Azithromycin

the low levels of azithromycin in breastmilk and use in infants in higher doses, it would not be expected
to cause adverse effects in breastfed infants. A single dose of azithromycin given during labor to women
who were nasal carriers of pathogenic Staphylococcus and Streptococcus reduced the counts of these
bacteria in breastmilk in one study.

Azithromycin can transfer in to breastmilk and will increase one hour till 30 hours since oral regiment.
The dose that the infant would receive in milk would gradually increase for several days because
maternal blood levels would increase until steady-state had been reached.

Azithromycin persisted in breastmilk up to 48 hours after a dose with a median breastmilk

concentration.

A cohort study of infants diagnosed with infantile hypertrophic pyloric stenosis found that affected
infants were 2.3 to 3 times more likely to have a mother taking a macrolide antibiotic during the 90 days
after delivery.

Lactmed. Drugs and Lactation Database (LactMed) since 2006 till now. NCBI. Bethesda (MD): National
Library of Medicine (US); 2006-.

An intense Infammatoryr esponse has been reported as one of the key features of severe COVID-19, and
as there is relative immunosuppression in pregnancy this may partly explain why many pregnant women
do not develop severe respiratory symptoms. Similar to nonpregnant patients, the predominant
features of COVID-19 in pregnancy are fever, cough, dyspnea and lymphopenia. Shortness of breath is
described in up to 18% of patients with COVID -19. This may be difficult to discern from physiologic
dyspnea due to increased maternal oxygen demands from heightened metabolism, gestational anemia
and fetal oxygen consumption, which are common in pregnancy.

The cesarean section (CS) rate for women with confirmed COVID-19 infection has been reported as
ranging from 42.9% to as high as 91–92%. It would appear that many of the CS procedures were
performed in maternal interest, due to concern for maternal respiratory function.

There is currently no evidence to suggest that COVID-19 i s teratogenic and early reports indicate no
increased rates of miscarriage or early pregnancy loss in relation to COVID-19 infection. There was no
evidence of vertical transmission.

An early study by Chen et al. tested for SARS-CoV-2 on neonatal throat swabs of eight newborns and
breast milk samples of three mothers, and no positive results were reported. Furthermore, studies
assessed if there is an increased risk of vertical transmission associated with vaginal delivery. vaginal
delivery was associated with a low-intrapartum risk of transmission.
It is recommended that all pregnant women observe social distancing and follow self-isolation guidance
to prevent exposure to COVID-19 and practice good hand hygiene. CS nor vaginal delivery confers any
additional risks to either the mother or the fetus, and mode of delivery should be determined on an
individualized basis.

In relation 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. With regards to expressing
breast milk, women should use a dedicated breast pump and ensure appropriate cleaning after each
use.

Chloroquine is known to have the property of increasing the ph of the endosome and thereby
preventing virus-cell fusion. It is also widely distributed in the whole body

A brief overview of the management of a pregnant woman with COVID-19.

Azithromycin, given in the dose of 500 mg daily for 3–5 days, may reduce the risk of super-added
infections. Its use appears to be safe in pregnancy and compatible with breastfeeding.

Ryan GA, Purandare NC, McAuliffe F, Hod M, Purandare CN. Clinical update on COVID-19 in pregnancy:
A review article. J. Obstet. Gynaecol. 2020. Vol. 46: 8. Pg 1235–1245.

Covid-19 contagion can transmit into two methods, close contact from infected people, the droplet
dispersion into the mouth, eye, nose, or airway tract until the alveoli, touch from a specific object that
contains the virus then the person sweep the mouth, nose or the eye. The maternal immune system
more susceptible to Covid-19 infection due to in these conditions undergo decrease of lymphocyte,
NGK2A inhibitor receptor, and increase of ACE2, IL-9, IL-10, and IP-10 receptors.

The scientific report already stated that vertical transmission to the fetus is low, around 3.2% in third-
trimester mother with Covid-19 infection, without an adverse event to the neonate. Covid-19 infection
does not correlate with the neonatal poor outcome but somehow isolates the mother from the baby
have an important role to cut off the transmission. Covid-19 is related to an increased risk of preterm
labor and fetal distress. No evidence that the virus is discovered in the breastmilk. Breastmilk gives
important nutrition for the baby.

Saroyo Y. Covid-19 and Pregnancy. Editorial : Covid-19 and Pregnancy 3. 2021. Vol 9. No 1. Pg 3-4.

Risk of infantile hypertrophic pyloric stenosis. For the estimated risk IHPS in infants breastfed by an AZI-
treated mother, the largest and most contemporary database available.

Salman S, Davis T, Page-Sharp M, Camara B, Oluwalana C, et al. Pharmacokinetics of Transfer of

Azithromycin into the Breast Milk of African Mothers. Antimicrobial agents and chemotherapy. 2016.
Vol 60:3. Pg 1592-9.

most data on vertical transmission are based on women who had infection during the third trimester,
and information regarding vertical transmission earlier in pregnancy is lacking.

Pregnant women do not appear to be more susceptible to infection or serious complications, but the
existing data are still limited, and sizable series are scarce [16–18]. In fact, physiological changes in
pregnancy – in the cardiovascular, respiratory, and coagulation systems – may confer an increased risk
of morbidity. In any case, COVID-19 complications during pregnancy should be identified and treated
early.

Cases of preterm delivery have been described in women with COVID-19, and this has also been
observed in maternal SARS-CoV and MERS-CoV infections. Although in many cases prematurity can be
induced to preserve maternal health, previous studies in pregnant women with other types of viral
pneumonia have shown that there is an increased risk of preterm labour, fetal growth restriction, and
loss of intrapartum fetal well-being.

Table 1. Admission criteria for pregnant women with COVID-19

Fig. 1. Summarized management of COVID-19 during pregnancy. COVID-19, coronavirus disease 2019;
CPAP, continuous positive airway pressure; CTG, cardiotocography; LMWH, low-molecularweight
heparin; SO2, oxygen saturation.
Pharmacological treatment:

• Lopinavir/ritonavir (100 mg/25 mg) 2 tablets every 12 h (7–14 days depending on the clinical
evolution).

• Hydroxychloroquine sulphate 400 mg every 12 h the first day followed by 200 mg every 12 h for the
following 4 days.

• Azithromycin 500 mg (first day) followed by 250 mg every 24 h to complete 4 days, orally or
intravenously.

These treatments are not contraindicated during pregnancy, but require informed consent for
compassionateuse.

In pregnant women with COVID-19 infection without severity criteria with spontaneous-onset delivery
or with an indication of induction due to obstetric indications, the mode of delivery will depend on
obstetric conditions and fetal status.

Caesarean section should follow usual obstetric indications. The potential risk of vertical transmission is
not an indication for caesarean section.

in women with respiratory compromise, labour may stress the pulmonary situation, and maternal
hypoxia also has fetal risks. Under this rationale, a caesarean section could be considered after 32–34
weeks in women with severe illness, when the risks of prematurity could be assumed.

Neonates from COVID-19-positive women should be tested, isolated, and cared following droplet and
contact preventive measures. The WHO recommends for mothers with COVID-19 infection to be able to
room in with their babies. Asymptomatic newborns could be discharged after delivery and cared by an
asymptomatic family member with the adequate isolation measures.

Breast milk is a passive source of antibodies and other protective factors. According to the current
evidence, most international scientific organizations allow breastfeeding if maternal and neonatal
conditions are favourable, always under contact and droplet precautions (use of a surgical mask, correct
hand hygiene before and after contact, cleaning breast skin and surfaces that could be in contact). Milk
extraction could be another alternative under strict hygiene measures, using an individual milk
extractor. This device should be cleaned after each use with adequate disinfectants. Breast milk should
be administered to the newborn by a healthy family member (not considered contact) or healthcare
personnel.

Lopez M, Gonce A, Meler E, Plaza A, Hernandez S. Coronavirus Disease 2019 in Pregnancy: A Clinical
Management Protocol and Considerations for Practice. Fetal Diagn THer. 2020. 47. Pg 519-528.

Women with symptomatic COVID-19 infections have an increased risk of preterm birth by approximately
threefold, principally from iatrogenic preterm birth (94% iatrogenic of which 57% for maternal
compromise and 15% for fetal compromise). Pregnant women with asymptomatic COVID-19 are not,
however, at increased risk of preterm birth. For women with symptomatic COVID-19, 78% of preterm
births were iatrogenic.

The royal college of midwives. The effect of COVID-19 on pregnant woman. 2021

Whether COVID-19 can be transmitted through breastmilk is unknown.

Rasmusen SA, Smulian JC, Ledenicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19)
and pregnancy: what obstetricians need to know. American Journal of Obstetrics & Gynecology. 2020.
Pg 415-426.

Pregnant women may be susceptible to developing more severe symptoms after infection with
respiratory viruses, due to physiological changes of the immune and cardiopulmonary systems during
pregnancy.

The most common clinical symptoms of COVID-19 in the general population are fever (91%), cough
(67%), fatigue (51%), and dyspnea (30%) [6]. Fever (68%) and cough (34%) are also the most common
symptoms in pregnant women with COVID-19, with other symptoms including dyspnea (12%), diarrhea
(6%), and malaise (12%) [7]. These clinical manifestations are similar to those in nonpregnant women.

A real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay is the gold standard for
diagnosis. Chest X-ray (CXR) and chest computed tomography (CT) may aid in the diagnosis, and can be
used to assess the extent and follow-up of COVID-19. CXR can be rapidly and easily performed at the
bedside, whereas chest CT is more sensitive in the early stage of infection. However, concerns regarding
the potential teratogenic effects to the fetus from radiation exposure are unavoidable. The accepted
cumulative dose of ionizing radiation during pregnancy is 5 rad, and no single diagnostic study exceeds
this dose.

COVID-19 is not an indication for cesarean section.

Wang CL, Liu Y, Wang CY, Wang CH, Long CY. Impact of COVID-19 on Pregnancy. Int. J. Med. Sci. 2021.
Vol. 18(3). Pg 763-7.

Karena kadar azitromisin yang rendah dalam ASI dan lazim digunakan pada bayi dalam dosis yang lebih
tinggi, penggunaan selama menyusui tidak menyebabkan efek buruk pada bayi yang disusui.

Tidak ada informasi tersedia tentang penggunaan acetylcysteine selama menyusui, untuk menghindari
paparan terhadap bayi, ibu menyusui disarankan mempertimbangkan memompa dan membuang ASI
mereka selama 30 jam setelah pemberian NAC.

PDPI, PERKI, PAPDI, PERDATIN, IDAI. Pedoman Tatalaksana Covid-19 edisi 3. 2020.
During normal pregnancy, the plasma volume expands by 40–60%, whereas the red blood cell mass
expands by 20–50%. Thus, a physiologic anemia (“dilutiomal anemia”) develops, leading to a normal
hematocrit value of 30–32%. 30–32%. Hemoglobin levels lower than 10 g/dL suggest the possibility of a
pathologic process, such as nutritional deficiency. The prevalence of anemia in pregnancy increases from
8% in the first trimester to 12% and 34% in the second and third trimester. some studies indicate greater
risk of intrauterine growth restriction (IUGR) and adverse effects on fetal growth when the hemoglobin
falls below 8 g/dL.

Iron deficiency accounts for 75% of cases of nonphysiologic anemia in pregnancy, and the incidence of
iron deficiency anemia during pregnancy world-wide is about 41.8%.

Differential diagnosis of pregnancy-related anemias

Besides poor nutrition, other factors impairing iron absorption include antacids and micronutrient
deficiencies, including vitamin A, vitamin C, zinc, and copper deficiency. In the absence of iron
supplementation, hemoglobin falls to 10.5 g/dL at 27–30 weeks of gestation;
Al-Khaffaf A, Frattini F, Gaiardoni R, Mimola E, Sisa C, Franchini M. Diagnosis of Anemia in pregnancy.
Journal of Laboratory and Precision Medicine. 2020. Vol 5 (9). Pg 1-5.

The prevalence of anemia was 23.2%. Globally 1.62 billion people (25%) are anemic, among which 56
million are pregnant women. Around 40% of women begin their pregnancy with low or absent iron
stores (serum ferritin <30 mg/l) and up to 90% have iron stores of <500 mg (serum ferritin <70 mg/l)
worldwide, which is insufficient to meet the increased iron needs during pregnancy and postpartum.

Lebso M, Anato A, Loha E. Prevalence of anemia and associated factors among pregnant women in
Southern Ethiopia: A community based cross-sectional study. PLOS ONE. 2017. Pg 1-11.

Pregnant women can suffer from anemia due to iron requirements increase for the developing fetus
during pregnancy. The results of pregnancy with anemia include intra uterine growth retardation (IUGR),
premature birth, low birth weight (LBW), and an increased risk of neonatal death. Anemia in TM III has
an influence on the incidence of LBW and preterm birth.

The definition of anemia in pregnancy by CDC (2012) considers normal hemodilution occurring in
pregnancy where hemoglobin levels are less than 11 g/dl in the first and third trimesters, and less than
10.5 g/dl in second trimester.

Prahesti R, Indarto D, Akhyar M. Analysis of Factors Associated with Anemia in Pregnant Women at
Prambanan Community Health Center, Sleman, Yogyakarta. Journal Maternal and Child Health. 2016.
VOl 1(2). Pg 131-7.

Anemia during pregnancy is a main public health problem worldwide, particularly in developing
countries where there is inadequate diet and poor prenatal vitamins and iron and folic acid intake and it
affects the physical health and mental development of individual causing low productivity and poor
economic development of a country. Globally, every year anemia causes more than 115,000 maternal
and 591,000 perinatal deaths.

Gudeta TT, Regasa TM, Belay AS. Magnitude and factors associated with anemia among pregnant
women attending antenatal care in Bench Maji, Keffa and Sheka zones of public hospitals, Southwest,
Ethiopia, 2018: A cross -sectional study. Plos One. 2019. Pg 1-13.

Higher amounts of myopia have the potential to cause vision impairment by myopic macular
degeneration or its comorbidities, cataract, retinal detachment, and glaucoma.
Holden B, Fricke T, Wilson D, Jong M, Naidoo K, et al. Global Prevalence of Myopia and High Myopia
and Temporal Trends from 2000 through 2050. American Academy of Ophthalmology. 2016. VOl 123
(5). Pg 1036-1042.

the most frequent eye diseases associated with C-sections delivery were refractive errors (myopia)
(57%), followed by retinopathy (20%), retinal detachment (7%), and glaucoma (5%).

During pregnancy, corneal sensitivity decreases, while corneal thickness and curvature increases. While
these changes can change the refractive status of patients.

Mohammadi S, Nejad M, Ashrafi E, Aghdam H. A survey of ophthalmologists and gynecologists

regarding termination of pregnancy and choice of delivery mode in the presence of eye diseases.
Journal of Current Ophthalmology. 2017. Vol 29. Pg 126-132.

The rise in intraocular pressure during the second stage of labor results in the vitreous body being
pressed against the retina, which reduces the risk of retinal tears and retinal detachment.

the predominant ophthalmological indications for a cesarian section or assisted delivery in myopic
parturients were peripheral retinal degenerative lesions (some already treated with (laser
photocoagulation) and retinal thinning.

During pregnancy, the eye undergoes a number of physiological, hormone-induced, hemodynamic

changes. An increase in circulating blood volume and water retention cause corneal thickening, which
changes corneal curvature, thus inducing temporary myopia (inducing or exacerbating visual impairment
by –1 DS) and an associated distance vision impairment. This phenomenon is most commonly observed
during the third trimester of pregnancy and resolves after childbirth.

Before the 1990s, myopia was the predominant contraindication for spontaneous vaginal delivery. The
reasoning behind this belief was that the fluctuations in intraocular and orbital pressures (induced by
the Valsalva manoeuvre) would lead to a displacement or even partial detachment of the vitreous body,
which would facilitate rhegmatogenous retinal detachment in cases with pre-existing retinal
degenerations.

There are no available reports illustrating the relationship between natural delivery on one hand and
retinal detachment and refraction error on the other. Kuba et al. maintained that an increase in
intraocular pressure during the second stage of labor pushed the vitreous body against the retina,
eliminating the risk of retinal tears or detachment.

cesarean section is recommended in myopic patients only when there is concomitant choroidal
neovascularization in a macular region (which in some cases accompanies high myopia) due to the
associated risk of retinal hemorrhage during the second stage of labor and the ensuing sudden
deterioration of visual acuity.

Grabowska M, Ciszewska J, Godowska J, Sawa A, Laszewicz P, Bartha E, Pietrzak B. Delivery in Myopic

Women: A Comparison of Mode of Delivery in Years 1990, 2000, and 2010. Med Sci Monit. 2019. Vol
25. Pg 7715-19.

Based on standard correction, myopia can be classified into; mild myopia (<3.00 D), moderate myopia
(3.00-6.00 D), and severe myopia (>6.00 D).

Iskandar F, Surya R, Sungkar A, Anggriany FD. Kontroversi Persalinan Spontan pada Miopia Tinggi.
CDK-291. 2020. vol. 47(10). Pg 778-780.

1. Grabowska M, Ciszewska J, Godowska J, Sawa A, Laszewicz P, Bartha E, Pietrzak B.

Delivery in Myopic Women: A Comparison of Mode of Delivery in Years 1990, 2000,
and 2010. Med Sci Monit. 2019. Vol 25. Pg 7715-19.
2. Iskandar F, Surya R, Sungkar A, Anggriany FD. Kontroversi Persalinan Spontan pada
Miopia Tinggi. CDK-291. 2020. vol. 47(10). Pg 778-780.
3. Saroyo Y. Covid-19 and Pregnancy. Editorial : Covid-19 and Pregnancy 3. 2021. Vol 9.
No 1. Pg 3-4.
4. Wang CL, Liu Y, Wang CY, Wang CH, Long CY. Impact of COVID-19 on Pregnancy.
Int. J. Med. Sci. 2021. Vol. 18(3). Pg 763-7.
5. Ryan GA, Purandare NC, McAuliffe F, Hod M, Purandare CN. Clinical update on
COVID-19 in pregnancy: A review article. J. Obstet. Gynaecol. 2020. Vol. 46: 8. Pg
1235–1245.
6. Lopez M, Gonce A, Meler E, Plaza A, Hernandez S. Coronavirus Disease 2019 in
Pregnancy: A Clinical Management Protocol and Considerations for Practice. Fetal
Diagn THer. 2020. 47. Pg 519-528.
7. The royal college of midwives. The effect of COVID-19 on pregnant woman. 2021
8. Rasmusen SA, Smulian JC, Ledenicky JA, Wen TS, Jamieson DJ. Coronavirus Disease
2019 (COVID-19) and pregnancy: what obstetricians need to know. American Journal of
Obstetrics & Gynecology. 2020. Pg 415-426.
9. Al-Khaffaf A, Frattini F, Gaiardoni R, Mimola E, Sisa C, Franchini M. Diagnosis of
Anemia in pregnancy. Journal of Laboratory and Precision Medicine. 2020. Vol 5 (9). Pg
1-5.
10. Prahesti R, Indarto D, Akhyar M. Analysis of Factors Associated with Anemia in
Pregnant Women at Prambanan Community Health Center, Sleman, Yogyakarta. Journal
Maternal and Child Health. 2016. VOl 1(2). Pg 131-7.
11. Lebso M, Anato A, Loha E. Prevalence of anemia and associated factors among pregnant
women in Southern Ethiopia: A community based cross-sectional study. PLOS ONE.
2017. Pg 1-11.
12. PDPI, PERKI, PAPDI, PERDATIN, IDAI. Pedoman Tatalaksana Covid-19 edisi 3. 2020.