Care pathways for pregnant women with COVID‐19

From the start of the coronavirus disease 2019 (COVID-19) outbreak, concern has mounted as to the impact of the virus on pregnancy. However, there has been little professional consensus on the best way to manage pregnancy during the pandemic, given the limited data currently available.

A recent review published in the journal Global Challenges in October 2020, sums up what is currently known about the treatment of COVID-19 during pregnancy and offers recommendations for how healthcare professions might better manage pregnant COVID-19 patients in the future.

Study: Management of Pregnancy during the COVID‐19 Pandemic. Image Credit: Africa Studio / Shutterstock
Study: Management of Pregnancy during the COVID‐19 Pandemic. Image Credit: Africa Studio / Shutterstock

Diagnosis of COVID-19 in pregnancy

The diagnosis of COVID-19 in pregnant women should be based on the usual symptoms like a fever or a cough and confirmed by virus testing and imaging. Testing is indicated for those with these symptoms or a history of contact with a known or suspected COVID-19 case and conducted using real‐time reverse‐transcriptase polymerase chain reaction (RT‐PCR) via swap samples.

With throat‐swab specimens, this test is around 90% sensitive but can produce many false positives, depending on the setting. Its positive predictive value (PPV) ranges from around 47% to around 96%. Increased accuracy would be possible with high-throughput sequencing, but this would take more time and a specific set-up.

Another alternative is serologic testing (via blood samples), which detects the presence of IgM and IgG (antibody) responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen that causes COVID-19. This could identify both asymptomatic individuals as well as those who have had the virus and recovered. A rapid point‐of‐care lateral flow immunoassay is now available, with results within 15 minutes. IgM antibody tests identify current or very recent infection and decline over time. They pick up only half of infected cases, but are around 90% specific. IgG indicates a past infection and increase over time.

Imaging tests in pregnancy

For a pregnant woman suspected to have this infection – or indeed, any hospitalized pregnant woman in an area with high COVID-19 prevalence – the researchers recommend a low-dose chest CT scan to increase the detection rate and ensure minimal fetal impact.

The chief chest CT findings present in around 70% to around 80% of pregnant women with COVID-19 include ground-glass opacities, a crazy-paving style pattern and consolidation. Compared to RT-PCR testing, chest CTs are 97% sensitive, with a PPV of 65%, but not specific.  Unpublished research by the current authors corroborates this finding.

Treatment of COVID-19 in pregnancy

The researchers recommend quarantine for pregnant women with SARS-CoV-2 infection, rather than self-care at home. Discharge criteria include a normal temperature for three or more days, marked improvement in respiratory symptoms, resolution of chest imaging signs, two consecutive negative RT-PCR tests and no other pregnancy-associated condition.

General disease management includes rest, good nutrition and the close monitoring of respiratory symptoms, heart and lung function. Other indices of inflammation, such as the CRP, and chest imaging, should be monitored, along with oxygen administration, if necessary. Traditional Chinese herbs may also help in cases of mild COVID-19.

Antiviral therapy

Remdesivir may be effective and safe. Chloroquine and hydroxychloroquine also have "apparent efficacy." However, high doses of chloroquine may cause systolic hypotension, which could cause hemodynamic changes during pregnancy due to compression of the inferior vena cava and the aorta by the pregnant uterus.

Other antivirals known to be safe and effective in pregnancy include oseltamivir or zanamivir, recommended for the treatment of influenza in pregnancy by the American College of Obstetricians and Gynecologists (ACOG). The researchers say more data is required for these drugs to be used in pregnancy, especially with respect to cardiac complications.

Severe COVID-19 in pregnancy

Severe COVID-19 is marked by deterioration in vital signs, shock, organ failure, low lymphocyte count, high inflammatory marker levels, or signs of rapidly progressing lung disease. This indicates intensive care unit (ICU) admission and perhaps invasive mechanical ventilation, to maintain adequate oxygen saturation. Support of renal function or hemopurification, where required, are effective in severely ill pregnant patients.

Pregnant patients before 28 Weeks

Before 28 weeks of pregnancy, supportive therapy and antivirals are used to promote recovery and continuation of the pregnancy to term, provided both mother and baby are in good condition. Careful fetal monitoring, and corticosteroid administration for fetal lung maturation are necessary. Progressive disease or another obstetrical indication may indicate delivery.  

Prevention of COVID-19 in pregnancy

Pregnancy requires family care and medical attention, making quarantine difficult. Therefore, protection is a priority. This involves self-isolation at home unless medical reasons prohibit and staying away from any family member with suspected or confirmed infection. Mask wearing and handwashing are mandatory to reduce the odds of infection.

Daily disinfection of high-contact surfaces such as furniture, doorknobs, handles, computers, cellphones and toilets are other recommendations provided by the researchers to prevent infection during pregnancy.

To prevent infection during obstetric examinations in hospitals, only mandatory examinations should be carried out, individualizing each patient's schedule and prioritizing home visits. This should be complemented by online or telemedicine consults, with remote monitoring of fetal heart rate. Hospital visits should be by appointment using other anti-infection precautions and avoiding crowding in waiting areas.

Delivery in COVID-19-positive pregnancy

Having COVID-19 per se is not an indicator for delivery at any time. Stable patients between 28 and 34 weeks may expect to continue their pregnancy, even with pneumonia if they have no other complications, without evidence of fetal infection or anomalies.

Timely delivery should be expedited if the mother has progressive pneumonic or systemic illness with COVID-19, or for obstetric indications. Cesarean delivery should be opted for as per the obstetric indication, or in severe COVID-19, as per patient request, or any other contraindication to normal delivery.

Precautions during delivery

With full standard precautions in place, delivery should be carried out in isolation wards with a negative pressure airflow. For pain relief required, spinal anesthesia is preferred, or, for very sick patients, general anesthesia with intubation.

For Cesareans, general or epidural anesthesia can be used. The former could cause viral spread through the body, worsening of the disease, or fetal deterioration, but the latter may cause hypotension.

Following childbirth

Potential complications during the puerperium include higher risk of infection, worsening of clinical severity, and challenges with breastfeeding. The researchers point to the US CDC (Centers for Disease Control and Prevention) guidelines for breast pumping, with the milk fed to the infant by a healthy individual. Once the mother is healing well, and other criteria for removal from quarantine are satisfied (as above), she may be discharged.

Management of the newborns

Very few researchers think, from available evidence, that newborns can be infected before or during childbirth. Nonetheless, care should be taken to minimize the risk, promptly cutting the cord, cleaning the mouth and nose, and drying the baby off to remove maternal body fluids.

Diagnosis in newborns may be more accurate with serology and chest CT rather than viral RNA testing. IgM antibodies appear at 3-5 days from the onset of infection. Their appearance may signal intrauterine or perinatal infection. Serology-positive infants should be isolated and the diagnosis confirmed, and if required, hospitalized in the neonatal ICU.

Follow-up after discharge

Since some patients have had positive PCR tests or persistent lesions after discharge, strict follow-up is recommended for pregnant women as well, in another unit for 14 more days. This will also protect them from other infections in view of the observed lower T cell count.

Conclusion

The researchers lay out general and special measures to prevent and treat SARS-CoV-2 infection in pregnancy. This guidance will encourage fewer complications related to pregnancy and better outcomes.

Journal reference:
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.

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