Aboubakr Mohamed Elnashar

1. 5/8/2020
ABOUBAKR ELNASHAR 1
COVID-19 &
Pregnancy
What obstetrician needs to
know?
 Sexual intercourse
 Infertility
 ART
 Pregnancy
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
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 Vertical transmission
(transmission from mother to baby antenatally or intrapartum)
 China: no evidence
{amniotic fluid, cord blood, neonatal throat swabs,
placenta swabs, genital fluid, breast milk samples
from infected mothers: negative for the virus}.
 RCOG, 2020, 21 April: probability
 2 reports: {IgM for SARS-COV-2 in neonatal
serum at birth. Since IgM does not cross the
placenta,± represent a neonatal immune
response to in utero infection}.ABOUBAKR ELNASHAR

2. 5/8/2020
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Sexual transmission (UNICEF, 2020)
 NO
{not found in semen or vaginal fluid}
 But: SI involves close contact, kissing& touching,
these are the ways of transmitting this virus
 Avoid sex if you or your husband (New York City Health, 2020)
1. Confirmed Covid19
2. Suspected Covid 19
3. High risk for severe Covid-19
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DIAGNOSIS
 Suspected cases (22.4.2020)
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3. 5/8/2020
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22.4.2020
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 Single chest radiograph
 Very low fetal radiation dose (0.0005 to 0.01 mGy)
Abdominal shielding
 CT
 should be performed, if indicated
 fetal radiation dose is low
 Not associated with an increased risk of
 fetal anomalies or
 pregnancy loss.
 Pulmonary ultrasound
 quick diagnosis of pneumonia
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4. 5/8/2020
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EFFECTS ON PREGNANCY
1. Maternal
 Not more likely to contract COVID19
1. More severe infection
 Pneumonia
 Marked hypoxia
 In late pregnancy, compared with early
pregnancy.
 The absolute risks: Small
2. Increased risk of DVT
{Reduced mobility from self-isolation at home, or hospital
admission}
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5. 5/8/2020
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2. Effect on the fetus
 No increased risk of
 Miscarriage or early pregnancy loss
 Teratogenicty .
1. Fetal compromise
2. Prelabour PROM
3. Hyperthermia during organogenesis: congenital
anomalies, NTD, or miscarriage.(Theoretical)
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 Yan et al, 2020. 24 April
116 pregnant women withCOVID-19 in China
 The most common symptoms
 Fever: 50.9%
 Cough: 28.4%
 No sym: 23.3%.
 Abnormal radiologic findings in 96.3% of cases.
 Severe pneumonia: 6.9%. no maternal deaths.
 PTL: 23.2%
 Spontaneous PROM: 6.1%
 CS: 85.9%
 NICU: 47% Neonatal death: 1%.ABOUBAKR ELNASHAR

6. 5/8/2020
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MANAGEMENT
 MULTIDISCIPLINARY TEAM
1. Chest specialist
2. Intensivist
3. OBSTETRICIAN
4. Anesthesiologist
5. Neonatologist
6. Microbiologist
7. infection control specialist
A. MEDICAL
B. OBSTETRICAL
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A. MEDICAL
22.4.2020
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7. 5/8/2020
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OBSTETRICAL
I. ANTENATAL CARE (RCOG, 2020)
 Appointments
 Limited with remote consultation by telephone
 Women who have had symptoms
 deferred until 7 days after the start of
symptoms, unless symptoms (aside from
persistent cough) persevere.
 Suspected or confirmed COVID-19
 delayed until after the recommended period of
isolation 14 days
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8. 5/8/2020
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 Antenatal Clinic
 Separate for suspected or confirmed COVID-19.
 Dedicated team
 appropriate PPE.
 Dedicated equipment
 Remove non-essential items
 US machine
 decontaminated after each use.
 Transducers are cleaned and disinfected
 Protective covers for probes and cables.
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9. 5/8/2020
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 Procedures
 US & other investigations (urine &blood tests in
same visit
 US for F growth& anatomy.
 Electronic FHR monitoring
 Doppler assessment
 Amniocentesis
 Not recommended in active infection.
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2. Use of medications to manage pregnancy
 Antenatal betamethasone
 CDC: avoiding glucocorticoids in COVID-19-
positive { increased risk for mortality}
 ACOG: between 24+0 &33+6 w in patients at
high risk of PTL within 7 days
 Not 34+0 to 36+6 w
 {benefits to the neonate are less clear}
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10. 5/8/2020
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 Low-dose aspirin
 For prevention of PET.
 Suspected or confirmed COVID-19 for whom LDA
would be indicated, the decision to continue should
be individualized & is usually possible.
 Continuing is not worthwhile in
 Severely or critically ill patients or
 Near term
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 NSAIDs (ibuprofen)
 Early in the course of infection: severe disease
 No clinical or population-based data that directly address
the risk of NSAIDs.
 WHO do not recommend avoiding NSAIDs in COVID-19 patients
when clinically indicated
 Acetaminophen
 In the first trimester
 Fever
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11. 5/8/2020
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 Tocolysis
 Nifedipine
 Not:
 Indomethacin, which is subject to the concerns
discussed above
 Beta sympathomimetics, which can further
increase the maternal heart rate.
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3. Delivery timing
 Depend upon:
1. Mother's clinical status
2. Gestational age
3. Fetal well-being.
 Improvement mother's condition: improve fetal
status: pregnancies allowed to continue to term.
 If woman is critically ill, deterioration : IUF demise
or loss of both mother& infant: early delivery
 Infectious: Elective CS ± delayed, if possible
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12. 5/8/2020
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 Mg sulfate —
 Indication
 maternal seizure prophylaxis
 neonatal neuroprotection
 Women with respiratory compromise
{Mg sulfate ±depress respirations}.
 Consultation with maternal-fetal medicine&
pulmonary/critical care specialists.
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II.INTRAPARTUM
1. Evaluation of all patients on admission
2. PPE on labor
 All clinicians
 All asymptomatic patients
3. Mode of delivery
 Based on obstetric indications, as there is no clear
benefit of delivery via CS
 Seriously ill patients & need urgent delivery
should be by category 1 CS.
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13. 5/8/2020
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4. Analgesia & anesthesia
 Regional Anasthesia by epidural or spinal
 Recommended .
 General anesthesia (intubation & extubation)
 Considered an aerosolizing procedure
 The scrub team should
 Scrub & wear PPE (N-95) before the general
anesthesia is commenced.
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 Nitrous oxide
 Not recommended
 {insufficient data about cleaning, filtering, potential
aerosolization of nitrous oxide systems}.
 Intravenous, patient-controlled analgesia
 limiting use
 {risk of respiratory depression}.
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14. 5/8/2020
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5. Labor management
 Person-to person contact & time in the labor unit &
hospital should be limited
 Maternal observations:
 T, RR, oxygen saturation to be kept above 94%.
 Fluid chart to avoid fluid overload.
 Continuous CTG
 Shortening of the second stage
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 Rupture of membranes&internal FHR monitoring
 ±performed, but data are limited
 {COVID19 has not been detected in vaginal secretions or
amniotic fluid}
 Pushing
 often causes loss of feces, which can contain the
virus & spread the infection
 Not delaying pushing in 2nd stage.
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15. 5/8/2020
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 Delayed cord-clamping:
 Unlikely to increase the risk of transmitting virus
from infected mother to the fetus
(ACOG, RCOG, EMH, April 2020)
 Oxygen therapy for fetal resuscitation
 Should be abandoned
{no proven fetal benefit
nasal cannula& face mask used are in contact with
the maternal respiratory tract& secretions: increases
contamination/exposure between pt. &provider}.
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 Neonate should be
 Cleaned& dried immediately
 Leaving vernix caseosa in place for 24 h since it
contains antimicrobial peptides.
 Isolated for 14 days
 Closely monitored for clinical manifestations of
infection.
 The mother & newborn
 May need to be isolated separately until both are
cleared
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16. 5/8/2020
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III. Post partum care
1. Placental disposal
 The placenta should be treated as biohazardous
waste
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3. Breast feeding: (EMH, April 2020)
 Not recommended.
 If the mother is severely or critically ill
 express breast milk with a pump to maintain milk production (the
pump should be cleaned after each use).
 Can be considered
 If the mother is asymptomatic or mildly affected,
{virus is transmitted by respiratory droplets rather than breast milk}
 Mothers should:
 wash their hands
 wear a mask
 avoid coughing or sneezingABOUBAKR ELNASHAR

17. 5/8/2020
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5. Postpartum fever
 COVID-19 should be part of the dd particularly
 respiratory symptoms &
 reduced oxygenation.
 Such patients should be
 tested for the virus
 evaluation for common causes of intrapartum
&postpartum infection:
 Chorioamnionitis
 Endometritis
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6. Postpartum office visits
 Should be limited to reduce the risk of inadvertent exposure.
 Early postpartum assessments: wound &blood
pressure checks, with telephone.
 After 4-8 w: psychological assessment
 Screen for postpartum depression: self-report,
10-item Edinburgh Postnatal Depression Scale,
which can be completed in 5 minutes
 Severe anxiety and support offered.
 After 12W: A comprehensive assessment
especially in patients with comorbiditiesABOUBAKR ELNASHAR

18. 5/8/2020
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TAKE HOME MESSAGE
1. No evidence of miscarriage, F. congenial fetal
malformation.
2. It may cause PTL, PPROM, F. compromise
3. ANC should be delayed till the symptoms improve
4. Separate room, dedicated team, appropriate PPE.
dedicated equipment
5. Delivery timing depend upon: Mother's clinical status
G. age & F. well-being.
6. Mode of delivery based on obstetric indications
7. Regional anasthesia by epidural or spinal
8. The placenta is treated as biohazardous waste
9. Breast feeding not recommended if the mother is
severely or critically ill
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 For CONID 19 AND Pregnancy: The following
statements are correct except
A. Increased risk of DVT during pregnancy
B. It is not sexually transmitted
C. Corticosteroid is indicated between 24+0 &33+6 w
in patients at high risk of PTL within 7 days
D. Oxygen therapy for fetal resuscitation is
recommended
E. Delayed cord-clamping is unlikely to increase risk
of transmitting virus from infected mother to fetus
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