Safe Motherhood and COVID-19
Although several questions remain unclear about pregnant women and their newborns, prior epidemics give us a frame of reference for what can happen with respiratory viral infections in pregnancy. Today, reducing the public health burden of COVID-19 should be our number one priority.
As obstetricians and gynecologists, we must help achieve that by implementing measures as simple as spreading awareness in our community and among pregnant women about the safe practices of hand hygiene, cough etiquette, social distancing, staying home when sick and disinfecting contaminated surfaces.
Another way is by encouraging telephone triaging wherever feasible to screen for recent travel, fever and respiratory symptoms to assess the patient’s need for inpatient support or supplemental testing before they show up to their appointments. Reducing patient risk through healthcare exposure is of paramount importance, understanding that health systems and healthcare providers may become the most common vector for transmission of COVID-19.
Antenatal care is based on years of evidence to keep mothers and babies safe in pregnancy, and as such, is essential care. However, with this pandemic, it seems prudent that the general principle should be to minimise in-person office visits.
For low-risk women, a reasonable scheme would be to see the patient in each trimester, timed with scheduled testing. For example, at 12 weeks for genetic screening, 20 weeks for the morphology scan and review, 28 weeks for gestational diabetes screening, anti-immunoglobulin administration and Tdap vaccination, 32 weeks, 36 weeks for Group B Streptococcus culture, and 38 weeks’ appointment.
As the pandemic expands, where practical, appointments should be conducted on the telephone or with videoconferencing, as appropriate for follow up of medical comorbidity.
Women with symptoms of COVID-19 should be tested and delay an appointment if possible, during the self-quarantine period. If symptoms persist, they need to call and make an appointment for testing and or hospitalisation. Advances in telehealth and remote monitoring make virtual visits a reality in some locations. Additional measures should include limiting the number of support persons/visitors with patients for outpatient and inpatient visits, including labour and delivery areas.
Patients suspected of COVID-19
There are no studies that provide guidance on fetal monitoring of an asymptomatic pregnant woman; monitoring should be based on the type of symptoms experienced. If a patient is febrile or has respiratory difficulties, she needs to be hospitalised. Some recommendations propose continuous intrapartum monitoring for infected women given the rate of fetal compromise in two Chinese series. Adherence to infection precautions is critical at all steps. Limited data exist to guide the postnatal management of infants of infected mothers. However, they should be considered Person Under Investigation (PUI) although no vertical transmission in these cases has been reported, so far. Research focusing on antibody detection may change our understanding of the disease process and possible transplacental communication.
There is agreement that infants born to infected mothers should be tested for COVID-19. Whether a mother-baby unit should experience isolation has not been studied. Some have recommended that infants should be isolated from the infected mother for 14 days or until the mother’s transmission-based precautions are discontinued. This can be done by putting them in separate rooms or using physical barriers (e.g., a curtain between the mother and newborn) and keeping the newborn ≥6 feet away from the mother. The decision to separate mother and newborn should be made with obstetrician, paediatrician, neonatologist, midwife and or nursing staff and fully involving the mother.
When it comes to breastfeeding, in a woman who is COVID-19 positive, the main risk for infants is the close contact with the mother, who is likely to shed infective airborne droplets. The research from China, although limited, has not shown virus in breastmilk. In light of the current evidence, the benefits of breastfeeding seem to outweigh any potential risks of transmission of the virus through breastmilk. Therefore, breast milk provision directly or via pumping is encouraged. This guidance may change as our knowledge evolves. For women who wish to breastfeed, precautions should be taken to limit the viral spread to the baby by observing strict hand hygiene before touching the baby. While breastfeeding, a facemask should be worn. For those who wish to pump, a dedicated breast pump should be used, and proper pump cleaning should be performed after each.
As obstetricians, it is of utmost importance to stay up to date as the situation with COVID-19 rapidly unfolds.
This includes updates about local transmission in the area of our practice as we have obligations towards our patients who deserve no less than our full commitment during these challenging times.