Covid in pregnancy COURSE IN PREGNANCY Pregnancy and

Covid in pregnancy

COURSE IN PREGNANCY Pregnancy and childbirth DO NOT increase the risk for acquiring SARS-Co. V-2 infection DO NOT worsen the clinical course of COVID-19 compared with non-pregnant individuals of the same age Most infected mothers recover without undergoing delivery

Pregnancy complications 15%delivered before 37 weeks. 70% delivered by cesarean. Fever and hypoxemia in severe pneumonia and fever may increase the risks: Preterm labor Premature rupture of membranes Abnormal fetal heart rate patterns

Most Frequent Symptoms (33 studies) Fever (67 percent) Headache Cough (66 percent) Possibly abnormalities in Dyspnea (7 percent) smell and/or taste. Sore throat (7 percent) Fatigue (7 percent) Lymphopenia (14%) Myalgia (6 percent) Modest increase in liver enzymes(5%) Rhinorrhea/nasal congestion Anorexia, nausea/vomiting Thrombocytopenia (1%)

It is known that some patients with severe COVID-19 have laboratory evidence of an exuberant inflammatory response (similar to cytokine release syndrome), which has been associated with critical and fatal illnesses. Whether the normal immunologic changes of pregnancy affect the occurrence and course of this response is unknown Severe sequelae of maternal infection include prolonged ventilatory support and need for extracorporeal membrane oxygenation (ECMO). In pregnant women who develop COVID-19 pneumonia, there appears to be an increased risk of preterm and cesarean delivery.

Maternal deaths from cardiopulmonary complications, sometimes with multiorgan failure, have been reported in the medical literature Most of these women were generally healthy prior to the SARS-Co. V-2 infection. The risk of death does not appear to be increased in pregnancy compared with nonpregnant, reproductive-age women

Hyperthermia, which is common in COVID-19, is a theoretical concern as elevation of maternal core temperature from a febrile illness during organogenesis in the first trimester may be associated with an increased risk of congenital anomalies, especially neural tube defects, or miscarriage; however, an increased incidence of these outcomes has not been observed. Use of acetaminophen in pregnancy, including in the first trimester, has been shown overall to be safe

Prevalence of congenital infection Possible vertical transmission has been reported in several cases of peripartum maternal infection in the third trimester, suggesting congenital infection is possible but uncommon (<3 percent of maternal infections ) Most neonatal infections are thought to result from respiratory droplets when neonates are exposed after delivery to mothers or other caregivers with SARS-Co. V-2 infection. The frequency of spontaneous abortion does not appear to be increased, but data on firsttrimester infections are limited.

Only two well-documented cases of probable vertical transmission have been published [53, 54]. Both infants were delivered at 35 to 36 weeks of gestation and did well. One had transient mild hypothermia, hypoglycemia, and feeding difficulties consistent with prematurity but no respiratory difficulties. The other required resuscitation at birth but was extubated within six hours and then on day 3 of life developed irritability, poor feeding, axial hypertonia, and opisthotonos but recovered. Newborn and placental specimens were positive for SARS-Co. V-2 RNA.

Defining COVID-19 severity Asymptomatic/pre-symptomatic Mild Moderate Severe Critical illness

Asymptomatic or pre-symptomatic positive COVID-19 test result with no symptoms Mild disease Flu-like symptoms: fever, cough, myalgia, without dyspnea, shortness of breath, or abnormal chest imaging

Moderate disease: Evidence of lower respiratory tract disease; Clinical assessment ; dyspnea, Pneumonia on imaging, Abnormal blood gas results Refractory fever of 39 C/102 F or greater not alleviated with acetaminophen Oxygen saturation >93% on room air

Severe disease : Respiratory rate > 30 (bpm) Hypoxia with oxygen saturation <= 93% Ratio of PIO 2/FIO 2 < 300 Lung involvement on imaging > 50%

Critical disease: Multi-organ failure or dysfunction Shock Respiratory failure requiring mechanical ventilation or high-flow nasal cannula

PRENATAL CARE Preventing exposure in the community Social and physical distancing, wearing a mask at work and in public places, and hygienic measures (eg, hand washing) are recommended Patients with potential exposure Pregnant patients with an epidemiologic history of contact with a person with confirmed, probable, or suspected COVID-19 should self-isolate and be monitored for symptoms. The incubation period is up to 14 days. Diagnostic testing for SARS-Co. V-2 infection depends on test availability

Routine prenatal care in uninfected women modifying traditional protocols for prenatal visits. These modifications, which should be tailored for lowversus high-risk patients (eg, multiple gestation, hypertension, diabetes) telehealth, reducing the number of in-person visits, timing of visits, grouping tests for the same visit/day (eg, aneuploidy, diabetes, infection screening) to minimize maternal contact with others, restricting visitors during visits and tests, timing of indicated obstetric ultrasound examinations (eg, gestational age, fetal anomaly, fetal growth, placental attachment), and timing and frequency of use of nonstress tests and biophysical profiles. There are many ways to reduce the time patients. For example, the clinician can order a 75 gram two-hour oral glucose tolerance test (GTT) instead of a glucose challenge test and 100 gram three-hour GTT (in women with positive results); cellfree DNA screening can be used (at >10 weeks) for Down syndrome screening rather than the combined test (ie, nuchal translucency on ultrasound and serum analytes). Ideally, every woman should have telehealth capabilities and a means for measuring blood pressure at home.

In the author's practice, during the pandemic, most low-risk pregnant women come to the office only for in-person prenatal visits at approximately 12, 20, 28, and 36 weeks of gestation (ie, at gestational ages when ultrasound and/or laboratory tests can also be performed) to minimize person-to-person contacts. Some practices are encouraging that even these visits occur by telehealth, and others include a visit at approximately 32 weeks [64]. When an outpatient office visit occurs, all patients and health care workers wear at least a surgical mask; no partner is allowed, but video communication is encouraged.

he US Food and Drug Administration has expanded its approval for use of noninvasive fetal and maternal monitoring devices in the home in patients who require fetal and/or maternal monitoring for conditions unrelated to COVID-19 This can help reduce patient and health care provider contact and potential exposure to COVID-19 during the pandemic.

Should all SARS covid 2 pregnant woman be admitted in hospital for further evaluation? Further evaluation and management of patients who become symptomatic depend on illness severity, underlying comorbidities, and clinical status.

Protocols for outpatient care: Asymptomatic/ Mild Limited prenatal care for all patients 1 st , 2 nd and most of 3 rd trimester visits can be delayed, Monitored closely by their obstetric care providers for worsening symptoms Daily self-assessments Tele-health Reliable feedback mechanism for early detection of a worsening condition.

Protocols for outpatient care Detailed anatomy US for 1 st and early 2 nd trimester infection Growth US 1 -3 weeks after quarantine ends and no longer infectious (not earlier than 28 wk).

Reasons to call a health care provider or emergency medical services Worsening shortness of breath Tachypnea Unremitting fever Inability to tolerate oral hydration or needed medications Oxygen saturation < 95% either at rest or on exertion Persistent pleuritic chest pain New onset confusion or lethargy Cyanotic lips, face, or fingertips Obstetrical complaints, such as preterm contractions, vaginal bleeding, or decreased fetal movement

Follow up There is no guidance about the timing of frequency for followup outpatient care. At least once within 2 weeks of diagnosis of COVID-19. These visits can either be through telemedicine or specialized COVID-19 clinics where available. Antenatal testing (NST, biophysical profiles) : Usual indications, with consolidating Consolidate visits: eg, clinic and ultrasound on the same date and in the same location

When is a patient not infectious? Test-based strategy: No fever, no symptoms AND 2 neg swabs>24 hrs apart Non-test based strategy: >3 d with no fever or symptom (w/o meds) AND >7 days since symptom onset. Asymptomatic patients: >10 days since positive test.

In-patient care Moderate Illness ? ? ? Severe illness or oxygen saturation less than 95%, Comorbid conditions: un-controlled HTN or DM, Fever>39 C despite acetaminophen, Secondary hemophagocytic lymphohistiocytosis (s. HLH) or Cytokine storm syndrome : fatal hypercytokinemia associated with multi-organ failure , unremitting fever, cytopenia, and high ferritin levels.

Inpatient care Pregnant patients with clinical findings of COVID-19 that warrant pharmacologic treatments should be considered for inpatient monitoring

Protocols for inpatient care Frequency of vital sign assessment depends on the severity of illness ( continuous pulse oximetry and/or telemetry) Mild disease : q 4 -8 h Severe disease: q 2 -4 h

Protocols for inpatient care Critical illness: Continuous pulse oximetry and telemetry Non-invasive and invasive cardiovascular monitoring Vital signs: including respiratory support as needed, should be recorded every 1 to 2 hours. Fetal and CTG monitoring : when fetal intervention, including delivery, would be considered based on gestational age, fetal and maternal status, and maternal preferences An abnormal tracing might also help guide maternal oxygen therapy. In patients with stable oxygen saturation (Sa. O 2), a nonstress test can be performed once or twice daily, as one option.

Management of Severe Disease Early warning signs : An increased sensation of dyspnea and/or work of breathing, Inability to maintain adequate oxygen saturation, Persistent or more frequent fevers, Worsening of myalgia

Treatment options Mostly supportive for COVID-19 disease, including strategies to optimize ventilation. several pharmacologic treatment. None of these therapies are contraindicated in pregnancy

Use of antibiotics If clinicians suspect community-acquired pneumonia co-infection, the use of antibiotics is reasonable. Culture If antibiotics are indicated, clinicians should not wait more than 45 minutes to start antibiotic therapy. Ceftriaxone plus azithromycin or ceftriaxone alone are commonly used.

Use of antibiotics Broad-spectrum agents : Severe disease Have risk factors for hospital or ventilator-acquired, ↓ Drug-resistant types of pneumonia cefepime, meropenem, piperacillin tazobactam, linezolid, and vancomycin. procalcitonin level is not required in the assessment of COVID-19, it can be used to help delineate superimposed bacterial pneumonia

Timing of Delivery for Critically ill Pregnant Patients Should be individualized based on: Maternal status, Concurrent pulmonary disease (eg, cystic fibrosis, asthma, sarcoidosis Critical illness Ability to wean off the ventilator and ventilator mechanics Gestational age at time of delivery Shared decision-making with the patient or healthcare proxy. The timing of delivery requires carefully weighing the benefits and risks for the patient and fetus, and the decision to deliver requires close communication between the maternal-fetal medicine and critical care teams

In the third trimester, the pressure of the uterus can decrease expiratory reserve volume, inspiratory reserve volume, and functional residual capacity, and increase the risk of severe hypoxemia in pregnant patients, especially those who are critically ill.

If delivery is considered based on severe hypoxemia, other options should also be discussed, including prone positioning, extracorporeal membrane oxygenation(ECMO), and the use of other advanced ventilator methods, especially if the gestational age is less than 30 to 32 weeks.

Timing of Delivery in Asymptomatic or Mildly Symptomatic Pregnant Patients COVID-19 -positive status is not an indication for delivery, and delivery should be reserved for routine obstetrical indications COVID-19 -positive status is not an indication for C/S 37 to 38 6/7 WKS without other indications for delivery: expectant management can be considered until "14 days after (PCR) result was positive OR → until 7 days after onset of symptoms OR 3 days after resolution of symptoms decreased exposure of health care workers and the neonate to SARSCo. V-2 and decreased PPE utilization in areas with supply-chain limitations.

Timing of Delivery in Asymptomatic or Mildly Symptomatic Pregnant Patients At 39 weeks of gestation or later: Delivery can be considered to decrease the risk of worsening maternal status

Fetal monitoring The need for and frequency of fetal testing depend on gestational age, stability of maternal vital signs and oxygenation, other maternal comorbidities, and discussions with the patient and her family that consider the possibly increased risks of stillbirth and perinatal morbidities in the absence of testing. The monitor can be used continuously in unstable hospitalized patients in whom emergency cesarean delivery would be performed for a persistent nonreassuring fetal heart rate pattern.

Monitoring for preterm labor Monitoring pregnant patients for signs and symptoms of preterm labor is a routine component of obstetric care and should be a component of maternal monitoring of pregnant patients hospitalized in nonobstetric settings

Maternal respiratory support During pregnancy, maternal peripheral oxygen saturation (Sp. O 2) should be maintained at ≥ 95 percent, which is in excess of the oxygen delivery needs of the mother. If Sp. O 2 falls below 95 percent, an arterial blood gas is obtained to measure the partial pressure of oxygen (Pa. O 2): Maternal Pa. O 2 greater than 70 mm. Hg is desirable to maintain a favorable oxygen diffusion gradient from the maternal to the fetal side of the placenta. The World Health Organization (WHO) suggests maintaining maternal Sp. O 2 ≥ 92 to 95 percent once the patient is stable

In the ICU, severely ill patients with COVID -19 are often managed in the prone position; the left lateral position is an alternative but may not be as effective. Permissive hypercapnia (PCO 2 <60 mm. Hg) and extracorporeal membrane oxygenation (ECMO), if indicated for management of ARDS, do not appear to be harmful to the fetus, but data are limited High positive end-expiratory pressure strategies (>10 mm. Hg), if considered, require close ongoing maternal and fetal monitoring because they decrease preload and cardiac output

venous thromboembolism prophylaxis routine pharmacologic venous thromboembolism prophylaxis in patients hospitalized with COVID-19 is recommended unless there is a contraindication (eg, bleeding, severe thrombocytopenia). We initiate prophylaxis in all pregnant/postpartum women with COVID-19 admitted to the hospital for management of an antepartum or postpartum obstetric or medical disorder or because of the severity of COVID-19 alone. Unfractionated heparin is generally preferred in pregnant women who might be proximate to delivery because it is more readily reversed than low molecular weight heparin. Low molecular weight heparin (eg, enoxaparin 40 mg daily) is reasonable in women unlikely to be delivered within several days and those who are postpartum.

dexamethasone Dexamethasone 6 mg daily for 10 days or until discharge is recommended for severely ill nonpregnant patients who are on supplemental oxygen or ventilatory support. Glucocorticoids may also have a role in the management of refractory shock in critically ill patients with COVID-19 for a preterm delivery at 24+0 and 33+6 weeks of gestation within seven days, we suggest initiating therapy with the usual doses of dexamethasone (four doses of 6 mg given intramuscularly 12 hours apart) or betamethasone (two doses of 12 mg given intramuscularly 24 hours apart) to induce fetal pulmonary maturation followed by either prednisolone (40 mg orally daily) or hydrocortisone (80 mg intravenously twice daily) to complete the maternal steroid course.

Safety of antiviral drug therapy ●Remdesivir It has been used without reported fetal toxicity in some pregnant women with Ebola virus disease ●Other drugs – Data from randomized trials generally suggest no benefit from administration of hydroxychloroquine or chloroquine. Furthermore, adverse maternal effects include abnormal heart rhythms (QT interval prolongation and ventricular tachycardia), especially in patients taking other drugs associated with QTc prolongation. Hydroxychloroquine crosses the placenta. Accumulation in fetal ocular tissue has been observed in animal studies, but an increased risk of fetal ocular abnormalities has not been observed in humans, which is reassuring given that the drug has been used by pregnant women for treatment of systemic lupus erythematosus or for prevention of malaria. Available data are limited, however, and a risk to the fetus cannot be ruled out when used at different doses for other indications

lopinavir-ritonavir, which is primarily used for treatment of HIV infection, including during pregnancy. It crosses the placenta and may increase the risk for preterm delivery, but an increased risk of teratogenic effects has not been observed in humans. Investigational drugs for COVID-19 that are known to be teratogenic include ribavirin and baricitinib.