COVID-19 INFECTION IN

PREGNANCY
Dr. Asmita Pantha
3rd year Resident
Department of OBGYN
KUSMS
INTRODUCTION

• Novel coronavirus (SARS-CoV-2) -new strain of coronavirus (single

stranded RNA virus) causing COVID-19, first in Wuhan City, China on
31st Dec 2019.

• WHO declared COVID-19 infection as pandemic on 11th March, 2020.

• Pregnant women do not seem to be at higher risk than non-pregnant

individuals of severe COVID-19 infection requiring hospital admission.

Docherty AB, Harrison EM, Green CA, et al. Features of 16,749 hospitalised UK patients with COVID-
19 using the ISARIC WHO clinical Characterisation Protocol.
 Effect on Pregnant women
• In a case series in New York, all 215 women in 2 weeks - screened for SARS-CoV-
2 infection. 15.4% of women tested positive from nasopharyngeal swabs.
Mostly asymptomatic, only 2% had symptoms of fever & flu-like symptoms.

• 86% had mild disease,9.3% had severe disease and 4.7% developed critical
disease.

• Of the 427 pregnant women reported in the UKOSS study, 9% of women

required level-3 critical care, 1.2% (5 women) case fatality rate and SARS-CoV-2
associated maternal mortality rate of 5.6 per 100000 maternities.
Effect on fetus or neonate
• No data suggesting an increased risk of miscarriage or early pregnancy loss in
relation to COVID-19.

• No evidence of teratogenicity.

• Probable risk of vertical transmission is there, although proportion of

pregnancies affected and significance to neonate has yet to be determined.
Dong L, Tian J, He S,et al. Intrauterine vertical transmission of SARS-CoV-2 From an infected
Mother to Her Newborn.JAMA 2020
Effect on fetus or neonate

Of the 427 pregnant women reported in the UKOSS study

• 27% preterm births; 47% of - iatrogenic for maternal compromise and
15% - iatrogenic for fetal compromise.

• 10% of term babies required admission to neonatal unit.

• 2.5% babies had a positive test for SARS-CoV-2 during first 12 hours after
birth.

• 2 perinatal deaths, but unclear cause.

• There are currently no data suggesting an increased risk of
miscarriage or early pregnancy loss in relation to COVID-19.
• There is no evidence currently that the virus is teratogenic. Long term
data is awaited.
• COVID-19 infection is currently not an indication for Medical
Termination of Pregnancy.
(ICMR guideline)
• With regard to vertical transmission (transmission from mother to
baby antenatally or intrapartum), emerging evidence now suggests
that vertical transmission is probable, although the proportion of
pregnancies affected and the significance to the neonate has yet to be
determined.
• At present, there are no recorded cases of vaginal secretions being
tested positive for COVID-19.
• At present, there are no recorded cases of breast milk being tested
positive for COVID-19.
(ICMR guideline)
 Antenatal Care: Organization of Care
• Develop a sustainable ANC service delivery model.

• All women should be triaged and screened for

symptoms of COVID-19 before entering the health
facility.

• Discourage groups of more than 20 women from

attending ANC at any one time.

• Reduce wait times and contacts with other patients.

• Encourage women to wait outside or in designated ,

marked areas, maintain social distancing of 2 arms
lengths.
Antenatal Management
Triaging and Risk Screening for COVID-19

Females Provided with face mask

Maternity care providers involved in direct care of

patients must have access to PPE

Handwashing after any episode of patient contact

Cleaning surfaces with a cleaning product (5% sodium

hypochlorite)

Physical distance of 2 arms lengths among all

Antenatal appointments modified schedules-WHO
• Antenatal visits : WHO 4 visits
• At 12 weeks, 20 weeks, 28 weeks, 36 weeks
• Maintain respiratory hygiene : All patients should wear surgical masks
• Health Care Workers : N95, visor and goggles, cap , gown
• Social distancing : limit number of patients , one way exit and entry,
no visitors within OPD, 1m distance apart
• Disinfection of surfaces and instruments
• Wash hands, clean surfaces like table and stethoscope with antiseptic
or 70% alcohol swab after every patient
• Telemedicine as far as possible
Antenatal appointments modified schedules-
WHO
• At 1st ANC visit (12 weeks) • At 2nd ANC visit (20 weeks)
Confirm pregnancy, LMP, EDD Assess FHS,BP
Screen high risk cases USG-anomaly scan
Baseline investigations Td immunization
Start Fe/Ca supplementation Ensure Fe/Ca intake
Educate mother on pregnancy ,
childbirth, social distancing, hand
hygiene and respiratory hygiene
ONE STOP management
Antenatal appointments modified schedules-
WHO
• At 3rd ANC visit (28 weeks) • At 4th ANC visits (36 weeks)
Assess fetal growth, BP Assess fetal growth, presentation
Test to rule out GDM Assess pelvic adequacy
If Rh-ve consider prophylaxis Instruct about warning signs
Educate patient regarding self Watch for complications
monitoring-FM, BP, warning signs , Work out birth plan – delivery and
labour pain new born
• Elective procedures like induction of labour for indications that are
not strictly necessary, routine growth scans not for a strict guidance-
based indication and routine investigations should be reduced to
minimum at discretion of care provider. (ICMR guideline)
Antenatal appointments modified schedules
LOW RISK WOMEN(FOR COVID)-
• Minimum of six antenatal contacts in total.

• One-stop clinic appointment that booking and scan together in 1st trimester. Screening for low
risk and high risk should be done at this time.

• Next visit at 18-20 weeks- Check BP & Urine, Routine anomaly scan, Inj Td vaccine
Continue Iron/calcium.

• Then at 28 weeks, 32 weeks, 36 weeks & 40 weeks POG-

- Measure fundal height, BP, and test urine
- At 28 wks- GCT, Anti D titre (in case of Rh negative women)
- Ask to maintain DFMC
- Explain danger signs
- Give information about options for prolonged pregnancy.
Antenatal appointments modified schedules
• Consider scheduling the post-dates appointment on a day where
induction of labour can be commenced .

• Consider using outpatient induction of labour for low risk women.

National Institute for Care Excellence (NICE) guidelines 30 th March 2020

 FOR WOMEN WITH SYMPTOMS OF
COVID-19
• If woman meets the “stay at home” guidance, the ANC appointment should
be rebooked or after the isolation period ends.

• The woman can stop home isolation under the following 3 conditions:
3 full days without use of medicine that reduces fever and other symptoms have
improved.
At least 7 days have passed since her symptoms first appeared.
Seek medical help if condition is worsening(soon) or if symptoms are not improving
after 7 days.

• If the woman has access to testing facilities, leave home after isolation: woman no
longer has fever and other symptoms have improved and had two negative tests in a
row, 24hrs apart.
FOR WOMEN WITH SYMPTOMS OF COVID-19
• Women with symptoms of COVID-19 and
are experiencing any pregnancy related
complications need to be seen separately
from others in an isolated room if
possible or at the beginning or at the end
of clinic.

• Women with symptoms need to wear a

mask and maternity care providers should
wear PPE as per WHO recommendations.
 Managing COVID-19 in pregnancy
• Suspected COVID-19 should be isolated and transferred to hospital
with facilities.

• Pregnant women are categorized as

Mild : symptomatic with stable vital signs
Severe : RR≥30/min, SPO2≤93%,arterial blood oxygen partial
pressure≤300 mm Hg
Critical: shock with organ failure, respiratory failure requiring MV,
refractory hypoxia requiring ECMO (Extracorporeal membrane
Oxygenation) .
 Managing COVID-19 in pregnancy
Supportive therapy: Adequate rest, hydration, nutrition, electrolyte balance

Pharmaceutical care:
• No drug is currently approved.

• Antiviral treatment: Lopinavir/ Ritonavir(400mg/100mg) BD+ α-interferon (5 million IU in

2ml of WFI)
- Category C drug

• Remdesivir (Nucleotide analog) and Chloroquine inhibit SARS-CoV-2 virus in vitro.

• IV Ceftriaxone (in case of secondary bacterial infection)- while awaiting culture &
sensitivity reports.
 Managing COVID-19 in pregnancy
• Corticosteroids- not used to treat or clearance of virus.

• Methylprednisolone (1-2mg/kg ,short term 3-5 days) used cautiously in

critically ill patients with hypoxic conditions.

• Inj Betamethasone 12mg IM 24 hrs, 2 doses if preterm delivery is anticipated.

Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: what clinical
recommendations to follow? Acta Obstet Gynecol Scand. 2020.
 Timing and Mode of Delivery
Timing of delivery:
• Individualized based on existing obstetric comorbidities.
• Mild disease- till term under close surveillance
• Critical disease- may need preterm delivery.

Mode of delivery:
• Determined by obstetric indications
• Consider choice of anesthesia
• Vaginal delivery considered in stable patients- lack of evidence of
vaginal shedding of virus and vertical transmission.
COVID 19: INTRAPARTUM CARE
 Setting for birth
• Separate delivery setting for suspected/confirmed COVID 19 cases ,if not possible- 1 st stage
1 m distance between beds and 2 m distance in 2nd stage of labor.
RMNCH guideline-2020

• Designated separate isolation and or delivery area for positive patients with designated
personnel and PPE setup

• Potential increase risk of fetal compromise - continuous electronic fetal monitoring (EFM).

• Universal precaution measures to room with negative pressure if not exhaust fan.

• Mock Drill to be conducted

• Training all personel about hand hygiene, respiratory hygiene

RCOG -2020
 On arrival to hospital
• Ask for covid 19-symptoms (fever, cough, SOB, travel history)

• CDC- prioritize testing of pregnant women with suspected symptoms

• Testing all patients upon presentation to labor and delivery (or the day before scheduled
admission) with a rapid SARS-CoV-2 test.(Now,being done at KUSMS)
Di Mascio D, Khalil A, Saccone G, et al. Outcome of Coronavirus spectrum infections (SARS,MERS, COVID 1 -19) during pregnancy: a systematic review and meta-
analysis. Am J Obstet Gynecol MFM 2020; :100107

• Triage - Women with suspected/confirmed COVID-19- escorted to an isolation ward.

• Designated area for donning and doffing of PPE

• Only essential staff - enter the isolation ward/OT room and visitors - minimum.
UNFPA/ACOG/RCOG/RMNCH
 Timing for birth
• Induction of labour / CS - in suspected COVID-19 - an individual assessment by Multi disciplinary team
(urgency, risk of transmission) whether it is safe to delay procedure during period of self-isolation.

• If result positive, the patient may become more severely ill over time since symptoms more severe in the
2nd week of the illness – not to delay

• Induction in low risk cases- outpatient (Miso)

• Admit on day of induction and cases admitted 24 hrs isolation before elective CS

• Elective CS - routine PCR

• Steroids - given when indicated

NICE, RCOG and RMNCH guideline

• MgSO4 - neuroprotection when POG < 32 weeks or for eclampsia prophylaxis

American College of Obstetricians and Gynecologists Committee on Obstetric Practice; Society for Maternal-Fetal Medicine. Committee opinion no. 455:
magnesium sulfate before anticipated preterm birth for neuroprotection. Obstet Gynecol 2010;115:669–71.
 Mode for birth
• Mode of birth not to be influenced by the presence of COVID-19, unless
the woman’s respiratory condition demands urgent intervention for
birth.

• Shortening duration of 2nd stage of labour - instrumental birth in

symptomatic woman who is exhausted or hypoxic.
RCOG 2020

• Em CS- donning PPE (time-consuming) - delay on the decision to

delivery interval and inform this possibility to family.
 Mode for birth
• El CS - scheduled at the end of the operating list.

• Cat –II PPE (RMNCH 2020)

• Spinal preferred , If CS under GA

Cesarean section with PPE
- PPE with FFP3 mask (RCOG 2020)

• Avoid cautery as much as possible

Yalini Vigneswaran et al, Department of Surgery, University of Chicago
Medical Center, 5841 S. Maryland, Rm. G-210, Chicago, IL 60637 USA
FETAL SURVELLIANCE:
• Labour Monitoring as in normal cases –continous EFM preferred - as
fetal compromise reported as indication for emergency birth in
COVID-19.
• Rupture of membrane - fetal scalp electrode or fetal blood sampling -
not contraindicated (vaginal secretions or amniotic fluid report for
COVID -19 - negative)
 Pain relief
• Epidural/spinal analgesia and anesthesia- not contraindicated in COVID -
19 cases

• Epidural - ↓ cardiopulmonary stress from pain and anxiety - ↓ viral

dissemination, is advantageous if Em CS required.

• Entonox – use with a single-patient microbiological filter.

RCOG 2020

• Suspend use of N2O for labor analgesia.

The Society of Obstetric Anesthesia and Perinatology
 Intrapartum monitoring
• Multidisciplinary team

• Women with mild COVID-19 symptoms - remain at home (self-isolating) in early labour
(latent phase) as per standard practice.

• Hand washing with alcohol based after every patient contact and appropriate donning and
doffing of PPE critical

• Remove extra items from labour room /OT room

• Maternal assessment - hourly oxygen saturations –SpO2 > 94%

• Hourly fluid input/output charts.

 Intrapartum monitoring
• In active labor - concerns of viral dissemination: patient forcefully exhales and
fecal contamination.
Boelig RC, Manuck T, Oliver EA, Di Mascio D, et al. Labor and Delivery Guidance for COVID-19. Am J Obstet
Gynecol MFM 2020
Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens.JAMA 2020

• ACOG and RCOG– Use PPE with N95 mask in 2nd stage of labor of suspected or
confirmed positive COVID-19 cases (potential for aerosolisation in context of
forceful exhalation).

• CDC – forceful exhalation during 2nd stage not expected to generate aerosol to
same extent as procedure considered to AGP.
- surgical mask, protective eyewear, gown and gloves.
N-95 mask (if available)
 Intrapartum monitoring
• If develops fever, investigate and treat as per guidance on sepsis in
pregnancy, but also consider active COVID-19 as a cause.

• In addition to standard oxytocin - prophylactic tranexamic acid and

misoprostol (RMNCH) to avoid PPH
Rupsa C. et al. Labor and delivery guidance for COVID-19, AJOG MFM Month 2020

• Signs of decompensation - ↑ O2 requirements or FiO2 > 40%, RR > 30,

reduction in urine output, or drowsiness, even if SpO2 normal.

• Radiography- chest X-ray and CT chest (abdominal shielding)

 Immediate neonatal care
• Delayed cord clamping recommended (RCOG, ACOG, WHO and American Academy of Pediatrics)

• Early cord clamping - minimize newborn exposure to any virus in the immediate
environment
Ashokka B, et al. Care of the Pregnant Woman with COVID-19 in Labor and Delivery: Anesthesia, Emergency cesarean delivery, Differential diagnosis in the acutely ill
parturient, Care of the newborn, and Protection of the healthcare personnel. Am J Obstet Gynecol 2020

• Resusictation area: separate preferred or 6 feets away

• Bathing newborns as soon as possible after birth to remove virus potentially

present on skin surface American Academy of Pediatrics

• Leaving vernix caseosa for 24 hours after birth (antimicrobial peptides)

Favre G, Pomar L, Qi X, et al. Guidelines for pregnant women with suspected SARS-CoV-2infection. Lancet Infect Dis 2020.
Covid-19 :Postpartum
Care
Post partum care
 Hospital Stay
 Thromboprophylaxis
 Newborn care
 Breastfeeding and vaccination
 Psycho-social support
 Discharge from hospital
 Contraception
 Follow up visit
 Vaccination
Hospital Stay
• Post partum fever: D/D Covid 19
• Asymptomatic/known/ suspected cases: Routine maternal care
• Mild illness : Vitals, I/O q 4 hrs : 24 hours(VD)
: 48 hours( CS)
• Moderate illness: Continuous pulse oximetry for 24 hours or
until improvement in Sign/Symptom whichever is longer
• Severe or critical: Very close maternal monitoring
ICU or labor care unit
Thromboprophylaxis
• Individual risk assessment (RCOG: all women)
• COVID 19: not single most indication ( except in critical
cases )
• High risk factor in ante/post partum: recommended
• Continue prophylaxis for 7- 14 days( or up to 6 weeks in
high risk )
• LMWH : prophylactic dose
NEWBORN CARE
Evaluation:
o Infant born to Covid mother: suspect cases
o Isolate, test, and care accordingly
o Isolate from healthy infants.
Test 1st test: ASAP or W/I 24 HOL
Repeat: 48 hours (CDC, APA)
Nasopharyngeal/ throat/rectal swab
If positive: repeat q 48 hours till 2 consecutive negative

• Inform neonatal team beforehand to allow doning and dofing of PPE.

• UKOSS: 2.5% babies, positive swab w/I 12 hours of birth

BABY MOTHER CONTACT

• WHO recommendation
All suspected/probable/confirmed cases: skin to skin contact permitted
• CDC recommendation
• Individaulize the cases
• Consider clinical condition, test result, desire to breast feed, facilities
available, continuity of the separation
• If separation:
-Isolate like other Covid 19 suspect.
-PPE : recommended for healthy caretaker.
• If separation indicated but not done:
-Physical barriers like Curtain
-Temperature control isolate > 6 feet away from mother
-Face mask , hand hygiene
-Family member can involve
• Criteria to discontinue precautions
• Symptomatic cases :
• At least 3 days( 72 hours) after recovery i.e. no fever w/o any
antipyretic
• Improvement in respiratory symptoms
• 10 days have passed since symptoms 1st appeared
• Lab confirmed asymptomatic cases: At least 10 days passed after 1st
diagnostic test positive
 Breastfeeding
• Unclear transmission
• Very small case series: breast milk positive
• WHO/CDC/ACOG/RCOG: encourages breast feeding
• Maternal COVID: Passive immunity to child via breast
milk / Anti-infective factors
• Mother and baby separation: Ideally infant fed (EBM
with dedicated breast pump) by healthy caregiver
until recovery following hygiene protocol
Breastfeeding in Covid 19: RCOG
If no separation: Breast feeding with strict precautions
• Fluid resistant surgical mask by mother.
• Avoid sneezing and coughing.
• Clean hands with soap and water( if NA sanitizer).
• Clean pump parts, bottles & artificial nipple.
• If possible cleaned by healthy person.

Kangaroo mother care permitted ( with use of mask and hygiene): in preterm
and LBW babies.
RMNCH 2020
Vaccination:
• As per national schedule
• 3 to 6 feet distance maintenance
• Strict time allocation to avoid crowd and maintain social distance.

Baby with fever and cough: COVID suspected signs: withheld vaccine
Subsidence of signs and symptoms

Vaccinate and counselling

 Vaccination
• If baby has: pneumonia and • One who gives vaccine:
diarrhea must maintain hygiene, wear
mask and gloves
Resides/travel pandemic area Should not give if has cough and
fever

• Disinfection of vaccine carriers :

Refer to COVID IMNCI 0.5% chlorine.
clinic or fever clinic protocol
Analgesics
• No definitive guideline

• NSAIDS: possible negative effects in COVID-19(WHO and

the European Medicines Agency do not recommend
avoiding NSAIDS when clinically indicated).

• Acetaminophen preferred (lowest dose if possible)

Discharge and postpartum office visits
• Early discharge postpartum : 1 day after vaginal delivery
2 days after cesarean delivery
• Postpartum office visit :
Early postpartum assessment of wound and blood pressure checks .

• Psychological impact of COVID-19

Screened for postpartum depression : 4 to 8 weeks(Edinburgh
Postnatal Depression scale completed in 5 minutes)
Severity of Covid-19 and discharge
• Mild/asymptomatic: 10 days of symptom onset and no fever for 3
days
• Moderate: No O2 required for 3 consecutive days
No fever W/I 3 days after discontinuing antipyretics
No breathlessness
• Severe: Clinical recovery
Negative PCR test after resolution of symptom
Contraception
• Permanent and reversible: method of choice
• Reversible contraception: Immediate postparturm long-
acting contraception (IUCD/implants) or depot
medroxyprogesterone acetate
• Barrier/ pills – must be given for 3 months duration.
• Tubal sterilization can be performed if planned :no
additional risk both in CS or VD.
• Avoids additional outpatient visits
VACCINATION:FIGO Statement
(2 March 2021)

Given that clinical trials of COVID-19 vaccines specifically in pregnant

women have not yet been conducted (some are underway or planned
soon6), limited data are available on their efficacy and safety during
pregnancy.
Hence, there is not sufficient evidence to recommend the routine use of
COVID-19 vaccines for pregnant or breastfeeding women. Limited data
from animal studies are reassuring and do not indicate direct or indirect
harmful effects on embryo/fetal development or pregnancy.
Additional reassuring data come from a statement, released in the USA in
the first week of February, that 20,000 pregnant women had been
vaccinated with no alarming signs reported.
• FIGO, therefore, considers that there are no risks – actual or
theoretical – that would outweigh the potential benefits of
vaccination for pregnant women. We support offering COVID-19
vaccination to pregnant and breastfeeding women.
• FIGO urges health care providers to support pregnant women to make an
informed decision regarding COVID-19 vaccination in consultation with
their obstetrician. Important considerations when offering the vaccine
should include the:
• level of activity of the virus in the local community
• potential efficacy of the vaccine
• lack of safety data specific to its use in pregnancy
• risk and potential severity of maternal disease, including the possible
effects of the disease on the fetus (preterm birth) and newborn
• timing of vaccination during pregnancy.
• There is currently no preference for the use of a particular COVID-19
vaccine, but pregnant women who agree to be vaccinated should be
advised to complete their two-dose series (where applicable) with the
same vaccine product.
• It is advisable that a COVID-19 vaccine series should be administered
without any other vaccine, with a minimum interval of 14 days before
or after administration of any other vaccine
VACCINE ADMINISTRATION FOR BREASTFEEDING WOMEN

• Breastfeeding confers many health benefits to mother and newborn.

COVID-19 vaccines are believed to pose minimal to no potential risk
to the newborn through breastmilk.
• Based on previously administered vaccines, there is the potential for
direct neonatal benefit if the vaccine-stimulated immunoglobulin A
prove to pass through breastmilk.
• For breastfeeding women, therefore, the COVID-19 vaccine can be
offered if the mother meets the criteria based on prioritisation
groups, such as a breastfeeding health care provider.
 References
1. RCOG. COVID-19 virus infection and pregnancy. Occupational health advice for employers and pregnant women during
the COVID-19 pandemic
2. World Health Organziation. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is
suspected. Interim guidance 13 March 2020
3. American College of Obstetricians and Gynecologists. COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics.
4. Favre G, Pomar L, Qi X, et al. Guidelines for pregnant women with suspected SARS-CoV-2infection. Lancet Infect Dis 2020
5. The Society for Obstetric Anesthesia and Perinatology. Interim considerations for obstetric anesthesia care related to
COVID19
6. Boelig RC, Manuck T, Oliver EA, Di Mascio D, et al. Labor and Delivery Guidance for COVID-19. Am J Obstet Gynecol MFM
2020
7. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens.JAMA 2020
8. American College of Obstetricians and Gynecologists Committee on Obstetric Practice; Society for Maternal-Fetal
Medicine. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. Obstet
Gynecol 2010;115:669–71
9. American Academy of Pediatrics
10. RMNCH guideline, Nepal 2020
11. Rupsa C. et al. Labor and delivery guidance for COVID-19, AJOG MFM MONTH 2020
12. UNFPA 2020
`

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