The guideline on coronavirus disease (COVID-19) infection control during pregnancy and puerperium was released on March 11, 2020 by the International Society of Ultrasound in Obstetrics and Gynecology.
Screening
During the COVID-19 epidemic period, a detailed history regarding recent travel, occupation, significant contact and cluster (TOCC) and clinical manifestations should be acquired routinely from all pregnant women attending for routine care.
On presentation to triage areas, pregnant patients with TOCC risk factors should be placed in an isolation room for further assessment.
Pregnant patients with known TOCC risk factors and those with mild or asymptomatic COVID-19 infection should delay antenatal visit and routine ultrasound assessment by 14 days.
In units in which routine group B streptococcus (GBS) screening is practiced, acquisition of vaginal and/or anal swabs should be delayed by 14 days in pregnant women with TOCC risk factors or should be performed only after a suspected/probable case tests negative or after recovery in a confirmed case. Intrapartum prophylactic antibiotic cover for women with ante- or intrapartum risk factors for GBS is an alternative.
Chest Radiography during Pregnancy
In a pregnant woman with suspected COVID-19 infection, a chest CT scan may be considered as a primary tool for the detection of COVID-19 in epidemic areas. Informed consent should be acquired (shared decision-making) and a radiation shield be applied over the gravid uterus.
Treatment during Pregnancy
Management of COVID-19-infected pregnant women should be undertaken by a multidisciplinary team (obstetricians, maternal–fetal-medicine subspecialists, intensivists, obstetric anesthetists, midwives, virologists, microbiologists, neonatologists, infectious disease specialists).
Suspected, probable, and confirmed cases of COVID-19 infection should be managed initially by designated tertiary hospitals with effective isolation facilities and protection equipment.
Suspected/probable cases should be treated in isolation and confirmed cases should be managed in a negative-pressure isolation room. A patient with a confirmed case who is critically ill should be admitted to a negative-pressure isolation room in an ICU.
Designated hospitals should set up a dedicated negative-pressure operating room and a neonatal isolation ward. All attending medical staff should don personal protective equipment (PPE; respirator, goggle, face protective shield, surgical gown, and gloves) when providing care for patients with confirmed cases of COVID-19 infection. However, in areas with widespread local transmission of the disease, health services may be unable to provide such levels of care to all suspected, probable, or confirmed cases.
Pregnant women with a mild clinical presentation may not initially require hospital admission and home confinement can be considered, provided that this is possible logistically and that monitoring of the woman’s condition can be ensured.
If negative-pressure isolation rooms are not available, patients should be isolated in single rooms, or grouped together once COVID-19 infection has been confirmed.
For transfer of confirmed cases, the attending medical team should don PPE and keep themselves and their patient a minimum distance of 1–2 meters from any individuals without PPE.
- Suspected/probable cases –
General treatment: Maintain fluid and electrolyte balance; provide symptomatic treatment, such as antipyrexic and antidiarrheal medicines.
Surveillance: Close and vigilant monitoring of vital signs and oxygen saturation level to minimize maternal hypoxia; conduct arterial blood-gas analysis; repeat chest imaging (when indicated); regular evaluation of complete blood count, kidney and liver function testing, and coagulation testing.
Fetal monitoring: Undertake cardiotocography (CTG) for fetal heart rate (FHR) monitoring at ≥26 or ≥28 weeks of gestation (depending on local practice), and ultrasound assessment of fetal growth and amniotic fluid volume with umbilical artery Doppler if necessary. Note that monitoring devices and ultrasound equipment should be disinfected adequately before further use.
The pregnancy should be managed according to the clinical and ultrasound findings, regardless of the timing of infection during pregnancy. All visits for obstetric emergencies should be offered in agreement with current local guidelines. All routine follow-up appointments should be postponed by 14 days or until positive test results (or two consecutive negative test results) are available.
- Confirmed cases – non-severe disease –
The approach to maintaining fluid and electrolyte balance, symptomatic treatment, and surveillance is the same as for suspected/probable cases.
Currently there is no proven antiviral treatment for COVID-19 patients, although antiretroviral drugs are being trialed therapeutically on patients with severe symptoms. If antiviral treatment is to be considered, this should be done following careful discussion with virologists; pregnant patients should be counseled thoroughly on the potential adverse effects of antiviral treatment for the patient herself as well as on the risk of fetal growth restriction (FGR).