Special Considerations in Pregnancy
Last Updated: August 27, 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 (SMFM) on the management of pregnant patients with COVID-19.1-4 This section of the COVID-19 Treatment Guidelines complements that guidance. Below are key considerations regarding the management of COVID-19 in pregnancy.
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion
Epidemiology of COVID-19 in Pregnancy
Initial reports of COVID-19 disease acquired in the third trimester were reassuring, although most early data were limited to case reports and case series.5-7 Since that time, a large population-based cohort study in the United Kingdom evaluated outcomes in pregnant women hospitalized with confirmed severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection. Among 427 pregnant women admitted to 197 obstetric units across the United Kingdom, the rates of critical care admission and severe SARS-CoV-2-associated maternal mortality were similar to those in the general population of women of reproductive age hospitalized with COVID-19 in the United Kingdom, although the pregnant women were not compared with age-matched, nonpregnant controls.8
In June 2020, the Centers for Disease Control and Prevention (CDC) released surveillance data evaluating SARS-CoV-2-related outcomes in reproductive aged women by pregnancy status. Among 326,335 women aged 15 to 44 years with positive test results for SARS-CoV-2, pregnant women were more likely to be hospitalized, be admitted to an intensive care unit (ICU), and receive mechanical ventilation. However, the overall absolute increase in rates of ICU admission and mechanical ventilation was low among the pregnant women and the nonpregnant women (1.5% vs. 0.9% for ICU admission, respectively, and 0.5% vs 0.3% for mechanical ventilation, respectively). COVID-19-related death rates were similar in the pregnant and nonpregnant populations. Pregnancy outcomes such as preterm birth or pregnancy loss were not evaluated.
This analysis has a number of significant limitations, including:
- Pregnancy status was only available for 28% of the women of reproductive age with SARS-CoV-2 infection.
- It was not possible to determine whether the reasons for hospitalization, ICU admission, or mechanical ventilation were related to COVID-19, pregnancy, and/or delivery.
Pregnant women who are Hispanic or Black may be disproportionately affected by SARS-CoV-2 infection.9 Pregnant women should be counseled about the potential for severe disease from SARS-CoV-2 and measures to protect themselves and their families from infection, including physical distancing, face coverings, and hand hygiene. CDC, ACOG, and SMFM highlight the importance of accessing prenatal care. ACOG provides an FAQ on using telehealth to deliver antenatal care, when appropriate.
ACOG has developed an algorithm to evaluate and manage pregnant outpatients with suspected or confirmed SARS-CoV-2 infection. As in nonpregnant patients, SARS-CoV-2 infection in pregnant patients can present as asymptomatic/presymptomatic disease or with a wide range of clinical manifestations, from mild symptoms that can be managed with supportive care at home to severe disease and respiratory failure requiring ICU admission. As with other patients, in the pregnant patient with symptoms compatible with COVID-19, the illness severity, underlying comorbidities, and clinical status should all be assessed to determine whether in-person evaluation for potential hospitalization is needed.
If hospitalization is indicated, care should be provided in a facility that can conduct maternal and fetal monitoring, when appropriate. The management of COVID-19 in the pregnant patient may include:
- Fetal and uterine contraction monitoring, when appropriate, based on gestational age
- Individualized delivery planning
- A multispecialty, team-based approach that may include consultation with obstetric, maternal-fetal medicine, infectious disease, pulmonary and critical care, and pediatric specialists, as appropriate.
Other recommendations on the management of COVID-19, as outlined for the nonpregnant patient, also apply in pregnancy.
Timing of Delivery
- Detailed guidance relating to timing of delivery and risk of vertical transmission of SARS-CoV-2 is provided by ACOG.10
- In most cases, the timing of delivery should be dictated by obstetric indications rather than maternal diagnosis of COVID-19. For women who had suspected or confirmed COVID-19 early in pregnancy who recover, no alteration to the usual timing of delivery is indicated.
- Vertical transmission of SARS-CoV-2 via the transplacental route appears to be rare but possible.11-13
Management of COVID-19 in the Setting of Pregnancy
- Potentially effective treatment for COVID-19 should not be withheld from pregnant women because of theoretical concerns related to the safety of therapeutic agents in pregnancy (AIII).
- Decisions regarding the use of drugs approved for other indications or investigational agents for the treatment of COVID-19 in pregnant patients must be made with shared decision-making between the patient and the clinical team, considering the safety of the medication for the woman and the fetus and the severity of maternal disease. For detailed guidance on the use of COVID-19 therapeutic agents in pregnancy, please refer to Considerations in Pregnancy in the Antiviral Therapy and Immune-Based Therapy sections of these Guidelines.
- To date, most SARS-CoV-2-related clinical trials have excluded, or included only a very few, pregnant women and lactating women. This limitation makes it difficult to make evidence-based recommendations on the use of SARS-CoV-2 therapies in these vulnerable patients and potentially limits their COVID-19 treatment options. When possible, pregnant women and lactating women should not be excluded from clinical trials of therapeutic agents or vaccines for SARS-CoV-2 infection.
- Specific guidance for post-delivery management of infants born to mothers with known or suspected SARS-CoV-2 infection, including breastfeeding recommendations, is provided by the CDC14,15 and the American Academy of Pediatrics.16
- Centers for Disease Control and Prevention. Considerations for inpatient obstetric healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html. Accessed August 26, 2020.
- The American College of Obstetricians and Gynecologists. Novel coronavirus 2019 (COVID-19): practice advisory. August 2020. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019. Accessed August 26, 2020.
- Society for Maternal-Fetal Medicine. Coronavirus (COVID-19) and Pregnancy: What Maternal Fetal Medicine Subspecialists Need to Know. July 2020. https://s3.amazonaws.com/cdn.smfm.org/media/2468/COVID19-What_MFMs_need_to_know_revision_7-23-20_(final).PDF. Accessed August 26, 2020.
- 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;222(5):415-426. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105680.
- 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.
- 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.
- 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 August 26, 2020.
- Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ. 2020;369:m2107. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32513659.
- Ellington S, Strid P, Tong VT, et al. Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22-June 7, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):769-775. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32584795.
- The American College of Obstetricians and Gynecologists. COVID-19 FAQs for Obstetricians-Gynecologists, Obstetrics. 2020. Available at: https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics. Accessed August 26, 2020.
- Thomas P, Alexander PE, Ahmed U, et al. Vertical transmission risk of SARS-CoV-2 infection in the third trimester: a systematic scoping review. J Matern Fetal Neonatal Med. 2020:1-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32611247.
- Matar R, Alrahmani L, Monzer N, et al. Clinical presentation and outcomes of pregnant women with COVID-19: a systematic review and meta-analysis. Clin Infect Dis. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32575114.
- Vivanti AJ, Vauloup-Fellous C, Prevot S, et al. Transplacental transmission of SARS-CoV-2 infection. Nat Commun. 2020;11(1):3572. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32665677.
- Centers for Disease Control and Prevention. Evaluation and management considerations for neonates at risk for COVID-19. 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html. Accessed August 26, 2020.
- Centers for Disease Control and Prevention. Care for breastfeeding women: interim guidance on breastfeeding and breast milk feeds in the context of COVID-19. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-breastfeeding-women.html. Accessed August 26, 2020.
- American Academy of Pediatrics. FAQs: management of infants born to mothers with suspected or confirmed COVID-19. 2020. Available at: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/faqs-management-of-infants-born-to-covid-19-mothers/. Accessed August 26, 2020.