Re: Guidance on COVID-19 During Pregnancy and the Puerperium (ISUOG, 2020)
Title: Expectant Mother + Baby + Virus: “Three’s a Crowd”
Pregnancy and the puerperium together represent a unique medical environment that centers on the interactions of two persons—the expectant mother and her baby. Care during the continuum of these phases involves well established protocols for caring for the pregnant woman and her unborn baby and care of the recently delivered woman as she transitions into a resumption of a non-pregnant physiology.
The special condition of pregnancy makes COVID-19 different from non-pregnancy-related infection
With the SARS-CoV-2 virus (which is the virus causing COVID-19 disease), the obstetrical care protocol (caring from pregnancy through the postpartum period) must be adjusted and revised—on the fly—to accommodate possible exposure, asymptomatic and symptomatic disease, and a mindful awareness and sensitivity to the COVID-19 incubation period. Since COVID-19 disease has reached pandemic status and since so much is at stake in pregnancy (two patients), 14-day interruptions into the carefully formulated flowsheet of pregnancy care must be accommodated.
Girl interrupted
Obstetrical care involves a lot of timing:
· Dating the gestation accurately with serial ultrasonography in the first and second trimesters
· Screening for genetic disease during the first and/or second trimester via blood tests and/or ultrasound
· Chorionic villous sampling during first trimester or amniocentesis in the second trimester, when screening indicates the need to rule out genetic disease
· Screening for gestational diabetes during the third trimester
· Screening for vaginal colonization of Group B beta-hemolytic strep in the third trimester
· Beginning of “post-dates” surveillance at 39-weeks’ gestation
Three’s a crowd
While pregnancy presents two persons for care, when the SARS-CoV-2 virus enters the picture, its notoriously long incubation period of 2 weeks can throw off the above timing. Recently, the ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) has issued guidelines1,2 for adjusting this schedule of care, including imaging, due to its status of expertise on this.
COVID-19 Screening
Initial screening, besides the traditional obstetrical history (last menstrual period, prior pregnancy and delivery outcomes, medical conditions, family history, etc.), must now add screening for the SARS-CoV-2 and the COVID-19 disease it causes. These additional considerations revolve around the “TOCC”2 (Travel, Occupation, Contact, and Cluster) algorithm:
· Any recent travel out of state to COVID-19 “hot spots,” or international travel in the prior 2 weeks.
· Occupational risk, e.g., health care worker or working in areas of high volume (school, transit, etc.).
· Any contact with persons who have COVID-19 or are suspected of having it.
· Any encounters with potential COVID-19 disease clusters (visiting nursing homes, prisons, etc.)
Adjusted timing of obstetrical screening in pregnant women with TOCC risk factors
· Any antenatal office visits should be delayed 14 days* in pregnant women.
· Routine ultrasound should be delayed 14 days.
· Group B strep (GBS) screening should be delayed 14 days, and if delivery were to ensue prior to screening due to this delay, GBS prophylaxis during labor should be implemented. Alternatively, intrapartum prophylaxis can be implemented in lieu of screening at all.
· Invasive genetic procedures should be timed, if feasible, around the 14-day window of observation for infection.
* In those at term or post-dates (>41 weeks gestation), management should be done according to obstetrical protocols, but with the use of barriers (masks, gloves, gowns, etc.) as per high-risk contact medical management.
Alternatively, any of the above can ensue after a suspected or probable case tests negative or after recovery (in a confirmed case).
Other diagnostics
A chest X-ray, which complements the symptoms of fever and cough with the diagnostic sign of pulmonary infiltrates, is a legitimate test (primary tool) to diagnose COVID-19 disease in epidemic areas or at term/post-dates with a need for obstetrical management.
COVID-19 barrier implementation
Pregnancy involves additional diagnostic maneuvers that involve imaging (ultrasound, X-ray, even MRI) and these “contact” diagnostics require disinfection of transducer, table, probe, skin surfaces, etc. When feasible, bedside imaging is preferable in order to keep the patient isolated.
Treatment during pregnancy in patients with COVID-19 or TOCC risk factors
Strategies should involve a multidisciplinary team in a designated tertiary hospital with isolation, negative-pressure ORs, PPE, and ventilator/ICU capabilities. If negative-pressure isolation is not available, single rooms or group wards should be used.
· Symptomatic treatment, with maintenance of fluid and electrolyte balance and antipyretics/antidiarrheals.
· Supplemental oxygen as indicated to prevent maternal or fetal hypoxia.
· Surveillance of maternal vital signs, oxygen saturation, and fetal monitoring in the third trimester combined with amniotic fluid volume (“biophysical profile”) assessment and umbilical artery Doppler flow assessment.
· Pneumonia indicates the need for antibiotics and antivirals, in consultation with infectious disease and maternal-fetal medicine specialists.
· The use of antenatal steroids, used frequently to enhance lung maturity in the fetus in danger of pre-term birth, should be used with caution according to a sensitive risk-vs-benefit approach.
· Spontaneously aborted pregnancies (“miscarriage”) should be considered infectious tissues and managed accordingly.
Delivery
COVID-19 is not an indication for delivery unless either mother or baby is in life-threatening jeopardy; but delivery is an indication for extensive COVID-19 precautions, including all of the barrier methods and negative-pressure environments, preferably in a tertiary facility designated for COVID-19-related obstetrics. Stage II of labor can be shortened with operative maneuvers, such as forceps or vacuum extraction. (“Pushing” during this stage may increase the risk of exposure to healthcare workers even when donning PPE.) Delivery should be expedient, such that methods like “water birth” should be avoided.
In newborns of suspected or confirmed COVID-19 mothers, the umbilical cord should be clamped promptly and the neonate transferred to an isolated resuscitation area and team, and the infant should be isolated from his/her mother. Breastfeeding causes a high risk for transmission of infected droplets, not from the milk, but from the mother’s proximity; therefore, milk can be expressed, stored, and administered to the infant by non-infected persons, separated from his/her mother.
As with COVID-19 precautions in general, reduce the number of persons participating to those needed and follow protocols of hand-washing, PPE, hand-sanitizers (70% alcohol), and close contact avoidance
Conclusion
Pregnancy and delivery present a special population for care, and the co-morbidity of COVID-19 disease or the suspicion of it doesn’t intersect it, but is additive to it. That is, precautions will alter pregnancy and delivery care according to COVID-19 protocols, which includes delay of routine care or the adoption of COVID-19 strategies if intervention is indicated for obstetrical reasons.
RESOURCES:
1. Poon LC, Yang H, Lee JCS, et al. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals. Ultrasound Obstet Gynecol. 2020 Mar 11.https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.22013
3. Yen, M. Y., Schwartz, J., King, C. C., Lee, C. M., & Hsueh, P. R. (2020). Recommendation on protection from and mitigation of COVID-19 pandemic in long-term care facilities. Journal of Microbiology, Immunology and Infection
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