Prof. Aboubakr Elnashar

1. COVID-19
&
Pregnancy
RCOG,
19
February
2021
Prof.
Aboubakr
Elnashar
Benha
university
Hospital,
Egypt
ABOUBAKR
ELNASHAR
CONTENTS
I.
INTRODUCTION
II.
ANTENATAL
CARE
1.
General
2.
Prevention
of
VTE
3.
Managing
Clinical
Deterioration
III.
INTRAPARTUM
CARE
IV.
POSTPARTUM
CARE
❑
CONCLUSION
ABOUBAKR
ELNASHAR

2. I.
INTRODUCTION
▪
Vertical
transmission:
▪
uncommon.
▪
If
it
does
occur,
it
appears
to
not
be
affected
by
1.
Mode
of
birth
2.
Delayed
cord
clamping
3.
Skin-to-skin
contact
4.
Method
of
feeding
or
5.
Whether
the
woman&
baby
stay
together
(rooming
in)
ABOUBAKR
ELNASHAR
▪
Vaccination
in
pregnancy
&
breast
feeding
▪
Available
data
do
not
indicate
any
safety
concerns
or
harm
▪
Should
be
considered
where:
1.
The
risk
of
exposure
is
high
or
cannot
be
avoided
2.
The
woman
at
very
high
risk
of
serious
complications
of
COVID-19.
ABOUBAKR
ELNASHAR

3. ▪
More
than
two-thirds
of
pregnant
women
with
COVID-
19
are
asymptomatic
▪
Pregnant
women
with
COVID
compared
to
non-
pregnant
women
with
COVID:
▪
Higher
rates
of
ICU
admission:
this
may
reflect
a
lower
threshold
for
admission
to
ICU,
rather
than
more
severe
disease.
▪
Not
at
increased
risk
of
death,
according
to
the
largest
SR
▪
More
recent
data
from
the
USA
&
Mexico:
slightly
higher
risk
of
death
ABOUBAKR
ELNASHAR
II.
ANTENATAL
CARE
1.
General
Guidelines
▪
Continuity
of
care
▪
Unless
self-isolation
criteria
with
suspected
or
confirmed
COVID-19
▪
Particularly
for
vulnerable
groups
who
may
also
be
at
greater
risk
from
COVID-19.
▪
Modified
ABOUBAKR
ELNASHAR

4. ▪
Modifications
to
▪
Enable
social
distancing
measures
▪
Reduce
risk
of
transmission
between
women,
staff
&
other
clinic/hospital
visitors
▪
Provide
care
to
women
who
are
self-isolating
for
suspected
or
confirmed
COVID-19
for
whom
a
hospital
attendance
is
essential
ABOUBAKR
ELNASHAR
▪
Procedures:
▪
BP,
urine
testing,
fundal
height.
▪
Screening
for
diabetes
in
pregnancy
▪
Blood
tests,
maternal
examination,
US:
same
visit
ABOUBAKR
ELNASHAR

5. ▪
Appointments
▪
During
‘local
lockdown’:
teleconference
or
videoconference,
telephone
consultation
▪
Pregnant
women
to
▪
contact
emergency
antenatal
services
if
they
have
any
concern
about
their
or
their
baby’s
wellbeing
▪
attend
if
they
have
concerns
about
their
or
their
baby’s
wellbeing
▪
All
women
&any
accompanying
visitors
(where
permitted)
should
be
advised
to
wear
facemasks
or
face
coverings
▪
Shared
waiting
areas
should
be
avoided
▪
Adequate
PPE
is
used
ABOUBAKR
ELNASHAR
▪
Advice:
▪
Folic
acid,
vit
D
supplements
acc
to
national
recommendations
▪
Influenza
vaccination
is
safe
at
all
gestations
of
pregnancy
&
is
recommended
▪
Mental
health:
▪
Ask
about
at
every
contact
▪
Women
who
express
concern
about
their
mental
health
or
‘red
flag’
symptoms,
such
as
▪
suicidal
thoughts
or
sudden
mood
changes,
or
▪
where
their
families
express
these
concerns
on
their
behalf:
should
be
supported
to
access
urgent
care
ABOUBAKR
ELNASHAR

6. ▪
Suspected
or
Confirmed
COVID-19
Needing
Hospital
Attendance
▪
If
women
report
symptoms
attributed
to
COVID-19
on
the
phone
to
maternity
services:
consider
DD
for
fever,
cough,
or
shortness
of
breath:
▪
UTI,
chorioamnionitis,
pulm.
embolism.
▪
If
women
have
symptoms
suggestive
of
COVID-19:
should
be
advised
to
COVID19
testing.
▪
Maternity
units
should
develop
triage
tools
to
assess
the
severity
of
illness:
an
assessment
of
symptoms,
clinical
and
social
risk
factors
and
escalation
pathways
‘safety
netting
advice’
about
the
risks
of
deterioration
and
when
to
seek
urgent
medical
attention.
ABOUBAKR
ELNASHAR
▪
Possible
or
confirmed
COVID-19,
for
whom
hospital
attendance
is
required
or
who
self-present
▪
Patient:
▪
with
a
fluid-resistant
surgical
mask
▪
should
not
be
removed
until
she
is
isolated
▪
Staff:
▪
should
wear
appropriate
PPE.
▪
Only
essential
staff
should
enter
the
isolation
room
▪
Isolation
rooms
from
which
all
non-essential
items
have
been
removed
▪
Visitors
to
isolation
rooms
should
be
kept
to
a
minimum
ABOUBAKR
ELNASHAR

7. 2.
Prevention
of
VTE
▪
Women
who
are
self-isolating
at
home
▪
Should
stay
hydrated
&
mobile
▪
VTE
risk
assessment:
Infection
with
SARS-CoV-2
is
a
transient
risk
factor
▪
Ensure
women
are
supplied
with
LMWH
▪
Thromboprophylaxis
should
be
continued
until
they
have
recovered
from
the
acute
illness
(between
7
&
14
days).
ABOUBAKR
ELNASHAR
▪
Women
admitted
with
confirmed
or
suspected
COVID-19
▪
Prophylactic
LMWH,
unless
▪
Birth
is
expected
within
12
hs
or
▪
There
is
significant
risk
of
hge
▪
Duration:
▪
Continue
for
10
days
following
hospital
discharge
▪
Longer
duration
for
women
with
persistent
morbidity.
▪
Women
admitted
with
confirmed
or
suspected
COVID-19
within
6
ws
postpartum,
should
be
offered
thromboprophylaxis
▪
Duration
▪
During
admission
and
for
10
days
after
discharge
▪
6
ws
postpartum
for
women
with
significant
morbidity
ABOUBAKR
ELNASHAR

8. 3.
Managing
Clinical
Deterioration
▪
Fever:
▪
Testing
for
SARS-CoV-2
in
addition
to
blood
cultures.
▪
Possibility
of
bacterial
infection
should
be
considered:
▪
Full
sepsis
screen
▪
Action
Tool
and
IV
antibiotics
▪
Bacterial
(rather
than
viral)
infection
should
be
considered
if
the
white
blood
cell
count
is
raised
(lymphocytes
are
usually
normal
or
low
with
COVID-19)
and
antibiotics
should
be
commenced.
ABOUBAKR
ELNASHAR
▪
Chest
imaging
▪
Should
be
performed
when
indicated:
chest
X-ray
&
CT.
▪
Essential
for
the
evaluation
of
the
unwell
woman
▪
Diagnosis
of
pulm.
embolism
or
heart
failure
▪
should
be
considered
for
▪
Chest
pain
▪
Worsening
hypoxia
or
▪
Respiratory
rate
above
20
breaths/min
(particularly
if
there
is
a
sudden
increase
in
oxygen
requirements),
or
▪
Breathlessness
persists
or
worsens
after
expected
recovery.
▪
Additional
tests
to
DD:
▪
ECG,
echocardiogram,
CT
pulmonary
angiogram
▪
Ventilation
perfusion
lung
scan
ABOUBAKR
ELNASHAR

9. ▪
Principles
of
care
▪
Women
with
suspected
COVID-19
should
be
treated
as
though
it
is
confirmed
until
test
results
are
available.
▪
The
priority
for
medical
care
should
be
to
stabilise
the
woman’s
condition
with
standard
therapies.
▪
An
urgent
MDT
meeting
should
be
arranged
for
any
unwell
woman
1.
Women
who
are
requiring
oxygen
to
maintain
saturations
between
94%
and
98%
2.
RR
≥20
breaths/m
3.
HR
≥110
beats/m.
ABOUBAKR
ELNASHAR
▪
MDT:
▪
Consultant
obstetrician,
anaesthetist,
neonatologist,
intensivist,
respiratory
physician,
infection
control
team,
midwife-in-charge,
neonatal
nurse-in-charge
▪
The
discussion
should
be
shared
with
the
woman&
her
family
▪
The
following
should
be
considered:
▪
Key
priorities
for
medical
care
of
the
woman&her
baby,
and
her
birth
preferences.
▪
The
most
appropriate
location
of
care:
▪
intensive
care
unit
▪
‘specific
COVID-19
wards
▪
isolation
room
in
infectious
disease
ward
ABOUBAKR
ELNASHAR

10. ▪
Observations
&
investigations
▪
Fetus:
▪
The
frequency&
suitability
of
FHR
monitoring
▪
should
be
considered
on
an
individual
basis
▪
gestational
age
▪
maternal
condition.
▪
Mother:
▪
Monitor
both
the
absolute
values&
trends
of
the
hourly
observations:
HR,
RR
and
O2
saturation
ABOUBAKR
ELNASHAR
▪
The
woman’s
care
should
be
escalated
urgently
if
any
of
the
following
signs
of
decompensation
develop:
1.
Increasing
oxygen
requirements
or
fraction
of
inspired
oxygen
(FiO2)
above
35%
2.
Increasing
RR
despite
oxygen
therapy
of
or
above
25
breaths/m
or
a
rapidly
rising
RR
3.
Reduction
in
urine
output
4.
Acute
kidney
injury
(serum
creatinine
levels
above
77
µmol/l
in
women
with
no
pre-existing
renal
disease)
5.
Drowsiness,
even
if
the
oxygen
saturations
are
normal
▪
Possibility
of
myocardial
injury
should
be
considered
{symptoms
are
similar
to
those
of
respi
complications
of
COVID-19}
ABOUBAKR
ELNASHAR

11. ▪
Interventions
▪
Oxygen
should
be
titrated
to
target
saturations
to
94–98%.
▪
Caution
should
be
applied
to
IV
fluid
management:
▪
Hourly
fluid
input/output
char
ts
should
be
used
to
monitor
fluid
balance
in
women
with
moderate
to
severe
symptoms
of
COVID-19.
▪
The
aim
should
be
to
maintain
a
neutral
fluid
balance
in
labour.
▪
When
required,
boluses
in
volumes
of
250–500
ml
should
be
employed
and
an
assessment
for
fluid
overload
made
before
proceeding
with
fur
ther
fluid
resuscitation.
ABOUBAKR
ELNASHAR
▪
Antibiotics
▪
should
be
commenced
at
presentation
if
there
is
clinical
suspicion
of
bacterial
infection
or
sepsis.
▪
IV
antibiotics
in
woman
with
fever&prolonged
ROM
ABOUBAKR
ELNASHAR

12. ▪
Thromboprophylaxis
▪
All
pregnant
women
should
be
assessed
for
risk
of
VTE
▪
LMWH
unless
there
is
a
contraindication.
▪
The
dose
▪
should
be
individualized
basis.
▪
Therapeutic
doses
when
VTE
is
suspected
▪
Women
with
thrombocytopenia
(platelets
≤
50
×
10
9
/l):
▪
Aspirin
&
LMWH
should
be
discontinued
▪
Haematology
advice.
▪
Mechanical
aids
(intermittent
pneumatic
compression)
should
be
used
if
LMWH
therapy
is
contraindicated
or
paused
secondary
to
thrombocytopenia.
ABOUBAKR
ELNASHAR
▪
Corticosteroid
therapy
▪
Should
be
considered
for
10
days
or
up
to
discharge
whichever
is
sooner,
for
▪
women
who
are
unwell
with
COVID-19
and
requiring
oxygen
supplementation
or
ventilatory
support.
▪
If
steroids
are
not
indicated
for
fetal
lung
maturity:
▪
Oral
prednisolone
40
mg
once
a
day,
or
▪
IV
hydrocortisone
80
mg
twice
daily
▪
If
steroids
are
indicated
for
fetal
lung
maturity:
▪
IM
dexamethasone
6
mg
every
12
hs
for
4
doses,
then
oral
prednisolone
40
mg
once
a
day,
or
▪
IV
hydrocortisone
80
mg
twice
daily
ABOUBAKR
ELNASHAR

13. ▪
Remdesivir
▪
During
pregnancy:
▪
Should
be
avoided
{Fetal
risk
is
largely
unknown}.
▪
If
clinicians
believe
the
benefits
outweigh
the
risks
▪
Decision
should
be
taken
by
an
MDT
▪
During
breastfeeding:
▪
consider
the
benefits
and
risks
▪
Use
only
in
women
where
benefit
has
been
reported
▪
hospitalised
patients
requiring
oxygen
therapy
▪
especially
early
in
disease
course
▪
not
in
patients
who
are
mechanically
ventilated.
ABOUBAKR
ELNASHAR
▪
Other
therapies
▪
Hydroxychloroquine
▪
lopinavirritonavir
and
▪
Azithromycin
▪
ineffective
in
treating
COVID-19
infection
▪
should
not
be
used
for
this
purpose.
ABOUBAKR
ELNASHAR

14. ▪
Planning
for
the
birth
for
pregnant
women
▪
in
the
third
trimester
who
are
unwell:
▪
An
individualized
assessment
by
the
MDT
to
▪
Decide
whether
emergency
CS
or
IOL
?
▪
Facilitate
maternal
resuscitation
(including
the
need
for
prone
positioning)
or
▪
Because
of
concerns
regarding
f.
health.
▪
If
maternal
stabilisation
is
required
before
delivery
can
be
undertaken
safely,
this
is
the
priority
▪
If
urgent
intervention
for
fetal
reasons,
then
birth
should
be
accelerated
as
for
usual
obstetric
indications,
as
long
as
the
maternal
condition
is
stable.
ABOUBAKR
ELNASHAR
▪
When
iatrogenic
preterm
birth
is
required
▪
Corticosteroids
to
promote
fetal
lung
maturation
▪
Mg
SO
for
fetal
neuroprotection,
should
be
considered
by
the
MDT.
▪
Urgent
intervention
for
birth
should
not
be
delayed
for
their
administration.
ABOUBAKR
ELNASHAR

15. III.
INTRAPARTUM
CARE
1.
Asymptomatic
women
positive
for
SARS-CoV-2?
▪
CEFM
during
labour
using
CTG
▪
Delayed
cord
clamping
&
skin-to-skin
contact
with
their
baby
in
line
with
usual
practice.
ABOUBAKR
ELNASHAR
2.
Symptomatic
suspected
or
confirmed
COVID-19
in
labour
▪
Women
with
mild
COVID-19
symptoms
can
be
encouraged
to
remain
at
home
(self-isolating)
in
early
(latent
phase)
labour
consistent
with
routine
care.
▪
The
number
of
staff
members
entering
the
room
should
be
minimized
▪
PPE.
▪
MDT
should
be
informed
▪
Confirmation
of
the
onset
of
labour.
▪
Assessment
of
the
severity
of
COVID-19
symptoms
ABOUBAKR
ELNASHAR

16. ▪
Maternal
observations:
▪
Hourly
▪
Temp,
RR,
oxygen
saturation:
Oxygen
therapy
should
be
titrated
to
aim
for
saturation
above
94%.
▪
Fetal
observation:
▪
CEFM
using
CTG.
▪
Maternal
infection
with
SARS-CoV-2
is
in
itself
not
a
contraindication
to
performing
a
fetal
blood
sample
or
using
fetal
scalp
electrodes
▪
Delayed
cord
clamping
and
skin-to-skin
contact
with
their
baby
if
the
condition
of
the
woman&infant
ABOUBAKR
ELNASHAR
❑Timing
of
birth
▪
Personalised
assessment
▪
Consider
the
urgency
of
the
birth
&
the
risk
of
infectious
transmission
to
other
women,
healthcare
workers
and,
postnatally,
to
her
baby.
▪
If
a
planned
CS
or
IOL
cannot
be
delayed:
▪
Senior
obstetric
&
medical
input
should
be
sought
to
aid
supportive
care
of
a
woman
with
severe
or
critical
COVID-19
ABOUBAKR
ELNASHAR

17. ❑
Mode
of
birth
▪
Discuss
mode
of
birth
with
the
woman&
her
family.
▪
Consideration
should
be
given
to
▪
her
preferences
▪
obstetric
or
fetal
indications.
▪
Consider
whether
the
benefits
of
an
urgent
CS
outweigh
any
risks
to
the
woman?.
▪
PPE
for
CS
should
be
followed.
ABOUBAKR
ELNASHAR
❑
Labour
analgesia
or
anaesthesia
▪
Entonox
(50%
nitrous
oxide
and
50%
oxygen)
can
be
safely
offered
with
a
standard
single-patient
microbiological
filter.
▪
Epidural
analgesia
▪
should
be
discussed
with
women
with
suspected
or
confirmed
COVID-19
when
they
are
in
early
labour
so
they
can
make
informed
decisions
regarding
use
or
type
of
labour
analgesia.
▪
Women
should
be
informed
that
the
use
of
epidural
analgesia
may
avoid
the
need
for
GA
in
some
cases,
and
the
associated
additional
risks
in
this
scenario.
ABOUBAKR
ELNASHAR

18. ❑
PPE
during
labour
▪
For
CS
where
GA
is
planned
▪
From
the
outset
all
staff
in
theatre
should
wear
PPE,
including
an
FFP3
mask
&
visor.
▪
PPE
should
be
donned
prior
to
commencing
the
GA.
ABOUBAKR
ELNASHAR
❑Obstetric
theatres
for
suspected
or
confirmed
COVID
▪
Elective
procedures
▪
such
as
CS
should
be
scheduled
at
the
end
of
the
operating
list.
▪
Emergency
procedures
▪
should
be
conducted
in
a
second
obstetric
theatre,
allowing
time
for
a
full
postoperative
theatre
clean
▪
Staff
in
the
operating
theatre
▪
should
be
kept
to
a
minimum
▪
should
wear
appropriate
PPE.
ABOUBAKR
ELNASHAR

19. IV.
POST
PARTUM
CARE
▪
Women
with
suspected
or
confirmed
COVID-19
▪
should
remain
with
their
baby
and
be
supported
to
practice
skin-to
skin/kangaroo
care,
if
the
newborn
does
not
require
additional
medical
care
▪
Adopt
a
precautionary
approach
to
minimize
any
risk
of
women-to-infant
transmission
ABOUBAKR
ELNASHAR
❑Breastfeeding
▪
Infection
with
COVID-19
is
not
a
contraindication.
▪
Should
be
recommended
to
all
women
▪
Individualized
support,
advice
&
guidance
▪
Risks&
benefits
should
be
discussed
▪
When
a
woman
is
not
well
enough
to
care
for
her
infant
or
where
direct
breastfeeding
is
not
possible:
▪
Woman
to
express
her
breastmilk
by
hand
or
using
a
breast
pump,
▪
and/or
offer
access
to
donor
breast
milk.
ABOUBAKR
ELNASHAR

20. ▪
Precautions
to
limit
viral
spread
to
the
baby:
1.
Wash
hands
before
touching
baby,
breast
pump
or
bottles.
2.
Avoid
coughing
or
sneezing
on
the
baby
while
feeding
3.
Face
covering
or
fluid-resistant
facemask
while
feeding
or
caring
for
the
baby.
▪
Postnatal
care
up
to
8
weeks
after
birth
▪
Self-isolate
at
home
for
14
days
after
birth
of
a
baby
▪
Thromboprophylaxis
▪
For
10
days
following
hospital
discharge.
▪
A
longer
duration
should
be
considered
for
women
with
persistent
morbidity.
ABOUBAKR
ELNASHAR
▪
Effective
contraception
should
be
discussed
with
and
offered
to
all
women
prior
to
discharge
from
maternity
services.
▪
Advice:
▪
Safe
sleeping,
smoke-free
environment
▪
Hand
hygiene
&
infection
control
measures
when
caring
for
and
feeding
the
baby
▪
Signs
of
illness
in
their
newborn
or
▪
Worsening
of
the
woman’s
symptoms
ABOUBAKR
ELNASHAR

21. ▪
Should
be
provided
with
appropriate
contact
details
if
they
have
concerns
or
questions
about
their
baby’s
wellbeing
▪
In-person
home
or
clinic
appointments
▪
to
allow
an
overall
assessment
of
the
▪
physical
and
▪
psychological
health
and
wellbeing
of
the
woman
and
her
baby.
ABOUBAKR
ELNASHAR
Thanks
ABOUBAKR
ELNASHAR