Dip Obs

1. COVID-19 in pregnant and
postpartum women
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. Intro
• COVID-19 is a respiratory tract infection caused by coronavirus-
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
• Pregnant and postpartum women with suspected or confirmed
COVID-19 should be managed with supportive care, and consider the
immunologic and physiologic adaptations during and after pregnancy.
• Pregnant women are not at an increased risk of becoming infected
with COVID-19.
• However, pregnant women who contract COVID-19 are likely to have
severe morbidity and mortality, particularly in the third trimester of
pregnancy

3. COVID-19 testing
In pregnant and postpartum women
• Pregnancy does not alter the criteria for testing.
• Pregnant women should be investigated and diagnosed as per local
criteria.
• For pregnant women the same infection prevention and COVID-19
investigation and diagnostic guidance applies, as for non-pregnant
adults

4. Preventative measures
• COVID-19 vaccination is recommended
• Wear a face mask
• Social distancing
• Maintain good personal hygiene: Wash hands, use hand sanitizer
• They should phone their local health facility or the National COVID-19
helpline (0800 029 999/0600123456) to enquire about whether they
should be tested for COVID-19
• Personal protective equipment (PPE) must be used by those working
in the healthcare environment according to local guidelines

5. COVID-19 vaccination policy
For pregnant and postpartum women
• COVID-19 vaccination is recommended in pregnancy.
• Vaccination against COVID-19 should be offered to all pregnant and lactating women,
irrespective of the presence of co-morbidities.
• Pregnant and lactating women are to be immunized with any of the vaccines currently
available in the country.
• Vaccines can be offered at any gestational age in pregnancy and breastfeeding period.
• COVID-19 vaccination should be offered at the same time as the rest of the population
based on age and clinical risk (as per local national guidelines).
• Vaccination of pregnant and breastfeeding women during routine antenatal and
postnatal visits should be encouraged and facilitated.
• Where this is not possible, women should be encouraged to access vaccination at nearby
sites.
• Women planning a pregnancy or fertility treatment can receive the COVID-19 vaccine
and do not need to delay conception.

6. Benefits of getting the COVID-19 vaccine
During pregnancy
• The vaccines are effective at preventing COVID-19 disease, especially
severe disease and mortality.
• Help transfer protective antibodies to the fetus or neonate. This may
decrease the chance of a neonate getting COVID-19.
• Potential reduction in the risk of preterm birth associated with
COVID-19.
• Potential reduction in transmission of COVID-19 to vulnerable
household members.
• Potential reduction in the risk of stillbirth associated with COVID-19

7. Side effects
In pregnant and breastfeeding women
• No additional safety concerns have been reported for vaccinated
pregnant women or their newborns.
• Pregnant women receiving a COVID-19 vaccine show similar common
minor adverse effects to non-pregnant population.
• The rare syndrome of vaccine-induced thrombosis and
thrombocytopenia (VITT) is an idiosyncratic reaction not associated
with any of the usual venous thromboembolism risk factors.
• There is no evidence that pregnant or postpartum women are at
higher risk of VITT.

8. Risk factors for severe COVID-19
• BMI ≥ 30 kg/m2
• Pre- pregnancy co-morbidities (e.g. diabetes or hypertension)
• Maternal age ≥ 35 years
• Socio-economic deprivation
• Working in healthcare or public essential services

9. The effects of maternal COVID-19 on the fetus
• There is no reported increase in congenital anomalies because of COVID-19
infection
• Vertical transmission is rare
• Increased risk of stillbirth
• Increased incidence of small-for-gestational- age babies
• Increased preterm birth rate

10. Investigations
In pregnant and postpartum women
• Pregnancy does not alter the criteria for testing.
• Pregnant women should not be excluded from testing and investigations if clinically indicated.
• COVID-19 PCR testing is the gold-standard with the greatest sensitivity and specificity
• Use of an antigen-detecting rapid diagnostic tests is useful in the setting of pregnant women who may not
be able to plan their admission, and allows immediate isolation of those who are positive.
• Each facility must assess their access to testing and determine which testing strategy is most appropriate
based on local guidelines:
• During a COVID-19 wave, all pregnant women who need admission must be tested for COVID-19 using a
rapid antigen test, conducted on arrival.
• Further management will depend on the rapid antigen test result and the presence or absence of symptoms
suggestive of COVID-19.
• During times when there is no COVID-19 wave, all pregnant women needing admission who screen negative
for COVID-19 symptoms and who can provide evidence that they are fully vaccinated against COVID-19 do
not need a COVID-19 admission test and can be managed as COVID-19 negative.
• They must be screened daily for COVID-19 symptoms.

11. Symptoms of COVID-19 present Symptoms of COVID-19 absent
COVID-19 rapid antigen test positive Admit to designated COVID-19 section of the maternity
unit at the appropriate level of care
Admit to designated COVID-19 section of the maternity
unit
at the appropriate level of care
COVID-19 rapid antigen test negative Do COVID-19 PCR test. Admit to PUI cubicle of maternity
unit until PCR result available
Admit and manage as COVID-19 negative patient. Daily
screening for COVID-19 symptoms

12. COVID-19 symptoms
In pregnant and postpartum women
• There is currently no known difference between the clinical
manifestations of COVID-19 in pregnant and non-pregnant women.
• Most symptomatic women experience mild or moderate cold/flu-like
symptoms
• The most common symptoms of COVID-19 in pregnant women are
cough, fever, sore throat, dyspnoea, myalgia, loss of sense of taste or
smell and diarrhoea.

13. Referral and admission criteria
For women with suspected or proven COVID-19
• Obstetric risk factors or complications needing admission
• Co-morbidities
• Severity of COVID-19 disease (moderate and severe COVID-19 disease)
• Mild COVID-19 disease but, home isolation is not feasible
• Mild COVID-19 disease but monitoring by teleconsultation is not available

14. Level of care
Were pregnant women with COVID-19 should be admitted
• Mild COVID-19 can be managed at home or in a designated isolation facility
if available.
• Moderately severe COVID-19 requiring oxygen by mask to maintain oxygen
saturations above 95% must be managed in a hospital with a maternity
service and a doctor full-time on-site.
• Severe COVID-19 requiring ICU care should be managed at a hospital that
has ICU and or a multidisciplinary team were such services are available
(regional, tertiary, central or private hospital).
• Pregnant women in labour or with obstetric risk factors and complications
must be managed at the appropriate level of care according to existing
obstetric referral criteria.

15. COVID-19 status and
disease severity
Management protocol
COVID-19 confirmed case
with asymptomatic, mild
disease
Isolate at home with healthcare facility surveillance by telemonitoring/SMS/WhatsApp unless other obstetric risk factors, co-morbidities, and social
circumstances require admission.
Provide supportive care: Paracetamol for fever and headache, hydration and rest.
Women should monitor themselves for worsening symptoms and obstetric danger signs during home isolation.
Worsening symptoms include difficulty breathing/talking, coughing blood, chest pain, unremitting fever, dizziness, confusion, and obstetric warning signs.
If present, she should call a local facility or the Helpline 0800 029 999
The emergency services and the receiving facility should be informed that the woman is in self-isolation for COVID-19 so that IPC measures can be
adhered to during transfer and arrival at the facility.
COVID-19 confirmed with
moderate disease
An isolated bed or cubicle in the maternity unit.
Obstetrics management individualised.
Admit to dedicated COVID-19 hospital or wad as per local availability in consultation with a multidisciplinary team.
Supportive care includes:
Oxygen therapy: Maintain SpO2 >94%.
Antibiotics for superimposed infection
Corticosteroid therapy for severe disease
Corticosteroids for fetal lung maturity to be individualised based on the woman’s condition and GA
Venous thromboembolism prophylaxis: low molecular weight heparin/ unfractionated heparin
Hydration and rest
COVID-19 confirmed case
or PUI with severe or
These patients should ideally be transferred to an ICU where specialist or multi-disciplinary care can be provided. Notify the receiving facility before
transfer.
Adhere to ICP and PPE.

16. Method of induction of labour, mode and
timing of delivery
Mode of delivery
• Mode of delivery in pregnant women with COVID-19 should be guided by obstetric indications and physiological stability
(cardiorespiratory status and oxygenation).
Timing of delivery
• Timing of delivery should be individualized and based on the disease severity, associated co-morbidities, and the gestational
age.
• In asymptomatic/mild disease, delivery should be reserved for appropriate obstetric indications and should not be delayed
solely due to COVID-19.
• In severe or critical disease, a multi-disciplinary team should assess and make the clinical decision.
Induction of labour
• COVID-19 infection per se is not an indication for induction of labour.
• Both the indication and the cervical status should be evaluated in pregnant women scheduled for labour induction.
• Those who have an unfavourable cervix (e.g., Bishop score <6) can be induced by mechanical or pharmacological methods as
per the local/hospital protocol.
• Fetal monitoring as per standard guidelines according to obstetric risk factors. Not for fetal monitoring if the mother is unstable.
• Healthy neonates should be allowed to room-in with their mothers. This is very important for the wellbeing of the mother-baby
pair. The mother-baby pair must be isolated from uninfected mothers and neonates.

17. Assessment and management

19. Thank You