Pregnancy and COVID-19

These are scary and unsure times that COVID-19 is creating. We all have a story to inform – who we all know, the way it is affecting us, and the way our lives are changing. Some patient populations face unique experiences and challenges. The evidence on prenatal, intrapartum, and postnatal risks and transmission is proscribed, but there are some data and proposals from Centers for Disease Control and Prevention (CDC)and skilled organizations comparable to American College of Obstetricians and Gynecologists (ACOG) and Society of Maternal-Fetal Medicine (SMFM).

The landscape is changing rapidly. We know that immunological and physiological changes occur while pregnant which will make pregnant women more prone to respiratory viral infections, including COVID-19 (CDC, 2020). However, based on limited evidence, it doesn’t appear that pregnant women are at increased risk for severe disease (ACOG, 2020).

In some situations, respite care could also be needed while pregnant, childbirth and the postpartum period.

“ACOG encourages local facilities and systems to work with obstetric care providers to develop innovative protocols that meet the health care needs of their patients while taking into account CDC guidelines, local and state health department guidelines, community spread of disease, availability of health care personnel, geographic location, access to readily available local resources, and coordination with other facilities.”

Prenatal care

Changes in prenatal care could also be needed to cut back the chance of exposure of the mother and fetus or infant to the virus. ACOG (2020) recognizes the possible need for these temporary modifications:

• Meetings Schedule
• Alternative or Shortened Prenatal Care Schedules
• Grouping Care Elements to Reduce the Number of In-Person Visits
• Telephone and telemedicine screening prior to in-person visits to evaluate COVID-19 exposure or symptoms
• Prudent use of ultrasound and avoidance of scheduled ultrasound examinations
• Postponing or canceling certain tests or investigations if the chance of exposure and infection in the neighborhood outweighs the advantages of testing

If a pregnant woman becomes infected with the COVID-19 virus, the next recommendations must be considered (SMFM, 2020):

• Detailed ultrasound examination of midtrimester anatomy following maternal infection in the primary trimester
• Ultrasound scan to evaluate fetal growth within the third trimester of pregnancy in women who develop COVID-19 later in pregnancy

Regarding steroid use, it is strongly recommended to avoid corticosteroids in patients with COVID-19 attributable to the prolonged period of viral replication observed in patients with MERS-CoV. However, in pregnant patients with suspected or confirmed COVID-19, the recommendations for using antenatal corticosteroids for fetal maturation are as follows (ACOG, 2020):

• From 24 0/7 weeks to 33 6/7 weeks of pregnancy and if there’s a risk of preterm delivery inside 7 days: proceed to make use of antenatal corticosteroids as advisable.
• Between 34 0/7 weeks and 36 6/7 weeks of gestation and susceptible to preterm delivery inside 7 days: antenatal corticosteroids shouldn’t be offered.

Changes could be tailored to individual needs, taking into consideration the advantages to the neonate and the chance of potential harm to the pregnant patient.

Group B streptococcal (GBS) screening must be performed as indicated on the typically advisable time point, 36 0/7–37 6/7 weeks of gestation, although consideration could also be given to grouping other components of care right now to cut back the variety of in-person prenatal visits which might be needed. Or, if self-testing is accessible, patients may self-collect the sample after appropriate patient education (ACOG, 2020).

Additional considerations through the prenatal period include offering mental health or social work services or referrals, in addition to contraceptive counseling regarding communication with the team, changes in labor and postpartum plans, visitation, and postpartum contraception.

Perinatal care

Hospitals and birthing centers which might be each licensed and accredited remain secure places to present birth within the United States (ACOG, 2020). When a pregnant patient with suspected or confirmed COVID-19 is admitted and delivery is anticipated, the obstetric, pediatric or family medicine, and anesthesia teams must be notified. Key ACOG recommendations include:

• In the case of a girl with suspected or confirmed COVID-19 infection within the third trimester of pregnancy, it is affordable to try and postpone delivery (unless there are other medical indications) until a negative test result’s obtained or the quarantine is lifted.
• Therefore, the choice to perform a cesarean section must be made based on obstetric indications and never solely on COVID-19 status.
• Decisions regarding induction of labor and cesarean delivery must be made on the local and system level, taking into consideration the provision of health care personnel, geographic location, access to available local resources, and coordination with other facilities.
• Delayed cord clamping is indicated provided the physician uses appropriate personal protective equipment.

Postpartum care

Recommendations for the postpartum period include (ACOG, 2020):

• When the mother and infant are healthy, it might be appropriate to expedite discharge. Decisions regarding early discharge would require advice from the pediatric team, and telehealth home visits for the mother and infant must be considered.

As with the prenatal period, additional considerations must be given, comparable to offering mental health or social work services or referrals, in addition to contraceptive counseling regarding communication with the team, changes in postnatal plans, visitation, and postnatal contraception.

There are currently no additional restrictions for pregnant healthcare staff attributable to COVID-19 itself. As with all healthcare staff, strict adherence to CDC Interim Recommendations for Infection Prevention and Control for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation (PUI) for 2019-nCoV Infection in Healthcare Settings Must be kept.

If staffing allows, facilities will probably want to consider limiting the exposure of pregnant healthcare staff to patients with confirmed or suspected COVID-19 infection, especially during aerosol-generating procedures (CDC, 2020). CDC risk assessment and infection control guidelines must be followed when exposure to patients with suspected or confirmed COVID-19 infection occurs.

Vertical transmission is the transmission of a pathogen from the mother to the fetus or newborn before, during, or immediately after delivery (CDC, 2020). Some pregnant women with COVID-19 have had preterm births, but it surely is unclear whether the preterm births were attributable to COVID-19; it’s also unclear whether COVID-19 could be transmitted to the fetus during delivery (ACOG, 2020).

Recent studies have shown that there have been no findings suggestive of COVID-19 in neonates born to affected moms, and amniotic fluid, cord blood, and breast milk were negative for SARS-CoV-2 (Chen et al., 2020). However, in a single cohort, three of 33 infants (9%) had early SARS-CoV-2 infection that resolved after 6–7 days (Zeng et al., 2020). In these cases, the likely sources of SARS-CoV-2 within the upper respiratory tract or rectum of the neonates were maternal, but vertical maternal-fetal transmission can’t be ruled out (Zeng et al., 2020). Therefore, maternal screening and shut monitoring of at-risk neonates are essential.

ACOG (2020) also provides the next recommendations for infants born to moms with confirmed COVID-19, based on limited data and considerations for other respiratory viruses comparable to influenza, SARS-CoV, and MERS-CoV:

• Infants must be isolated in accordance with Infection prevention and control guidelines for PUI.
• Facilities should consider temporarily separating moms from their infants until precautions to forestall maternal infection are lifted.
• Discharge from hospital for girls after childbirth should follow the recommendations described in Interim Considerations for Management of Patients Hospitalized with COVID-19.

In the limited case series reported up to now, there isn’t any evidence of the virus within the breast milk of girls with COVID-19 and there isn’t any information on the transmission of SARS-CoV-2 through breast milk. Antibodies to SARS-CoV have been detected in no less than one sample (CDC, 2020).

There are rare exceptions when breastfeeding or feeding expressed breast milk shouldn’t be advisable, and decisions about breastfeeding must be made by the mother in collaboration along with her family and health care providers. The primary concern at present is whether or not an infected mother can transmit the virus through respiratory droplets during breastfeeding, not whether the virus could be transmitted through breast milk (ACOG, 2020).

American College of Obstetricians and Gynecologists. (2020). A practice guide for the 2019 novel coronavirus (COVID-19). Retrieved from https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019

Centers for Disease Control and Prevention (CDC). (2020). Information for healthcare professionals: COVID-19 and pregnant women. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html

Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., Li, J.,…Zhang, Y. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. (10226). doi: https://doi.org/10.1016/S0140-6736(20)30360-3

Society for Maternal-Fetal Medicine. (2020). Coronavirus (COVID-19). Retrieved from https://www.smfm.org/covid19

Zeng, L., Xia, S., Yuan, W., Yan, K., Xiao, F., Shao, J., and Zhou, W. (2020). Early neonatal SARS-CoV-2 infection in 33 neonates born to moms with COVID-19 in Wuhan, China. JAMA Pediatrics. doi: 10.1001/jamapediatrics.2020.0878
AND

• ACOG Guide to Obstetrical Preparedness for COVID-19
• Outpatient ACOG Evaluation and Treatment for Pregnant Women with Suspected or Confirmed Novel Coronavirus (COVID-19) Infection
• COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics
• Patient Education from March of Dimes