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Covid19 & pregnancy
1. 5/8/2020
ABOUBAKR ELNASHAR 1
COVID-19 &
Pregnancy
What obstetrician needs to
know?
Sexual intercourse
Infertility
ART
Pregnancy
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR
Vertical transmission
(transmission from mother to baby antenatally or intrapartum)
China: no evidence
{amniotic fluid, cord blood, neonatal throat swabs,
placenta swabs, genital fluid, breast milk samples
from infected mothers: negative for the virus}.
RCOG, 2020, 21 April: probability
2 reports: {IgM for SARS-COV-2 in neonatal
serum at birth. Since IgM does not cross the
placenta,± represent a neonatal immune
response to in utero infection}.ABOUBAKR ELNASHAR
2. 5/8/2020
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Sexual transmission (UNICEF, 2020)
NO
{not found in semen or vaginal fluid}
But: SI involves close contact, kissing& touching,
these are the ways of transmitting this virus
Avoid sex if you or your husband (New York City Health, 2020)
1. Confirmed Covid19
2. Suspected Covid 19
3. High risk for severe Covid-19
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DIAGNOSIS
Suspected cases (22.4.2020)
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3. 5/8/2020
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22.4.2020
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Single chest radiograph
Very low fetal radiation dose (0.0005 to 0.01 mGy)
Abdominal shielding
CT
should be performed, if indicated
fetal radiation dose is low
Not associated with an increased risk of
fetal anomalies or
pregnancy loss.
Pulmonary ultrasound
quick diagnosis of pneumonia
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4. 5/8/2020
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EFFECTS ON PREGNANCY
1. Maternal
Not more likely to contract COVID19
1. More severe infection
Pneumonia
Marked hypoxia
In late pregnancy, compared with early
pregnancy.
The absolute risks: Small
2. Increased risk of DVT
{Reduced mobility from self-isolation at home, or hospital
admission}
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5. 5/8/2020
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2. Effect on the fetus
No increased risk of
Miscarriage or early pregnancy loss
Teratogenicty .
1. Fetal compromise
2. Prelabour PROM
3. Hyperthermia during organogenesis: congenital
anomalies, NTD, or miscarriage.(Theoretical)
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Yan et al, 2020. 24 April
116 pregnant women withCOVID-19 in China
The most common symptoms
Fever: 50.9%
Cough: 28.4%
No sym: 23.3%.
Abnormal radiologic findings in 96.3% of cases.
Severe pneumonia: 6.9%. no maternal deaths.
PTL: 23.2%
Spontaneous PROM: 6.1%
CS: 85.9%
NICU: 47% Neonatal death: 1%.ABOUBAKR ELNASHAR
6. 5/8/2020
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MANAGEMENT
MULTIDISCIPLINARY TEAM
1. Chest specialist
2. Intensivist
3. OBSTETRICIAN
4. Anesthesiologist
5. Neonatologist
6. Microbiologist
7. infection control specialist
A. MEDICAL
B. OBSTETRICAL
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A. MEDICAL
22.4.2020
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7. 5/8/2020
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OBSTETRICAL
I. ANTENATAL CARE (RCOG, 2020)
Appointments
Limited with remote consultation by telephone
Women who have had symptoms
deferred until 7 days after the start of
symptoms, unless symptoms (aside from
persistent cough) persevere.
Suspected or confirmed COVID-19
delayed until after the recommended period of
isolation 14 days
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8. 5/8/2020
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Antenatal Clinic
Separate for suspected or confirmed COVID-19.
Dedicated team
appropriate PPE.
Dedicated equipment
Remove non-essential items
US machine
decontaminated after each use.
Transducers are cleaned and disinfected
Protective covers for probes and cables.
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9. 5/8/2020
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Procedures
US & other investigations (urine &blood tests in
same visit
US for F growth& anatomy.
Electronic FHR monitoring
Doppler assessment
Amniocentesis
Not recommended in active infection.
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2. Use of medications to manage pregnancy
Antenatal betamethasone
CDC: avoiding glucocorticoids in COVID-19-
positive { increased risk for mortality}
ACOG: between 24+0 &33+6 w in patients at
high risk of PTL within 7 days
Not 34+0 to 36+6 w
{benefits to the neonate are less clear}
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10. 5/8/2020
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Low-dose aspirin
For prevention of PET.
Suspected or confirmed COVID-19 for whom LDA
would be indicated, the decision to continue should
be individualized & is usually possible.
Continuing is not worthwhile in
Severely or critically ill patients or
Near term
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NSAIDs (ibuprofen)
Early in the course of infection: severe disease
No clinical or population-based data that directly address
the risk of NSAIDs.
WHO do not recommend avoiding NSAIDs in COVID-19 patients
when clinically indicated
Acetaminophen
In the first trimester
Fever
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11. 5/8/2020
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Tocolysis
Nifedipine
Not:
Indomethacin, which is subject to the concerns
discussed above
Beta sympathomimetics, which can further
increase the maternal heart rate.
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3. Delivery timing
Depend upon:
1. Mother's clinical status
2. Gestational age
3. Fetal well-being.
Improvement mother's condition: improve fetal
status: pregnancies allowed to continue to term.
If woman is critically ill, deterioration : IUF demise
or loss of both mother& infant: early delivery
Infectious: Elective CS ± delayed, if possible
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12. 5/8/2020
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Mg sulfate —
Indication
maternal seizure prophylaxis
neonatal neuroprotection
Women with respiratory compromise
{Mg sulfate ±depress respirations}.
Consultation with maternal-fetal medicine&
pulmonary/critical care specialists.
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II.INTRAPARTUM
1. Evaluation of all patients on admission
2. PPE on labor
All clinicians
All asymptomatic patients
3. Mode of delivery
Based on obstetric indications, as there is no clear
benefit of delivery via CS
Seriously ill patients & need urgent delivery
should be by category 1 CS.
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13. 5/8/2020
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4. Analgesia & anesthesia
Regional Anasthesia by epidural or spinal
Recommended .
General anesthesia (intubation & extubation)
Considered an aerosolizing procedure
The scrub team should
Scrub & wear PPE (N-95) before the general
anesthesia is commenced.
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Nitrous oxide
Not recommended
{insufficient data about cleaning, filtering, potential
aerosolization of nitrous oxide systems}.
Intravenous, patient-controlled analgesia
limiting use
{risk of respiratory depression}.
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14. 5/8/2020
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5. Labor management
Person-to person contact & time in the labor unit &
hospital should be limited
Maternal observations:
T, RR, oxygen saturation to be kept above 94%.
Fluid chart to avoid fluid overload.
Continuous CTG
Shortening of the second stage
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Rupture of membranes&internal FHR monitoring
±performed, but data are limited
{COVID19 has not been detected in vaginal secretions or
amniotic fluid}
Pushing
often causes loss of feces, which can contain the
virus & spread the infection
Not delaying pushing in 2nd stage.
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15. 5/8/2020
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Delayed cord-clamping:
Unlikely to increase the risk of transmitting virus
from infected mother to the fetus
(ACOG, RCOG, EMH, April 2020)
Oxygen therapy for fetal resuscitation
Should be abandoned
{no proven fetal benefit
nasal cannula& face mask used are in contact with
the maternal respiratory tract& secretions: increases
contamination/exposure between pt. &provider}.
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Neonate should be
Cleaned& dried immediately
Leaving vernix caseosa in place for 24 h since it
contains antimicrobial peptides.
Isolated for 14 days
Closely monitored for clinical manifestations of
infection.
The mother & newborn
May need to be isolated separately until both are
cleared
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16. 5/8/2020
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III. Post partum care
1. Placental disposal
The placenta should be treated as biohazardous
waste
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3. Breast feeding: (EMH, April 2020)
Not recommended.
If the mother is severely or critically ill
express breast milk with a pump to maintain milk production (the
pump should be cleaned after each use).
Can be considered
If the mother is asymptomatic or mildly affected,
{virus is transmitted by respiratory droplets rather than breast milk}
Mothers should:
wash their hands
wear a mask
avoid coughing or sneezingABOUBAKR ELNASHAR
17. 5/8/2020
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5. Postpartum fever
COVID-19 should be part of the dd particularly
respiratory symptoms &
reduced oxygenation.
Such patients should be
tested for the virus
evaluation for common causes of intrapartum
&postpartum infection:
Chorioamnionitis
Endometritis
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6. Postpartum office visits
Should be limited to reduce the risk of inadvertent exposure.
Early postpartum assessments: wound &blood
pressure checks, with telephone.
After 4-8 w: psychological assessment
Screen for postpartum depression: self-report,
10-item Edinburgh Postnatal Depression Scale,
which can be completed in 5 minutes
Severe anxiety and support offered.
After 12W: A comprehensive assessment
especially in patients with comorbiditiesABOUBAKR ELNASHAR
18. 5/8/2020
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TAKE HOME MESSAGE
1. No evidence of miscarriage, F. congenial fetal
malformation.
2. It may cause PTL, PPROM, F. compromise
3. ANC should be delayed till the symptoms improve
4. Separate room, dedicated team, appropriate PPE.
dedicated equipment
5. Delivery timing depend upon: Mother's clinical status
G. age & F. well-being.
6. Mode of delivery based on obstetric indications
7. Regional anasthesia by epidural or spinal
8. The placenta is treated as biohazardous waste
9. Breast feeding not recommended if the mother is
severely or critically ill
ABOUBAKR ELNASHAR
For CONID 19 AND Pregnancy: The following
statements are correct except
A. Increased risk of DVT during pregnancy
B. It is not sexually transmitted
C. Corticosteroid is indicated between 24+0 &33+6 w
in patients at high risk of PTL within 7 days
D. Oxygen therapy for fetal resuscitation is
recommended
E. Delayed cord-clamping is unlikely to increase risk
of transmitting virus from infected mother to fetus
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