Antenatal care
Antenatal care services are one of the essential services that any pregnant women should get irrespective of Covid-19 infection status. But there are limited guidelines on the provision of ANC to women with COvid-19. Both the WHO and SOGC recommend considering to delay routine visits in pregnant women who are positive until they recover and in those who are being tested for COVID-19 until they test negative. [8, 9]. The FIGO recommends follow up appointments be postponed until 2wks or until 2 negative results [10]. The mode of ANC services delivery should be modified, and innovative ways of care provision (such as telemedicine) are recommended with due consideration of individualized care plan. In those pregnant women with mild illness home confinement can be considered provided that this is possible logistically and that monitoring of the woman’s condition can be ensured without compromising the safety of her family [9, 10]
Anatomic scanning
It is not still well known if Covid-19 infection is associated with congenital anomalies because of limited number of pregnant patients with Covid-19. The consensus statement from China obstetricians society who have managed several pregnant mothers is to do anatomic scanning in those who have acquired the Covid-19 infection in the first trimester. [11]. But the FIGO consensus guideline (interim guidance) recommends anatomic scanning at gestational age of 18 to 23weeks for all women with Covid-19 infection. [10]
Antenatal Surveillance
A routine antenatal surveillance as a standard of practice is not as such recommended. Four of the guidelines has addressed the issue. The consensus statement from Chinese experts states that continuous EFM in the setting of severe illness should be considered only when delivery would not compromise maternal health [11]. Cardiotocography (CTG) for fetal heart rate (FHR) monitoring and ultrasound beyond gestational age of viability are recommended in those who have recovered from severe illness is also recommended [8, 9, 10,12, 13,]. But the frequency of antenatal surveillance is not well stated.
Growth monitoring
One of the complications of Covid-19 infection in pregnancy is intrauterine growth restriction as a result of the viral pathogenic effects in the placental vasculature. Six of the guidelines have stated on importance of growth monitoring in ongoing pregnancies but they lack consistency on interval growth monitoring (frequency) [9,11-15,]. ISUOG and ICM state monitoring every 4 wks while the SOGC and FIGO recommend every 2-4wks. Both US for BPP and CTG/Doppler are options for fetal surveillance.
Medication during Pregnancy
Antenatal Corticosteroids
Generally, it is advised to use antenatal corticosteroids cautiously because of the potential effect of steroid in delaying viral clearance. Only 4 of the guidelines have addressed the issue and the use of corticosteroid in severely ill patients should be considered only after consultation with ID specialist [10, 13]. But in those women with preterm pregnancy (<34 wks.) and mild illness administration of a single course of antenatal steroids is recommended [9, 15]
Low dose Aspirin
The use of NSAID (esp. Ibuprofen) has been associated with a theoretical risk of facilitating Covid-19 infection. Only the MFM guidance published on journal of Obstetrics & Gynecology has addressed the issue and recommended that it can be used in pregnant women for the prevention of preeclampsia [15]
Tocolytics
Clinical use of tocolytic agents was addressed in 2 of the guidelines. Tocolysis should not be used in an attempt to delay delivery in order to administer antenatal steroids [13]. The SMFM recommends that If tocolytics are indicated, Indomethacin should be avoided in face of uncertainty regarding NSAIDs and Nifedipine should be preferred over indomethacin [15].
The use of magnesium for seizure prophylaxis is also not recommended in severely ill patients with Covid-19 [15]
Labor and Delivery
One of the challenges encountered in the management of pregnant women with covid-19 is regarding labor and delivery care. This is because there are no strong clinical evidences to base on the standard of care for covid-19 pregnant mothers.
Timing and place of delivery
Timing of delivery is generally recommended based on maternal & fetal conditions. [10, 11, 15] But pre-viable termination is recommended in those with organ failure and in pts with respiratory failure where improved oxygenation is expected with delivery of the fetus [11]. Timing of delivery in those with mild illness should not be dictated by maternal COVID-19 infection and in those pregnant mothers in 3rd trimester, it is better to wait until negative test results [11] or quarantine status is lifted in an attempt to avoid transmission to the neonate [15]. Place of delivery in covid-19 infected mothers is addressed only the RCOG guidance which states that hospital birth is preferred to home birth for women who have or are being tested for COVID-19, in light of the challenges associated with ensuring appropriate personal protective equipment in the home setting and the high rates of fetal distress that reported in the literature [12]. For the protection of the medical team, water birth should be avoided [13]
Labor companionship
One of the intriguing issues is labor companionship as there is a concern of transmission of covid to the companion and to the family. In institutional deliveries limiting the number of attendants is recommended but with due consideration of making sure that there is always a family member around in emergency situations. Six of the guidelines have recommended a single, asymptomatic or screen negative birth partner be permitted to stay with the woman [8, 10, 11-14].
Conduct of labor and delivery
Most of the guidelines recommend that Labor and delivery be conducted in isolated room if possible with negative pressure [13]. The room should be disinfected immediately after each delivery (10). Guidance on intrapartum fetal monitoring is very limited and has been addressed in only 2 of the guidelines [9, 10]. Fetal monitoring in the form of EFM should be considered given evidence showing fetal distress during labor is common in women with Covid-19 infection [9]. Early epidural to minimize need for GA in the event of emergent CD is recommended in the MFM guidance [15]. There are no recommendations regarding rupture of membranes, oxytocin augmentation of labor and peculiarity in the definition of labor abnormalities. But, the event that an infected woman has spontaneous onset of labor with optimal progress, she can be allowed to deliver vaginally [13].
Shortening of the second stage
The practice of instrumental delivery in the context of Covid-19 infection is addressed in only 2 of the documents revised. The China consensus statement and ISUOG state that shortening of the 2nd stage with instrumental delivery in those with respiratory distress who are on masks because active pushing while wearing a surgical mask may be difficult for the patient [11,13]. The ICM advocates against the practice of routine instrumental delivery [14]. With respect to a pregnant woman without a diagnosis of COVID-19 infection, but who might be a silent carrier of the virus, the ISUOG urges caution regarding the practice of active pushing while wearing a surgical mask, as it is unclear if there is an increased risk of exposure to any healthcare professional attending the delivery without PPE, because forceful exhalation may significantly reduce the effectiveness of a mask in preventing the spread of the virus by respiratory droplets [13]
Cesarean Delivery
Regarding cesarean delivery most of the guidelines consistently state that it is reserved for routine obstetric indications [ISUOG, SOGC, RCOG, ICM, FIGO, CHINA, MFM]. But the ICM guidance emphasizes that patients’ decision be respected and the China consensus statement advocates CD in those mothers with severe respiratory distress in whom oxygenation might be improved by immediate delivery of the fetus [11]. Regional anesthesia as the choice of anesthesia for CD in Covid-19 positive mothers is recommended in the FIGO interim guidance [10] as it decreases staff exposure to Covid-19 but the ISUOG states both regional and general can be considered after consultation with anesthesiologists [13].
Cord clamping
There is no consensus on the practice of cord clamping. Four of the guidelines including RCOG & ISUOG recommend avoiding delayed cord clamping although there is lack of clear evidence against it [10 12, 13]. But guidance from the WHO and SOGC recommend to continue with the usual practice of delayed cord clamping as the theoretical risk of increased neonatal exposure to the Corona virus in the extra few minutes is negligible [8, 9].
Miscarried embryos/fetuses and placentae of COVID-19-infected pregnant women should be treated as infectious tissues and they should be disposed of appropriately; if possible, testing of these tissues for COVID-19 by qRT-PCR should be undertaken [13]
Breast feeding and maternal fetal bonding
The practice of Skin-to-skin contact can be continued with the mother wearing a mask and after having washed her hands as stated in the FIGO and SOGC guidelines [9, 10]. One of the controversial areas with no consistent recommendations is the practice breast feeding. The WHO and ICM have strongly recommended exclusive breast feeding in women with Covid-19 patients [8, 14]. But the guidance didn’t consider the severity of the illness. Rooming-in with Expressed breast milk (during time of separation) or suckling in mildly affected is recommended by ISUOG [13]. The necessary precautions should be made when woman with suspected/confirmed COVID 19COVID-19 infection wants to breast feed: the mother should wear a face mask, avoid coughing or sneezing on the newborn,
Standard COVID-19 hand washing principles should be followed prior to each feeding and prior to each time the mother touches the baby [16, 17]
Regarding maternal separation, the guidance from the WHO and RCOG do not generally recommend separation [8, 12]. In the ISUOG interim guideline, If the mother is severely or critically ill, separation appears to be the best option, with attempts to express breastmilk in order to maintain milk production. Precautions should be taken when cleaning the breast pumps and the option of using a screen negative relative wearing appropriate protective equipments to pump breast are recommended [13]. The Canadian society of Obstetrics and Gynecology guidance does not recommend universal isolation of the infant from either confirmed of suspected infection in the mother. However, depending on a family’s values and availability of resources they may choose to separate infant from mother until isolation precautions for the mother can be formally discontinued [9].
Post-natal care,
Modification of postnatal services is recommended with decreased number of visits and provision of care with telehealth. The majority of postpartum visits may be conducted remotely as long as the patient does not have specific concerns that require in-person examination [10]