Pregnant women with suspected or confirmed COVID-19 and their newborn infants form a special vulnerable group that needs immediate attention unlike other elective medical and surgical problems for which care can be deferred during the pandemic. Available data suggests that in general the outcome among pregnant women and neonates is good. A large proportion of infected pregnant women are likely to be asymptomatic or have mild symptoms. However, severe disease needing admission to intensive care unit has been reported among the pregnant women. Pregnant women over the age of 35, those who are overweight or obese, and those who have pre-existing medical problems such as high blood pressure and diabetes are also at higher risk of developing severe illness and require admission to hospital.
Neonates are said to be exposed to COVID-19 if they are born to mothers with a history of COVID-19 infection diagnosed within 14 days before delivery or 28 days after delivery or if the neonate is directly exposed to close contacts with COVID-19 infection.
Since this is a very new virus, all the information and evidence is still not available to us at present. There is no current evidence to suggest an increased risk of miscarriage if exposed to COVID-19. There is also no current evidence of vertical transmission, which refers to the ability of the virus to pass to unborn baby during pregnancy.
Precautions for a pregnant women against Coronavirus
Hands should be washed frequently. Social distancing to be practised by maintaining a distance of at least 2 meters or 6 feet from others in a public place. Flu vaccination should strongly considered as even though it does not protect from exposure to COVID-19, as it does make one less susceptible to influenza, which can cause complications during pregnancy.
Respiratory symptoms should not be ignored and if one develops a cough or any respiratory distress, do not hesitate to call the doctor. After taking a detailed history, the doctor will decide if COVID-19 testing needs to be done. As much as possible, virtual consultations should be considered and minimal essential prenatal visits to gynaecologist be made with avoidance of spending time in the doctor’s waiting room or in the hospital. Certain tests such as the ultrasound, blood tests, and fetal assessment do require physical presence.
Working from home should be opted for whenever possible. One should avoid coming in close contact with anyone showing symptoms like high fever with or without continuous cough which may indicate a possible coronavirus infection. Emails, messages or video chats are a good medium to keep in touch and seek support from family and friends. Working on a new hobby or acquisition of a new skill can make one happy and reading or meditation can help to put the mind at ease. A balanced diet, appropriate supplements(including Vit D) and regular exercise are very important as per doctor’s advice. There is no need to stress too much if the due date is nearing, as hospitals have a system in place for safe deliveries and to ensure minimal risk of exposure for newborns.
Testing for Pregnant Women
Pregnant women with a history of travel or exposure to a confirmed/suspected case of COVID-19 should be isolated by using the ICMR guidelines for non-pregnant adults. Pregnant women presenting in labour or likely to deliver in next five days should be tested even if asymptomatic.
Care of Pregnant women by healthcare professional
Pregnant women with active COVID-19 infection should be managed with supportive care recommended for non-pregnant adults. Currently recommended national management includes: – oxygen therapy/respiratory support for treatment of hypoxemic respiratory failure, fluid therapy, antibiotics and management of shock. The choice of specific antiviral therapy is likely to change with rapidly emerging evidence and updated national guidance should be consulted.
When providing healthcare to women in labour with confirmed or suspected COVID-19 infection, follow standard universal precautions to prevent contact with body fluids. In addition, use personal protective equipment (PPE) to prevent acquiring infection through respiratory droplets. The PPE should include masks such as the N95 and face protection by a face shield or at least goggles.
Mode of delivery in pregnant women infected with COVID-19 should be guided by their obstetric assessment and physiological stability (cardio-respiratory status and oxygenation). COVID-19 infection itself is not an indication for induction of labour or operative delivery.
Safe breastfeeding practices by Covid 19 affected mothers
Stable neonates exposed to COVID-19 infection from mothers or other relatives should be roomed-in with their mothers and be exclusively breastfed. For supporting lactation, nurses trained in essential newborn care and lactation management should be provided. A healthy willing family member who is not positive for COVID-19, and has not been in direct contact with suspected or confirmed COVID-19 person and is asymptomatic may be allowed in the room to provide support for breastfeeding and helping in taking care of the neonate.
Mothers should perform hand hygiene frequently, including before and after breastfeeding and touching the baby. Mothers should practice respiratory hygiene and wear a mask while breastfeeding and providing other care to the baby; they should routinely clean and disinfect the surfaces.
COVID-19 infected mother may be allowed to visit her neonate admitted in NICU if there is resolution of fever without the use of antipyretics for at least 72 hours and improvement (but not full resolution) in respiratory symptoms and negative results of a molecular assay for detection of SARS-CoV-2 from at least two consecutive nasopharyngeal swab specimens collected 24 hours apart.
Mothers and family members should be counselled regarding the danger signs and advised to report back to the facility if the neonate develops any of the danger signs. Routine immunization policy should be followed in healthy neonates born to mothers with suspected/proven COVID-19 infection. In neonates with suspected/proven infection, vaccination should be completed before discharge from the hospital as per existing policy.
Parents and families of the COVID-19 exposed, suspected and infected mothers and neonates should receive informed healthcare. They should be aware of and understand the isolation, monitoring, diagnostic and treatment plans of the mothers/babies and be given a periodic update about the health condition.