These are scary and uncertain times that COVID-19 is creating. We all have a story to tell – who we know, how we are being impacted, and how our lives are changing. Certain patient populations are facing unique experiences and challenges. The evidence on prenatal, intrapartum, and postpartum risk and transmission is limited, however, there is some data available and there are some recommendations being provided by the Centers for Disease Control and Prevention (CDC)
and professional organizations, such as The American College of Obstetricians & Gynecologists (ACOG)
and the Society for Maternal-Fetal Medicine (SMFM)
Special considerations for care of pregnant women
The situation is rapidly changing. We do know that in pregnancy, immunologic and physiologic changes do occur which could make pregnant women more susceptible to viral respiratory infections, including COVID-19 (CDC, 2020). However, based on limited evidence, pregnant women don’t appear to be at increased risk for severe disease (ACOG, 2020).
Alternate care delivery during pregnancy, labor, and postpartum may be necessary in some settings.
“ACOG encourages local facilities and systems, with input from their obstetric care professionals, to develop innovative protocols that meet the health care needs of their patients while considering CDC guidance, guidance from local and state health departments, community spread, health care personnel availability, geography, access to readily available local resources, and coordination with other centers.”
Changes to prenatal care delivery may be necessary to limit the risk of exposure to the virus for the mother and the fetus or infant. ACOG (2020) recognizes the possible need for these temporary modifications:
- Spacing out appointments
- Alternate or reduced prenatal care schedules
- Grouping components of care together to reduce the number of in-person visits
- Phone and telehealth screenings before in-person visits to assess COVID-19 exposure or symptoms
- Prudent use of ultrasonography and avoidance of elective ultrasound examinations
- Postponement or cancellation of some testing or examinations if the risk of exposure and infection within the community outweighs the benefit of testing
If a pregnant woman is infected with COVID-19, consider the following recommendations (SMFM, 2020):
- Detailed mid-trimester anatomy ultrasound following first-trimester maternal infection
- Ultrasound for fetal growth in the third trimester for women who have experienced COVID-19 later in pregnancy
Regarding steroid use, the recommendation is to avoid corticosteroids in patients with COVID-19 due to prolonged viral replication period observed in MERS-CoV patients. However, in pregnant patients with suspected or confirmed COVID-19, the recommendations for antenatal corticosteroid use for fetal maturation are as follows (ACOG, 2020):
- Between 24 0/7 weeks and 33 6/7 weeks of gestation and at risk of preterm birth within 7 days : antenatal corticosteroids should continue to be offered as recommended.
- Between 34 0/7 weeks and 36 6/7 weeks of gestation and at risk of preterm birth within 7 days: antenatal corticosteroids should not be offered.
Modifications may be individualized, weighing the neonatal benefits with the risks of potential harm to the pregnant patient.
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Group B streptococcus (GBS) screening should occur as indicated during the usual recommended time period, 36 0/7–37 6/7 weeks of gestation, however consideration may be given to grouping other components of care at that time to reduce the number of in-person prenatal visits needed. Or, if self-testing is available, patients can self-collect after proper patient education is provided (ACOG, 2020).
Additional considerations during the prenatal period include offering mental health or social work services or referrals, and anticipatory counseling related to communication with team, changes to labor and postpartum plans, visitation, and postpartum contraception.
Hospitals and birth centers that are both licensed and accredited remain safe places to give birth in the United States (ACOG, 2020). When a pregnant patient with suspected or confirmed COVID-19 is admitted and birth is anticipated, the obstetric, pediatric or family medicine, and anesthesia teams should be notified. Highlights from the ACOG recommendations include:
- It is reasonable to attempt to postpone delivery (if no other medical indications arise) for a woman with suspected or confirmed COVID-19 in the third trimester until a negative testing result is obtained or quarantine status is lifted.
- Cesarean delivery should therefore be based on obstetric indications and not COVID-19 status alone.
- Decisions related to labor inductions and cesarean deliveries should be made at the local and systems level based on health care personnel availability, geography, access to readily available local resources, and coordination with other centers.
- Delayed cord clamping is appropriate in the setting of appropriate clinician personal protective equipment.
Recommendations for the postpartum period include (ACOG, 2020):
- When mother and infant are healthy, it may be appropriate to expedite discharge. Decisions regarding early discharge will require input from the pediatric team and home telehealth visits for the mother and infant should be considered.
Similar to during the prenatal period, additional considerations include offering mental health or social work services or referrals, and anticipatory counseling related to communication with team, changes to postpartum plans, visitation, and postpartum contraception.
Pregnant healthcare workers
At the present time, there are no additional restrictions on pregnant health care workers because of COVID-19 alone. As for all health care providers, strict adherence to the CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation(PUI) for 2019-nCoV in Healthcare Settings
should be maintained.
If staffing permits, facilities may want to consider limiting exposure of pregnant health care personnel to patients with confirmed or suspected COVID-19 infection, especially during aerosol-generating procedures (CDC, 2020). If exposure to patients with suspected or confirmed COVID-19 occurs, CDC risk assessment and infection control guidelines should be followed.
Vertical transmission is transmission of a pathogen from a mother to her fetus or newborn before, during, or immediately after delivery (CDC, 2020). Some pregnant women with COVID-19 have had preterm births, but it is not clear whether the preterm births were because of COVID-19; it’s also not clear if COVID-19 can pass to a fetus during labor and delivery (ACOG, 2020).
Recent studies have shown that there were no findings suggestive of COVID-19 in neonates born to affected mothers, and amniotic fluid, cord blood, and breast milk, were negative for SARS-CoV-2 (Chen et al., 2020). However, in one cohort, three of 33 infants (9%) presented with early-onset SARS-CoV-2 infection which resolved by days 6-7 (Zeng et al., 2020). In these cases, the likely sources of SARS-CoV-2 in the neonates’ upper respiratory tracts or anuses were maternal in origin, however the vertical maternal-fetal transmission cannot be ruled out (Zeng et al., 2020). Therefore, screening of mothers and close monitoring of neonates at risk are essential.
ACOG (2020) also provides the following recommendations for infants born to mothers with confirmed COVID-19, based on limited data and considerations for other respiratory viruses, such as influenza, SARS-CoV, and MERS-CoV:
In limited case series reported to date, no evidence of virus has been found in the breast milk of women with COVID-19 and no information is available on the transmission of SARS-CoV-2 through breast milk. Antibodies against SARS-CoV were detected in at least one sample (CDC, 2020).
There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended and the decisions on breastfeeding should be made by the mother in coordination with her family and health care practitioners. At present, the primary concern is whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding, not whether the virus can be transmitted through breastmilk (ACOG, 2020).
The American College of Obstetricians and Gynecologists. (2020). Novel Coronavirus 2019 (COVID-19) Practice Advisory. Retrieved from https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
Centers for Disease Control and Prevention (CDC). (2020). Information for Healthcare Providers: COVID-19 and Pregnant Women. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html
Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., Li, J.,…Zhang, Y. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, 395 (10226). doi: https://doi.org/10.1016/S0140-6736(20)30360-3
Society for Maternal-Fetal Medicine. (2020). Coronavirus (COVID-19). Retrieved from https://www.smfm.org/covid19
Zeng, L., Xia, S., Yuan, W., Yan, K., Xiao, F., Shao, J., & Zhou, W. (2020). Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatrics. doi: 10.1001/jamapediatrics.2020.0878