Managing SARS-CoV-2 Infection During Pregnancy: Proposed Algorithm

By Marilynn Larkin

March 10, 2020

NEW YORK (Reuters Health) - Researchers have developed an algorithm for managing pregnant women at risk of SARS-CoV-2 infection and urge its adoption by healthcare facilities.

"At present, there are little data on the rate of infection and the evolution of COVID-19 coronavirus infections in pregnant women," Dr. David Baud of Lausanne University Hospital in Switzerland told Reuters Health by email.

However, experience with other coronavirus epidemics suggest that pregnant women are at risk of severe disease, and although no instances of vertical transmission have been identified as yet, he said, "we suggest that ongoing pregnancies be closely monitored."

Further, he added, the severe outcomes in newborns seen with the recent emergence of Zika virus "suggest that when a new pathogen emerges, we should be prepared for the worst-case scenario."

With that in mind, Dr. Baud and colleagues created an algorithm for clinicians caring for pregnant women. (http://bit.ly/3cLvW5W)

"We strongly believe that an algorithm is easier to read and understand than a text," he said. "It is probably too early at the moment to see medical societies adopting our guidelines, but it has been mentioned in some of them, such as the Swiss Society of Gynecology and Obstetrics (see http://bit.ly/3aMmA8h).

The algorithm and guidelines, both published in The Lancet Infectious Diseases, will be updated as new data emerge, he added.

Highlights of the guidelines include:

- A pregnant woman who has traveled in a country affected by SARS-CoV-2 in the past 14 days or who has had close contact with an individual with confirmed infection should be tested with a SARS-CoV-2 nucleic acid amplification test, even if asymptomatic.

- Asymptomatic pregnant women with laboratory-confirmed SARS-CoV-2 infection should be self-monitored at home for at least 14 days; these women and those recovering from mild illness should be monitored with bimonthly fetal growth ultrasounds and Doppler assessments.

- Pregnant women with COVID-19 pneumonia should be managed by a multidisciplinary team at a tertiary care center.

- For pregnant women with confirmed infection, delivery timing should be individualized depending on the week of gestation and maternal, fetal, and delivery conditions. Whenever possible, vaginal delivery via induction of labor, with eventual instrumental delivery to avoid maternal exhaustion, is preferred.

- Newborns of mothers positive for SARS-CoV-2 should be isolated for at least 14 days or until viral shedding clears; direct breastfeeding is not recommended during this time.

- Recommendations should be adapted to local healthcare facilities and in response to further updates on SARS-CoV-2 and COVID-19.

Dr. Baud said, "We need more data regarding potential vertical transmission, impact on the fetus when COVID-19 infection occurs during the second or third trimester, rate of severe infection in the mother, and long-term follow-up."

His team has launched an international registry called Covi-Preg (International COVID-19 and Pregnancy Registry) and medical centers and maternity facilities globally are invited to join. For more information, contact Dr. Baud directly at: David.Baud@chuv.ch.

Dr. Ashley Roman, Director of the Division of Maternal Fetal Medicine at NYU Langone Health in New York City, commented in an email to Reuters Health, "The general tenets guiding (these) recommendations are consistent with other guidelines - the concern that pregnant women may be more likely to be severely affected by COVID-19 and the consideration that infants born to women with (the) infection should be protected from contracting COVID-19 from their mothers."

"Management strategies like close surveillance of pregnancies affected by COVID-19, with frequent evaluation of the fetus on ultrasound, hospitalization of symptomatic pregnant women with confirmed COVID-19 infection make sense," she said.

"Some of the specifics recommended by the authors will be subject to regional and international variations in standards of care," she noted. "For instance, these authors advise against all breastfeeding whereas the U.S. Centers for Disease Control and Prevention indicates that breastfeeding is advised and that the pumped breast milk should be administered by a healthy caregiver."

"But the guiding principles are the same - pregnancies complicated by COVID-19 infection should be considered high risk and close surveillance of the mother, developing fetus, and newborn are merited," she concluded.

SOURCE: http://bit.ly/3aFfqSZ and http://bit.ly/3cLvW5W The Lancet Infectious Diseases, online March 3, 2020.

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