This document discusses COVID-19 and pregnancy. It outlines that COVID-19 infection does not seem to be worse for pregnant women or affect the fetus. Antenatal care is emphasized through telehealth to reduce risk of exposure. For suspected or confirmed COVID-19 in pregnancy, a multidisciplinary approach is recommended based on symptom severity and obstetric issues. Management includes isolation, testing, monitoring for maternal and fetal well-being, and individualizing care during labor and postpartum based on the mother's condition.
2. OUTLINE
-The virus and modes of transmission
- Effect of COVID -19 infection on Pregnancy
- Effect of COVID -19 infection on fetus
- Perinatal care for suspected or confirmed
COVID 19 infection
3. NOVEL CORONA VIRUS DISEASE -2019
Severe acute respiratory infection caused by Novel
coronavirus : SARS COV -2
First identified in Wuhan china.
Outbreak of pneumonia of unknown cause
Detected in bronchoalveolar lavage samples
4. EFFECT OF COVID-19 ON MOTHER
• Some viral infections are worse in pregnant women
due to :
Physiologic changes in pregnancy
Relative Immunosuppression in pregnancy
• No such evidence for coronavirus infection
• Pregnant women not more susceptible to
consequences of COVID 19 infection vs general
population
• Maternal disease is not aggravated by pregnancy
unless associated co-morbidities
5. • Hypertension
• Diabetes
• Asthama
• HIV
• Heart disease
• Chronic liver , kidney or lung diseases
• Blood dyscrasia
• Patient on immunosuppressive medications
HOW DO WE ASSESSING CO- MORBIDITIES :
6. Effect of COVID- 19 on mother : clinical picture :
M a j o r i t y :
Only mild or moderate
flu :
• Cough
• Sore Throat
• Fever (37.8• C)
A F e w :
Severe :
• Shortness of breath
• SARI
• Pneumonia
• Marked hypoxia
Critically ill :
• Tachypnoea, hypoxia ,
• Imaging:>50% lung
involvemnt
7. No increased risk of :
Miscarriage
Early pregnancy loss
Pre term birth
No evidence of :
Intrauterine fetal
infection
Congenital
malformation
Effect on fetal
growth
Vertical
transmission
Transmission
through genital
fluid
Effect of COVID- 19 infection on fetus :
8. ANTENATAL PREPAREDNESS :
maternity health care providers need to prepare :
• Prevent consequences of the infection to
mother
• Prevent consequences of the infection to
newborn
• Prevent consequences of the infection from
infected pregnant woman to other pregnant
woman
• Prevent consequences of the infection from
infected pregnant woman to other health care
workers
9. ANTENATAL CARE FOR NON COVID PREGNANT WOMAN :
IMPORTANT ASPECT :
Antenatal contact :
• Reduce , postpone and increase the interval
between antenatal visits/ routine scan
• Shorten the duration of antenatal visits
• Limit visitors while in hospital
• We Must Continue to provide perinatal care for
high risk people
10. ANTENATAL CARE FOR NON COVID PREGNANT
WOMAN :
• Teleconferencing and video conferencing which could be
- As replacement or
- In addition
- Especially if maternal tests are not required
- what can be done ?
- Virtual prenatal visits
- Online communication with providers
- Consultation with specialist ( maternal medication, genetic
counselling )
- Mental health care
11. ANTENATAL CARE FOR NON COVID PREGNANT
WOMAN :
ADVISE FOR HOME MONITORING
• Blood pressure check
• Maternal weight check
• Daily fetal movement
• Dietary advice : Recommend High protein diet ,
vitamin/ micronutrient supplementation
12. ANTENATAL CARE FOR NON COVID PREGNANT
WOMAN
Advice on hygiene :
Attention to infection prevention
“ Do the five “
Staying at home
Hand hygiene
avoid touching the face- Eye, nose , mouth
Social distancing
Respiratory hygiene -use mask
13. ANTENATAL CARE FOR NON COVID PREGNANT WOMAN
ADVICE ON TRAVEL AND QUARANTINE :
Avoid all non essential travel
Criteria for Quarantine Same for pregnant woman and general
population
SHIELDING : Measure to protect clinically extremely vulnerable people
• Pregnant women with heart disease HT, DM , Immunocompromised
women
minimise all interaction with extremely vulnerable group and others
• Stay home
• Minimise all non essential contact with other members ( 1 meter
distance )
• Access medical assistance remotely whenever possible
14. ANTENATAL CARE FOR PREGNANT WOMAN
SUSPECTED OR CONFIRMED COVID -19 :
Pregnant woman with suspected , probable or
confirmed COVID-19, Including women who
may need to spend time in isolation , should
have access to woman centred , respectful
skilled care including obstetric , foetal medicine
and neonatal care , as well as mental health and
psychological support with readiness to care for
maternal and neonatal complication.
15. PREGNANCY WITH SUSPECTED COVID 19
INFECTION :
How and where to contact ?
Must not attend routine clinic
Attend triage and screening area for suspected
cases
keep minimum number of people with you
Use private transport
If ambulance required, inform to call handler
about the current suspect status
16. ALGORITHM OF SUSPECTED CASES :
First point of contact / initial assessment area for triage and screening
Any patient with symptoms :
• Fever
• Cough
• Breathing difficulty
History of exposure :
• Travel to infected
country within 14 days
• Contact with infected
person
Give medical mask and maintain 1 mt.
distance
O
R
17. ASSESSMENT OF SUSPECTED CASES :
Iinfectious
disease specialist
Assess severity :
Elevated risk ?
Moderate risk ?
Obstetrician
Does she have
any obstetric
emergency /
labour / delivery
Isissue ?
No
Isolation for 14 days and
clinical monitoring
Yes
Needs
admission
18. MANAGEMENT OF SUSPECTED CASES NOT IN LABOUR
On admission :
• Institute infection prevention and control meassures :
- Immediately transfer to an identified isolation room
- Donning appropriate PPE by health care provider
• Testing of the pregnant woman with suspected infection ;
- To be done urgently
- Samples to be sent : Nasopharyngeal swab
- Do not delay obstetric care in order to test for COVID 19
- Treat as confirmed cases until test results are available
- Multidisciplinary approach is required : obstetric, neonatal
and intensive care specialist
19. ANTENATAL CARE FOR PREGNANT WOMEN WITH
SUSPECTED OR CONFIRMED COVID -19 :
• Routine appointments delayed untill after the
recommended period of isolation
• No additional tests are required.
• If concerns about well being of self or fetus during
isolation , patient should be advised to contact
maternity team
• Additional care if any complications
• Provide counselling and information about potential
risk of adverse pregnancy outcomes
20. MANAGEMENT OF CONFIRMED CASES:
• Hospitalise the pregnant woman
based on :
- severity of symptoms
- obstetric emergency / labour
21. Admission criteria
• Assess the need for
ICU admission using
maternal early warning criteria
Systolic BP < 90 or > 160 mm of Hg
Diastolic BP> 100 mm of Hg
Heart rate < 50 or >120 /min
Respiratory rate < 10 or >30 /min
Oxygen saturation in room air of <94
Oliguria defined as urine output <35 ml/hr for ≥ 2
hours
Maternal confusion, agitation, unresponsiveness.
Known patient with preeclampsia reporting a non
remitting headache or shortness of breath.
Quick sequential organ failure assessment tool.
Systolic BP < 100mmhg
Respiratory rate > 22
Altered level of consciousness
yes no
Severe failure criteria :
(consider emergency
cesarean delivery)
Septic shock
Acute organ failure Consider ICU admission
Continue
monitoring
22. MANAGEMENT OF CONFIRMED CASES:
Maternal surveillance :
• TPR ,BP ( 3-4 times per day )
• Chest imaging (High resolution CT Scan )
- only if indicated
- with abdominal shield
- after informed consent
• Consider oxygen therapy to keep o 2 saturation > 95%
• Encourage oral hydration
• Limit IV fluid if concern for cardiovascular instability
23. MANAGEMENT OF CONFIRMED CASES:
Maternal surveillance (contd .) :
Antipyretic therapy :
• Maternal comfort
• Limit the fetus to the risk of maternal increased
body temperature
• Screen for viral infections and any bacterial
infection
• Consider empiric IV / oral antibiotics / antimalarial/
antiviral treatment :
24. MANAGEMENT OF CONFIRMED CASES:
FETAL SURVEILLANCE :
• Monitor FHR and daily fetal movement
• Antenatal corticosteroids :
women at risk of preterm birth where there is
NO clinical evidence of maternal infection
25. RECOVERY :
Recovery from illness :
• Little evidence of natural history of pregnancy after recovery
• Recovery from infection in 1st trimester :
- consider detailed mid trimester anatomy ultrasound
examination
• Recovery from infection in later half of pregnancy :
- consider sonographic assessment of fetal growth 2 weeks after
infection
26. INTRAPARTUM CARE IN COVID - 19
• A full maternal and foetal assessment should be conducted
• Assessment of the severity of COVID-19 symptoms, which should follow
a multi-disciplinary team approach including an infectious diseases or
medical specialist.
• Maternal observations including temperature, respiratory rate & oxygen
saturations.
• Confirmation of the onset of labour, as per standard care.
• Electronic foetal monitoring using cardiotocograph (CTG).
• Hourly oxygen saturation during labour.
• Positive ANC should be advised preferably to deliver at a tertiary facility
anticipating the complications during delivery if not then at least at an
FRU
27. CARE DURING LABOR IN COVID - 19
• If the woman has signs of sepsis, investigate and treat as per
guidance on sepsis in pregnancy, but also consider active COVID-19
as a cause of sepsis and investigate.
• Continuous electronic foetal monitoring in labour is recommended
• currently no evidence to favour one mode of birth over another.
Mode of birth should not be influenced by the presence of COVID-
19, unless the woman’s respiratory condition demands urgent
delivery.
28. CONT… CARE DURING LABOUR
• No evidence that epidural or spinal analgesia or anaesthesia is
contraindicated in the presence of coronaviruses.
• Epidural analgesia should be recommended in labour to women with
suspected/confirmed COVID-19 to minimise the need for general
anaesthesia
• In case of deterioration in the woman’s symptoms, make an individual
assessment regarding the risks and benefits of continuing the labour, versus
emergency caesarean
• When caesarean birth or other operative procedure is advised, it should be
done after wearing PPE.
• An individualized decision should be made regarding shortening the length
of the second stage of labour with elective instrumental birth in a
symptomatic woman who is becoming exhausted or hypoxic.
29. CARE AROUND BIRTH
Delayed cord clamping : Still
recommended if no contraindication.
Skin to skin contact :
Individual choice : risks Vs benefits
Can do if baby and mother is well.
30. POSTNATAL MANAGEMENT
• It is unknown whether new-borns with COVID-
19 are at increased risk for severe
complications.
• Transmission after birth via contact with
infectious respiratory secretions is a concern.
• Facilities should consider temporarily
separating (e.g. separate rooms) the mother
who has confirmed COVID-19, from her baby
until the mother’s transmission-based
precautions are discontinued.
31. CONSIDERATIONS FOR TEMPORARY SEPARATION OF
BABY
• The risks and benefits of temporary separation of the mother from
her baby should be discussed with the mother by the healthcare
team.
• A separate isolation room should be available for the infant
• The decision to discontinue temporary separation should be made
on a case-by-case basis in consultation with clinicians, infection
prevention and control specialists, and public health officials.
• Taking into account disease severity, illness signs and symptoms,
and results of laboratory testing for virus that causes COVID-19, of
mother and neonate.
32. CONT…
• If “rooming in” in the same hospital room occurs in
accordance with the mother’s wishes or is unavoidable
due to facility limitations- consider implementing
measures to reduce exposure of the new-born to the
virus.
• Consider using physical barriers e.g., a curtain and
keeping the new-born ≥6 feet away from the ill mother.
• If no other healthy adult is present to care for the new-
born, mother put on a facemask and practice hand
hygiene
33. BREASTFEEDING
• Close contact and early, exclusive breast feeding helps a baby to
thrive.
• During temporary separation, mothers should be encouraged to
express their breast milk.
• A dedicated breast pump should be provided.
• Prior to expressing breast milk, mothers should practice hand
hygiene.
• Expressed breast milk should be fed to the newborn by a healthy
caregiver.
• If rooming in – mother should put on a facemask and practice hand
hygiene before each feeding.
34. HOSPITAL DISCHARGE
• follow recommendations described in the guidelines
for discharge of Hospitalized Patients with COVID-
19.
• Two consecutive test should be negative 24 hours
apart.
• Maternal and fetal / neonatal condition should be
stable.
35. KEY MASSAGES :
• All pregnant women should follow the same
recommendations as other persons for avoiding exposure
COVID 19 infection
• Antenatal care through teleconferencing and
videoconferencing key to providing quality care during
pandemic.
• All women despite the pandemic have a right to have safe
and positive childbirth experience.
• Principles of labour management remain same except that
a facility for isolation should be there for safety of woman
and fetus/ Newborn.
36. KEY MESSAGES :
Pregnant women should follow the same recommendation as
nonpregnant persons for avoiding exposure COVID 19 infection
Antenatal care through teleconferincing and video conferencing key to
providig quality care during pandemic
Triage based on symptoms severity and obstetric emergencies
Multidisciplinary approach to management of suspected or confirmed
cases