Coronavirus disease 2019 (COVID-19) pandemic and pregnancy

Abstract

The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading globally at an accelerated rate, with a basic reproduction number (R0) of 2e2.5, indicating that 2e3 persons will be infected from an index patient. A serious public health emergency, it is particularly deadly in vulnerable populations and communities in which healthcare providers are insufficiently prepared to manage the infection. As of March 16, 2020, there are more than 180,000 confirmed cases of COVID-19 worldwide, with more than 7000 related deaths. The SARS-CoV-2 virus has been isolated from asymptomatic individuals, and affected patients continue to be infectious 2 weeks after cessation of symptoms. The substantial morbidity and socioeconomic impact have necessitated drastic measures across all continents, including nationwide lockdowns and border closures.Pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks. To date, the outcomes of 55 pregnant women infected with COVID-19 and 46 neonates have been reported in the literature, with no definite evidence of vertical transmission. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure in the gravida. Furthermore, the pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system. These unique challenges mandate an integrated approach to pregnancies affected by SARS-CoV-2.Here we present a review of COVID-19 in pregnancy, bringing together the various factors integral to the understanding of pathophysiology and susceptibility, diagnostic challenges with real-time reverse transcription polymerase chain reaction (RT-PCR) assays, therapeutic controversies, intrauterine transmission, and maternalÀfetal complications. We discuss the latest options in antiviral therapy and vaccine development, including the novel use of chloroquine in the management of COVID-19. Fetal surveillance, in view of the predisposition to growth restriction and special considerations during labor and delivery, is addressed. In addition, we focus on keeping frontline obstetric care providers safe while continuing to provide essential services. Our clinical service model is built around the principles of workplace segregation, responsible social distancing, containment of cross-infection to healthcare providers, judicious use of personal protective equipment, and telemedicine. Our aim is to share a framework that can be adopted by tertiary maternity units managing pregnant women in the flux of a pandemic while maintaining the safety of the patient and healthcare provider at its core.

Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection

“…There is no evidence that chloroquine, hydroxychloroquine or azithromycin are harmful to the developing fetus, and pregnancy is not a contraindication to their use. 49,50 Long-term risks of treatment include retinopathy, vacuolar myopathy, neuropathy, restrictive cardiomyopathy and cardiac conduction disturbances. [51][52][53] These risks are negligible in the context of treatment of SARS-CoV-2 but may be relevant if they are used for extended prophylaxis.…”

Postpartum exacerbation of antenatal COVID-19 pneumonia in 3 women

“…We hypothesize this may have been because of hemodynamic, immunologic and plasma volume changes that interfered with normal hormonal and diuresis changes postpartum, which predispose to changes in pulmonary vasculature and, potentially, decompensation. [5][6][7] These changes may be exacerbated, furthermore, in immunocompromised hosts who have systemic inflammatory changes, such as those with COVID-19.…”

Epidemiology of COVID-19

“…Studies also emphasized that the course of COVID-19 was normal in pregnant women as opposed to those of SARS and MERS [27,28]. Another study also reviewed that we have no definitive evidence of vertical transmission [29].…”