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COVID 19 infection and pregnancy RCOG2021

Prof. Aboubakr Elnashar

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COVID 19 infection and pregnancy RCOG2021

  1. 1. COVID-19 & Pregnancy RCOG, 19 February 2021 Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR CONTENTS I. INTRODUCTION II. ANTENATAL CARE 1. General 2. Prevention of VTE 3. Managing Clinical Deterioration III. INTRAPARTUM CARE IV. POSTPARTUM CARE ❑ CONCLUSION ABOUBAKR ELNASHAR
  2. 2. I. INTRODUCTION ▪ Vertical transmission: ▪ uncommon. ▪ If it does occur, it appears to not be affected by 1. Mode of birth 2. Delayed cord clamping 3. Skin-to-skin contact 4. Method of feeding or 5. Whether the woman& baby stay together (rooming in) ABOUBAKR ELNASHAR ▪ Vaccination in pregnancy & breast feeding ▪ Available data do not indicate any safety concerns or harm ▪ Should be considered where: 1. The risk of exposure is high or cannot be avoided 2. The woman at very high risk of serious complications of COVID-19. ABOUBAKR ELNASHAR
  3. 3. ▪ More than two-thirds of pregnant women with COVID- 19 are asymptomatic ▪ Pregnant women with COVID compared to non- pregnant women with COVID: ▪ Higher rates of ICU admission: this may reflect a lower threshold for admission to ICU, rather than more severe disease. ▪ Not at increased risk of death, according to the largest SR ▪ More recent data from the USA & Mexico: slightly higher risk of death ABOUBAKR ELNASHAR II. ANTENATAL CARE 1. General Guidelines ▪ Continuity of care ▪ Unless self-isolation criteria with suspected or confirmed COVID-19 ▪ Particularly for vulnerable groups who may also be at greater risk from COVID-19. ▪ Modified ABOUBAKR ELNASHAR
  4. 4. ▪ Modifications to ▪ Enable social distancing measures ▪ Reduce risk of transmission between women, staff & other clinic/hospital visitors ▪ Provide care to women who are self-isolating for suspected or confirmed COVID-19 for whom a hospital attendance is essential ABOUBAKR ELNASHAR ▪ Procedures: ▪ BP, urine testing, fundal height. ▪ Screening for diabetes in pregnancy ▪ Blood tests, maternal examination, US: same visit ABOUBAKR ELNASHAR
  5. 5. ▪ Appointments ▪ During ‘local lockdown’: teleconference or videoconference, telephone consultation ▪ Pregnant women to ▪ contact emergency antenatal services if they have any concern about their or their baby’s wellbeing ▪ attend if they have concerns about their or their baby’s wellbeing ▪ All women &any accompanying visitors (where permitted) should be advised to wear facemasks or face coverings ▪ Shared waiting areas should be avoided ▪ Adequate PPE is used ABOUBAKR ELNASHAR ▪ Advice: ▪ Folic acid, vit D supplements acc to national recommendations ▪ Influenza vaccination is safe at all gestations of pregnancy & is recommended ▪ Mental health: ▪ Ask about at every contact ▪ Women who express concern about their mental health or ‘red flag’ symptoms, such as ▪ suicidal thoughts or sudden mood changes, or ▪ where their families express these concerns on their behalf: should be supported to access urgent care ABOUBAKR ELNASHAR
  6. 6. ▪ Suspected or Confirmed COVID-19 Needing Hospital Attendance ▪ If women report symptoms attributed to COVID-19 on the phone to maternity services: consider DD for fever, cough, or shortness of breath: ▪ UTI, chorioamnionitis, pulm. embolism. ▪ If women have symptoms suggestive of COVID-19: should be advised to COVID19 testing. ▪ Maternity units should develop triage tools to assess the severity of illness: an assessment of symptoms, clinical and social risk factors and escalation pathways ‘safety netting advice’ about the risks of deterioration and when to seek urgent medical attention. ABOUBAKR ELNASHAR ▪ Possible or confirmed COVID-19, for whom hospital attendance is required or who self-present ▪ Patient: ▪ with a fluid-resistant surgical mask ▪ should not be removed until she is isolated ▪ Staff: ▪ should wear appropriate PPE. ▪ Only essential staff should enter the isolation room ▪ Isolation rooms from which all non-essential items have been removed ▪ Visitors to isolation rooms should be kept to a minimum ABOUBAKR ELNASHAR
  7. 7. 2. Prevention of VTE ▪ Women who are self-isolating at home ▪ Should stay hydrated & mobile ▪ VTE risk assessment: Infection with SARS-CoV-2 is a transient risk factor ▪ Ensure women are supplied with LMWH ▪ Thromboprophylaxis should be continued until they have recovered from the acute illness (between 7 & 14 days). ABOUBAKR ELNASHAR ▪ Women admitted with confirmed or suspected COVID-19 ▪ Prophylactic LMWH, unless ▪ Birth is expected within 12 hs or ▪ There is significant risk of hge ▪ Duration: ▪ Continue for 10 days following hospital discharge ▪ Longer duration for women with persistent morbidity. ▪ Women admitted with confirmed or suspected COVID-19 within 6 ws postpartum, should be offered thromboprophylaxis ▪ Duration ▪ During admission and for 10 days after discharge ▪ 6 ws postpartum for women with significant morbidity ABOUBAKR ELNASHAR
  8. 8. 3. Managing Clinical Deterioration ▪ Fever: ▪ Testing for SARS-CoV-2 in addition to blood cultures. ▪ Possibility of bacterial infection should be considered: ▪ Full sepsis screen ▪ Action Tool and IV antibiotics ▪ Bacterial (rather than viral) infection should be considered if the white blood cell count is raised (lymphocytes are usually normal or low with COVID-19) and antibiotics should be commenced. ABOUBAKR ELNASHAR ▪ Chest imaging ▪ Should be performed when indicated: chest X-ray & CT. ▪ Essential for the evaluation of the unwell woman ▪ Diagnosis of pulm. embolism or heart failure ▪ should be considered for ▪ Chest pain ▪ Worsening hypoxia or ▪ Respiratory rate above 20 breaths/min (particularly if there is a sudden increase in oxygen requirements), or ▪ Breathlessness persists or worsens after expected recovery. ▪ Additional tests to DD: ▪ ECG, echocardiogram, CT pulmonary angiogram ▪ Ventilation perfusion lung scan ABOUBAKR ELNASHAR
  9. 9. ▪ Principles of care ▪ Women with suspected COVID-19 should be treated as though it is confirmed until test results are available. ▪ The priority for medical care should be to stabilise the woman’s condition with standard therapies. ▪ An urgent MDT meeting should be arranged for any unwell woman 1. Women who are requiring oxygen to maintain saturations between 94% and 98% 2. RR ≥20 breaths/m 3. HR ≥110 beats/m. ABOUBAKR ELNASHAR ▪ MDT: ▪ Consultant obstetrician, anaesthetist, neonatologist, intensivist, respiratory physician, infection control team, midwife-in-charge, neonatal nurse-in-charge ▪ The discussion should be shared with the woman& her family ▪ The following should be considered: ▪ Key priorities for medical care of the woman&her baby, and her birth preferences. ▪ The most appropriate location of care: ▪ intensive care unit ▪ ‘specific COVID-19 wards ▪ isolation room in infectious disease ward ABOUBAKR ELNASHAR
  10. 10. ▪ Observations & investigations ▪ Fetus: ▪ The frequency& suitability of FHR monitoring ▪ should be considered on an individual basis ▪ gestational age ▪ maternal condition. ▪ Mother: ▪ Monitor both the absolute values& trends of the hourly observations: HR, RR and O2 saturation ABOUBAKR ELNASHAR ▪ The woman’s care should be escalated urgently if any of the following signs of decompensation develop: 1. Increasing oxygen requirements or fraction of inspired oxygen (FiO2) above 35% 2. Increasing RR despite oxygen therapy of or above 25 breaths/m or a rapidly rising RR 3. Reduction in urine output 4. Acute kidney injury (serum creatinine levels above 77 µmol/l in women with no pre-existing renal disease) 5. Drowsiness, even if the oxygen saturations are normal ▪ Possibility of myocardial injury should be considered {symptoms are similar to those of respi complications of COVID-19} ABOUBAKR ELNASHAR
  11. 11. ▪ Interventions ▪ Oxygen should be titrated to target saturations to 94–98%. ▪ Caution should be applied to IV fluid management: ▪ Hourly fluid input/output char ts should be used to monitor fluid balance in women with moderate to severe symptoms of COVID-19. ▪ The aim should be to maintain a neutral fluid balance in labour. ▪ When required, boluses in volumes of 250–500 ml should be employed and an assessment for fluid overload made before proceeding with fur ther fluid resuscitation. ABOUBAKR ELNASHAR ▪ Antibiotics ▪ should be commenced at presentation if there is clinical suspicion of bacterial infection or sepsis. ▪ IV antibiotics in woman with fever&prolonged ROM ABOUBAKR ELNASHAR
  12. 12. ▪ Thromboprophylaxis ▪ All pregnant women should be assessed for risk of VTE ▪ LMWH unless there is a contraindication. ▪ The dose ▪ should be individualized basis. ▪ Therapeutic doses when VTE is suspected ▪ Women with thrombocytopenia (platelets ≤ 50 × 10 9 /l): ▪ Aspirin & LMWH should be discontinued ▪ Haematology advice. ▪ Mechanical aids (intermittent pneumatic compression) should be used if LMWH therapy is contraindicated or paused secondary to thrombocytopenia. ABOUBAKR ELNASHAR ▪ Corticosteroid therapy ▪ Should be considered for 10 days or up to discharge whichever is sooner, for ▪ women who are unwell with COVID-19 and requiring oxygen supplementation or ventilatory support. ▪ If steroids are not indicated for fetal lung maturity: ▪ Oral prednisolone 40 mg once a day, or ▪ IV hydrocortisone 80 mg twice daily ▪ If steroids are indicated for fetal lung maturity: ▪ IM dexamethasone 6 mg every 12 hs for 4 doses, then oral prednisolone 40 mg once a day, or ▪ IV hydrocortisone 80 mg twice daily ABOUBAKR ELNASHAR
  13. 13. ▪ Remdesivir ▪ During pregnancy: ▪ Should be avoided {Fetal risk is largely unknown}. ▪ If clinicians believe the benefits outweigh the risks ▪ Decision should be taken by an MDT ▪ During breastfeeding: ▪ consider the benefits and risks ▪ Use only in women where benefit has been reported ▪ hospitalised patients requiring oxygen therapy ▪ especially early in disease course ▪ not in patients who are mechanically ventilated. ABOUBAKR ELNASHAR ▪ Other therapies ▪ Hydroxychloroquine ▪ lopinavirritonavir and ▪ Azithromycin ▪ ineffective in treating COVID-19 infection ▪ should not be used for this purpose. ABOUBAKR ELNASHAR
  14. 14. ▪ Planning for the birth for pregnant women ▪ in the third trimester who are unwell: ▪ An individualized assessment by the MDT to ▪ Decide whether emergency CS or IOL ? ▪ Facilitate maternal resuscitation (including the need for prone positioning) or ▪ Because of concerns regarding f. health. ▪ If maternal stabilisation is required before delivery can be undertaken safely, this is the priority ▪ If urgent intervention for fetal reasons, then birth should be accelerated as for usual obstetric indications, as long as the maternal condition is stable. ABOUBAKR ELNASHAR ▪ When iatrogenic preterm birth is required ▪ Corticosteroids to promote fetal lung maturation ▪ Mg SO for fetal neuroprotection, should be considered by the MDT. ▪ Urgent intervention for birth should not be delayed for their administration. ABOUBAKR ELNASHAR
  15. 15. III. INTRAPARTUM CARE 1. Asymptomatic women positive for SARS-CoV-2? ▪ CEFM during labour using CTG ▪ Delayed cord clamping & skin-to-skin contact with their baby in line with usual practice. ABOUBAKR ELNASHAR 2. Symptomatic suspected or confirmed COVID-19 in labour ▪ Women with mild COVID-19 symptoms can be encouraged to remain at home (self-isolating) in early (latent phase) labour consistent with routine care. ▪ The number of staff members entering the room should be minimized ▪ PPE. ▪ MDT should be informed ▪ Confirmation of the onset of labour. ▪ Assessment of the severity of COVID-19 symptoms ABOUBAKR ELNASHAR
  16. 16. ▪ Maternal observations: ▪ Hourly ▪ Temp, RR, oxygen saturation: Oxygen therapy should be titrated to aim for saturation above 94%. ▪ Fetal observation: ▪ CEFM using CTG. ▪ Maternal infection with SARS-CoV-2 is in itself not a contraindication to performing a fetal blood sample or using fetal scalp electrodes ▪ Delayed cord clamping and skin-to-skin contact with their baby if the condition of the woman&infant ABOUBAKR ELNASHAR ❑Timing of birth ▪ Personalised assessment ▪ Consider the urgency of the birth & the risk of infectious transmission to other women, healthcare workers and, postnatally, to her baby. ▪ If a planned CS or IOL cannot be delayed: ▪ Senior obstetric & medical input should be sought to aid supportive care of a woman with severe or critical COVID-19 ABOUBAKR ELNASHAR
  17. 17. ❑ Mode of birth ▪ Discuss mode of birth with the woman& her family. ▪ Consideration should be given to ▪ her preferences ▪ obstetric or fetal indications. ▪ Consider whether the benefits of an urgent CS outweigh any risks to the woman?. ▪ PPE for CS should be followed. ABOUBAKR ELNASHAR ❑ Labour analgesia or anaesthesia ▪ Entonox (50% nitrous oxide and 50% oxygen) can be safely offered with a standard single-patient microbiological filter. ▪ Epidural analgesia ▪ should be discussed with women with suspected or confirmed COVID-19 when they are in early labour so they can make informed decisions regarding use or type of labour analgesia. ▪ Women should be informed that the use of epidural analgesia may avoid the need for GA in some cases, and the associated additional risks in this scenario. ABOUBAKR ELNASHAR
  18. 18. ❑ PPE during labour ▪ For CS where GA is planned ▪ From the outset all staff in theatre should wear PPE, including an FFP3 mask & visor. ▪ PPE should be donned prior to commencing the GA. ABOUBAKR ELNASHAR ❑Obstetric theatres for suspected or confirmed COVID ▪ Elective procedures ▪ such as CS should be scheduled at the end of the operating list. ▪ Emergency procedures ▪ should be conducted in a second obstetric theatre, allowing time for a full postoperative theatre clean ▪ Staff in the operating theatre ▪ should be kept to a minimum ▪ should wear appropriate PPE. ABOUBAKR ELNASHAR
  19. 19. IV. POST PARTUM CARE ▪ Women with suspected or confirmed COVID-19 ▪ should remain with their baby and be supported to practice skin-to skin/kangaroo care, if the newborn does not require additional medical care ▪ Adopt a precautionary approach to minimize any risk of women-to-infant transmission ABOUBAKR ELNASHAR ❑Breastfeeding ▪ Infection with COVID-19 is not a contraindication. ▪ Should be recommended to all women ▪ Individualized support, advice & guidance ▪ Risks& benefits should be discussed ▪ When a woman is not well enough to care for her infant or where direct breastfeeding is not possible: ▪ Woman to express her breastmilk by hand or using a breast pump, ▪ and/or offer access to donor breast milk. ABOUBAKR ELNASHAR
  20. 20. ▪ Precautions to limit viral spread to the baby: 1. Wash hands before touching baby, breast pump or bottles. 2. Avoid coughing or sneezing on the baby while feeding 3. Face covering or fluid-resistant facemask while feeding or caring for the baby. ▪ Postnatal care up to 8 weeks after birth ▪ Self-isolate at home for 14 days after birth of a baby ▪ Thromboprophylaxis ▪ For 10 days following hospital discharge. ▪ A longer duration should be considered for women with persistent morbidity. ABOUBAKR ELNASHAR ▪ Effective contraception should be discussed with and offered to all women prior to discharge from maternity services. ▪ Advice: ▪ Safe sleeping, smoke-free environment ▪ Hand hygiene & infection control measures when caring for and feeding the baby ▪ Signs of illness in their newborn or ▪ Worsening of the woman’s symptoms ABOUBAKR ELNASHAR
  21. 21. ▪ Should be provided with appropriate contact details if they have concerns or questions about their baby’s wellbeing ▪ In-person home or clinic appointments ▪ to allow an overall assessment of the ▪ physical and ▪ psychological health and wellbeing of the woman and her baby. ABOUBAKR ELNASHAR Thanks ABOUBAKR ELNASHAR

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Prof. Aboubakr Elnashar


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