Coronavirus Disease 2019 in Pregnancy: A Clinical Management Protocol and Considerations for Practice

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has represented a major impact to health systems and societies worldwide. The generation of knowledge about the disease has occurred almost as fast as its global expansion. The mother and fetus do not seem to be at particularly high risk. Nevertheless, obstetrics and maternal-fetal medicine practice have suffered profound changes to adapt to the pandemic. In addition, there are aspects specific to and gestation that should be known by specialists in order to correctly diagnose the disease, classify the severity, distinguish specific signs of COVID-19 from those of obstetric complications, and take the most appropriate management decisions. In this review we present in a highly concise manner an evidence-based protocol for the management of CO-VID-19 in pregnancy. We briefly contemplate all relevant as-pects that we believe a specialist in obstetrics and maternal medicine should know, ranging from basic concepts about the disease and protection measures in the obstetric setting to more specific aspects related to maternal-fetal management and childbirth.[1]. With 220,000 infections and more than 22,000 deaths, Spain is the third country in number of cases [1]. In this paper, we aimed to share our management protocol and address considerations for maternal-fetal medicine practice based on a qualitative review of existing data. Disease TransmissionAvailable information [2] suggests that the infection was originally zoonotic. Still, the current transmission is person to person by respiratory droplets after contact with an infected person (< 2 m) or direct contact with contaminated surfaces by infected secretions [3]. Transmission could also occur through infected faeces, but the propagation throughout this route is much less relevant [4]. The possibility of vertical transmission is highly unlikely and has not been demonstrated in the Chinese CO-VID-19 outbreak [5] or in previous epidemics by other similar coronaviruses (severe acute respiratory syndrome [SARS]-CoV and Middle East respiratory syndrome [MERS]-CoV) [6,7]. Based on limited data, there is no evidence of the presence of the virus in genital fluids, urine, amniotic fluid, or breast milk [8]. The low maternal viremia found in this infection [9] also suggests a negligible placental seeding. However, most data on vertical transmission are based on women who had infection during the third trimester, and information regarding vertical transmission earlier in pregnancy is lacking.Reported cases of newborn infection probably came from horizontal transmission. The usual incubation period is about 4-6 days, which can vary between 2 and 14 days [10]. The median duration of viral shedding is 20.0 days (being the 75th centile at 24 days) [11].

Pregnancy and Childbirth in the COVID-19 Era—The Course of Disease and Maternal–Fetal Transmission

“…Previous studies suggested that pregnant women are not more susceptible to SARS-CoV-2 infection than the general population [ 6 ]. However, the presence of comorbidities (e.g., diabetes and chronic hypertension), which often appear in the second trimester of pregnancy [ 7 , 8 ], as well as increased maternal age and high BMI may increase their risk of developing severe COVID-19 symptoms [ 8 ]. A report published on 26 June 2020 mentioning that 8207 pregnant women were confirmed to have SARS-CoV-2 infection altered this perception as it revealed that pregnant women may have an increased risk of developing severe symptoms of COVID-19 as compared to nonpregnant patients [ 9 , 10 ].…”

COVID-19 and Pregnancy: A Review

“…Severely ill patients between 32 to 34 weeks of gestation (or beyond) with COVID-19 pneumonia may benefit from early delivery. 24,30 These patients in ICU should be considered for thromboprophylaxis with low molecular weight heparin (LMWH). 31…”

“…20 Fetal monitoring should be done by electronic fetal monitoring (EFM) using CTG. 30 Efforts made to minimize the number of staff members entering the room, and units should develop a local policy specifying essential personnel for emergency scenarios. Asymptomatic birth partners asked to wash their hands frequently.…”

“…22 Women admitted for delivery with confirmed COVID-19 should be given thromboprophylaxis with LMWH unless contraindicated. 20,30,31 It is given as injection enoxaparin 40 mg subcutaneously once daily until 2 weeks after delivery.…”

A Critical Review of the Coronavirus Disease (COVID-19) during Pregnancy & Risk of Vertical Transmission in the United States

“…Some experts even say that low-risk pregnant women infected with COVID-19 mild disease do not need clinical assessment and may follow the standard prenatal care and be safely isolated at home [12]. However, experts recommend frequent telehealth prenatal controls; hence COVID-19 patients may have sudden clinical deterioration [13].…”