120 CMAAO CORONA FACTS and MYTH BUSTER: ANC Care
Dr K K Aggarwal
President CMAAO
944: IMA-CMAAO
Webinar on Covid-19 in pregnancy
6th
June, 2020
4-5pm
Participants
Dr
KK Aggarwal, President CMAAO
Dr
RV Asokan, Secretary General IMA
Dr
Jayakrishnan Alapat
Dr
Sanchita Sharma
Faculty
Dr Raina Chawla
Bhatia
Associate
Professor, Dept. of Obs & Gyn
ESIC
Medical College, Faridabad
- Covid status of
the pregnant woman is important as this has huge implications for the
mother as well as the fetus and the neonate. There is also the risk of
spread of infection to the healthcare providers. They should be segregated
to prevent spread of infection.
- FOGSI has issued
good clinical practice recommendations for pregnant women to prevent
Covid-19 infection: Social distancing and Do the Five: Stay at home, hand
hygiene, respiratory hygiene, avoid touching the face and keeping
distance. Wearing a mask is recommended.
- Healthcare
workers should observe precautions as they are at high risk of getting the
infection: Distancing, PPE, chemoprophylaxis (hydroxychloroquine for HCW
with known contact with COVID-19 positive patients).
- Always ask
history (travel abroad, contact with Covid confirmed case, respiratory
symptoms). A Covid check list at the initial point of contact will help to
better segregate the suspected cases. A triage area in OPD is very
important.
- Most pregnant
women present with mild illness or are asymptomatic. But, if comorbidities
or obstetric risk factors such as pre-eclampsia, gestational diabetes will
aggravate the severity of the disease. Covid-19 can exaggerate the hypercoagulable
state also.
- There is now emerging
evidence that in-utero transplacental infection to the fetus may occur. There
have been single reports of vertical transmission from UK, Belgium. The
virus has not been isolated in amniotic fluid or vaginal secretions. There
is not enough evidence to say that there is no effect on the fetus, but
the effects seem to be minimal or are less in incidence.
- Testing:
Although there is no recommendation for testing every pregnant woman, we
test all pregnant women: more than 39 gestational weeks, from containment/cluster
areas and those who are likely to deliver in next 5 days or who are in
labor. Faridabad is a hot spot. Nasopharyngeal swab is done.
- Covid and
non-covid set ups should be defined to avoid intermingling of patients;
three areas: clean area, suspected area and confirmed area. Covid-positive
mothers should be delivered in separate and dedicated labor rooms or OTs. If
these facilities are not available, then the LR and OT should be properly
fumigated. There should be separate Covid-positive area.
- Optimize
antenatal visits and time them as per need; encourage teleconsultations –
first visit at 12 weeks can be timed with USG, 2nd visit at 20
weeks to time with level 2 USG at 20 weeks, then we call at 32 weeks and
then at delivery for low risk women to reduce transmission. This frequency
may be higher in high risk patients.
- USG: Avoid
unnecessary USGs; do at 11-14 weeks, 18-20 weeks and then only if
necessary; disinfect the USG machine and probes (fomite); the room should
be fumigated.
- Management: Keep doctors ready, immediate initiate
infection control measures (allow 30 minutes for this); if immediate
obstetric intervention required, admit directly to designated labor room
or OT. If the woman is not in labor, if mild/asymptomatic with no high
risk obstetric factors and good fetal status: Home isolation. Admit in
Covid ward if moderate to severe symptoms or high risk pregnancy.
- Medical
management: FOGSI has suggested two approaches: HCQ 600mg/day +
azithromycin (500 mg od x10 days) or antiviral therapy with lopinavir +
ritonavir (400mg+100mg) bd x 14 days. The decision of which line of
management is to be given should be in consultation with medicine team.
- Antipyretic
treatment is important as hyperpyrexia can lead to IUD; look for other
infections, consider empiric antibiotics and also thromboprophylaxis as
there may be prolonged admission and immobilization.
- Indications
of ICU management: oxygen saturation <93% at rest,
tachypnea (>30/min), qSOFA score can be used to aid decision making
- Obstetric
management: Counseling of mother (and attendants), neonatal
corner should be at a distance of 2 m away from the delivery table, during
labor monitor respiratory status. All suspected/confirmed Covid women
should be provided with a 3-layer surgical mask at all times. Till now,
all pregnant women with Covid have been delivered via cesarean section,
but there is no proven rationale for this, so treatment should be
individualized. Obstetric intervention should not be delayed because of
lack of testing.
- Newborn
care:
Testing if mother has Covid or if baby is asymptomatic. Breastfeeding is
encouraged with good hygiene practices. Rooming-in with direct
breastfeeding (if mother is asymptomatic or mildly symptomatic) is practiced
in India, whereas in the US or China, the mother and baby are kept in
separate rooms. Viral RNA has not been found in breast milk. If mother has
cough, fever, dyspnea or newborn needs ICU care, separate the baby and the
mother; the infant is given expressed breast milk from the mother. The
newborn of a Covid-positive woman is tested (RT PCR) on the day of birth
and then after 48 hours and then repeated ever week till the baby is 28
days old.
- Training
(donning and doffing PPE) and managing the healthcare cadre is very
important to prevent them from getting infected. It is also important to
keep up their morale.
Dr
Chawla also shared their experience of Covid-19 at the Dept. of Obs & Gyn,
ESIC Medical College & Hospital and shared a month’s data.
- A total of 225
women (data collected from 22.4.20 to 28.5.20 from ARI Clinic) were
tested; of these 10 tested positive. Only 2 were symptomatic.
- 24 patients were
admitted till 5th June; 17 were diagnosed antenatally and 7
were diagnosed postnatally. Two out of 24 were symptomatic; almost 90%
were asymptomatic.
- 7 of the 13
patients detected at term underwent LSCS for obstetric reasons; 2
delivered vaginally; of these, one baby tested positive on Day 0, had
fever on Day 2, developed respiratory distress and died on day 3 (this
could have been a case of vertical transmission). Three of the other
babies tested positive between Day 5-14 but are asymptomatic.
- Patients are
being monitored by daily NST if available. If not, check daily fetal heart
rate.
- HCQ started for
all as per institutional protocol
Amniotic fluid and placental swab are now being tested by RT PCR
- The incidence of
cesarean section is high as it is not easy to monitor patients for
prolonged time while wearing PPE.
- Challenges:
Separating Covid and non-Covid areas, getting PPE for non-Covid areas,
delay in reporting, motivating HCW, and working in PPE with no air
conditioning
- What
can we do? Checklists, appropriate PPEs in all areas, audit
donning and doffing procedures, conduct mock drills with new team members,
2 surgeons during cesarean is a must, develop institution SOP based on the
present guidelines
