• Saswati Mukherjee

PRENATAL CARE: COVID CARE – Dr. Girija Wagh

Some oft-asked questions and ones which we need to answer and know the facts. These are sourced from the recent up-to-date for all my friends here as a ready reckoner.


Are pregnant women more susceptible to COVID-19 or at higher risk for complications of COVID-19?


Pregnancy and childbirth generally do not increase the risk for acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but appear to worsen the clinical course of COVID-19 compared with non-pregnant individuals of the same sex and age; however, most (>90 percent) infected persons recover without undergoing delivery.


Does COVID-19 increase the risk for pregnancy complications?


Yes, infected women, especially those who develop pneumonia, appear to have an increased frequency of preterm birth (birth before 37 weeks of gestation) and possibly cesarean delivery, which is likely related to severe maternal illness. Most preterm births are iatrogenic


Does SARS-CoV-2 cross the placenta?


There is no definite evidence that SARS-CoV-2 crosses the placenta and infects the fetus. However, a few cases of placental tissue or membranes positive for SARS-CoV-2 and a few cases of possible in utero-infection have been reported. Some of the neonatal cases may have been false-positive test results or due to acquisition of infection soon after birth. Reports of COVID-19 infection in the neonate have generally described mild disease.


How can prenatal care be modified to decrease the risk of contracting COVID-19?


The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) support modifying traditional protocols for prenatal visits to limit person-to-person contact and thus help prevent the spread of COVID-19. Modifications should be tailored for low- versus high-risk pregnancies (e.g., multiple gestations, hypertension, diabetes) and may include telehealth in areas of active infection transmission, reducing the number of in-person visits, the timing of visits, grouping tests (e.g., aneuploidy, diabetes, infection screening) to minimize maternal contact with others, restricting visitors during visits and tests, timing of indicated obstetric ultrasound examinations, and timing and frequency of use of non-stress tests and biophysical profiles.


Should glucocorticoids be avoided in pregnant women with COVID-19?


No, pregnant women who meet the criteria for use of glucocorticoids for maternal treatment of COVID-19 can receive standard doses of dexamethasone. For those who also meet the criteria for use of antenatal corticosteroids for fetal lung maturity, we suggest administering the usual doses of dexamethasone (four doses of 6 mg given intravenously 12 hours apart) to induce fetal pulmonary maturation and continuing dexamethasone to complete the usual course of treatment for maternal COVID-19 (6 mg orally or intravenously daily for 10 days or until discharge, whichever is shorter).


Are SARS-CoV-2 vaccines safe for pregnant women and women planning a pregnancy?


Probably. Pregnant women have been excluded from trials evaluating COVID-19 vaccines, thus safety and efficacy data are limited in this population. We suggest COVID-19 vaccination for pregnant women rather than deferring vaccination until after delivery, particularly for those at higher risk of exposure or severe disease if infected.

Although pregnancy itself is associated with an increased risk of severe infection, some patients may reasonably elect to defer vaccination after weighing their personal risk of COVID-19 exposure and disease severity against the limited data regarding the safety and efficacy of COVID-19 vaccines during pregnancy.


Vaccination should be timed so that patients do not receive COVID-19 vaccines within 14 days of receipt of a routinely administered vaccine, such as the Tdap and influenza.


However, a shorter interval between COVID-19 vaccines and other vaccines is reasonable when timely administration of another vaccine is important (e.g., tetanus vaccination during wound management) or if it would avoid unnecessary delays in COVID-19 vaccination.


Vaccination is not thought to affect fertility, and it is not necessary to delay pregnancy after vaccination.


LABOR AND DELIVERY


Is maternal COVID-19 an indication for cesarean delivery?


No, COVID-19 is not an indication to alter the route of delivery. Even if the vertical transmission is confirmed as additional data are reported, this would not be an indication for cesarean delivery since it would increase maternal risk and would be unlikely to improve newborn outcomes.


Should planned induction of labor or cesarean delivery of asymptomatic women be postponed during the pandemic?


No, in asymptomatic women, inductions of labor and cesarean deliveries with appropriate medical indications should not be postponed or rescheduled. This includes 39-week inductions or cesarean deliveries after patient counseling.


How should labor pain be managed in women with COVID-19?


A neuraxial anesthetic is generally preferred to other options for the management of labor pain because it provides good analgesia and thus reduces cardiopulmonary stress from pain and anxiety. In addition, it is available in case an emergency cesarean is required, thus obviating the need for general anesthesia. The Society of Obstetric Anesthesia and Perinatology (SOAP) suggests considering suspending the use of nitrous oxide for labor analgesia in patients with confirmed or suspected COVID-19 because of insufficient data about cleaning, filtering, and potential aerosolization of nitrous oxide systems, but it remains an option for patients with a negative SARS-CoV-2 test.


Can an asymptomatic partner/support person attend labor and delivery?


Practices vary by institution. At a minimum, the support person should be screened following hospital policies, and those with any symptoms consistent with COVID-19, exposure to a confirmed case within 14 days, or a positive test for COVID-19 within 14 days should not be allowed to attend the labor and birth. Most facilities recognize that a support person is important to many laboring women and permit one support person who must remain with the laboring woman (may not leave the room and then return).


Additional support persons may be allowed or can be a part of the patient's labor and delivery via video.


POSTPARTUM


How should the baby be evaluated?


If the mother has known COVID-19, the infant is a COVID-19 suspect and should be tested, isolated from other healthy infants, and cared for according to infection control precautions for patients with confirmed or suspected COVID-19.


Should mothers with COVID-19 be separated from their babies?


Generally no because the newborn's risk for acquiring SARS-CoV-2 from the mother is low and data suggest no difference in risk of neonatal SARS-CoV-2 infection whether the neonate is cared for in a separate room or remains in the mother's room. However, mothers should wear a mask and practice hand hygiene during contact with their infants. At other times, physical distancing >6 feet between the mother and neonate or placing the neonate in an incubator is desirable when feasible.


How long should mother-baby precautions at home continue after a recent infection?


Previously symptomatic mothers with suspected or confirmed COVID-19 are not considered a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:


  • At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised).

  • At least 24 hours have passed since their last fever without the use of antipyretics.

  • Their other symptoms have improved.


For asymptomatic mothers identified only by obstetric screening tests, at least 10 days should have passed since the positive test.


Can breast milk transmit SARS-CoV-2?


There is a general consensus that breastfeeding should be encouraged because of its many maternal and infant benefits. It is unknown whether SARS-CoV-2 can be transmitted through breast milk because very few breast milk samples have been tested. In a World Health Organization (WHO) study, breast milk samples from 43 mothers were negative for SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR) and samples from three mothers tested positive, but specific testing for the viable and infective virus was not performed.


What precautions should mothers with confirmed or suspected COVID-19 take when breastfeeding?


Droplet transmission from infected mothers to their baby could occur through close contact during breastfeeding. Mothers can take precautions to prevent this by performing hand and breast hygiene and using a face mask. In a study from New York City that tested and followed 82 infants of 116 mothers who tested positive for SARS-CoV-2, no infant was positive for SARS-CoV-2 postnatally, although most roomed-in with their mothers and were breastfed. The infants were kept in a closed isolette while rooming-in and the mothers wore surgical masks while handling their infants and followed frequent hand and breast washing protocols.


Alternatively, the infant can be fed expressed breast milk by a healthy caregiver following hygiene precautions until the mother has recovered or is proven uninfected.


In such cases, the mother should use strict hand washing before pumping and wear a face mask during pumping.


Can pregnant and postpartum women with COVID-19 take NSAIDs and acetaminophen?


Yes, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be used for the treatment of fever and pain during pregnancy and postpartum. Antepartum, the lowest effective NSAID dose is used, ideally for less than 48 hours and guided by gestational age-related potential fetal toxicity (e.g., oligohydramnios, premature closure of the ductus arteriosus). Low-dose aspirin for the prevention of preeclampsia is safe throughout pregnancy. In patients with abnormal liver chemistries secondary to COVID-19, a potential concern of acetaminophen use is hepatic toxicity; however, doses less than 2 grams per day are likely safe in the absence of severe or decompensated hepatic disease.


Are SARS-CoV-2 vaccines safe for breastfeeding women?


Probably. Breastfeeding women have been excluded from trials evaluating COVID-19 vaccines, thus safety and efficacy data are limited in this population. We suggest COVID-19 vaccination for breastfeeding women rather than deferring vaccination until after breastfeeding, particularly for those at higher risk of exposure or severe disease if infected. Some women may reasonably elect to defer vaccination after weighing their personal risk of COVID-19 exposure and disease severity against the very limited data regarding the safety and efficacy of COVID-19 vaccines during breastfeeding.


- Dr. Girija Wagh