By Camille Hoffman, MD, MSc
Associate Professor, Maternal Fetal Medicine, University of Colorado Departments of Obstetrics and Gynecology and Psychiatry, Aurora, CO
Dr. Hoffman reports no financial relationships relevant to this field of study.
SYNOPSIS: While data remain limited on this particular coronavirus, extrapolation from other viruses (severe acute respiratory syndrome and Middle East respiratory syndrome), and best clinical observations and expert recommendations have led to current guidelines in care.
SOURCE: Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus disease 2019 (COVID-19) and pregnancy: What obstetricians need to know. Am J Obstet Gynecol 2020;222:415-426.
Coronavirus disease 2019 (COVID-19) symptoms during pregnancy range from asymptomatic/none to fever, cough, malaise, myalgia, headache, anosmia, and diarrhea. There also are reports of thrombocytopenia, disseminated intravascular coagulopathy, renal failure, sepsis, superimposed bacterial pneumonia, and severe acute respiratory syndrome.
The most severely affected populations are adults
> 65 years of age and those with comorbidities, such as diabetes and hypertension. Minority populations are affected disproportionately, with more severe COVID-19 infections and deaths. Men are hospitalized more frequently (54% to 73% of cases) than women. Generally, children are affected mildly with cold and flu-like symptoms or have no symptoms at all. Pregnant women with COVID-19 appear to be affected similarly, with most reported cases occurring during the third trimester, and clinical symptoms comparable to those in nonpregnant adult women. Cases of preterm delivery and fetal distress are reported as well. No strong evidence of vertical transmission and transfer into breastmilk are reported. Supportive care and mechanical ventilation, if indicated, are the mainstays of treatment during pregnancy.
Anticipatory guidance regarding deterioration in maternal status is a necessary precaution, and similar isolation, social distancing, and mask/handwashing recommendations exist for all. In addition to standard precautions, recommendations that pregnant women self-distance further, and essentially isolate at home, have been put forth for pregnant women > 37 weeks gestation as an attempt to reduce viral infection at the time of delivery and during the early postpartum period.
When I started writing this commentary, there already were 90 articles in PubMed under the search terms “COVID-19 AND pregnancy.” One week later, there now are 136 articles using the same search terms. This commentary may be obsolete by the time of publication, since data are emerging so quickly. As the world’s experts and researchers continue to make strides, it seems relevant to address the unique circumstances of the pregnant woman in this issue of OB/GYN Clinical Alert.
Open-access publication in our major obstetrics journals and regular weekly updates by the Society for Maternal-Fetal Medicine (SMFM) and the American College of Obstetricians-Gynecologists are helpful. These are the mainstay of “what the obstetrician needs to know” and will, undoubtedly, evolve and change as we better understand this disease. The Centers for Disease Control and Prevention also are active in maintaining clinical and research guidelines as data emerge. Researchers who currently are working from home, if at all, are rapidly producing proposals regarding researching the effects of COVID-19 and pregnancy. The University of California, Los Angeles and University of Southern California established a formal registry to track the effect of the virus on pregnant women. We will certainly have a better understanding over the next several months. Furthermore, this pandemic is the impetus to a complete and rapid paradigm shift in the administration of perinatal care (as well as healthcare delivery in general). Telehealth systems evolved overnight in many areas, and accessing care and medical guidance from one’s home has never been easier. Many are hopeful that these swift changes in healthcare delivery will lead to more accessible, and sensible, care for all patients — including our pregnant ones. The general recommendations from the SMFM (as of May 8, 2020) are sensible but also need to be tailored to the context of the patient.1
Reasons for the obstetrician to advise a patient to seek further evaluation (if the patient is COVID-19 positive or suspected):
- worsening shortness of breath
- unremitting fever (> 39°C or 102.5°F), despite appropriate use of acetaminophen
- inability to tolerate oral hydration or needed medications
- oxygen saturation < 95% either at rest or on exertion (if home pulse oximetry available)
- 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.
- Society for Maternal-Fetal Medicine. Management for Pregnant Patients With COVID-19. Published April 30, 2020. https://s3.amazonaws.com/cdn.smfm.org/media/2336/SMFM_COVID_Management_of_COVID_pos_preg_patients_4-30-20_final.pdf