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Special Considerations in Pregnancy and Post-Delivery

Last Updated: May 12, 2020

There is current guidance from the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal Fetal Medicine on the management of pregnant patients with COVID-19.1-4 This section of the Treatment Guidelines complements that guidance and focuses on considerations regarding management of COVID-19 in pregnancy.

Limited information is available regarding the effect of COVID-19 on obstetric or neonatal outcomes. Initial reports of COVID-19 disease acquired in the third trimester were largely reassuring, but most data are limited to case reports and case series.5,6 In one of the larger series from Wuhan, China, pregnant women did not appear to be at risk for more severe disease.7 Among 147 pregnant women with COVID-19 (64 confirmed cases, 82 suspected cases, and 1 case of asymptomatic infection), 8% had severe disease and 1% had critical disease. In comparison, in the general population of persons with COVID-19, 13.8% had severe disease and 6.1% had critical disease.8 While data are still emerging, the US experience has been similar to date. 9

ACOG has developed algorithms to evaluate pregnant outpatients with suspected or confirmed COVID-19.10 As with non-pregnant patients, a wide range of clinical manifestations of the disease occur, from mild symptoms that can be managed with supportive care at home to severe disease and respiratory failure requiring intensive care unit admission. As with other patients, in the pregnant patient with symptoms compatible with COVID-19, the illness severity, underlying co-morbidities, and clinical status should all be assessed to determine whether in-person evaluation for potential hospitalization is needed.

If hospitalization is indicated, ideally the care should be provided in a facility that has the capability to conduct close maternal and fetal monitoring. The principles of management of COVID-19 in the pregnant patient may include:

  • Fetal and uterine contraction monitoring
  • Individualized delivery planning
  • A team-based approach with multispecialty consultation.

Other recommendations, as outlined for the non-pregnant patient, will also apply in pregnancy.

Timing of Delivery:

  • In most cases, the timing of delivery should be dictated by obstetric indications rather than maternal diagnosis of COVID-19. For women with suspected or confirmed COVID-19 early in pregnancy who recover, no alteration to the usual timing of delivery is indicated.
  • For women with suspected or confirmed COVID-19 in the third trimester, it is reasonable to attempt to postpone delivery (if no other medical indications arise) until a negative test result is obtained or quarantine restrictions are lifted in an attempt to avoid virus transmission to the neonate.
  • In general, a diagnosis of COVID-19 in pregnancy is not an indication for early delivery.11
  • Based on limited data on primarily cesarean deliveries, there appears to be no clear evidence of vertical transmission of SARS-CoV-2 via the transplacental route, but this has not been definitively ruled out.11

Management of COVID-19 in the Setting of Pregnancy:

  • There are no Food and Drug Administration-approved medications for the treatment of COVID-19.
  • Most clinical trials to date have excluded pregnant and lactating women.
  • Decisions regarding the use of drugs approved for other indications or investigational agents to treat COVID-19 must be made with shared decision-making, considering the safety of the medication and the risk and seriousness of maternal disease (see Antiviral Therapy, Immune-Based Therapy and Considerations for Certain Concomitant Medications in Patients with COVID-19).
  • Involvement of a multidisciplinary team in these discussions, including, among others, specialists in obstetrics, maternal-fetal medicine, and pediatrics, is recommended.
  • Enrollment of pregnant and lactating women in clinical trials (if eligible) is encouraged.

Post-Delivery:

  • Currently the CDC recommends that the determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case-by-case basis using shared decision-making between the mother and the clinical team.
  • ACOG supports breastfeeding for infants. They recommend that, for women who are PUI or confirmed to have SARS-CoV-2 infection, the decision about whether and how to start or continue breastfeeding be made by the mother in coordination with her family and health care practitioners.11
  • CDC has developed interim guidance on breastfeeding, recommending that women who intend to breastfeed and who are temporarily separated from their infants express their breastmilk, ideally from a dedicated pump, practice good hand hygiene before and after pumping, and consider having a healthy person feed the infant.
  • CDC advises that women with COVID-19 who choose to room-in with their infants and feed them at the breast should practice good hand hygiene and wear a facemask to prevent transmission of the virus to the infant via respiratory droplets during breastfeeding.1 SARS-CoV-2 has not been isolated from breast milk.5

References

  1. Centers for Disease Control and Prevention. Interim considerations for infection prevention and control of coronavirus disease 2019 (COVID-19) in inpatient obstetric healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html. Accessed April 2, 2020.
  2. The American College of Obstetricians and Gynecologists. Practice advisory: novel coronavirus 2019 (COVID-19). 2020. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019.
  3. Society for Maternal Fetal Medicine. Coronavirus (COVID-19) and pregnancy: what maternal fetal medicine subspecialists need to know. 2020. Available at: https://www.smfm.org/covid19. Accessed April 8, 2020.
  4. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105680.
  5. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-815. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32151335.
  6. Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32145216.
  7. Breslin N, Baptiste C, Miller R, et al. COVID-19 in pregnancy: early lessons. American Journal of Obstetrics & Gynecology MFM. 2020. [In Press]. Available at: https://www.sciencedirect.com/science/article/pii/S2589933320300410?via%3Dihub.
  8. World Health Organization. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). 2020. Available at: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf. Accessed March 27, 2020.
  9. Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM. 2020:100118. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32292903.
  10. The American College of Obstetricians and Gynecologists. Outpatient assessment and management for pregnant women with suspected or confirmed novel coronavirus (COVID-19). 2020. Available at: https://www.smfm.org/covid19/. Accessed April 2, 2020.
  11. The American College of Obstetricians and Gynecologists. COVID-19 frequently asked questions for obstetricians-gynecologists, obstetrics. 2020. Available at: https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics. Accessed April 2, 2020.