Wednesday, May 20, 2020



Dr K K Aggarwal
President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

888: Pregnancy and COVIUD 19Source UPTODATE

1.     Pregnant women should follow the same recommendations as nonpregnant persons for avoiding exposure to the VOVID virus.

2.     Pregnant health workers in the third trimester, particularly those ≥36 weeks, stop face-to-face contact with patients.

3.     Clinical manifestations of COVID-19 in pregnant women are similar to those in nonpregnant individuals.

4.     A positive test for SARS-CoV-2 generally confirms the diagnosis of COVID-19, although false-positive and false-negative tests are possible.

5.     Pregnancy does not appear to increase susceptibility to infection or worsen the clinical course, and most infected mothers recover.  However, severe disease necessitating maternal intensive care unit admission and need for extracorporeal membrane oxygenation can occur.

6.     Infected women, especially those who develop pneumonia, appear to have an increased frequency of preterm birth and cesarean delivery. These complications are likely related to severe maternal illness as intrauterine infection does not appear to occur, but this is still under investigation. A few possible early newborn infections and one possible placental infection have been reported.

7.     The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have issued guidance regarding prenatal care during the COVID-19 pandemic

8.     For the general population, the Centers for Disease Control and Prevention recommend avoiding glucocorticoids in COVID-19-positive persons because of the potential for adverse effects on the course of the disease. Because of the clear benefits of antenatal betamethasone administration between 24+0 and 33+6 weeks of gestation in patients at risk of preterm birth within seven days, ACOG continues to recommend its use for standard indications to pregnant patients with suspected or confirmed COVID-19.

9.     For most women with preterm COVID-19 and nonsevere illness who have no medical/obstetric indications for prompt delivery, delivery is not indicated and ideally will occur sometime after a negative testing result is obtained or isolation status is lifted, thereby minimizing the risk of postnatal transmission to the neonate. Severely ill patients at least 32 to 34 weeks of gestation with COVID-19 pneumonia may benefit from early delivery.

10. In areas where the infection is active, we believe testing all patients upon presentation to labor and delivery (or the day before if a scheduled admission) is reasonable, if testing is available. In a city with a high infection prevalence, a high proportion of asymptomatic patients (13.5 percent in one study) admitted for delivery tested positive, which has clinical implications for triage, staff, and newborn care.

11. Generally, management of labor is not altered in women giving birth during the COVID-19 pandemic or in women with confirmed or suspected COVID-19. SARS-CoV-2 has not been detected in vaginal secretions or amniotic fluid, so rupture of fetal membranes and internal fetal heart rate monitoring may be performed for usual indications, but data are limited. COVID-19 is not an indication to alter the route of delivery. The partner/support person should be screened in accordance with hospital policies and those with any symptoms consistent with COVID-19, exposure to a confirmed case within 14 days, or a positive test for COVID-19 within 14 days should not be allowed to attend the labor and birth.

12. In patients with known or suspected COVID-19, neuraxial anesthetic is not contraindicated and has several advantages in laboring patients. The Society of Obstetric Anesthesia and Perinatology suggests suspending use of nitrous oxide for labor analgesia in these patients because of insufficient data about potential aerosolization of nitrous oxide systems.

13. At delivery of patients with known or suspected COVID-19, some institutions have chosen to prohibit delayed cord clamping in term infants, in whom the benefits are modest, to minimize newborn exposure to any virus in the immediate environment and reduce the chances that the newborn will require phototherapy for jaundice.

14. NSAIDs are commonly used for treatment of postpartum pain; however, there are anecdotal reports of possible negative effects of NSAIDs in patients with COVID-19. Given the uncertainty, use paracetamol (acetoaminophen). If NSAIDs are needed, the lowest effective dose should be used.

15. Infants born to mothers with known COVID-19 are COVID-19 suspects and should be tested, isolated from other healthy infants, and cared for according to infection control precautions for patients with confirmed or suspected COVID-19.

16. Whether to separate a mother with known or suspected COVID-19 and her infant is determined on a case-by-case basis. If the infant tests positive, separation is unnecessary. If separation is indicated (mother is on transmission-based precautions) but not implemented, other measures may be utilized to reduce potential mother-to-infant transmission, including physical barriers and ≥6 feet separation, personal protective equipment and hand hygiene, and utilization of other healthy adults for infant care (feeding, diapering, bathing).

17. The virus has only been found in one sample of breast milk, but data are limited.

18. Droplet transmission to the new-born could occur through close contact during feeding.

19. In mothers with confirmed COVID-19 or symptomatic mothers with suspected COVID-19, to minimize direct contact, ideally, the infant is fed expressed breast milk by another caregiver until the mother has recovered or been proven uninfected, provided that the other caregiver is healthy and follows hygiene precautions. In such cases, the mother should wear a mask and thoroughly clean her hands and breasts before pumping; the pump parts, bottles, and artificial nipples should be cleaned as well. If she breastfeeds the infant directly, similar personal hygienic precautions should be taken.

20.   Remdesivir is the most promising and has been used without reported fetal toxicity in some severely ill pregnant women.

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