There currently are no clear guidelines on optimal delivery timing or delivery method for women who are pregnant and have confirmed or suspected novel coronavirus (COVID-19). However, in a multidisciplinary teleconference of experts from China and the United States, recommendations for managing COVID-19 in pregnant women and neonates were developed, according to a review published in International Journal of Gynecology & Obstetrics.
The experts recommend that women with symptoms suggestive of COVID-19 be immediately isolated in a single room for screening, and confirmed cases should be treated in a negative pressure room or isolation ward. Women with signs of critical illness should be immediately transported to an intensive or critical care unit with negative pressure. Ideally, for women with confirmed COVID-19 infection who have to deliver, a dedicated neonatal negative pressure isolation room should be established in close proximity to the mother’s room, noted the experts. Visitation may also need to be limited.
In any suspected cases, COVID-19 should be distinguished from other respiratory distress infections such as viral pneumonia, bacterial pneumonia, and non-infectious lung disease. Hospital staff should continue to provide supportive care for patients with COVID-19 as there is no definitive treatment for the virus. Antiretroviral agents may be introduced to reduce the number of deaths associated with COVID-19, and providers should consider the most up-to-date recommendations for the use of the agents, noted the researchers.
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Since chest imaging is critical for the complete evaluation of COVID-19, “it should be performed in pregnant women, and due to a favorable risk-benefit ratio, both radiography and computed tomography should be used for pregnant women as clinically necessary and with informed consent,” the researchers said. Abdominal shielding and limiting exposure times to the minimum necessary may reduce the total fetal radiation dose.
Additional recommendations include:
- Symptomatic pregnant women lay in a lateral-decubitus position for optimal uteroplacental oxygenation
- Antibiotics should be provided to patients with suspected or confirmed secondary bacterial infections
- Critically ill patients without shock should be treated with conservative fluid management measures
- Oxygen should be given immediately to prevent hypoxemia and reduce the work of breathing and respiratory failure or arrest
- Hemodialysis may be required should severe sepsis infection lead to renal failure and if electrolyte imbalances become life-threatening.
Recommendations for fetal monitoring include electronic fetal heart rate monitoring and/or ultrasound to evaluate the fetal status upon the gestational age and more advanced monitoring once the fetus reaches viability. Timing of delivery should be individualized; in most cases, the improvement of the mother’s condition will improve the fetus’ condition, and if women can be successfully treated, pregnancies should be allowed to go to term, the researchers noted.
The indications for early delivery depend on the following: the mother’s clinical status; gestational age; and fetal well-being. Pregnant women who are critically ill due to COVID-19 infection in the previable period (which varies regionally, generally <26 weeks in China, <23-24 weeks in the US) may require early delivery as a life-saving measure, despite a high risk of neonatal death, the researchers said. In women with severe COVID-19 infection between 26 and 33 weeks of gestation, the safety of the mother and fetus should be taken into account; and at a gestational age of ≥34 weeks, the fetus likely has a high intact survival rate and late preterm delivery may be considered.
The mode of delivery should be based on the usual obstetric indications – there is no clear benefit of cesarean delivery vs vaginal delivery in women with COVID-19. If intubation is required due to infection, general endotracheal anesthesia should be used for cesarean delivery. The placenta of infected pregnant women should be treated as biohazardous waste.
According to the guidance, delayed cord-clamping for neonates born to pregnant women infected with COVID-19 is not recommended and the neonate should be cleaned and dried immediately. Newborns of mothers with suspected or diagnosed COVID-19 infection should be isolated for 14 days after birth and closely monitored for clinical manifestation of infection. It is uncertain if COVID-19 is present in breast milk; therefore, breastfeeding is not recommended.
Reference
Chen D, Yang H, Cao Y, et al. Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection. Int J Gynaecol Obstet. doi:10.1002/ijgo.13146. Accessed April 6, 2020.
