Editor:  Jon Hyett

COVID-19 in pregnancy part 2

Introduction

Having read about some of the science informing us about COVID-19 in pregnancy in Part 1, Part 2 focuses on the practicalities of providing reproductive healthcare in the midst of a pandemic and how to manage the pregnant patient with COVID-19.

Providing antenatal care

Maternity care is essential and saves lives. The fear of COVID-19 should not prevent a pregnant woman from seeking medical attention at any time and she should be reassured that midwifery and obstetric staff remain as ready to care for her as ever.

The timeline of most antenatal care remains unchanged; women still need to get their routine booking bloods done, should be offered first trimester screening as usual, and should attend for their morphology scan. However, most units are trying to reduce the number of face-to-face antenatal visits in order to minimise the risk of exposure for pregnant women, so changes are occurring. Telehealth and email have been invaluable helping to achieve this.

In line with these efforts, RANZCOG has suggested temporary changes to screening for gestational diabetes (GDM) to avoid exposing women to risk whilst attending their standard two-hour, 75g glucose tolerance test.[24]

RANZCOG Recommendations for GDM screening during the Pandemic

• Patients with identifiable risk factors for gestational diabetes should have a HbA1c performed with their antenatal serology bloods; a cut off of 5.9% being considered diagnostic of GDM.
• Women with a history of GDM may either be considered to have GDM and commence home blood glucose monitoring from 28 weeks’ gestation, or if they choose to proceed with testing, should have a fasting blood glucose level testing at 24-28 weeks’ gestation.
• All other women should have a fasting blood glucose at 24-28 weeks’ gestation, with a result >=5.1mmol/L considered diagnostic.

This will inevitably lead to a significant reduction in the recognition of GDM-affected pregnancies, which in turn could impact on pregnancy outcomes in those with a missed diagnosis. This highlights the difficulty in risk balance as we manage the threat from COVID-19 alongside the need to continue to provide antenatal care. Acknowledging this concern, some centres have chosen to continue to screen for GDM according to normal protocols, ensuring adequate social distancing within phlebotomy collection centres.

Pregnant COVID-19 patients

Women with infective symptoms, or those in quarantine should be advised not to attend for routine appointments; these should be rescheduled for an appropriate time.

If women have COVID-19 symptoms and require medical attention that cannot be delayed, they should contact their maternity unit so that plans can be made for review with staff donning appropriate personal protective equipment (PPE).

Women should be advised to maintain good hand hygiene and social distancing measures in line with advice from public health authorities.

They should be reassured that their intended mode of delivery should not be influenced by COVID-19.

RANZCOG is an excellent source of advice and reassurance for pregnant patients[25]: https://ranzcog.edu.au/statements-guidelines/covid-19-statement/information-for-pregnant-women

The sick COVID-19 pregnant patient

As the pandemic spreads, we will likely see more pregnant patients with severe respiratory symptoms from COVID-19 infection.

It is important to remember that fit, healthy women will compensate for reduced respiratory function, often maintaining normal saturations before decompensating. An increasing respiratory rate may herald impending deterioration.

Patients admitted with COVID-19 should be managed in conjunction with the Respiratory Team and in more severe cases, Intensive Care.

Oxygen should be administered as required, titrating to keep Oxygen saturations above 94%.[26]

Empirical antibiotics should be given to treat secondary bacterial pneumonia.

Thromboprophylaxis with subcutaneous low molecular weight heparin (LMWH) or unfractionated heparin, should be considered due to the increased risk of venous thromboembolism during pregnancy, and the concern for thrombotic complications in critically unwell patients with COVID-19.[27]

Imaging with chest x-ray or CT chest should proceed as indicated by the clinical status. Whilst many women will be anxious about the risk of ionising radiation in pregnancy, the risks are low and can be reduced further with abdominal shielding. The priority is always the well-being of the mother.[26]

This fact sheet is a good source of information for patients who may be concerned about radiation risks:[28]

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/273450/risk-of-x-rays-and-ct-scans-in-pregnancy-patient-factsheet-0.pdf

Deteriorating pregnant COVID-19 patients

Deteriorating patients should be managed by a multidisciplinary team, with early recourse to mechanical ventilation for progressive respiratory failure. For such patients, delivery will only be indicated for maternal reasons.

There have been some concerns raised that high dose steroids may delay the clearance of SARS CoV-2. RANZCOG and RCOG however support the administration of intramuscular steroids for fetal lung maturation where there is a risk of preterm birth before 34 weeks, in the absence of any definitive evidence that this causes harm. [26,29] Women requiring oxygen therapy may move rapidly to the point of requiring delivery. Such an escalation in treatment may therefore be a good time to consider steroids if the woman is preterm.

Given the theoretical risk of intrauterine growth restriction following maternal COVID-19 infection, recovered patients who remain pregnant should be referred for ultrasonographic surveillance to monitor fetal growth at appropriate intervals.[19]

Labour and delivery in a time of corona

Care of the labouring women in a time of Corona presents a number of challenges which will be addressed in this section.

Admission

• Women should be encouraged to call prior to presenting at their birthing unit.
• During that phone call they should be asked about symptoms of COVID-19.
• Only one birth partner should be in attendance.
• If the planned birth partner is symptomatic of COVID-19, they should be advised to self-isolate at home.
• Women in labour with signs and symptoms of COVID-19 should be screened for SARS CoV-2 appropriately.

Mode of delivery

• Mode of delivery should not be influenced by COVID-19 infection unless the mother’s respiratory condition requires urgent delivery.
• RCOG and RANZCOG both support vaginal birth for stable, COVID-19 positive patients.[25,26]
• Water birth should be avoided in positive or suspected COVID-19 patients due to the risk of infection to healthcare workers.[26]

General measures

• When a confirmed or suspected COVID-19 case is admitted in labour, all relevant personnel (midwifery, obstetric, anaesthetic, paediatric, theatre, infectious disease and support staff e.g. porters) should be informed and a multidisciplinary approach sought to determine ongoing management.
• Appropriate PPE for healthcare workers should be used in line with local hospital policy and infection control measures taken.

Maternal monitoring

• Maternal observations should be taken as per standard practice. In positive or suspected COVID-19 patients, oxygen saturations should also be measured.
• Fluid management should be monitored with hourly input/output measures in COVID-19 positive or suspected patients.
• Pregnant women are at additional risk of fluid overload, so large fluid boluses should be avoided.[26]
• Patients with signs of sepsis in labour should be investigated as per local unit guidelines, with appropriate commencement of antibiotics.

Fetal monitoring

• RCOG and RANZCOG recommend continuous electronic fetal monitoring (CEFM) in labour for all COVID-19 positive or suspected patients.[26]
• RANZCOG supports the use of fetal scalp electrodes and fetal blood sampling as in routine practice. This is in view of the fact that SARS CoV-2 is not blood-borne, has yet to be isolated in the genital tract, and is not clearly transmitted vertically.[30]
• It is important to appreciate that donning PPE is time-consuming and should a Category 1 Caesarean section be required, will increase the interval to delivery time. Families should be informed of this, with consideration of a lower threshold to proceeding to immediate delivery where there is evidence of fetal distress.

Pain relief

• The use of Entonox is not considered to be an aerosol generating procedure (AGP), but there is limited data on this. A single-use microbiological filter should be used for each patient as is standard practice. RANZCOG acknowledges that advice regarding its use may change as more data becomes available. Many groups have decided not to offer Entonox to high risk or infected cohorts, due to concerns about the risk to healthcare workers.[31]
• RCOG recommends the early use of epidural anaesthesia in COVID-19 positive patients, where acceptable to the mother. Ensuring the woman is comfortable in labour will reduce the risk of contamination of healthcare workers and may reduce the risk of the patient requiring a general anaesthetic (which is an AGP) should they proceed to the operating theatre for e.g. Caesarean section.[26]
• Medical staff should be aware that thrombocytopenia has been reported in COVID-19 patients, therefore a platelet count should be checked prior to use of regional anaesthesia.[32]

Second stage

• The active second stage of labour can be a messy business, with a high risk of contamination of healthcare workers from respiratory secretions, blood and faeces. It is not, however, considered an AGP.
• RANZCOG recommends protective apparel, fluid-repellent surgical mask, and eye protection when caring for ALL women in the second stage. When caring for COVID-19 patients, PPE should be in line with the individual hospital policy.[33]
• COVID-19 positive or suspected patients should be encouraged to wear a face mask during the second stage.[26]
• Consideration should be given to shortening the second stage with an assisted delivery should the COVID-19 patient become exhausted or hypoxic.[26]
• There should be a low threshold for having paediatric assistance in the room at the time of delivery of COVID-19 positive or suspected patients as there will be an inevitable delay in Paediatric attendance at resuscitation due to the need to don PPE.
• RANZCOG and RCOG support delayed cord-clamping in COVID-19 patients in the absence of any evidence to suggest it is harmful.[26,29]

Caesarean section

• Caesarean section should be undertaken for the usual obstetric indications.
• It may be required for maternal indications in the context of severe COVID-19 pneumonia.
• Regional anaesthesia is the anaesthesia modality of choice in stable COVID-19 positive or suspected cases.
• Appropriate PPE should be worn in line with local hospital guidelines.
• Diathermy has been considered an AGP and should be avoided where possible. When used staff should don appropriate PPE for aerosolising procedures.[34]

Post-partum and breastfeeding

Literature from China suggests that infants born to COVID-19 positive mothers were separated from their mothers for 14 days.[13–15] The decision to separate a mother and baby during this critical period of feeding and bonding should not be undertaken lightly. In recognition of this, both RANZCOG and RCOG support mother and baby staying together, providing both remain well.[25,26] Where the mother is too unwell to care for her baby, alternative care arrangements should be made for the baby at home.

WHO, RANZCOG and RCOG all acknowledge the importance of breastfeeding for early child health. Whilst there is no evidence that SARS CoV-2 is transmitted in breast milk, there is concern for respiratory droplet spread from close contact.[13] RCOG and RANZCOG recommend that breastfeeding continue in COVID-19 cases, providing the mother wears a facemask, practises good hand hygiene, and avoids coughing or sneezing whilst feeding.[25,26]

Recommendations for pregnant healthcare workers

Given the theoretical concerns regarding COVID-19 in the third trimester, the risk of providing front-line care in the middle of the pandemic, and the high prevalence of COVID-19 in the UK, RCOG has recommended that all pregnant healthcare workers stay at home from 28 weeks’ gestation. Prior to 28 weeks, pregnant healthcare workers can be supported to remain in their roles with appropriate PPE, but should be redeployed away from high-risk areas such as ICU.[35]

In Australia, where the prevalence of COVID-19 is relatively low, RANZCOG has recommended that where possible, pregnant healthcare workers be allocated to low-risk areas to reduce their risk of exposure. It does not currently advise cessation of all clinical work in the third trimester, but urges employers to be sensitive to the fact that pregnant women are, appropriately, often anxious about their own health and protective of their unborn baby. Where a healthcare worker has concerns, consideration should be given to them working from home or taking a leave of absence.[35]

Other reproductive health services

The Fertility Society of Australia has recommended that in the interests of public safety and preserving PPE for front-line healthcare workers, patients who are planning to start fertility treatment consult with their treating specialist and discuss the appropriateness of postponing their treatment. They acknowledge that there may be medical grounds that mean delaying treatment may not be advisable. Many public units have stopped further fertility treatments except in exceptional cases, such as for women undergoing cancer therapy.[36]

RANZCOG has published a statement emphasising that abortion is an essential, time-critical healthcare service, and must remain available to women in the current pandemic.[37]

Local access to both fertility and abortion services are dependent on individual hospital and clinic services.

Conclusion

Caring for pregnant women during the Corona pandemic presents a number of challenges, however, these are not insurmountable, and women should be reassured that they will continue to receive women-centred, comprehensive care throughout their pregnancy journey.