Scientists provide new information for the management of COVID-19 in pregnant women

The International Society for Ultrasound in Obstetrics and Gynecology (ISUOG) has released interim guidance to medical professionals on management of COVID-19 in pregnancy.

Joshua A. Copel, MD, professor and vice chair of obstetrics, gynecology, and reproductive sciences at Yale School of Medicine – and a past president of ISUOG – is a co-author.

While the guidelines in the document are directed toward clinical caregivers, they also contain valuable knowledge for pregnant women and their loved ones.

Copel says that although information on the virus is still highly limited, enough is already known – especially from experience in Asia – about how it can adversely affect pregnant women.

“High fevers early in pregnancy could lead to problems like birth defects or miscarriage,” he says, “and high fever and dehydration in the second or third trimester could lead to preterm labor.

We need to figure out how to test pregnant women, when they need to be cared for in a hospital versus being cared for at home, and how to take care of them when they are in labor. Those are the biggest things.”

Care teams also face other substantial challenges. Copel says one is self-protection, which can be difficult if the mother who is delivering is infected with the virus. Copel notes that the nature of obstetrics is such that hospitals and outpatient practices must remain available to patients at all times.

“Obstetrics doesn’t stop, ever, so we have to maintain enough staff, healthy, at facilities across the country. If all of a sudden 60% of the staff is either sick or under investigation and on home isolation, we have real problems dealing with situations both during the pregnancy and at the time of birth.”

The guidelines include best practices for minimizing those absences.

If anything, Copel says, the guidelines may be overcautious, but with so much still unknown about the coronavirus, “we would rather be cautious that cavalier about it.”

While the guidelines in the document are directed toward clinical caregivers, they also contain valuable knowledge for pregnant women and their loved ones.

Copel has basic advice for pregnant women.

“Wash your hands, wash your hands, wash your hands! Avoid people who are sick. Don’t go out if you are sick. Call your doctor or midwife if you are sick. Don’t go to their office. Call them instead.” Yale Medicine also has a hotline dedicated to questions about COVID-19.

The hotline number is 203-688-1700.

ISUOG is an international professional society with 15,000 members, focused on making sure that women around the worl.

Pregnant Women

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have developed an algorithm (fig 1) to aid practitioners in assessing and managing pregnant women with suspected or confirmed COVID-19.

At this time, very little is known about COVID-19, particularly related to its effect on pregnant women and infants, and there currently are no recommendations specific to pregnant women regarding the evaluation or management of COVID-19.

Currently available data on COVID-19 does not indicate that pregnant women are at increased risk. However, pregnant women are known to be at greater risk of severe morbidity and mortality from other respiratory infections such as influenza and SARS-CoV.

As such, pregnant women should be considered an at-risk population for COVID-19. Adverse infant outcomes (eg, preterm birth) have been reported among infants born to mothers positive for COVID-19 during pregnancy. However, this information is based on limited data and it is not clear that these outcomes were related to maternal infection.

Currently it is unclear if COVID-19 can cross through the transplacental route to the fetus. In limited recent case series of infants born to mothers infected with COVID-19 published in the peer-reviewed literature, none of the infants have tested positive for COVID-19 [
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, 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: 10.1016/S0140-6736(20)30360-3. Available at: http://www.sciencedirect.com/science/article/pii/S0140673620303603. Retrieved Feb 21, 2020. ].

Infection Prevention and Control in Inpatient Obstetric Care Settings

The CDC has published Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings.

These considerations apply to health care facilities providing obstetric care for pregnant patients with confirmed COVID-19 or pregnant persons under investigation (PUI) in inpatient obstetric health care settings including obstetrical triage, labor and delivery, recovery and inpatient postpartum settings.

The American College of Obstetricians and Gynecologists encourages physicians and other obstetric care practitioners to read and familiarize themselves with the complete list of recommendations.

Key highlights from the recommendations include:

• Health care practitioners should promptly notify infection control personnel at their facility of the anticipated arrival of a pregnant patient who has confirmed COVID-19 or is a PUI.
• Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. Airborne Infection Isolation Rooms should be reserved for patients undergoing aerosol-generating procedures.
• Facemasks are an acceptable alternative when the supply chain of respirators cannot meet the demand. During this time, available respirators should be prioritized for procedures that are likely to generate respiratory aerosols. When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19.
• Infants born to mothers with confirmed COVID-19 should be considered PUIs. As such, these infants should be isolated according to the Infection Prevention and Control Guidance for PUIs.
• To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.
• Discharge for postpartum women should follow recommendations described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19.

Due to the limited data on COVID-19, these recommendations are largely based on infection prevention and control considerations for other respiratory viruses such as influenza, SARS-CoV and MERS-CoV and are intentionally cautious as experts learn more about this new virus.

Breastfeeding

The CDC has developed Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation for COVID-19. There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended.

Whether and how to start or continue breastfeeding should be determined by the mother in coordination with her family and health care practitioners. Currently, the primary concern is not whether the virus can be transmitted through breastmilk, but rather whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding.

A mother with confirmed COVID-19 or who is a symptomatic PUI should take all possible precautions to avoid spreading the virus to her infant, including washing her hands before touching the infant and wearing a face mask, if possible, while breastfeeding.

If expressing breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump or bottle parts and follow recommendations for proper pump cleaning after each use.

If possible, consider having someone who is well feed the expressed breast milk to the infant.

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 (ie, infectious virus in the breast milk).

Source:
Yale