy may be associated with more severe symptoms¹ . This seems to be particularly relevant towards the end of pregnancy¹³. More critical symptoms described for COVID-19 in older people, immune-suppressed people and/or those with preexisting health conditions such as diabetes, cancer and chronic lung disease, could occur in pregnant women, although the absolute risks are small¹ . In other previously studied types of virus infection (SARS, MERS) risks for pregnant woman appear to increase in particular during the last trimester of pregnancy¹³. Comparable data collected from influenza in pregnancy identified a significant increase in critical cases during later pregnancy, compared with early pregnancy^2,3. Women above 28 weeks’ of gestation should therefore be recommended to be particularly attentive to social distancing¹³.

Regarding a risk of miscarriage or early pregnancy loss related to COVID-19, there is so far not data suggesting an increased risk⁴ . Early pregnancy studies with SARS and MERS did not demonstrate a convincing relationship between infection and increased risk of miscarriage or second trimester loss⁴ . There is also no evidence so far, that COVID-19 has teratogenic potential¹ . It is however probable that the virus may be vertically transmitted, i.e. transmission from mother to baby antenatally or intrapartum, although the proportion of pregnancies affected and the significance to the neonate has not yet been determined since there are few cases reported¹. Two reports published evidence of the presence of IgM antibodies for SARSCOV-2 in neonatal serum collected at birth^5,6. Since IgM antibodies do not cross the placenta, the findings may represent a neonatal immune response to an in utero infection^5,6. However, other case reports from China found no such evidence with amniotic fluid, cord blood, neonatal throat swabs, placenta swabs, genital fluid and breast milk samples collected from COVID-19 infected mothers all being tested negative for the virus so far.^7-10

General Considerations:

Maternity care remains essential in times of social distancing. Antenatal & postnatal care based on years of evidence aim at keeping mothers and babies safe during pregnancy and childbirth. Women not attending or being deprived of antenatal services are known to be at increased risk of adverse perinatal outcomes including maternal morbidity, stillbirth, depression and others.^11,12 Women should therefore be encouraged to adhere with antenatal care guidelines and screening recommendation despite being advised to otherwise strictly engage with social distancing measures.¹ There may be a need to reduce the number of antenatal visits or replace face-to-face visits by online consultations, but visits should not be reduced without agreeing so first with the treating healthcare provider or facility. This should be communicated with the patients taking into account available evidence on the safe number of visits required. If a routine scan or visit is due, patients should contact the maternity unit or clinic for advice and to agree on a plan. Scans should be prioritised in the following order¹ :

• Anomaly scan at 18+0 -23+0 weeks
• Ultrasound +/- screening at 11+2 -14+1
• Growth scans

Patients should have an understanding and a timeline of their next visits and receive patient education online or per telephone services. Electronic record systems should be used and, where remote access for staff or patients is an available function, this should be expedited. When seeing women face-to-face, simultaneous electronic documentation can facilitate future remote consultation or future missed appointments due to self-isolation. Recordkeeping remains paramount. Clinics should appoint a team coordinating patients forced to miss appointments due to self-isolation, reviewing appointments for urgency and either convert them to remote appointments, advice attendance or defer to a later point. Patients should be encouraged to attend antenatal care unless they meet current self-isolation guidance for individuals and households of individuals with symptoms. For women who have had symptoms recently, appointments can be deferred until 7 days after the start of symptoms¹, unless symptoms persevere. For women who are self-isolating because someone in their household has possible symptoms of COVID-19, appointments should be deferred for 14 days.¹

The symptoms to ask about are: fever ≥37.8 AND at least one of acute persistent cough, hoarseness, nasal discharge/congestion, shortness of breath, sore throat, wheezing or sneezing. Women with an isolated fever should be investigated, including sending a full blood count¹. If lymphopenia is identified on the full blood count, testing for COVID-19 should be arranged¹. Clinics should develop a system to flag women who have missed serial appointments, which is a particular risk for women with other children who may become repeatedly unwell or can´t be left unmonitored. Any pregnant who has a routine appointment delayed for more than 3 weeks should be contacted proactively by the clinic.

Considerations in Labour

When a woman with confirmed or suspected COVID-19 is admitted to the delivery ward, the following staff should be informed: consultant obstetrician, consultant anesthetists, midwife in-charge, consultant neonatologist, neonatal nurse in charge and infection control team.¹ Efforts should be made to minimize the number of staff members entering the room and units should develop a local policy specifying essential personnel for emergency scenarios. The use of personal protective equipment (PPE) should be in line with the guidelines for the current COVID-19 pandemic.¹⁹

With regard to mode of birth, an individualized decision should be made, with no obstetric contraindication to any method except water birth.¹ Caesarean birth should be performed if indicated based on maternal and fetal condition as in normal practice. Asymptomatic birth partners should adhere to hygiene guidelines. If symptomatic, birth partners should remain in self-isolation and not attend. Women should be advised to identify an alternative birth partner in advance, should the need arise. Maternal observation and assessment should be continued as per standard practice, with the addition of oxygen saturation monitoring.

Given the rate of fetal compromise reported in the two Chinese case series^7,10 the current recommendation is for continuous electronic fetal monitoring in labour. There is currently no evidence to favour one mode of birth over another.¹ The mode of birth should be discussed with the patient, taking into consideration her preferences and any obstetric indications for intervention. Mode of birth should not be influenced by the presence of COVID-19, unless the woman’s respiratory condition demands urgent delivery.¹

Patients with known or suspected COVID-19 should be cared for in a single-person room. Airborne Infection Isolation Rooms should be reserved for patients undergoing aerosolgenerating procedures. There is no evidence that the use of Entonox is an aerosol-generating procedure (AGP).¹ Entonox should be used with a single-patient microbiological filter.¹

There is also no evidence that epidural or spinal analgesia is contraindicated in the presence of corona virus.¹ Epidural analgesia may be recommended in labour, to women with suspected or confirmed COVID-19 to minimize the need for general anaesthesia if an urgent delivery is needed.

An individualized decision may be required regarding shortening the length of the second stage of labour with elective instrumental birth in a symptomatic woman who is becoming exhausted or hypoxic. Given a lack of evidence to the contrary, delayed cord clamping is still recommended following birth, provided there are no other contraindications. The baby can be cleaned and dried as normal, while the cord is still intact.¹

The neonatal team should be informed of plans for the birth of the baby of a woman affected by moderate to severe COVID-19 as far in advance as possible and should also be given sufficient notice at the time of birth, to allow them to attend and secure PPE before entering the room/theatre.

Given the association of COVID-19 with acute respiratory distress syndrome women with moderate to severe symptoms of COVID-19 should be monitored using hourly fluid input/output charts.14 Efforts should be targeted towards achieving neutral fluid balance in labour, in order to avoid the risk of fluid overload.

Considerations in Neonatal Care

There are limited data guiding the postnatal management of babies of mothers who tested positive for COVID-19 in the third trimester of pregnancy. Some literature advises to separate isolation of the infected mother and her baby for 14 days, considering infants born to mothers with confirmed COVID-19 PUIs.²⁵ However, routine precautionary separation of a mother and a healthy baby should not be undertaken lightly, given the potential detrimental effects on feeding and bonding. Given the current limited evidence, RCOG advises that women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate postpartum period.¹

Considerations in Breastfeeding

Currently, the primary concern is not whether the virus can be transmitted through breast milk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.¹ So the main risk of breastfeeding is the close contact between the infant and the mother. The risks and benefits of breastfeeding, including the risk of holding the baby in close proximity, should they be infected, needs to be discussed with the parents. The guidance may change as knowledge evolves, but in the light of the current poor evidence, the benefits of breastfeeding outweigh potential risks of transmission of the virus through breast milk.¹ The following precautions should be taken to limit viral spread to the baby:

• Wash hands before touching the baby, breast pump or bottles.
• Avoid coughing or sneezing while feeding.
• Consider wearing a face mask, if available, while feeding or caring for the baby.
• Where a breast pump is used, follow recommendations for pump cleaning after use.
• For babies who are bottle fed with formula or expressed milk, strict adherence to sterilization guidelines is recommended.
• Where mothers are expressing breast milk in hospital, dedicated pumps to be used.

In limited case series reported to date, no evidence of virus has been found in the breast milk of women infected with COVID-19; however, it is not yet known if COVID-19 can be transmitted through breast milk (i.e., infectious virus in the breast milk).^1,16 RCOG is currently developing, together with a wide range of co-authors, a series of guidance documents to during the COVID-19 pandemic. These will be available on the RCOG website and include:

• Guidance for early pregnancy services
• Guidance for antenatal and postnatal services
• Guidance for antenatal screening (including screening ultrasound)
• Guidance for fetal medicine services

References

1. Royal College of Obstetricians and Gynaecologists (RCOG) – Guidelines – “Coronavirus (COVID19) infection and pregnancy”, Published: 03/04/2020

2. Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study. BMJ 2010;340:c1279. doi: 10.1136/bmj.c1279

3. Mullins E, Evans D, Viner R, et al. Coronavirus in pregnancy and delivery: rapid review. Ultrasound in Obstetrics and Gynaecology (In press) doi: doi: 10.1002/uog.22014 46

4. Zhang J, Wang Y, Chen L, et al. Clinical analysis of pregnancy in second and third trimesters complicated severe acute respiratory syndrome. Zhonghua Fu Chan Ke Za Zhi 2003;38:516-2

5. Dong L, Tian J, He S, et al. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. JAMA 2020 doi: 10.1001/jama.2020.4621
6. Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA 2020 doi: 10.1001/jama.2020.4861

7. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020 doi: https://doi.org/10.1016/S0140-6736(20)30360-3

8. Chen Y, Peng H, Wang L, et al. Infants Born to Mothers With a New Coronavirus (COVID-19). Frontiers in Pediatrics 2020;8(104) doi: 10.3389/fped.2020.00104

9. Li N, Han L, Peng M, et al. Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case-control study. . Pre-print doi: 10.1101/2020.03.10.20033605

10. Zhu H, Wang L, Fang C, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9(1):51-60. doi: http://dx.doi.org/10.21037/tp.2020.02.06

11. Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low‐risk pregnancy. Cochrane Database of Systematic Reviews 2015(7) doi: 10.1002/14651858.CD000934.pub3

12. Knight M, Bunch K, Tuffnell D, et al. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014– 16. In: MBRRACE-UK, ed., 2018.

13. Mullins E, Evans D, Viner R, et al. Coronavirus in pregnancy and delivery: rapid review. Ultrasound in Obstetrics and Gynaecology (In press) doi: doi: 10.1002/uog.220

14. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 2020;395(10223):497-506. doi: 10.1016/S0140-6736(20)30183-5

15. Infection Prevention and Control in Inpatient Obstetric Care Settings, The American College of Obstetricians and Gynecologists, https://www.acog.org/clinical/clinical-guidance/practiceadvisory/articles/2020/03/novel-coronavirus-2019

16. CDC Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation for COVID-19.

17. CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation for 2019-nCoV in Healthcare Settings

18. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, https://www.cdc.gov/coronavirus/2019- ncov/hcp/inpatient-obstetric-healthcare-guidance.html

19. Personal Protective Equipment for Labour : see guidance for use of personal protective equipment (PPE) by health and social care workers, in the context of the current COVID-19 pandemic.