Pregnancy management in coronavirus disease – Challenges in developing countries

What are the symptoms?

The most common symptoms at onset of COVID-19 illness are fever, cough, and fatigue, while other symptoms include sputum production, headache, hemoptysis, rhinorrhea, sore throat, diarrhea, dyspnea, parosmia, anosmia, altered taste and neurological manifestations, and lymphopenia.^[1] Clinical features revealed by a chest computed tomography (CT) scan presented as pneumonia, acute respiratory distress syndrome, acute cardiac injury, and incidence of grand-glass opacities that led to death. The symptoms appear after an incubation period of approximately 5.2 days. The period from the onset of COVID-19 symptoms to death ranged from 6 to 41 days with a median of 14 days.^[2]

Similarity in symptoms with other beta coronaviruses

Symptoms of COVID-19 and earlier beta coronavirus such as fever, dry cough, dyspnea, lymphopenia, and bilateral ground-glass opacities on chest CT scans are comparable. COVID-19 showed some unique clinical features that include the targeting of the lower airway as evident by upper respiratory tract symptoms such as rhinorrhea, sneezing, and sore throat. Some show an infiltrate in the upper lobe of the lung with increasing dyspnea with hypoxemia. Patients infected with COVID-19 can develop gastrointestinal symptoms like diarrhea, but diarrhea is uncommon in Middle East respiratory syndrome coronavirus (MERS-CoV) or SARS-CoV.^[2] Fecal and urine samples should be tested to exclude alternative route of transmission. Case fatality rate of SARS and MERS in pregnancy was very high compared to COVID-19.

Testing for SARS COV-2

1. Reverse transcription polymerase chain reaction (RT-PCR) of throat and nasal swab-positive rate bronchoalveolar lavage 95%, sputum 72%, nasal swab 63%, and oropharyngeal swab 32%

2. Rapid antigen test-immunoglobulin (Ig) M antibodies become positive after the 7^th day and IgG on the 14^th day

3. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and value of a CT chest in diagnosing COVID-19 in China are 97%, 25%, 65%, and 83%, respectively (using RT-PCR as a reference)^[3]

4. The teratogenic effects of ionizing radiation on the fetus are inevitable for CT

5. Exposure to radiation doses <50 mGy is not associated with an increased risk of fetal anomalies or pregnancy loss. The dose of fetal radiation exposure for a routine CT chest is 0.03 mGy. Studies have not demonstrated teratogenicity or thyroid dysfunction in the newborn by intravenous iodinated contrast media (as it crosses the placenta).

In our setup, only RTPCR nasal and throat swabs are allowed.

How COVID infection affects fetus? [Figure 2]

Cohort studies in patients with other infections have not shown increased risks of congenital anomalies from maternal pyrexia in the first trimester but possibility cannot be ruled out. Childhood inattention disorders are more common, due to hyperthermic injury to fetal neurons. Till date, there is no evidence of:

• Intrauterine fetal infection,

• Congenital malformations,

• Effect on fetal growth, and

• Transmission through genital fluids.

How mothers are affected in our study at Agra?

Fever, with a median temperature of 38.1–39.0°C, is the prevailing symptom in COVID-19.

More than 50% of hospitalized pregnant women affected by CoV infections have radiological signs of pneumonia, at chest X-ray or computerized tomography and other most common manifestations are cough and lymphopenia [Figure 3].

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Figure 3:

Clinical picture of severe acute respiratory syndrome coronavirus 2 in pregnancy.

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Pregnancies affected by CoV infections have high rates of preterm birth before 37–34 weeks and miscarriage when the infection is acquired earlier in pregnancy. Miscarriage and preterm birth cannot be attributed solely to COVID since there are no control groups of uninfected women in most studies. Stress in the community might be contributory.

Preeclampsia and cesarean delivery are also more common compared to general population. Perinatal mortality is about 10%, while the most common adverse perinatal outcome is fetal distress, with more than half of the newborn admitted in neonatal intensive care unit (NICU).

According to a retrospective non-randomized review, it is difficult to draw any convincing evidence on this clinical management strategies. This is very short-term follow-up data and thus infections that occurred proximate to the delivery. Risks of pulmonary tuberculosis might be overestimated.

No case of fetal distress, neonatal asphyxia, and admission to NICU was reported. No intrauterine fetal infection occurred as a result of SARS-CoV-2 infection during the third trimester of pregnancy when the time interval from clinical manifestation to delivery was up to 38 days.

Six studies reported information on COVID-19 infection during pregnancy. Miscarriage occurring during the first trimester has not been reported. Preterm birth <37 weeks was approximately 40% and 15% at 34 weeks of gestation, pPROM in 19% while preeclampsia was 13.6% (1/12 95%,CI L2-36.0), with no cases of fetal growth restriction. Cesarean delivery was 91%.^[5]

In a small study conducted on women in their third trimester by Wang and Chen who were confirmed to be infected with the coronavirus, there was no evidence that there is transmission from mother to child.^[6] However, all pregnant mothers underwent cesarean sections, so it remains unclear whether transmission can occur during vaginal birth. This is important because pregnant mothers are relatively more susceptible to infection by respiratory pathogens and severe pneumonia.

At our center, we have admitted 36 COVID-19-positive pregnancies till now, out of which more than 90% were asymptomatic, 90% were delivered by lower segment cesarean section (LSCS). About 80% elective repeat cesarean were done for 37–39 weeks pregnancy with previous or two LSCS. In all cases, post-operative recovery was uneventful. All babies were negative for COVID 19, enforcing there is no vertical transmission. We have not done testing in amniotic fluid or breast milk. Babies are not breastfed. No case of maternal death has been reported at our institute. It seems infection acquired in the third trimester do not alter maternal and fetal outcomes.

At Rainbow Hospital, Agra, since the COVID disease appearance, 128 deliveries have taken place. As being a tertiary referral care center, the C-section rate is over 50%.

Only RT-PCR negative cases were taken for elective delivery, test done 1 week before date. No COVID positive test case was taken up for delivery as per Government of India guidelines such cases to be referred to COVID hospital. Two COVID-positive antenatal cases were referred. Twenty-five cases emergency C-section was done without COVID test (which was sent just before operation).

However, emergency C-section was done without COVID test in 25 cases with universal precaution and in high-risk OT with all the proper personal protective equipment (PPE). Testing swab for RT-PCR done in all these just prior or at the time of delivery out of 25 asymptomatic non-tested deliveries two came to be +ve postoperatively and was shifted to COVID hospital for L2 case. On follow-up, these were fully recovered and have crossed the 28 days quarantine period also.

Management at COVID hospital, Agra, and Rainbow Hospital, Agra (non-COVID hospital), algorithm for pregnant women with suspected or confirmed COVID-19 infection [Figures 4-7] show the protocols followed at our center for antenatal care.

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Figure 4:

Antenatal care for pregnant women with suspected, Probable, or confirmed severe acute respiratory syndrome coronavirus 2 infection.

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Figure 5:

Antenatal care for pregnant women with suspected, Probable, or confirmed severe acute respiratory syndrome coronavirus 2 infection.

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Figure 6:

Antenatal care for pregnant women with suspected, probable, or confirmed severe acute respiratory syndrome coronavirus 2 infection.

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Figure 7:

Pregnancy with suspected severe acute respiratory syndrome coronavirus 2 infection.

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First point of contact/initial assessment area for triage and screening.

Any patient with the following symptoms:

• Fever ≥38°C [≥100.4 F]

• Cough, difficulty in breathing or shortness of breath

• Gastrointestinal symptoms.

OR

History of exposure:

• Travelled to an affected country within the previous 14 days

• Close contact with a confirmed case of COVID-19, that is, <1 m for >15 min, living together, direct contact with body fluids.

Red Tag is given and sampling is done. Give the woman a surgical face mask Maintain minimum 1 m distance from each other Checks for obstetric emergency or labor/delivery issues

Management of suspected cases not in labor

On admission [Figure 8], management depends on severity of disease. Hand hygiene includes use of alcohol-based hand sanitizer that contains 60–95% alcohol before and after all patient contact, contact with potentially infectious material, and before putting on and on removal of PPE, including gloves and washing with soap and water for at least 20 s is also effective. If hands are visibly soiled, use soap and water before use of alcohol-based hand sanitizer.

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Figure 8:

Management of confirmed cases symptomatic (severe acute respiratory syndrome coronavirus 2-positive pregnant women).

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Institute infection prevention and control measures:

• Immediately transfer to an identified isolation room

• Donning appropriate PPE by health-care provider.

Testing of the pregnant woman with suspected infection:

• Do not delay obstetric care to test for COVID-19

• Treat as confirmed COVID-19 until test results are available.

Multidisciplinary approach: By obstetric, neonatal and intensive care specialist. Antenatal care for pregnant woman with suspected or confirmed COVID-19. Assessment is based on clinical picture.

Antenatal contact

• Routine appointments (growth scams, oral glucose tolerance test, and antenatal care appointment) delayed until after the recommended period of isolation

• No additional tests required

• If concerns about the well-being of self or fetus during self-isolation period, patient should be advised to contact maternity team

• Provide counseling and information about potential risk of adverse pregnancy outcomes.

Management of confirmed or suspected cases in antenatal care

Hospitalize the pregnant woman based on:

• Severity of symptoms

• Obstetric emergency/labor.

Maternal early warning criteria [Figure 9]

• Systolic blood pressure (BP) <90 or >160 mm of Hg

• Diastolic BP 100 mm of Hg

• Heart rate <50 or >120/min

• Respiratory rate <10 or >30/min

• Oxygen saturation in room air of <94

• Oliguria defined as urine output

• Maternal confusion, agitation, unresponsiveness

• Known patient with preeclampsia reporting a nonremitting headache or shortness of breath.

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Figure 9:

Triage based assessment of severity: Suspected cases in labor.

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Or

Quick sequential organ failure assessment tool–2 out of 3 [Figure 10]

• Systolic BP < 100 mmHg

• Respiratory rate >22

• Altered level of consciousness.

If these criteria are yes – ICU admission, If no – continue monitoring

Severe failure criteria:

(Consider emergency cesarean delivery)

• Septic shock

• Acute organ failure.

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Figure 10:

Maternal early warning criteria, place of admission – assess the need for ICU admission using.

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Monitoring of confirmed cases symptomatic

Maternal surveillance: [Figure 11]

• Antipyretic therapy

• Limit the fetus to the risk of maternal increased body temperature

• Screen for other viral infections and/or superimposed bacterial infections

• Consider empiric IV/oral antibiotics

• Ant malarial/antiviral treatment

• Consider thromboprophylaxis.

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Figure 11:

Monitoring of confirmed cases (severe acute respiratory syndrome coronavirus 2-positive pregnant women).

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Fetal surveillance [Figure 12]

• FHR and fetal movement count

• Antenatal corticosteroids – for obstetric indications can be given

• Women at risk of preterm birth from 24 to 34 weeks of gestation when there is no clinical evidence of maternal infection

• Mild COVID-19: Clinical benefits might outweigh the risks of harm to mother.

Antenatal care for pregnant women with suspected or confirmed novel coronavirus. Little evidence of natural history of pregnancy after recovery. Recovery from infection in the 1^st trimester: Consider detailed midtrimester anatomy ultrasound examination. Recovery from infection in later half of pregnancy: Consider sonographic assessment of fetal growth 2 weeks after infection

• Pregnant women should follow the same recommendations as non-pregnant persons for avoiding exposure to COVID-19 infection

• Antenatal care through teleconferencing and video conferencing is the key to providing quality care during pandemic

• Triage based on symptom severity and obstetric emergencies [Figure 9]

• Multidisciplinary approach to management of suspected or confirmed cases [Figure 10]. MEWS criteria to be adapted for ICU admission.

• First and second stage of labor should be managed as in non-COVID cases. Delayed cord clamping has been advocated by some at this stage.^[6]

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Figure 12:

Fetal surveillance: Symptomatic confirmed cases.

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Indian Council of Medical Research (ICMR) guidelines for obstetric units

The ICMR and the Ministry of Health and Family Welfare have issue the following guidelines [Figures 13-15].

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Figure 13:

Latest Indian Council of Medical Research guidelines April 2020.

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Figure 14:

Latest Indian Council of Medical Research guidelines April 2020.

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Figure 15:

Latest Indian Council of Medical Research guidelines April 2020.

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