Covid19 in pregnancy

COVID-19 IN
PREGNANCY
SUPERVISED BY:
DR. AHLAM AL-KHARABSHEH

INTRODUCTION
 At the end of 2019, a novel coronavirus was identified as the cause of a cluster of
pneumonia cases in Wuhan, China.
 In February 2020, the World Health Organization designated the disease COVID-19,
which stands for coronavirus disease 2019, and the virus that causes it is designated
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

VIROLOGY
 Coronaviruses are enveloped positive-stranded RNA
viruses. SARS-CoV-2 are betacoronavirus in the same
subgenus of the SARS virus, and the closest RNA
sequence similarity is to two bat coronaviruses, which
indicates that bats are likely the primary source;
whether COVID-19 virus is transmitted directly from
bats or through some other mechanism (eg, through
an intermediate host) is unknown.
 The host receptor for SARS-CoV-2 cell entry is the
same as for SARS-CoV, the angiotensin-converting
enzyme 2 (ACE2), The host receptor for SARS-CoV-2
cell entry is the same as for SARS-CoV, the
angiotensin-converting enzyme 2 (ACE2), SARS-CoV-2
binds to ACE2 through the receptor-binding gene
region of its spike protein.

NOTABLE VARIANTS
 B.1.1.7 lineage, was first identified in the United Kingdom in late 2020 and was temporally associated with an
increase in regional infections. early estimates were that the variant was 50 to 75 percent more transmissible.
 Thus far, there is no evidence that the B.1.1.7 variant is associated with immune escape that could impact
vaccine efficacy.
 Others like, B.1.351 lineage in South Africa, P
.1 lineage in Japan.

EPIDEMIOLOGY
Globally, over 110 million confirmed cases of COVID-19 have been reported.
The reported case counts underestimate the overall burden of COVID-19, as only a
fraction of acute infections are diagnosed and reported. Seroprevalence surveys in the
United States and Europe have suggested that after accounting for potential false
positives or negatives, the rate of prior exposure to SARS-CoV-2, as reflected by
seropositivity, exceeds the incidence of reported cases by approximately 10-fold or
more.

TRANSMISSIO
N
 Direct person-to-person respiratory transmission is the
primary means of transmission of SARS-CoV-2. Mainly
through close-range contact (ie, within approximately
six feet or two meters) via respiratory particles; when a
person with infection coughs, sneezes, or talks can
infect another person if it is inhaled or makes direct
contact with the mucous membranes.
 SARS-CoV-2 can also be transmitted longer distances
through the airborne route (through inhalation of
particles that remain in the air over time and distance),
but the extent to which this mode of transmission has
contributed to the pandemic is controversial.
 The risk of transmission from an individual with SARS-
CoV-2 infection varies by the type and duration of
exposure, use of preventive measures, and likely
individual factors (eg, the amount of virus in
secretions)

 Viral shedding and period of infectiousness — The precise interval during which an individual with
SARS-CoV-2 infection can transmit infection to others is uncertain. The potential to transmit SARS-
begins prior to the development of symptoms and is highest early in the course of illness; the risk of
transmission decreases thereafter. Transmission after 7 to 10 days of illness is unlikely, particularly for
otherwise immunocompetent patients with nonsevere infection.
 Detectable viral RNA, however, does not necessarily indicate the presence of infectious virus, and
there appears to be a threshold of viral RNA level below which infectiousness is unlikely.

 The risk of transmission from an individual who is asymptomatic appears less than that from
one who is symptomatic.
 Virus present on contaminated surfaces may be another source of infection if susceptible
individuals touch these surfaces and then transfer infectious virus to mucous membranes in
the mouth, eyes, or nose.
 There is no evidence suggesting animals (including domesticated animals) are a major
source of infection in humans.

IMMUNITY FOLLOWING INFECTION
 Humoral immunity – the magnitude of antibody response may be associated with severity of disease,
and patients with mild infection may not mount detectable neutralizing antibodies. Most studies suggest
that neutralizing activity is maintained for up to six to eight months
 Risk of reinfection — Overall, the short-term risk of reinfection (eg, within the first few months
initial infection) appears low. Nevertheless, sporadic cases of reinfection have been documented.

PREVENTION
 Personal preventive measures:
-Diligent hand washing, particularly after
surfaces in public. Use of hand sanitizer that
contains at least 60% alcohol is a reasonable
alternative if the hands are not visibly dirty.
-Respiratory hygiene (eg, covering the cough or
sneeze).
-Avoiding touching the face (in particular eyes,
nose, and mouth).
-Cleaning and disinfecting objects and surfaces
that are frequently touched.
-Ensure adequate ventilation of indoor spaces.
-Physical distancing (2 meters).

WEARING MASKS IN THE COMMUNITY
 WHO recommends patients to wear masks*when
in public spaces (indoors or outdoors) or when
around individuals outside of their household.
Cloth masks and disposable masks (eg,
commercially available surgical masks) are
recommended for community use.
 Rationale — The rationale for all individuals
(regardless of symptoms) to wear a mask in the
community is primarily to contain secretions of
and prevent transmission from individuals with
infection, including those who have asymptomatic
or presymptomatic infection. Masks can also
reduce exposure to SARS-CoV-2 for the wearer.

POST-EXPOSURE MANAGEMENT
 Additional measures are recommended for those who had a close contact with a patient with suspected
or confirmed COVID-19 in the community.
● Daily monitoring for fever, cough, or dyspnea for 14 days.
● Self-quarantine at home, with maintenance of at least 2 meters from others.
The preferred quarantine period is 14 days; shorter quarantine periods of 7 days (following a negative
viral test within 48 hours) or 10 days are acceptable alternatives.
● Testing (ideally five to seven days following exposure).

INFECTION CONTROL IN
HEALTHCARE SETTINGS
 All health care workers (HCWs) who enter the
room of a patient with suspected or confirmed
COVID-19 should wear personal protective
equipment (PPE) to reduce the risk of
exposure. This includes the use of a gown,
gloves, a respirator or medical mask, and eye
or face protection. We suggest an N95
respirator rather than a medical mask when
caring for all patients with suspected or
confirmed COVID-19.

VACCINES
 The primary antigenic target for COVID-19 vaccines
is the large surface spike protein, which binds to the
angiotensin-converting enzyme 2 (ACE2) receptor on
host cells and induces membrane fusion.
 Indications: Pfizer – 18 years or older, Moderna – 16
years or older, according to local allocation priorities.
 Pregnant individuals — Safety of these vaccines has
not yet been established in children or pregnant
individuals. However, pregnancy is not a
contraindication to vaccine receipt. The decision to
vaccinate individuals 16 years and older who are
pregnant or breastfeeding should be made on a
case-by-case basis, taking into account the
individual's preferences, risk of COVID-19, and the
unknown fetal effects of the vaccines.

VACCINES IN PREGNANCY
 We recommend not withholding COVID-19 mRNA vaccines on the basis of pregnancy/lactation
alone for those who are eligible for and desire vaccination, in agreement with other expert
guidance. In fact, we believe withholding these vaccines from pregnant/lactating patients would
be unethical. If an individual becomes pregnant after receiving the first dose of the COVID-19
vaccine series, the second dose should be administered when indicated.
 Vaccination should be timed so that patients do not receive a COVID-19 vaccine within 14 days of
receipt of a routine vaccination, such as the Tdap or influenza.
 Anti-D immunoglobin does not interfere with the immune response to vaccines, so timing of
administration for prevention of alloimmunization is based on standard clinical protocols.

CLINICAL FEATURES
 Many pregnant women are asymptomatic, but the proportion of asymptomatic cases is not well defined. In
a systematic review, 7 percent of pregnant persons universally screened for COVID-19 tested positive, and 75
percent of these persons were asymptomatic [16]. In another systematic review, 95 percent (95% CI 45-100
percent) of COVID-19 infections in pregnant persons were asymptomatic, and 59 percent (95% CI 49-68
percent) remained asymptomatic through follow-up.
 Some of the clinical manifestations of COVID-19 overlap with symptoms of normal pregnancy (eg, fatigue,
shortness of breath, nasal congestion, nausea/vomiting), which should be considered during evaluation of
afebrile symptomatic pregnant persons.

CLINICAL FEATURES
Symptoms frequency in pregnancy
Cough – Pregnant 50.3 percent (nonpregnant 51.3
percent)
Headache – Pregnant 42.7 percent (nonpregnant 54.9
percent)
Muscle aches – Pregnant 36.7 percent (nonpregnant 45.2
percent)
Fever – Pregnant 32.0 percent (nonpregnant 39.3
percent)
Sore throat – Pregnant 28.4 percent (nonpregnant 34.6
percent)
Shortness of breath – Pregnant 25.9 percent
(nonpregnant 24.8 percent)
New loss of taste or smell – Pregnant 21.5 percent
(nonpregnant 24.8 percent)

CLASSIFICATION OF DISEASE SEVERITY
●Asymptomatic or presymptomatic infection – Positive test for SARS-CoV-2
but no symptoms.
●Mild illness – Any signs and symptoms (eg, fever, cough, sore throat, malaise, headache, muscle pain)
without shortness of breath, dyspnea, or abnormal chest imaging.
●Moderate illness – Evidence of lower respiratory disease by clinical assessment or imaging and a
saturation of oxygen (SaO2) ≥94 percent on room air at sea level.
●Severe illness – Respiratory frequency >30 breaths per minute, SaO2 <94 percent on room air at sea
level, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung
infiltrates >50 percent.
●Critical illness – Respiratory failure, septic shock, and/or multiple organ dysfunction.

LABORATORY FINDINGS
 In a systematic review of pregnant and recently pregnant persons with suspected or confirmed COVID-19,
laboratory findings included:
●Lymphopenia (35%)
●Leukocytosis (27%)
●Elevated procalcitonin level (21%)
●Abnormal liver chemistries (11%)
●Thrombocytopenia (8%)
 Leukocytosis can be normal in pregnancy, and some of the other laboratory findings overlap with those
caused by pregnancy-related disorders (eg, thrombocytopenia and elevated liver chemistries in preeclampsia
with severe features).

DIAGNOSIS
 The diagnosis of COVID-19 is made primarily by direct detection of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) RNA by nucleic acid amplification tests (NAATs), most
commonly reverse-transcription polymerase chain reaction (RT-PCR) from the upper
respiratory tract.

WHOM TO TEST
 All symptomatic patients
 Following close contact with an individual with COVID-19 (this includes neonates born to mothers
with COVID-19).
 Screening hospitalized patients at locations where prevalence is high (eg, ≥10 percent PCR
positivity in the community).
 Prior to time-sensitive surgical procedures or aerosol-generating procedures.
 Prior to receiving immunosuppressive therapy (including prior to transplantation).
 In areas where the infection is prevalent, we believe testing all patients upon presentation to
labor and delivery with a rapid test for SARS-CoV-2 is reasonable, if testing is available. Patients
with scheduled inductions and cesarean deliveries can be tested within 72 hours of the scheduled
admission.

 Negative NAAT test — If initial testing is negative but the suspicion for COVID-19 remains (eg,
suggestive symptoms without evident alternative cause) and confirming the presence of infection is important
for management or infection control, we suggest repeating the test. The optimal timing for repeat testing is
not known; it is generally performed 24 to 48 hours after the initial test. Repeat testing within 24 hours is
not recommended.

 The evaluation of hospitalized patients with documented or suspected COVID-19 should focus on
features associated with severe illness (table 2) and identify organ dysfunction or other
comorbidities that could complicate potential therapy. The evaluation is the same regardless of
pregnancy status.

 At least initially, we check the following laboratory studies daily:
●Complete blood count (CBC) with differential, with a focus on the total lymphocyte count
trend
●Complete metabolic panel
●Creatine kinase (CK)
●C-reactive protein (CRP)
 Initially, we check the following studies every other day (or daily if elevated or in the intensive care unit):
●Prothrombin time (PT)/partial thromboplastin time (PTT)/fibrinogen
●D-dimer
 We check the following studies at baseline and repeat them if abnormal or with clinical worsening:
●Lactate dehydrogenase, repeated daily if elevated
●Troponin, repeated every two to three days if elevated
●Electrocardiogram (ECG)

IMAGING
 Chest radiographs may be normal in early
or mild disease. In a systematic review of
427 pregnant patients diagnosed with
COVID-19, the most frequently
encountered pulmonary findings on chest
computed tomography were ground-glass
opacities (77 percent), posterior lung
involvement (73 percent), multilobar
involvement (72 percent), bilateral lung
involvement (69 percent), peripheral
distribution (68 percent), and
consolidation (41 percent).

 A portable chest radiograph is sufficient for initial evaluation of pulmonary complications and
extent of lung involvement in hospitalized patients with COVID-19. A single chest radiograph
carries a very low fetal radiation dose of 0.0005 to 0.01 mGy.
 Computed tomography (CT) should be performed, if indicated, as the fetal radiation dose for
a routine chest CT is also low and not associated with an increased risk of fetal anomalies or
pregnancy loss.
 Some authorities have advocated lung ultrasound, possibly at the same time as the obstetric
scan, for quick diagnosis of pneumonia in symptomatic pregnant women.

 Sources:
 Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention
 Coronavirus disease 2019 (COVID-19): Pregnancy issues and antenatal care
 Coronavirus disease 2019 (COVID-19): Diagnosis
 Coronavirus disease 2019 (COVID-19): Infection control in health care and home settings

Covid19 In Pregnancy II
Presented by : Balqees Majali
Supervised by : Dr. Ahlam Al-Kharabsheh
Assistant Professor, OBS & GYN department
Mu’tah University

•Course during pregnancy -
•Complications and outcomes -
•Differential diagnosis -
•Prenatal care -
•Timing of delivery -

Pregnancy appears to worsen the clinical course of COVID-19
compared with nonpregnant females of the same age.
Risk factors for severe illness in pregnancy include older mean
age, higher body mass index, and preexisting medical
comorbidities
symptomatic pregnant patients are at increased risk of death
compared with symptomatic nonpregnant females of
reproductive age. Maternal death rates of 0.15 to 0.60 percent
have been attributed to COVID-19
Pregnant women were more likely to need ICU admission
compared with nonpregnant women of reproductive age with
COVID-19

In a systematic review including over 11,000 pregnant and recently pregnant women
with suspected or confirmed COVID-19
49% had pneumonia
30% received oxygen by cannula
13% had severe disease
4% were admitted to an intensive care unit (ICU)
3% received invasive ventilation
0.8% received extracorporeal membrane oxygenation (ECMO)
0.6% died

With most COVID-19 studies of pregnant and postpartum patients,
PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) is an ongoing
prospective nationwide study in the United States, 95 percent of
participants to date were outpatients:
•The most prevalent first symptoms in the 594 patients who tested
positive for SARS-CoV-2 infection were cough (20%), sore throat (16%),
body aches (12%), and fever (12%).
•Median time to symptom resolution was 37 days, but symptoms persisted
for ≥8 weeks in 25 percent of participants.

Descriptive analyses of
clinical findings
Data were collected from
the first 60 pregnant
women with COVID‐19
who were treated at
Puerta de Hierro
University Hospital
Madrid, Spain from 14
March to 14 April 2020
Symptoms 60 N (%)
Asymptomatic COVID‐19 15 (25.0%)
Symptomatic COVID‐19 45 (75.0%)
Fever 34 (75.5%)
Cough 34 (75.5%)
Dyspnea 17 (37.8%)
COVID‐19 stages 60 N (%)
Stage I or early infection phase 42 (70.0%)
Stage II or lung disease phase 15 (25.0%)
Stage III or hyperinflammatory phase 3 (5.0%)

CURB65 scale
0 57 (95.0%)
1 3 (5.0%)
≥2 0 (0%)
Pregnant women with COVID‐19 60 N (%)
Without pneumonia 42 (70.0%)
With pneumonia 18 (30.0%)
Mild 9 (50.0%)
Moderate 7 (38.9%)
Severe 2 (11.1%)
Respiratory co‐infection 5 (27.8%)

Hospital admissions 41 Median (range)
COVID‐19 length of stay (days). N = 18 3 (1‐13)
Delivery length of stay (days). N = 23 3 (1‐9)
Delivery 60 N (%)
Overall 23 (38.3%)
Spontaneous vaginal delivery 14 (60.9%)
Instrumental delivery 4 (17.4%)
Cesarean section 5 (21.7%)
Premature delivery 2 (8.7%)
Vertical transmission to newborn 0 (0%)

Treatment 60 N (%)
Symptomatic 39 (65.0%)
Hydroxychloroquine 10 (16.7%)
Hydroxychloroquine + lopinavir + ritonavir 3 (5.0%)
Hydroxychloroquine + darunavir + ritonavir 3 (5.0%)
Hydroxychloroquine + darunavir + ritonavir + toc
ilizumab
2 (3.3%)
Hydroxychloroquine + darunavir + cobicistat 3 (5.0%)

Clinical feature of patients
with CoV infection
SARS-CoV-2
Study (n) Reports (n) Pregnancies (n) Pooled % (95%-CI)
Fever 19 575 870 66.1% [56.1–79.8]
Cough 18 458 869 52.7% [34.7–67.7]
Fatigue 8 192 634 30.3% [14.4–49.6]
Dyspnea 7 49 303 16.2% [7.6–22.3]
Myalgia 5 61 293 20.8% [7.5–27.8]
Shortness of Breath 6 186 586 31.7% [18.2–41.5]
Sore throat 6 78 668 11.7% [5.1–29.1]
Chill 3 44 480 9.2% [4.7–71.1]
Headache 5 88 674 13.1% [8.5–33.2]
Muscle pain 3 67 628 10.7% [4.9–25.4]
Diarrhea 9 41 753 5.4% [2.2–10.3]
Abdominal pain 2 5 64 7.8% [3.5–17.1]
Pneumonia 21 368 517 71.2% [68.6–95.8]

• Respiratory disorders – Pneumonia, respiratory failure, acute respiratory
distress syndrome (ARDS)
• Cardiac disorders (arrhythmias, acute cardiac injury)
• Thromboembolic complications
• Secondary infections
• Acute kidney failure
• Neurologic disorders – Headache, dizziness, myalgia, alteration of
consciousness, disorders of smell and taste, weakness, strokes, seizures
• Cutaneous disorders – Morbilliform rash; urticaria; pernio-like, acral
lesions; livedo-like, vascular lesions; and vesicular, varicella-like eruption
• Gastrointestinal and liver disorders
• Psychiatric illness (eg, anxiety disorders, depressive disorders, insomnia
disorder, posttraumatic stress disorder)

It is known that some patients with severe COVID-19 have
laboratory evidence of an exaggerated inflammatory response (similar
to cytokine release syndrome), which has been associated with critical
and fatal illnesses. Whether the normal immunologic changes of
pregnancy affect the occurrence and course of this response is
unknown.

Congenital infection
- Criteria for diagnosis :
In a mother with SARS‐CoV‐2 infection, we would make a definitive
diagnosis of congenital infection in a live born neonate if SARS-CoV-2 is
detected by polymerase chain reaction in :
• umbilical cord blood
• neonatal blood collected within the first 12 hours of birth
• amniotic fluid collected prior to rupture of membranes

• Viremia rates in patients with COVID-19 appear to be low
(1% in one study but higher in severe disease and transient)
suggesting placental seeding and in utero transmission
would not be common
Hematogenous
• Data on positive vaginal swabs and positive swabs
and amniotic fluid suggesting the ascending route of
infection and intrapartum transmission from contact
with vaginal secretions are rare
Ascending
• viral shedding in maternal feces is common, so fecal
contamination of the perineum could theoretically be a
source of intrapartum transmission
Intrapartum
• could occur through ingestion of breast milk or from an
infected mother (or other caregiver) to her infant through
respiratory or other infectious secretions.
Postpartum

SARS-CoV-2 cell entry is thought to depend on the angiotensin-
converting enzyme 2 receptor and serine protease TMPRSS2, which are
minimally coexpressed in the placenta .
This may account for the infrequent occurrence of placental SARS-CoV-
2 infection and fetal transmission. However, SARS-CoV-2 could reach
the fetus as a result of ischemic injury to the placenta, without
requiring placental cell infection .

Frequency of congenital infection
The extent of vertical transmission (in utero, intrapartum, early
postnatal period) remains unclear. Only a few well-documented cases
of probable vertical transmission have been published . Many other
possible cases of congenital infection have been reported in the setting
of third-trimester maternal infection within 14 days of delivery,
suggesting congenital infection is uncommon (approximately 2 % of
maternal infections

In a systematic review of infants born to 936 COVID-19-infected mothers, neonatal
viral RNA testing was positive in:
- 27/936 (2.9 percent) nasopharyngeal samples taken immediately after birth or
within 48 hours of birth,
- 1/34 cord blood samples,
- 2/26 placental samples;
- in addition, 3/82 neonatal serologies were immunoglobulin M (IgM) positive for
SARS-CoV-2
In the CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team
report of over 5000 pregnant persons with laboratory-confirmed SARS-CoV-2
infection, 2.6 % of the 610 infants with available SARS-CoV-2 test results had a
positive test, primarily those born to women with infection at delivery

• The frequency of miscarriage does not appear to be
increased, but data on first- and second-trimester infections
are limited
Risk of
miscarriage
• Preterm birth and cesarean delivery rates have been increased
in many studies but not all
• The increased risk appears to be limited to patients with
severe or critical disease
• Fever and hypoxemia may increase the risks for preterm labor,
prelabor rupture of membranes, and abnormal fetal heart rate
patterns, but preterm deliveries also occur in patients without
severe respiratory disease.
Preterm
and CS

In a systematic review including over 11,000 pregnant and recently pregnant persons with suspected or
confirmed COVID-19
17 percent delivered before 37 weeks of gestation 65 percent delivered by cesarean
Most preterm deliveries were iatrogenic; only 6 percent were spontaneous.
In two large cohort studies of pregnant patients with COVID-19 in the United States
With covid19 Without covid19
Overall preterm delivery rate 7.2% 5.8%
12.9% 10.2%
The overall rates of cesarean
delivery
28.9% 27.5
34.0% 31.9

Outcome by disease severity
32 of the 64 pregnant women hospitalized for severe or critical COVID-19
delivered during the course of infection
9 of 44 women with severe disease
13 of the 20 women with critical disease were delivered because of the
maternal status while only three deliveries were for fetal status
Birth was preterm in 9 percent of women with severe disease and 75 percent of
those with critical disease.

• Fetal outcome :
It has been found that there is a significant increase in the rate of
sillbirth among pregnant patients with covid19 about 3% compared to a
percentage of 0.4-0.5% in patients without covid19
- There is limited information on the reasons for the increase in stillbirth
in patients hospitalized because of COVID-19.
- Severe and critical maternal illness likely accounted for some stillbirths.
- It is possible that some stillbirths have been related to disruptions in
prenatal care and to a higher frequency of home birth
- Testing for lupus anticoagulant is part of the evaluation of stillbirth and
also has been found transiently in patients with COVID-19

Pooled proportions of the different maternal and postnatal outcomes and coexisting disorder identified in the
present systematic review
Pregnancy and perinatal
postnatal outcome
Study (n) Number of reports Pregnancies or neonate
(n)
Pooled % (95%–CI)
Pregnancy outcome
PTB < 34 week 25 68 719 9.5% [7.1–39.5]
PTB < 37 week 22 91 637 14.3% [10.2–30.2]
> 37 week 25 330 709 46.5% [41.2–56.3]
Pre-eclampsia 9 10 169 5.9% [3.6–11.7]
pPROM 11 17 183 9.3% [6.6–14.8]
FGR 14 3 108 2.8% [1.8–8.9]
Miscarriage 4 9 62 14.5% [7.7–26.5]
ICU admission 29 66 211 31.3% [27.2–55.5]
Maternal death 11 15 557 2.7% [1.4–14.6]
Cesarean delivery 32 440 772 56.9% [48.2–78.9]
Normal delivery 17 198 692 28.6% [22.4–41.6]

Prenatal outcome
Fetal distress 17 18 68 26.5% [17.5–39.5]
Apgar score < 7 16 1 81 1.2% [0.0–7.7]
Neonatal asphyxia 11 1 71 1.4% [0.0–8.9]
Admission to NICU 8 9 73 11.3% [5.6–20.3]
Perinatal death 21 10 452 2.2% [1.2–12.8]
Vertical transmission 39 0 1316 0.0% [0.0–1.0]

Coexisting disorders
Hypertension 7 81 954 8.5% [7.1–17.4]
Gestational diabetes 9 85 881 9.6% [6.6–20.7]
Cardiovascular disease 2 27 470 5.7% [3.0–12.1]
Digestive disease 3 4 111 3.6% [1.1–9.8]
Asthma 4 44 794 5.5% [2.3–36.4]

• Early symptoms of COVID-19 can be similar to those of multiple other viral and bacterial
respiratory infections
• it is reasonable to also test for influenza when testing for SARS-CoV-2 as this could have
management implications.
• Coinfection with tuberculosis has also been reported and should be considered in patients
with impaired immunity or at increased risk for exposure to Mycobacterium tuberculosis.
Other
infections
• In pregnant women, some COVID-19-related laboratory abnormalities (elevated liver
enzyme levels, thrombocytopenia) are identical to those that occur in preeclampsia
with severe features and HELLP syndrome
• The diagnosis of preeclampsia with severe features or HELLP syndrome should be
considered in the differential diagnosis of persons under investigation for COVID-19,
as well as in patients with confirmed COVID-19 as these pregnancy-related disorders
may coexist with the infection
• The presence of acute hypertension can be helpful as it is a common finding in
patients with preeclampsia or HELLP syndrome and not a feature of COVID-19
Preeclampsia,
HELLP
syndrome

• Uninfected pregnant persons
• Asymptomatic pregnant persons with potential exposure
• Asymptomatic patients
• Symptomatic patients
• Maternal and fetal follow up after recovery
• Timing of delivery

Uninfected pregnant persons
The American College of Obstetricians and Gynecologists ,the Society for
Maternal-Fetal Medicine, and others have issued guidance regarding
prenatal care during the COVID-19 pandemic. It includes general guidance
for testing and preventing spread of COVID-19, and suggestions for
modifying traditional protocols for prenatal visits

telehealth
reducing the
number of in-
person visits
limiting the number
of persons in
waiting rooms and
physical distancing
grouping tests for
the same visit/day
timing of indicated
obstetric ultrasound
examinations
cell-free DNA screening can be
used (at >10 weeks) for Down
syndrome screening rather than
the combined test (ie, nuchal
translucency on ultrasound and
serum analytes)
75g 2hours OGGT instead of GCT
or 100g 3 hour OGTT

In addition, The psychological impact of COVID-19 should also be
recognized and support offered . The COVID-19 pandemic may be
associated with new onset or exacerbation of subsyndromal psychiatric
symptoms as well as full-blown psychiatric disorders, including anxiety
disorders, depressive disorders, posttraumatic stress disorder, or
substance use disorders.

Asymptomatic pregnant persons with potential exposure
Testing (ideally five to seven days following exposure) is also recommended following close contact to promptly identify new
infections . However, a negative test performed earlier after exposure should not be used to reduce the quarantine period to
shorter than seven days
the CDC acknowledges that shorter durations of quarantine may ameliorate the associated community burdens and adherence
challenges in exchange for a slightly increased risk of post-quarantine transmission
A 7day quarantine period, provided that the individual remained asymptomatic
throughout and has a negative NAAT or antigen SARS-CoV-2 test within 48 hours of the
planned end of quarantine
A 10-day quarantine period, provided that the individual remained
asymptomatic throughout
Self-quarantine at home, with maintenance of at least six feet (two meters) from others at all times. In particular, they should
avoid contact with individuals at high risk for severe illness
The preferred quarantine period is 14 days following the date of the last exposure
Daily monitoring for fever, cough, or dyspnea for 14 days. Individuals who develop such signs or symptoms should stay home and
maintain distance from other individuals, including those in their household, if they are not doing so already

Asymptomatic patients
Care of asymptomatic patients with confirmed or probable SARS-CoV-2
infection involves :
- assessing their risk for developing severe disease,
- close monitoring for respiratory decompensation (which may occur
rapidly), infection control and self-isolation for the anticipated
duration of illness,
- and appropriate timing of discontinuation of precautions

Comorbidities the CDC classifies as established or possible risk factors for severe COVID-19[1,2]
Established risk factors
•Cancer
•Chronic kidney disease
•Chronic obstructive pulmonary disease
• Down syndrome
•Immunocompromised state from solid organ transplant
•Obesity (body mass index ≥30 kg/m
2
)
•Pregnancy
•Serious cardiovascular disease
•Heart failure
•Coronary artery disease
•Cardiomyopathies
•Sickle cell disease
•Smoking
•Type 2 diabetes mellitus
Possible risk factors
•Asthma (moderate to severe)
•Cerebrovascular disease
•Cystic fibrosis
•Hypertension or high blood pressure
•Immunocompromised state from hematopoietic cell transplant, HIV, use of corticosteroids or other immunosuppressing agents, other immunodeficiencies
•Liver disease
•Neurologic conditions, such as dementia
•Overweight (body mass index ≥25 but <30 kg/m
2
)
•Pulmonary fibrosis (having damaged or scarred lung tissue)
•Thalassemia (a type of blood disorder)
•Type 1 diabetes mellitus

Symptomatic patients
The clinical care of symptomatic patients depends on:
• illness severity,
• underlying medical comorbidities,
• coexistent pregnancy complications,
• social situation

Home care
When to call the provider :
• If they experience worsening dyspnea,
• Unremitting fever >39°C despite appropriate use of acetaminophen,
• Inability to tolerate oral hydration and medications,
• Persistent pleuritic chest pain,
• Confusion,
• Obstetric complications (eg, preterm contractions, vaginal bleeding,
rupture of membranes) . Those in the third trimester should
perform fetal kick counts and report decreased fetal movement

Supportive care and medications
Generally
• Hydration, adequate rest, and frequent ambulation with more advanced activity as
soon as tolerated are advised.
Medications
• We suggest heated humidified air for congestion
• acetaminophen for sore throat/headache/fever
• ipratropium bromide and cromolyn nasal spray for symptomatic relief of rhinorrhea
Monoclonal
antibodies
• Bamlanivimab is a neutralizing monoclonal antibody available as an option for the treatment of
nonhospitalized patients with mild to moderate COVID-19 who are at high risk for progressing to
severe disease and/or hospitalization
• The combination casirivimab-imdevimab is another monoclonal antibody option for
nonhospitalized COVID-19 patients.

Hospital care
Candidates for inpatient care :
• ●A comorbid condition warranting admission (eg, poorly controlled hypertension or
diabetes, preeclampsia, prelabor rupture of membranes, uterine bleeding).
• ●Fever >39°C despite use of acetaminophen (which raises concern for cytokine storm
syndrome).
• ●Moderate or severe signs and symptoms (eg, oxygen saturation <95 percent [when
pulse oximetry is available] on room air and while walking, respiratory frequency >30
breaths per minute, rapidly escalating supplemental oxygen requirement).
• ●Critical disease – Respiratory failure, hypotension despite appropriate hydration, and/or
new end-organ dysfunction (eg, mental status changes, hepatic or renal insufficiency,
cardiac dysfunction).

Maternal respiratory support
• Patients with severe disease often need oxygenation support. High-
flow oxygen and noninvasive positive-pressure ventilation have been
used, but the safety of these measures is uncertain, and they should
be considered aerosol-generating procedures that warrant specific
isolation precautions.
• Some patients may develop acute respiratory distress syndrome
(ARDS) and warrant intubation with mechanical ventilation
• In the ICU prone position for severely ill patients is encouraged.
Padding above and below the gravid uterus >24 weeks is desirable to
offload the uterus and avoid aortocaval compression

maternal peripheral oxygen saturation (SpO2) should be maintained
at ≥95 percent
If SpO2<95 obtain ABG for PaO2, PaO2>70mmHg is desirable
The World Health Organization (WHO) suggests maintaining
maternal SpO2 ≥92 to 95 percent once the patient is stable
Permissive hypercapnia (PCO2 <60 mmHg) and extracorporeal
membrane oxygenation (ECMO), if indicated for management of
ARDS, do not appear to be harmful to the fetus, but data are limited
High positive end-expiratory pressure strategies (>10 mmHg), if
considered, require close ongoing maternal and fetal monitoring
because they decrease preload and cardiac output

Venous thromboembolism prophylaxis
• .
in one series of 1219 pregnant patients with COVID-19, the
incidence of VTE was :
In severe to critical disease 6%
In mild to moderate disease 0.2%
In asymptomatic patients 0%
•pregnancy
•Reduced mobility
•Dehydration
Risk factors of
VTE in covid19
patients

Prophylactic-dose anticoagulation is recommended for pregnant
patients hospitalized for severe COVID-19, if there are no
contraindications to its use, and generally discontinued when the
patient is discharged to home
Unfractionated heparin is usually preferred
5000 units in the first trimester, 7500 to 10,000 units in the second
trimester, and 10,000 units in the third trimester, administered
subcutaneously every 12 hours (reduce if the activated partial
thromboplastin time is elevated).
Intermittent pneumatic compression is suggested when pharmacologic
prophylaxis is contraindicated.

Dexamethasone use
— dexamethasone 6 mg daily for 10 days or until discharge is recommended for severely ill
nonpregnant patients who are on supplemental oxygen or ventilatory support. Glucocorticoids may also
have a role in the management of refractory shock in critically ill patients with COVID-19.
In pregnant patients who meet criteria for use of glucocorticoids for maternal treatment of COVID-19
and also meet criteria for use of antenatal corticosteroids to induce fetal maturity, we suggest
administering the usual doses of dexamethasone (four doses of 6 mg intravenously 12 hours apart)
and continue maternal treatment to complete the course of dexamethasone (6 mg orally or
intravenously daily for 10 days or until discharge, whichever is shorter)
Others have suggested using glucocorticoids such as methylprednisolone or hydrocortisone to complete
the course of maternal treatment because they result in less fetal steroid exposure

NSAIDs
• The lowest effective dose is used, ideally for less than 48 hours and guided by
gestational age-related potential fetal toxicity
• we use acetaminophen as the preferred antipyretic and analgesic agent, if possible
Antiviral
• remdesivir is being used to treat pregnant patients with severe COVID-19
• Ribavarin is teratogenic and should be avoided
• Baricitinib , risk-benefit ratio ?
Convalescent
plasma
• Is one approach that may be combined with other aspects of disease-specific and
supportive care

Fetal monitoring
• A specific management issue in pregnant patients is fetal
monitoring in those who are at a viable gestational age (ie,
gestational age when delivery for fetal indications and neonatal
resuscitation would be considered). The need for and frequency of
fetal testing depend on gestational age, stability of maternal vital
signs and oxygenation, other maternal comorbidities, and
discussions with the patient and the family that consider the
possibly increased risks of stillbirth and perinatal morbidities in the
absence of testing.

• For hospitalized patients, a Bluetooth-enabled external fetal monitor
can transmit the fetal heart rate tracing to the obstetric provider. The
monitor can be used continuously in unstable hospitalized patients in
whom emergency cesarean delivery would be performed for a
persistent nonreassuring fetal heart rate pattern. An abnormal tracing
might also help guide maternal oxygen therapy. In patients with stable
oxygen saturation (SaO2), a nonstress test can be performed once or
twice daily, as one option.
• Monitoring for preterm labor — Monitoring pregnant patients for signs
and symptoms of preterm labor is a routine component of obstetric
care and should be a component of maternal monitoring of pregnant
patients hospitalized in nonobstetric settings

Maternal follow up after recovery
• Patients with COVID-19 generally warrant outpatient follow-up
through telehealth or an in-person visit within a few days following
discharge to home
• reinforce the importance of infection control and provide counseling
on the warning symptoms which should prompt reevaluation.
• Patients with documented VTE or those at high risk should be
discharged on anticoagulation

Fetal follow up after recovery
authorities have suggested that pregnant persons with confirmed infection
should have at least one ultrasound assessment of fetal amniotic fluid volume,
beginning in the third trimester and at least 14 days after symptom resolution
For those with first- or early second-trimester infection, a detailed fetal
morphology scan at 18 to 23 weeks of gestation is also indicated and is a
standard part of routine prenatal care.
Antenatal testing (nonstress test, biophysical profile) can be reserved for
routine obstetric indications

Timing of delivery
Nonsevere illness
at ≥39 weeks of gestation, delivery can be
considered
<39 with nonsevere illness delivery is considered
according to the usual obstetric indications
Severe disease but not
intubated
delivery in pregnancies >32 to 34 weeks in the
setting of worsening status may be considered
Most authorities do not advocate delivery prior to
32 weeks, even though the maternal situation may
worsen in the second week

severe/critical disease and intubated
After 32 to 34 weeks, the decision of delivery is controversial
Between viability and <30 to 32 weeks, continuing maternal support with fetal
monitoring is suggested

Intrapartum and postpartum care
Preparedand presentedby:
Aseel Al-mahameed

THE OUTLINES THAT WILL BE DISCUSSED IN
THIS SEMINAR
precautions should be taken in the
labor and delivery unit
the route of delivery
Intrapartum considerations
Breast feeding & postpartum
care
Newborn Evaluation And Care
Discharge from hospital

Should home birth be
encouraged in areas of active
transmission?
some asymptomatic patients are
concerned about leaving their homes because
of the COVID-19 pandemic, hospitals and
accredited birth centers are the safest settings
for birth.
The American College of Obstetricians and
Gynecologists, considers hospitals a safer
location for birth than the home because of the
availability of physicians, blood transfusions,
antibiotics, anesthesia, and other resources for
intensive/emergency maternal and newborn
care, if needed . However, the Society of
Obstetricians and Gynaecologists of Canada,
describes a planned home birth with a registered
midwife or appropriately trained physician in
their integrated system as a reasonable choice for
persons with a low degree of risk where the birth
is anticipated to be uncomplicated and neither
the mother nor the neonate will require
resources beyond the local capacity.

What infection control precautions should be taken on
the labor and delivery unit?
Screen patients for clinical
manifestations of COVID-19
Ensure that all patients and any
exempted visitors are given
surgical masks to wear upon entry
into the health care setting for
universal source control
in areas with widespread
community infection, universal
testing with a rapid SARS-CoV-2 test
upon presentation to the labor and
delivery unit (or the day before if a
scheduled admission) is reasonable,
if testing is available.
ensure that appropriate personal protective
equipment [PPE] is available
Provide care for pregnant patients
with COVID-19 in a well-ventilated,
single-occupancy room with a
closed door and dedicated
bathroom. An airborne infection
isolation room (ie, negative-pressure
room) should be prioritized for
patients undergoing aerosol-
generating procedures. Providers
should use full PPE (gown, gloves,
cap, N95 mask, face shield).
1
2
3
4
5

What infection control precautions should be taken on the labor and delivery unit?
1. Screen patients for clinical manifestations of COVID-19 (eg, cough, headache, sore throat, myalgia, fever, shortness of
breath, loss of taste/smell) and close contact with a confirmed case or persons under investigation prior to and upon
entry into the health care facility .
2. Make appropriate infection control preparations when a screen-positive patient is identified (eg, identify the most
appropriate room for labor and delivery, ensure that appropriate personal protective equipment [PPE] is available, discuss
risk to the patient's close contacts). In the United States, health care facilities should ensure that infection control
practices for hospitalized pregnant patients who have suspected or confirmed COVID-19 are consistent with the Centers
for Disease Control and Prevention's (CDC) Considerations for Inpatient Obstetric Healthcare Settings .
3. Ensure that all patients and any exempted visitors are given surgical masks to wear upon entry into the health care setting
for universal source control. When there is ongoing community transmission of SARS-CoV-2, it is reasonable to use
certain enhanced infection control precautions when caring for patients who are not suspected of having COVID-19, even
those who had a negative test for SARS-CoV-2 upon entry into the health care setting.
4. Prioritize testing of pregnant persons admitted with suspected COVID-19 or those who develop symptoms consistent with
COVID-19 during hospitalization . Although the CDC recommends discretionary testing of asymptomatic pregnant
persons, we believe that, in areas with widespread community infection, universal testing with a rapid SARS-CoV-2 test
upon presentation to the labor and delivery unit (or the day before if a scheduled admission) is reasonable, if testing is
available. This information is useful to inform infection control precautions both intrapartum and postpartum, including
newborn care. For example, during the active phase of labor, viral dissemination is a concern when an asymptomatic or
presymptomatic infected patient is repeatedly exhaling forcefully .

Whencaring for patients with confirmed or suspected
COVID-19, health care workers should use contact and droplet
precautions (ie, gown, gloves, mask, face shield or goggles).
In particular, during episodes of patient deep respiratory efforts
and during the second stage of labor, health care workers
should also use airborne precautions (ie, N95 mask or powered
air purifying respirator, where available), in addition to contact
and droplet precautions.
Person-to-person contact and time in the labor unit and hospital
should be limited, as is safely feasible.
Health care workers are at risk for developing COVID-19 through
exposures in the community and in the health care setting.
Guidelines for work restriction and monitoring after exposure and
returning to work after exposure and after confirmed or
suspected COVID-19 are available separately.

Should planned cesarean delivery or labor induction
be postponed in patients with mild symptoms?
Patients undergoing planned induction or cesarean delivery can have screening
and laboratory testing either as point-of-care testing or 24 to 72 hours before
the planned procedure in an attempt to have results available before admission.
We evaluate mildly symptomatic patients to determine whether it is
obstetrically feasible to reschedule induction or cesarean delivery until
results of COVID-19 testing are available. This is an individualized decision
and requires assessing patient-specific risks of continuing the pregnancy in
the setting of an unknown, positive, or negative test result.
1. In particular, if the test result is positive, patients may benefit from delivery since they may
become more severely ill over time (symptoms are often more severe in the second week
of the illness).
2. In asymptomatic or mildly symptomatic patients with a positive SARS-CoV-2 test result,
induction of labor or cesarean delivery performed for appropriate medical/obstetric
indications (including week 39 induction of labor) should not be postponed or rescheduled.
For those who require cervical ripening, outpatient mechanical ripening with a balloon
catheter is an option. For inpatient cervical ripening, using two methods (eg, mechanical
and misoprostol or mechanical and oxytocin) may decrease the time from induction to
delivery, compared with using one agent only.

Should support persons be permitted on the labor and
delivery unit?
• Most facilities recognize that a support person is important to many laboring women
and permit one support person. A doula is considered a type of health care
personnel by some facilities and a visitor by others.
• The support person should be screened for symptoms (eg, cough, headache, sore
throat, myalgia, fever, shortness of breath, loss of taste/smell) before entering the
facility and in accordance with hospital policies. A support person with any
signs/symptoms consistent with COVID-19 or a positive test for COVID-19 within
10 days is not allowed to physically attend the labor and birth.
• Support persons should wear a face covering and remain with the laboring woman
(may not leave the room and then return) throughout labor and delivery.
• When screen-positive or additional support persons are desired, they can be a part
of the patient's labor and delivery via video.

 Patients with asymptomatic or nonsevere infections
COVID-19 is not an indication to alter the planned route of delivery in
these patients . Cesarean delivery does not appear to reduce the already
low risk for neonatal infection .
• Even if future studies determine the potential for vertical transmission at delivery, this
would not be an indication for cesarean because it would increase maternal risk and
would be unlikely to improve newborn outcome since reports of COVID-19 infection in
the neonate have generally described mild disease.
 Patients with severe or critical disease : In patients with
severe or critical COVID-19, cesarean delivery is performed for
standard obstetric indications, which may include concerns of acute
decompensation of intubated and critically ill mothers.

• Induction of labor can be performed safely in
intubated patients, cesarean birth was
associated with an increased risk for clinical
deterioration
• Although induction of labor can be performed
safely, a long induction can be impractical
logistically if the patient is intubated and
laboring in an operating room or intensive
care unit, because of the specialized
equipment and personnel in these sites.
Cesarean delivery is often performed in such
patients.
• Regardless of the type or site of delivery (eg,
labor and delivery unit, main operating room,
intensive care unit), a multidisciplinary care
team should be present (eg, intensivists,
maternal-fetal medicine, neonatology,
nursing support from obstetrics, pediatrics,
and medical disciplines) to care for the
severely/critically ill mother and the
potentially heavily sedated newborn.

SHOULD be based on maternal and fetal status,
comorbidities, expected duration and difficulty of the
procedure, and the presence (or absence) of an in situ
epidural or spinal catheter.
For patients in whom either neuraxial or general
anesthesia would be appropriate for CD, neuraxial
anesthesia is the preferred anesthetic technique .
General anesthesia may be indicated for emergency CD, for
patients who cannot cooperate with neuraxial anesthesia, and
for patients with contraindications to neuraxial anesthesia.

Neuraxial anesthesia is not
contraindicated in patients with
known or suspected COVID-19 and
has several advantages in laboring
patients.
1. it provides good analgesia and thus
reduces cardiopulmonary stress from
pain and anxiety and, in turn, the
chance of viral dissemination.
2. and it is available in case an emergency
cesarean is required, thus obviating the
need for general anesthesia.

In nonintubated patients with respiratory compromise due to COVID-
19, those receiving magnesium sulfate for seizure prophylaxis and/or neonatal
neuroprotection should be monitored especially carefully (magnesium levels,
frequent respiratory rates, pulse oximetry) since high magnesium levels (10 to 13
mEq/L [12 to 16 mg/dL or 5.0 to 6.5 mmol/L]) can cause respiratory paralysis.
In patients who also have COVID-19-related acute renal injury, we suggest dose-
adjusting magnesium sulfate rather than withholding the drug
In intubated, mechanically ventilated patients, signs of
magnesium-related respiratory toxicity will not be observed; thus, cardiac
arrhythmias or arrest can be the first sign of serious toxicity. Consultation with
maternal-fetal medicine and pulmonary/critical care specialists is advised.

In laboring women with COVID-19 who are not severely
ill, maternal and fetal monitoring and procedures are
generally routine, with the following exceptions:
●Continuous electronic fetal monitoring is recommended
since an increased frequency of nonreassuring tracings has
been reported among pregnant patients with suspected or
confirmed COVID-19, but these case series typically had a high
proportion of women with pneumonia.
●SARS-CoV-2 has rarely been detected in vaginal
secretions or amniotic fluid, so rupture of fetal membranes
and internal fetal heart rate monitoring may be performed for
usual indications, but data are limited . It should be noted that
labor, and particularly pushing, often causes loss of feces,
which can contain the virus .

• As intrapartum oxygen has no proven fetal
benefit, the practice of maternal oxygen therapy for
fetal resuscitation should be abandoned; the nasal
cannula and face mask used are in contact with the
maternal respiratory tract and secretions, so handling
of such equipment increases contamination/exposure
between patient and provider.
• We suggest not delaying pushing in the
second stage, although others have suggested
minimizing the duration of active pushing because
deep breathing and maternal expulsive efforts may
increase exposure to the patient's respiratory
secretions.

• As in noninfected patients, we perform delayed umbilical cord
clamping in women with known or suspected infection since it is highly
unlikely to increase the risk of transmitting pathogens from an infected
mother to the fetus . However, some institutions have chosen to
prohibit this practice in term infants, in whom the benefits are modest,
to minimize newborn exposure to any virus in the immediate
environment and reduce the chances that the newborn will require
phototherapy for jaundice.
• We permit skin-to-skin contact between mothers and
newborns in the delivery room. Some institutions prohibit
skin-to-skin contact in cases of known or suspected maternal
infection , although the American Academy of Pediatrics has not
advised against this . It appears that mothers can safely practice
skin-to-skin care and breastfeed in the delivery room if they
wear a surgical mask and use proper hand hygiene .
• Umbilical cord blood banking can be performed if planned;
the risk of COVID-19 transmission by blood products has not
been documented and is unclear at present .

Management of the third stage of labor is not affected by COVID-19, and most
patients who develop postpartum hemorrhage can be managed according to
standard protocols. However, some clinicians avoid tranexamic acid in COVID-
19 patients because its antifibrinolytic properties may increase the risk for
thrombosis in those with a hypercoagulable state, such as those with severe or
critical disease, and alternative strategies for control of bleeding are available .
Some authorities suggest avoiding methylergometrine because it has been
associated with rare cases of respiratory failure and severe vasoconstriction in
severely ill patients . There is no consensus about this among the contributors
of this topic and no data on which to base a recommendation.
In patients who develop intrapartum fever, COVID-19 infection should be part
of the differential diagnosis, particularly when accompanied by respiratory
symptoms and reduced oxygenation. Such patients should be tested for the
virus (or retested), along with evaluation for common causes of intrapartum
fever (eg, chorioamnionitis, epidural fever)
Management of the third stage of labor

Post
partum
care
New born evaluat
and care

In general, mothers with suspected or confirmed SARS-CoV-2 infection should be isolated from
other healthy mothers and cared for according to standard infection control guidelines.
Maternal monitoring
asymptomatic with mild illness moderate illness
severe or critical
illness
For patients with
known or
suspected COVID-
19 who are
asymptomatic,
postpartum
maternal
monitoring is
routine.
we check vital
signs and monitor
intake and output
every 4 hours for
24 hours after
vaginal delivery
and 48 hours
after cs delivery.
we perform continuous pulse
oximetry monitoring for the first
24 hours or until improvement in
signs and symptoms, whichever
takes longer. The type and
frequency of follow-up laboratory
studies and chest imaging (initial
or repeat) are guided by the
patient's course.
very close
maternal
monitoring and
care on the labor
and delivery unit
or intensive care
unit are indicated.

V
T
E
Venous thromboembolism prophylaxis
• Prophylactic-dose anticoagulation is recommended for postpartum
patients with severe/critical COVID-19, if there are no
contraindications to its use, and generally discontinued when the
patient is discharged to home.
• Postpartum patients with COVID-19 who are asymptomatic or mildly
symptomatic and hospitalized for reasons other than COVID-19 (eg,
labor and delivery) do not require postpartum anticoagulation unless
they have other thrombotic risk factors, such as prior venous
thromboembolism (VTE) or, in some cases, cesarean delivery. Either
low molecular weight heparin or unfractionated heparin is acceptable,
and both are compatible with breastfeeding.
• In patients who develop dyspnea and hypoxemia postpartum, the
differential diagnosis includes severe COVID-19, sepsis, influenza,
cardiomyopathy, and pulmonary embolism.

Pain management is routine Acetaminophen is the preferred analgesic agent; however, we do not avoid
use of nonsteroidal anti-inflammatory drugs (NSAIDs) when clinically indicated.
• The differential diagnosis of postpartum fever in patients with COVID-
19 includes the infection itself as well as postpartum endometritis,
surgical site infection, breast inflammation or infection, influenza,
pyelonephritis, other viral or bacterial respiratory infections, and,
rarely, pseudomembranous colitis due
to Clostridioides (formerly Clostridium) difficile. The combination of
composite symptoms, physical examination, and laboratory tests can
usually distinguish among these disorders.
• Acetaminophen is the preferred antipyretic agent.
• Postpartum patients with new onset of symptoms of COVID-19
In newly symptomatic patients who previously tested negative for SARS-
CoV-2, retesting is appropriate as part of the evaluation of fever or other
potential manifestations of COVID-19 .

Newborn evaluation
The infants of mothers with suspected or confirmed COVID-19 are considered
persons under investigation, and they should be tested for SARS-CoV-2 RNA by
reverse transcription polymerase chain reaction (RT-PCR) The American Academy of
Pediatrics (AAP) suggests the following for diagnosis of newborn infection:
• NOTE:Some centers have transitioned to swabs of the anterior nares. The specifics
of testing depend on the requirements of local testing platforms
Test at approximately 24
hours of age
if negative
again at approximately 48 hours of
age since some infants have had a
negative test at 24 hours only to have
a positive test at a later time
If a healthy, asymptomatic newborn will be discharged prior to 48 hours
of age, a single test at 24 to 48 hours of age can be performed.
Obtain either
a single swab of the
nasopharynx
a single swab of the
throat followed by
the nasopharynx
two separate swabs
from each of these
sites, and submit for
a single test

We recommend not separating the mother and newborn after birth in situations in which
the mother has suspected or confirmed SARS-CoV-2 infection. The newborn's risk for
acquiring SARS-CoV-2 from its mother is low, and data suggest no difference in risk of
neonatal SARS-CoV-2 infection whether the neonate is cared for in a separate room or
remains in the mother's room.
However, mothers should wear a mask and
practice hand hygiene during contact with
their infants, and at other times, reasonable
physical distancing between the mother and
neonate or placing the neonate in an
incubator is desirable, when feasible

1. Separation may be necessary for mothers who are too ill to care for
their infants or who need higher levels of care.
2. Separation may be necessary for neonates who may be at higher risk
for severe illness (eg, preterm infants, infants with underlying
medical conditions, infants needing higher levels of care).
3. Separation to reduce the risk of mother-to-newborn transmission is not
useful if the neonate tests positive for SARS-CoV-2, and probably not
useful if the mother and newborn will not be able to maintain separation
after discharge until they meet criteria for discontinuation of quarantine.
If separation is implemented, newborn COVID-19 suspects/confirmed
cases should be isolated from other healthy newborns and cared for, in the
United States, according to the Centers for Disease Control and
Prevention's (CDC).
If another healthy family member is providing newborn care (eg,
diapering, bathing, feeding), they should use appropriate personal
protective equipment and procedures (eg, mask, hand hygiene).
Rooming-in helps establish breastfeeding, facilitates bonding and parental education,
and promotes family-centered care.

Symptomatic mothers : Previously symptomatic mothers
with suspected or confirmed COVID-19 are not considered a
potential risk of virus transmission to their neonates if they have
met all of the criteria for discontinuing isolation and precautions :
• At least 10 days have passed since symptoms first appeared
(up to 20 days if they have more severe to critical illness or
are severely immunocompromised).
• At least 24 hours have passed since their last fever without
the use of antipyretics.
• Symptoms have improved.
Asymptomatic mothers : For asymptomatic mothers
identified because of routine SARS-CoV-2 screening upon
hospital admission, at least 10 days should have passed
since the positive test before discontinuing mother-newborn
infection precautions.

The risk of SARS-CoV-2 transmission from ingestion of
breast milk is unclear.
There is general consensus that breastfeeding should
be encouraged because of its many maternal and infant
benefits. In the setting of maternal COVID-19 infection, the
infant may receive passive antibody protection from the
virus since breast milk is a source of antibodies and other
anti-infective factors.
The AAP supports breastfeeding in mothers with COVID-
19, but mothers should perform hand hygiene before, and
wear a mask during, breastfeeding . This approach
considers the clear mother-infant benefits of
breastfeeding, the low likelihood of passing maternal
infection to the newborn when infection precautions are
taken, and the non severe course of newborn infection
when it does occur.

If mother and baby separation has been implemented, ideally, the infant is fed expressed breast milk by another
healthy caregiver until the mother has recovered or has been proven uninfected, provided that the other
caregiver is healthy and follows hygiene precautions . Expressing breast milk is important to
support establishment of the maternal milk supply.
Before pumping, ideally with a dedicated breast pump, mothers should wear a mask and thoroughly clean
their hands and breasts with soap and water and clean pump parts, bottles, and artificial nipples . If
possible, the pumping equipment should be thoroughly cleaned by a healthy person.
If feeding by a healthy caregiver is not possible, mothers with confirmed COVID-19 or symptomatic mothers with
suspected COVID-19 should take precautions to prevent transmission to the infant during breastfeeding (wear a
mask, hand and breast hygiene, disinfect shared surfaces that the symptomatic mother has contacted).
However, it should be noted that the value of precautions, such as cleansing the breast prior to
breastfeeding/milk expression or disinfecting external surfaces of milk collection devices (eg, bottles, milk bags)
for reducing potential transmission of SARS-CoV-2, has not been formally studied .
: Ideally, women who choose to formula feed should have another healthy caregiver
feed the infant. If this is not possible or desired, such women must also take appropriate infection control
precautions, as described above, to prevent transmission through close contact when feeding.

Regarding remdesivir , infants are not likely to absorb
clinically important amounts of the drug from breast milk. No
serious adverse drug reactions have been reported in
newborn infants who received intravenous remdesivir
therapy for Ebola.
Breastfeeding is not an exclusion to receiving the first
vaccines to become clinically available, which are based on
mRNA or protein subunits and do not contain infectious virus.
However, lactating women were not included in vaccine
trials. If any mRNA or protein subunits cross into breast milk
and are then ingested by the infant, they are likely to be
inactivated by the infant's digestive system, but maternal
COVID-19 antibodies induced by maternal vaccination can
pass into breast milk and may have protective effects

• If not performed or if a reversible contraceptive method is
desired, an alternative form of contraception should be
provided (eg, immediate postpartum long-acting
reversible contraception or depot medroxyprogesterone
acetate) as long as the patient desires one of these
methods. This avoids additional outpatient postpartum
visits.
Permanent contraception (tubal sterilization) does not add significant additional time or
risk when performed at an uncomplicated cesarean birth and, thus, should be
performed if planned. Permanent contraception after a vaginal birth is more of an
elective procedure, so such decisions should be made on a local level, based on available
resources.

Patients without COVID-19
In stable patients, we suggest early discharge postpartum, such as one
day after vaginal delivery and two days after cesarean delivery, to limit
their personal risk of acquiring infection in the hospital environment .
However, this should be considered in the context of the clinical scenario
since early discharge may place additional burdens on families to access
recommended newborn care and pediatric offices to provide this care
.Vaccination for prevention of COVID-19 is recommended, if a vaccine is
available. Breastfeeding is not a contraindication to vaccination.
Patients with known or suspected COVID-19
The decision to discharge a patient with COVID-19 is generally the
same as that for other conditions and depends on the need for
hospital-level care and monitoring.
We counsel all patients on the warning symptoms that should prompt
reevaluation by telehealth visit and in-person visit, including
emergency department evaluations. These include new onset of
dyspnea, worsening dyspnea, dizziness, and mental status
changes, such as confusion.

Modifying or reducing in-person
postpartum outpatient care in the midst of
the pandemic is appropriate to reduce the
risk of inadvertent exposure. For example, it
may be possible to perform early postpartum
assessments, including wound and blood
pressure checks, with telehealth. A
comprehensive postpartum visit may still
be important by 12 weeks, especially in
patients with comorbidities and in patients
who lose insurance coverage at that time.
All postpartum patients should still be
screened for postpartum depression four
to eight weeks after delivery.

https://www.uptodate.com/contents/coronavi
rus-disease-2019-covid-19-labor-delivery-and-
postpartum-issues-and-
care?search=labor%20an%20deliver%20covid
%2019&source=search_result&selectedTitle=1
~150&usage_type=default&display_rank=1
Sources

Covid19 in pregnancy

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