Editor: Jon Hyett
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.
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.
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.
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: https://ranzcog.edu.au/statements-guidelines/covid-19-statement/information-for-pregnant-women
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%.
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.
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.
This fact sheet is a good source of information for patients who may be concerned about radiation risks:
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.
Care of the labouring women in a time of Corona presents a number of challenges which will be addressed in this section.
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. 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]
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.
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.
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.
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.
Local access to both fertility and abortion services are dependent on individual hospital and clinic services.
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.