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COVID in Pregnancy

Heidi James, MD and Penny Wilson, MD
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ROP Breaking News: COVID in Pregnancy

Penny Wilson, MD and Heidi James, MD

Data we have

What they showed

  • Maternal presentation:
    • Clinically the same as for non-pregnant patients. 
    • Similar clinical presentation: fever, cough
    • Similar lab abnormalities (normal WBC, lymphopenia, some with LFT abnormalities)
    • The most consistently positive feature was typical Chest CT appearance. 
      • This is the most reliable diagnostic test if swab result isn’t available in a timely manner 
      • The risk to the fetus of the typical radiation dose for a maternal CT chest equates to an extra 1:10,000 to 1:100,000 cases of childhood cancer. So you can absolutely do it if it likely to be clinically beneficial to the patient 
  • Maternal complications:
    • Seem to be also consistent with general population. Ie, a similar proportion of patients with mild moderate and severe symptoms. 
    • There has been one 31 year old patient at 34 weeks gestation with severe ARDS, multiorgan failure requiring mechanical ventilation and ECMO. So severe illness can certainly happen in this group even though the risk is low. 
  • Obstetric complications:
    • Increased rates of fetal distress, Pre-labor ROM and pre-term birth (some of which is iatrogenic due to concerns about maternal condition).  
  • Mode of delivery: 
    • All but 3 babies delivered by caesarean section (In the Lancet paper, “COVID infection” was cited as an indication for caesarean section in all 9 patients so it’s possible that some of these patients could have delivered vaginally based on usual obstetric indications). 
  • Vertical transmission:
    • The lancet paper tested the amniotic fluid, breastmilk, cord blood and neonatal swabs and all were NEGATIVE. Ie – no evidence of vertical transmission. 
    • There have been reports in the media of a couple of infants being infected with COVID at 30-something hours and 17 days of age, both of whom are reportedly well. These are not thought to be due to vertical transmission but rather due to infection after birth. 
  • Neonatal outcomes
    • The patient with the severe multiorgan failure on ECMO had a stillbirth.
    • However, all the other babies were delivered in pretty good condition. APGARS – 8s, 9s and 10s with a couple of 7s.  
    • Two of the babies born in the 34th week developed respiratory distress, thrombocytopenia and DIC and one of those has died. 
    • Several other babies were reported as experiencing respiratory distress but have since recovered. 
    • It doesn’t seem like there’s evidence those babies were infected with COVID themselves but were likely suffering from complications of maternal illness and pre-term delivery. 

What we don’t know

  • If there is any risk of vertical transmission through the birth canal (vaginal secretions or from maternal feces) or indeed if outcomes would be different for vaginal vs caesarean deliveries
  • If expedited delivery improves outcomes for mothers who are significantly unwell. 
  • If there are additional risks with infection in earlier pregnancy, eg if vertical transmission is more likely in earlier pregnancy
  • If there is an increased risk of miscarriage 

Comparison to other coronavirus pandemics (SARS and MERS) and influenza

  • There is an AJOG paper in pre-proof stage looking at previous pandemics in more detail (Rasmussen et al)
  • The data from those previous outbreaks was also primarily from very small case reports. Largest series were only 12 and 13 patients. 
  • Infection was much more severe in pregnant patients compared to general population:
    • Higher rates of mechanical ventilation, sepsis, DIC, and death (fatalities around 23 – 25%). This is not reflective of what we are seeing so far in COVID19
    • First trimester miscarriage was also seen in SARS, but neither SARS nor MERS had evidence of vertical transmission. 
  • Influenza is also typically more dangerous in pregnant women due to changes to their immune system and their physiological respiratory reserve that makes them more susceptible to respiratory compromise.  That doesn’t seem to be the case so far in COVID. 

Management

  • Recommendations and position papers have come out from all the major colleges, CDC, WHO etc. 
  • In general:
    • Indication for swabbing, case identification, travel advice, isolation / quarantine is the same as for non-pregnant patients so check local advisories. 
    • Social distancing and hand hygiene remains crucial for limiting population spread so it is a good idea to cancel those baby showers and gender reveal parties, particularly to protect the grandparents and older relatives. 
    • Transferring non-essential routine pre and post-natal visits to telehealth is wise, and facilities conducting in-person assessments need to have infection control procedures in place. 
    • Society for maternal fetal medicine is recommending detailed second trimester anatomy scans for early infections and third trimester growth scans for patients who have COVID and recover. This is due to the potential risk of growth restriction which we have historically seen with other severe respiratory viral infections. 
    • Intra partum:
      • Patients with confirmed or suspected COVID – mask on arrival and single room. Staff and visitors should be minimised. PPE is as per droplet precautions
      • Some units are removing nitrous oxide due to concerns over aerosolization although I haven’t seen any specific data around this. 
      • For caesarean sections – full PPE including n95 for all staff in the OR in case of need for intubation. This includes cat 1 sections. 
      • Decision around timing of delivery and mode of delivery should be based on usual obstetric indications. 
      • These patients should have continuous external fetal monitoring during labour due to increased risk of fetal distress. 
      • Elective deliveries should be postponed until after the COVID isolation period if possible. 
    • Post partum
      • There are differing recommendations as to whether babies should be isolated from COVID positive / suspected mums, with some (eg ACOG) recommending up to 14 days separation. 
      • Others (e.g. CDC, SOGC) recommending case-by-case decision after discussion with patients. 
      • For babies who are rooming in with mother – she should hand wash and don a mask before handling / breastfeeding baby, or pump breastmilk to be given by a healthy caregiver. Also keep baby >1.5m distance behind a curtain.  
    • Pre-partum:
      • ESHRE recommending against IVF / assisted reproduction right now due to unknown effects of virus in early pregnancy, and unknown effects on health care resources availability in the coming months. (Those currently mid-fertility treatment are advised to “freeze all” oocytes/embryos for future implantation). 

Summary

  • We don’t know much, but based on the data we have:
    • There is no evidence of vertical transmission, no evidence of more severe disease in pregnant patients, and while there is a greater risk of fetal distress and pre-term birth, the outcomes for the majority of neonates are good, but they do need to be watched closely after birth for respiratory distress. 
    • Infection control and social distancing advice is the same as for other patients, and decisions around delivery should be made based on usual obstetric indications, in collaboration with neonatologists, and critical care teams as applicable. 

mackenzie g. -

Can you comment on healthcare workers in the third trimester? We are obviously suggesting that pregnant women perform social distancing and isolation when able and working very hard to perform tele-visits but we are still having pregnant healthcare workers take care of COVID patients.
Interestingly, in the very small studies that everyone is referring to, the 9 babies were all delivered via c-section (either due to maternal concerns or to decrease risk of potential vertical transmission) and in the study with 4 patients all of those babies were immediately taken from the mother and isolated and fed formula. So despite the babies and moms doing OK but why would we allow late term pregnant women to risk exposure when it may force them to isolation from their newborn, taking away the opportunity to breast feed, and potentially to c-section?

Penny W. -

From my perspective the biggest risk to contracting COVID in third trimester is the risk of fetal distress and pre-term delivery as we have seen higher rates of those complications in the third trimester. But yes, the risk of disruption of the maternal-newborn dyad after delivery is also a "complication" that is worth avoiding. I certainly think reducing exposure of pregnant health care workers would be ideal, in the same way that reducing exposure risk for older clinicians would be ideal. I'm advising my patients to take leave if they can. But, pragmatically I guess it depends on local heathcare service needs and their own appetite for risk vs providing service.

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ROP 2020 March 19 Breaking News - COVID in Pregnancy Full episode audio for MD edition 13:40 min - 27 MB - M4A