Original Article: RCOG, Coronavirus (COVID-19) Infection in Pregnancy
Author of summary: Daria Di Filippo; Reviewer: Gianmarco Taraschi
Original Article Published on March 28th, 2020
Guidelines released from the Royal College of Obstetrician and Gynaecologists on the antenatal, intrapartum and postpartum care of women suspected or confirmed to be positive for COVID-19 with moderate or severe symptoms.
Priorities of the following recommendations are (i) the reduction of transmission to pregnant women and (ii) the provision of safe care for suspect/confirmed women
The virus, isolated in respitatory secretions, faeces and fomites, can be transmitted by direct contact (within 2 meters) with an infected person (especially if symptomatic) or indirectly through contaminated surfaces, objects or hands.
Pregnant women do not seem to have a higher risk of infection than the general population. Vertical transmission seems possible.
Effect on the pregnant woman
Dyspnea and coughing are relevant symptoms. The modification of the immune system and the response to viral infections due to pregnancy, makes possible more severe symptoms and pictures such as pneumonia and marked hypoxia, particularly at term. At the moment, no deaths have been reported in pregnant women.
Effect on the fetus
There is no data suggesting an increased risk of miscarriage or evidence that the virus is teratogenic.
Advice for health professionals to share with pregnant women
– Avoid contact with positive or symptomatic people, if after the 28th week of gestation minimize contact with others.
– Call your caregiver to confirm short-term appointments that could be safely postponed or cancelled. Go to confirmed appointments when you are feeling well. Limit the number of accompanying persons.
– If you have coronavirus symptoms, contact your obstetrics team to arrange the optimal time and place for your checkups.
– If you are infected, you will likely have no symptoms or just a mild malaise followed by a prompt recovery. If you develop more severe symptoms or recovery is delayed, contact your obstetric team or emergency numbers.
Advice for all midwifery and obstetric services caring for pregnant women
– Teleconferencing and videoconferencing are strongly recommended to visit patients, storing electronic recordings. Appoint a group of clinicians to coordinate the care of patients forced to skip an appointment for self-isolation.
– Postpone visits by 7 days for symptomatic women unless symptoms (other than coughing) persist and by 14 days for women in self-isolation for symptomatic family members.
– Perinatal anxiety and depression may occur more easily during the epidemic, as well as domestic violence: support women and families, especially if in complex conditions (poverty, substance abuse, etc.) by questioning patients about their mental health at each visit and encouraging them to ask for help remotely if necessary.
– Smoking has a high probability of being associated with worse outcomes: invite patients to stop smoking.
General advice regarding intrapartum services
–Adapt services such as labor induction (reduced fetal movements or before 41 weeks in low risk healthy women) or ultrasound scans for fetal growth that are not strictly necessary.
-Offer labour induction at home, depending on the availability of transport to the hospital.
– Intrapartum services should be offered with the minimum staff needed.
– A trusted person may be present during labour and childbirth, unless under general anesthesia.
– Home birth is only possible if an ambulance is available for rapid transfer.
Advice for services caring for women with suspected or confirmed COVID-19
Pre- and post-natal care should be mostly considered essential if not remotely feasible. – Women should travel by private transport if possible or by calling public emergency services and notifying the receiving operator of the situation. – Women should notify a staff member before entering the hospital and be received with the appropriate PPE and a surgical mask (not FFP3): remove the mask in the isolation room with a decontamination space (to put and remove the PPE) and en-suite bathroom, sound with the main required care activities. – Only the essential staff should enter the room and the number of visitors and objects inside should be reduced to the minimum.
Women presenting with symptoms suggestive of possible infection
Screening points should be set up near the hospital entrance to test and treat all suspect patients as confirmed cases, pending the results (see attached flowchart). The overlap between symptoms of pregnancy and COVID-19 (fever with ruptured membranes) can cause confusion: in case of uncertainty treat as suspected infection. In the case of a woman suspected or confirmed in the obstetric emergency room, follow infection prevention and control measures and then manage the obstetric emergency.
Women who develop new symptoms of COVID-19 during admission
The estimated incubation period is 0-14 days (average 5-6 days): in case of new respiratory symptoms or temperature above 37.8 degrees, isolate the patient and implement effective precautions.
Women attending for intrapartum care with suspected or confirmed COVID-19
· Hospital birth should be recommended. Women should call the midwife team in initial labor: patients should be encouraged to stay at home in the latent phase.
· Once in isolation room: – Evaluate infection symptoms and vital signs. – Confirm the onset of labour and perform continuous cardiotocography: If sent home, teach the patient the signs and symptoms suggestive of the worsening of her condition due to the infection, such as breathing difficulties.
Care in labour
At admission to the labour room inform gynecologist, anesthesiologist, chief obstetrician, neonatal nurse and infection control team, minimizing the number of professionals entering the room. – Treatment strategies in case of emergency must be agreed. – The birth attendant must constantly wash his hands if asymptomatic and not attend the birth if symptomatic: advise women to have a backup attendant. – Monitor oxygen saturation every hour, to be kept >94%. – The mode of delivery should not be influenced by the presence of COVID-19 except in respiratory conditions that require urgent delivery. – Water birth should be avoided because of the risk of contact with faeces. – Epidural analgesia should be recommended to minimize the need for general anesthesia in case of accelerated delivery. – Entonox is not an aerosol generating procedure: use disposable microbiological filter. – When deteriorating clinical conditions consider the risk/benefit of an emergency C-section. – Shortening the second stage of labour by elective operative delivery can be considered in a symptomatic exhausted or hypoxic patient. – Late cord clamping is still recommended if there are no contraindications. -Elective C-section: Postpone hospitalization if possible.
Additional considerations for women with confirmed COVID-19 and moderate/severe symptoms
At the hospitalization, arrange a multidisciplinary team meeting with an infectivologist if possible, a gynecologist, chief obstetrician and anesthesiologist to discuss the stabilization of clinical conditions as a priority, the most appropriate place of care and concerns about the newborn. Inform the woman of what has been discussed. – Managenement:
· Observation of vital parameters and oxygen saturation every hour, monitoring absolute values and trends: young and healthy women can compensate for a deterioration in respiratory function by maintaining normal saturation before rapidly decompensating: treat an increasing respiratory rate with increased oxygen supply.
· Perform X-rays and CT as in the general population using abdominal shielding.
· Make differential diagnosis in case of fever.
· Consider bacterial infection if white cells increased (lymphocytes are only low or normal with COVID-19) and start antibiotic.
· Initial fluid management with 250-500 ml boluses and then evaluate for fluid overload.
· Fetal heart rate frequency and variability should be evaluated according to gestational age and maternal conditions. If the mother is stable, vaginal birth is allowed. If maternal stabilization is necessary, it has priority over delivery.
· Administer steroids for fetal pulmonary maturation when indicated, without delaying an urgent delivery for this reason.
Women in labor with moderate/severe symptoms
Notify the neonatal team in advance if possible so they can wear PPE. Given the risk of Acute Respiratory Distress Syndrome, monitor the water balance every hour, aiming for a neutral balance in anticipation of delivery.
Do not separate mothers and infants that do not require additional care, after discussion of risk/benefit with neonatologist and parents.
The benefits of breastfeeding outweigh the risk of close contact with the mother and respiratory droplet infection. – Instruct parents to wash their hands before touching the baby, breast pump or feeding bottle and avoid coughing or sneezing on the baby while breast-feeding: consider using a mask. – Dedicate a personal breast pump to mothers who use it.
Discharge and readmission to hospital
Instruct patients to notify the hospital if they need to return to the hospital during self-isolation.
Advice for services caring for women following isolation for symptoms, or recovery from confirmed COVID-19 General recommendations for the emergency operating room
Program at the end of the day elective cerclages and caesarean sections. – Non-elective procedures should be performed in a second room or, if this is not available, with enough time to ensure complete post-operative disinfection. – The number of professionals in the rooms should be kept to a minimum and all should wear PPE. – Run simulations to increase confidence in health care professionals and identify critical points of emergency transfers in the operating room.
Recommendations for PPE in the C-section
Intubation is a procedure that generates aerosols and therefore increases the risk of contamination. – If general anaesthesia is planned, all OR staff should wear all PPE including an FFP3 mask and operators should wash themselves before anaesthesia begins.
– If the chance of requiring general anesthesia is low, perform locoregional anesthesia outside the room: staff will wear PPE with a water-repellent surgical mask and surgical goggles (to prevent droplet or fomite infection).
-If there is a known risk of having to convert the anaesthesia to general anaesthesia (emergency C-section in a patient with sub-optimal epidural analgesic coverage), the OR team will wear PPE including FFP3 mask before the procedure is started.
Antenatal care for pregnant women following self-isolation for symptoms suggestive of COVID-19
If the patient has not required hospitalization, no additional clinical evaluation will be necessary. – If a woman with a negative COVID-19 test seeks medical assistance with symptoms suggestive of infection, consider her to be infected and repeat the test
Antenatal care following hospitalisation for confirmed COVID-19
Further pre-natal care should be scheduled after the self-isolation period and it will be important to start ultrasound monitoring of fetal growth 14 days after the acute disease has been resolved.