Original Article: Dunjin Chen, Michael A. Belfort, Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection, Int J Gynaecol Obstet.
Author of summary: Gianmarco Taraschi; Reviewer: Daria Di Filippo
Original Article Published on March 21st, 2020
To provide these guidelines for the management of novel coronavirus (COVID- 19) in pregnancy, on February 5, 2020, a multidisciplinary teleconference was held comprising Chinese physicians and researchers. Ten were the key recommendations provided: not currently having enough evidence regarding optimal delivery timing, the safety of vaginal delivery and cesarean section in preventing vertical transmission, route and timing of delivery should be individualized based on obstetrical indications.
Isolation and screening
Isolate patients with typical symptoms: treat established cases in negative pressure rooms or isolation wards, and transfer those with critical disease to negative pressure intensive care. Establish negative pressure operating theatres and isolation rooms for infants, ideally close together to avoid the circulation of women and infants with suspected or confirmed infection. Limit visits.
Initial treatment and diagnostic confirmation
First, differential diagnosis and symptomatic treatment:
- Support: rest, caloric intake, oxygen, respiratory support, hydro-electrolytic balance;
- Broad-spectrum antibiotic therapy for community acquired pneumonia.
- Antiretroviral therapy: Alpha-interferon inhalation (5 million U twice a day) with informed consent for the risk of IUGR and Lopinavir/Ritonavir (200mg/50mg 2 tablets twice a day);
- Clinical surveillance: vital signs and oxygen saturation; arterial blood gas; imaging; complete blood count; CRP; metabolic screening; multi-organ failure and crasis tests;
- Pathogen identification: put in place all the optimal measures necessary to obtain a sufficient number of samples to analyse.
Diagnostic imaging Chest imaging (X-ray and CT) has crucial importance and is doable in pregnant women after informed consent, with abdominal shielding to reduce the fetal exposure time.
Management of confirmed cases
- Left side decubitus.
- Broad-spectrum antibiotics for cases of secondary bacterial infection. Select the molecule according to antibiogram. Drain abscesses.
- Conservative fluid management: recommended for patients with critical disease without shock. In case of septic shock, resuscitate with fluids and norepinephrine. Target = mean blood pressure at 60 mmHg or higher.
- Oxygen: Target = saturation > 95%. Oxygen should be delivered through a high-flow mask or anti-reflux device. Humidification, non-invasive ventilation or endotracheal intubation devices may be required. Use of ECMO should be restricted during pregnancy.
- Acute renal failure in severe renal failure or severe hydro-electrolytic imbalances may require dialysis.
Perinatal care considerations
Fetal Monitoring: depending on the gestational age, use cardiotocography and ultrasound. Do not perform amniocentesis in case of active infection.
Mild illness: pregnancy can be prolonged until term; severe illness: childbirth must be expedited (risk of intrauterine fetal demise or maternal and fetal death). Administer Magnesium sulphate for neuroprotection and pulmonary maturation to all viable fetuses. The risk of vertical transmission at the peak of the acute phase of the disease is not known, therefore preterm delivery should only be recommended if necessary.
Mode of delivery
In a negative pressure delivery room, patients should wear a mask. Modalities according to usual obstetrical indications. Both loco-regional and general anaesthesia can be used: in case of intubation necessary due to maternal clinical condition, perform a general endotracheal anesthesia
The placenta should be treated as biohazardous material.
Avoid delayed cord clamping. Infants should be isolated and monitored for 14 days, separated from their mother. Avoid direct breastfeeding, use of breast-pump allowed. Observe meticulous hand hygiene. Propose psychological support.
Personal Protection and Prevention Strategies:
There are no vaccines or therapies. Isolation and individual protection are the key to controlling the infection.
- Maintain good personal and social hygiene. Wash hands with soap. The whole medical team must wear a mask.
- Be proactive: seek the latest recommendations for COVID-19 infection.
- Symptomatic patients should consult their physician and follow recommendations for treatment and isolation from contact.