Presented by Dr Richa Manaswita, MBBS, DGO, DNB(obstetrics &gynecology), Junior consultant Coccon Hospital, Jaipur & Dr Vaibhav Agnihotri, MBBS, DCH, DNB Paediatric, IAP Fellowship Neonatology, PGPN Boston University, PCBD John Hopkins University.

CME INDIA Presentation on Pregnancy:

1. Are we dealing a vulnerable group?

Yes, these are high risk groups because of concerns about the effect of covid-19 on them during and after pregnancy, and on their neonates.

2. What is most important?

Quantification of the rates of covid-19, its risk factors, clinical manifestations, and outcomes is key to planning clinical maternal care and management.

3. Are clinical manifestations of covid-19 during pregnancy and after delivery same or different?

The most common symptoms reported by pregnant and recently pregnant women with suspected or confirmed covid-19:

• Fever (40%)
• Cough (39%)
• Lymphopaenia (35%)
• Raised C reactive protein levels (49%)

Very recent Meta Analysis in BMJ concludes as:

“Pregnant and recently pregnant women are less likely to manifest covid-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for covid-19. Pre-existing comorbidities, high maternal age, and high body mass index seem to be risk factors for severe covid-19. Preterm birth rates are high in pregnant women with covid-19 than in pregnant women without the disease” [BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3320] (Published 01 September 2020)

Thus, most pregnant women present with mild illness or are asymptomatic. If comorbidities or obstetric risk factors such as pre-eclampsia, gestational diabetes will aggravate the severity of the disease. Remember, Covid-19 can exaggerate the hypercoagulable state also.

4. Transmission Mystery:

Emerging evidence that in-utero transplacental infection to the fetus may occur. The virus has not been isolated in amniotic fluid or vaginal secretions. There is not enough evidence to say that there is no effect on the fetus, but the effects seem to be minimal or are less in incidence.

5. Testing Policy: Which pregnant female need testing for COVID-19?

Although there is no recommendation for testing every pregnant woman, we test all pregnant women: more than 39 gestational weeks, from containment/cluster areas and those who are likely to deliver in next 5 days or who are in labor. The criteria for offering a laboratory test are the same for pregnant women and the non-pregnant population

6. Where in a healthcare facility should a pregnant woman with suspected or active COVID-19 infection deliver?

• Separate delivery room and operation theatres are required for management of suspected or confirmed Covid19 mothers.
• Both should have neonatal resuscitation corners located at least 2m away from the delivery table.
• Resources required include space, equipment, supplies and trained healthcare providers for delivery, caesarean section and neonatal resuscitation.

7. Avoid intermingling of patients in Covid and non-Covid set ups

1. Clean area
2. Suspected area
3. Confirmed area.

Covid-positive mothers should be delivered in separate and dedicated labor rooms or OTs. If these facilities are not available, then the LR and OT should be properly fumigated. There should be separate Covid-positive area.

8. Optimize antenatal visits and time, Encourage teleconsultations

• First visit at 12 weeks can be timed with USG.
• Second visit at 20 weeks to time with level 2 USG at 20 weeks.
• Third call at 32 weeks and then at delivery for low risk women to reduce transmission. (This frequency may be higher in high risk patients.)
• USG: Avoid unnecessary USGs; do at 11-14 weeks, 18-20 weeks and then only if necessary.

9. What infection control measures should be taken in triage, labor and delivery of a pregnant woman with active or suspected COVID-19 infection?

• Follow standard universal precautions to prevent contact with body fluids.
• Use personal protective equipment (PPE) to prevent acquiring infection through respiratory droplets. The PPE should include masks such as the N95 masks and face protection by a face shield or at least goggles.
• The female should inform the facility in advance of her arrival if possible, in order to allow time for preparation.
• Reception and triage should be in the same room earmarked for admission in labor and delivery.
• Ideally, this should be a room with negative pressure
• Keep the room free from any unnecessary items (decorations, extra chairs, etc.) which could act as infected fomites later.
• There should be a restriction on the number of attendants and non-essential staff into the room.
• There should be facilities for health care providers to remove and safely discard PPE at the exit of the room in which the patient is being cared for.

10. What should be the method of labor induction and mode of delivery in pregnant women with active or suspected COVID-19 infection?

• Mode of delivery in pregnant women infected with COVID-19 should be guided by her obstetric assessment and her physiological stability (cardiorespiratory status and oxygenation).
• COVID-19 infection itself is not an indication for induction of labor or operative delivery.
• Continuous electronic fetal monitoring should be done during labor.
• Adequate equipment and trained healthcare providers should be available for intrapartum monitoring and obstetric interventions as indicated in the separate childbirth facilities for infected pregnant women.
• Oxygenation status of women during labor should be monitored by a pulse oximeter and oxygen therapy should be titrated to maintain oxygen saturation of more than 94%.

11. What should be the specific care of pregnant women with active COVID-19 infection?

• Pregnant women with active COVID-19 infection should be managed with supportive and specific therapy as recommended for non-pregnant adults.
• Currently recommended management includes: – oxygen therapy/respiratory support, fluid therapy, antibiotics, shock management.
• Specific drugs in severe cases. Options:
  • Hydroxychloroquine 200 mg thrice-a-day with meals x 10 days OR 400 mg twice-a-day on day 1 and 400mg once-a-day x 4 days + Azithromycin 500 mg twice-a-day x 7days (Weak recommendation; Low quality evidence)
  • Lopinavir/ Ritonavir, if any of the following criteria are met:
    1. Hypoxia,
    2. Hypotension,
    3. New onset organ dysfunction (one or more)

Dosage:

Lopinavir/ Ritonavir (200 mg/ 50 mg) – 2 tablets twice daily

For patients unable to take medications by mouth: Lopinavir 400mg/Ritonavir 100 mg – 5mL suspension

Twice daily

Duration: 14 days or for 7 days after becoming asymptomatic

12. What precautions should the neonatal resuscitation team take when attending the delivery of a woman with suspected or confirmed COVID-19 infection?

• Resuscitation of neonate may be done in a separate but inter-connected adjacent room earmarked for this purpose.
• If not feasible, the resuscitation warmer should be separated from the delivery area by a distance of at least 2 meters. A curtain can be used between the two areas to minimize opportunities for close contact.
• Minimum number of personnel should attend (one person in low risk cases and two in high risk cases where extensive resuscitation may be anticipated) and wear a full set of personal protective equipment including N95 mask.
• Mother should perform hand hygiene and wear triple layer mask.
• The umbilical cord should be clamped promptly and skin to skin contact avoided.
• Delivery team member should bring over the neonate to the resuscitation area for assessment by the neonatal team.
• Neonatal resuscitation should follow standard guidelines.
• If positive-pressure ventilation is needed, self-inflating bag and mask may be used over T-piece resuscitator.

13. What should be the feeding policy for stable neonates born to COVID-19 mothers?

• Stable neonates exposed to COVID-19 infection from mothers or other relatives should be roomed in with their mothers and be exclusively breastfed.
• If rooming-in is not possible because of the sickness in the neonate or the mother, the neonate should be fed expressed breast milk (EBM) of the mother by a nurse or family member who has not been in contact (Weak recommendation, based on consensus among experts in the absence of evidence for any beneficial effect or harm in the risk of COVID-19 following direct breastfeeding or expressed breastmilk feeding)
• Conditions to be met:
  • Mothers should perform hand hygiene frequently, including before and after breastfeeding and touching the baby.
  • Mothers should practice respiratory hygiene and wear a mask while breastfeeding and providing other care to the baby; they should routinely clean and disinfect the surfaces.
  • Mothers should express milk after washing hands and breasts and while wearing a mask.
  • If possible, a dedicated breast pump should be provided. It should be decontaminated as per protocol.
  • Expressed milk can be fed to the baby without pasteurization.
  • The collection and transport of EBM to the baby should be done very carefully to avoid contamination

14. Is it mandatory to separate the mother and baby if female is suspected or confirmed to be COVID19 positive?

• Scenario 1: If resources for isolation of normal, suspected to be infected and infected mothers can be made available AND there is no evidence of community spread
  • After immediate cord clamping, the neonate should be isolated from the mother.
  • During isolation, healthy neonates should preferably be cared for by a nurse or family member not in contact with mother.
  • Mother can express milk after washing hands and breasts and while wearing mask. This expressed milk can be fed to her own baby without pasteurization.
  • Mother and baby can be roomed-in once mother has been tested and declared to be clear of infection.
  • To facilitate early rooming-in, viral testing should be conducted and reported on priority.
  • If mother cannot be discharged and it is considered safe, early discharge to home with healthy family member followed by telephonic follow-up or home visit by a designated healthcare worker can be considered.

• Scenario 2: Resources for isolation of normal, suspected to be infected and infected mothers not available OR healthcare facilities are overwhelmed because of large number of Coronavirus infections OR evidence of community spread is present
  • Stable neonate may be roomed-in with mother in an isolation room. The mother-baby dyad must be isolated from other COVID-19 cases.
  • Direct breastfeeding can be done.
  • Mother should wash hands frequently including before breastfeeding and wear mask. If needed due to neonatal condition, expressed breast milk may also be fed.
  • If safe, early discharge to home followed by telephonic follow-up or home visit by a designated healthcare worker may be considered.

15. Should symptomatic neonates needing intensive or special care be nursed in common room NICU/SNCU or isolation facility?

• Symptomatic neonates should be managed in separate isolation NICU/SNCU.
• This area should be away from the usual NICU/SNCU in a segregated area.
• The access to isolation NICU/SNCU should be through dedicated lift or guarded stairs.
• Ideally, the isolation should be in single rooms.
• In case enough single rooms are not available,
• Closed incubators (preferred) or radiant warmers can be placed in a common isolation NICU/SNCU for neonates.
• The neonatal beds should be at a distance of at least 1 meter from one another.
• Suspected COVID-19 cases and confirmed COVID-19 cases should ideally be managed in separate isolations.
• If it is not feasible to have separate facilities facility,
• They should be segregated by leaving enough space between the two cohorts.
• The isolation ward should have a separate double door entry with changing room and nursing station.
• Negative air borne isolation rooms are preferred for patients requiring aerosolization procedures (respiratory support, suction, nebulization). If not available, negative pressure could also be created by 2-4 exhaust fans driving air out of the room.
• Isolation rooms should have adequate ventilation. If room is air-conditioned, ensure 12 air changes/ hour and filtering of exhaust air. These areas should not be a part of the central air-conditioning.
• The doctors, nursing and other support staff working in these isolation rooms should be separate from the ones who are working in regular NICU/SNCU.
• If the facilities of isolation intensive care are not available in the hospital where symptomatic or sick newborn is born or referred with COVID 19 infections, the newborn should be immediately shifted to State designated closest hospital where such facilities are available.

16. What are the special precautions to be taken while providing respiratory support to neonates exposed to COVID-19 infection?

• Respiratory support for neonates with suspected/proven COVID-19 infection is guided by usual principles of lung protective strategy recommended for newborns.
• Non-invasive ventilation is generally the preferred mode of respiratory support in neonates. Continuous positive airway pressure (CPAP) should be used with minimal required flow.
• However, due to high potential for aerosol generation, non-invasive positive pressure ventilation (NIPPV) and High Flow Nasal cannulas (HFNC) should be avoided.

17. In symptomatic neonates, what is the role of specific treatment in case of perinatal exposure and in case of confirmed infection with COVID-19?

• At present, specific anti-COVID-19 treatment –
  • Antivirals or chloroquine/hydroxychloroquine – is NOT recommended in symptomatic or asymptomatic neonates with confirmed or suspected COVID-19. (Weak recommendation, based on consensus among experts in the absence of evidence for any beneficial effect or harm with the use of any of the options available)
  • Use of adjunctive therapy such as systemic corticosteroids and intravenous gamma globulin is NOT recommended in symptomatic neonates with confirmed or suspected COVID-19. (Weak recommendation, based on consensus among experts in the absence of evidence for any beneficial effect or harm with the use of any of the options available)

18. What should be the specific disinfection practices in NICU/ SNCU?

• Disinfection of Surfaces in the childbirth and neonatal care areas for patients with suspected or confirmed COVID-19 infection are not different from those for usual Labor room/OT/NICU/SNCU areas and include the following:
• Wear personal protective equipment before disinfecting
• If equipment or surface is visibly soiled first clean with soap and water solution or soaked cloth as appropriate before applying the disinfectant
• 0.5% sodium hypochlorite (equivalent to 5000 ppm) can be used to disinfect large surfaces like floors and walls at least once per shift and for cleaning after a patient is transferred out of the area.
• 70% ethyl alcohol can be used to disinfect small areas between use, such as reusable dedicated equipment.
• Hydrogen peroxide (dilute 100 ml of H2O2 10% v/v solution with 900 ml of distilled water) can be used for surface cleaning of incubators, open care systems, infusion pumps, weighing scales, standby equipment-ventilators, monitors, phototherapy units, and shelves.
• Use H2O2 only when equipment is not being used for the patient. Contact period of 1 hour is needed for efficacy of H2O2.

19. What should be the testing protocol for neonates born to mothers with suspected or confirmed COVID-19?

Which neonates?

• Neonates born to mothers with COVID-19 infection within 14 d of delivery or up to 28 d after birth
• Symptomatic neonates exposed to close contacts with COVID-19 infection

When?

• If symptomatic, specimens should be collected as soon as possible  
• If asymptomatic and roomed-in, test only if and when mother’s test comes positive.
• If mother is COVID-19 positive and baby’s initial sample is negative, another sample should be repeated after 48 hours.

What sample?

• Not mechanically ventilated: Upper respiratory nasopharyngeal swab (NP).
• Collection of oropharyngeal swabs (OP) is a lower priority and if collected should be combined in the same tube as the NP.
• Mechanically ventilated: Tracheal aspirate sample should be collected and tested as a lower respiratory tract specimen

20. What should be the discharge policy of neonates born to suspected or confirmed COVID-19 mothers?

• Stable neonates exposed to COVID-19 and being roomed-in with their mothers may be discharged at time of mothers’ discharge. (Weak recommendation, based on consensus among experts based on the incubation period of SARS-CoV-2 infection in adults and older children
• Stable neonates in whom rooming-in is not possible because of the sickness in the mother and are being cared by a trained family member may be discharged from the facility by 24-48 hours of age. (Weak recommendation, based on consensus among experts in the absence of evidence for any beneficial effect or harm with early discharge following exposure to COVID-19)
• Early discharge to home may be followed by a telephonic follow-up or home visit by a designated healthcare worker.
• Mothers and family members should be counselled regarding the danger signs and advised to report back to the facility if the neonate develops any of the danger signs.
• If the neonate develops any danger signs or becomes unwell during home isolation, he/she should be taken to a designated hospital facility for assessment as well as COVID-19 testing (if indicated).
• Mothers and family members should perform hand hygiene frequently including before and after touching and feeding the baby.
• Mothers should practice respiratory hygiene and wear a mask while breastfeeding and providing other care to the baby; they should routinely clean and disinfect all the surfaces.

21. Last but not the least

• Antipyretic treatment is important as hyperpyrexia can lead to IUD; look for other infections, consider empiric antibiotics and also thromboprophylaxis as there may be prolonged admission and immobilization.
• Indications of ICU management: oxygen saturation <93% at rest, tachypnea (>30/min), qSOFA score can be used to aid decision making
• Training (donning and doffing PPE) and managing the healthcare cadre is very important to prevent them from getting infected. It is also important to keep up their morale.

Based on Inputs from Perinatal-Neonatal Management Of Covid-19 Infection – Guidelines Of The Federation Of Obstetric And Gynecological Societies Of India (Fogsi), National Neonatology Forum Of India (Nnf), And Indian Academy Of Pediatrics (Iap).

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